Teaching Tip Sheet: Social Support Networks

Social support networks have been studied extensively in health psychology and have been associated to stress management and to the following coping styles:

• Action-oriented

• Cognitive

• Emotional

• Avoidant

Both the quality and the quantity of social support are considered important. There is no clear causal direction in the relationship between social support and health. It is possible that "good social support promotes psychological well-being which in turn promotes good health" (Green, 1993), but it is also possible that those with good health find psychological adaptation easier, which then attracts a wider support. Some evidence exists that lack of good support precedes the onset of depression, although depression may then lead to changes in the quality of support. In sum, cyclical relationships may be operative.

Social support networks are key to preventing HIV transmission, to professional caregivers, to immediate family members providing direct care, in the bereavement process following AIDS-related death, and for the HIV-positive individual. The majority of U.S. AIDS cases to date have been in the populations of gay males and intravenous drug users, groups which have been historically stigmatized. In addition, even though the public is now better informed about how unlikely transmission of HIV through casual contact is, many people feel uncomfortable in the presence of someone with a life-threatening, infectious illness. Therefore it is harder for those with HIV/AIDS, who may feel "toxic," to establish and maintain social support networks that it is for persons with other illnesses. Feelings of isolation, alienation, and depression have been linked to a lack of social support (Hoffman, 1996).

For many, revealing that one is HIV-positive involves a double disclosure in which one's sexual orientation, sexual activities, and/or drug use are also revealed (Green, 1989). Therefore care must be taken when choosing sources of support. Gay men are less likely than other populations to seek support from family (Hays, Catani, McKusick, & Coates, 1990). Research has shown that gay men often have conflicted relations with their family and are hesitant to seek social support from them pertaining to their HIV/AIDS needs (Nott, Vedhara, & Power, 1995). Instead, they are more likely to seek support from professionals and peers. Factor analysis has identified four sources of support (friends, relatives, partner, and organization) for gay men (Schwarzer, Dunkel-Schetter, & Kemeny, 1994). Blame and fear are barriers in providing social support (Collins, 1994).

Gay men tend to have smaller support networks in dealing with HIV/AIDS than cancer patients have in coping with their illness, in part because many of their peers may have already died from AIDS complications (Nott, Vedhara, & Power, 1995).

Ethnicity is an important variable in help-seeking behavior. For example, in one study Spanish-speaking Latino men were more likely than either English-speaking Latino and Whites not to disclose being HIV-positive and being gay or bisexual to their significant others (Mason, Marks, Simoni, Ruiz, & Richardson, 1995). Of course, non-disclosure reduces the likelihood of engaging in safer-sex practices and seeking medical help. Another study concluded that measures of social support applied to the White but not the African American participants, which suggests that caution should be used in generalizing results across racial groups (Gant & Ostrow, 1995). A positive relationship between social support and psychological well-being in HIV-positive persons has only been established for White gay men (Hoffman, 1996).

Social support has been studied in homes with spouses and/or children. For example, in one controlled study, supportive home intervention for low-income, drug-using HIV-positive mothers was followed by less child-related stress (Black, Nair, & Harrington, 1994). In married couples with an HIV-positive hemophiliac husband, an avoidant coping style by either spouse was associated with poorer family functioning (Klein, Forehand, Armistead, & Wienson, 1994). Many scales have been developed to improve our understanding of social support networks for the HIV-positive person and to measure them better. Examples include the:

1. Social Support Inventory for People With AIDS

2. Mental Attitude to HIV Scale Health Related Quality of Life battery for HIV positive individuals

3. Adjustment to AIDS Scale

4. Healthcare Needs Scale for Patients with HIV/AIDS

CHESS (Comprehensive Health Enhancement Support System) is a computer-based support system that provides information, referrals, decision support, and social support to people living with AIDS/HIV. Initial results show that individuals were using the system in their homes, including modem use, for an average of one hour per day and found it very useful and easy to use (Boberg et al., 1995).

The unclear causal direction between social support and health is unclear for health conditions in general is a particularly intractable puzzle with AIDS/HIV, with its many biological markers and opportunistic infections. CD4 cell (a type of T cell in the immune system) counts are often used to gauge HIV disease progression, but there have been no conclusive studies that suggest that social support affects CD4 cell counts in the long term. Although studies have linked changes in psychosocial factors such as elicitation of social support with improved immunological status and physical functioning for up to two years, many results have been contradictory, perhaps due to lack of theoretical rationale for the measures and hypotheses (Mulder, 1994). Mulder therefore proposed a stress-coping-social support model to identify psychosocial risk factors for progression and to develop effective psychosocial interventions. It is possible that social support is a beneficial mediating variable, but that the causal paths among stress, coping, social support, and disease progression have not yet been clearly delineated.

A good point to keep in mind is that students may not readily understand all of the barriers relating to seeking and maintaining social support for those living with HIV/AIDS. Attending to issues of discrimination, oppression, and stigmatization (see the first "Lesson" above, re: stigma), may help students to grasp the complexity of social support networks in this population. Exercise: Ask students to imagine that a good friend of theirs has just learned that he/she is HIV-positive. Then ask the following questions:

• What would your reaction be?

• Whom would you tell?

• How would it change your relationship with your friend?

• What kind of support could you provide the friend?

• To what extent, if any, would you get involved with your friend's family, health care providers, and other branches of his/her support network?

• What are the ethical dilemmas involved in these issues and how would you go about resolving them?

Assignment: Have students research the support services available to HIV-positive persons in your community. Then, invite a speaker from one of those agencies to address your class on accessibility and potential barriers to seeking and receiving these services.

Hoffman, M. A. (1996). Counseling clients with HIV disease: Assessment, intervention, and prevention. New York, NY: Guilford Press.

Green, G. (1993). Social support and HIV. AIDS Care, 5, 87-104.

Mulder, C. L. (1994). Psychosocial correlates and the effects of behavioral interventions on the course of human immunodeficiency virus infection in homosexual men.

Patient Education & Counseling, 24(3), 237-247.

Nott, K. H., Vedhara, K., & Power, M. J. (1995). The role of social support in HIV infection. Psychological Medicine, 25(5), 971-983.

Black, M. M., Nair, P., & Harrington, O. (1994). Maternal HIV infection: Parenting and early child development. Journal of Pediatric Psychology, 19(5), 595-615.

Boberg, E. W., Gustafson, D. H., Hawkins, R. P., Chan, C., Bricker, E., Pingree, S., & Berhe, H. (1995). Development, acceptance, and use patterns of a computer-based education and social support system for people living with AIDS/HIV infection. Computers in Human Behavior, 11(2), 289-311.

Collins, R. L. (1994). Social support provision to HIV-infected gay men. Journal of Applied Social Psychology, 24(20), 1848-1869.

Gant, L. M., & Ostrow, D. G. (1995). Perceptions of social support and psychological adaptation to sexually acquired HIV among White and African American men. Social Work, 40(2), 215-224.

Green, J. (1989). Post-test counselling. In J. Green and A. McCreaner (Eds.) Counseling in HIV Infection and AIDS. (pp. 21-31). Cambridge, MA: Blackwell Scientific Publications.

Hays, R. B., Catania, J. A., McKusick, L., & Coates, T. J. (1990). Help-seeking for AIDS related concerns: A comparison of gay men with various HIV diagnoses. American Journal of Community Psychology, 18(5), 743-755.

Klein, K, Forehand, R., Armistead, L, & Wienson, M. (1994). The contributions of social support and coping methods to stress resiliency in couples facing hemophilia and HIV. Advances in Behavior Research and Therapy, 16(4), 253-275.

Mason, H. R. C., Marks, G., Simoni, J. M., Ruiz, M. S., & Richardson, J. L. (1995). Culturally sanctioned secrets? Latino men's nondisclosure of HIV infection to family, friends, and lovers. Health Psychology, 14(1), 6-12.

Schwarzer, R, Dunkel-Schetter, C, & Kemeny, M. (1994). The multidimentional nature of received social support in gay men at risk of HIV infection and AIDS. American Journal of Community Psychology, 22(3), 319-339.

David H. Whitcomb, PhD