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This study provides the first direct comparison of the relative importance of structural versus
functional aspects of social network ties as they relate to susceptibility to coronary artery disease.
Data from 119 men and 40 women undergoing coronary angiography provide an opportunity
to compare these associations in relation to a direct and continuous measure of atherosclerosis
while controlling for age, sex, income, hypertension, serum cholesterol, smoking, angina, di-
abetes, family history of heart disease, Type A behavior pattern, and hostility. Regression
analyses indicate that network instrumental support and feelings of being loved are more
important in predicting coronary atherosclerosis than is network size, independent of all covari-
ables (relative extent of atherosclerosis, low/high support = 1.74 and 1.5, respectively). More
"problem-oriented" emotional support did not show a similarly strong association (relative
extent of atherosclerosis = 1.01). These findings suggest that certain functional aspects of social
network ties are more strongly associated with host resistance to coronary atherosclerosis than
are structural characteristics like network size.
Social network ties are currently the ob- connectedness by counting various types
ject of much epidemiologic interest and of social ties (2-8). Others have measured
debate. Indeed, over the past decade, there the extent of social activities (9,10). Among
has been an explosion of research interest these studies, some have shown that greater
in the role of social ties in health and ill- network size or involvement is signifi-
ness. The result has been a deluge of re- cantly associated with decreased mortality
search with frequently mixed finding [see risk (2,4, 9,10) while others have not found
Broadhead et al. (1) for a review]. One pos- such strong or consistent associations (3,
sible explanation for these inconsistent 5). Results have also varied as to the rel-
findings is that every study has used dif- ative importance of more intimate ties with
ferent measures of social network ties and/ a spouse or close friends versus more for-
or support. Thus, some studies have de- mal ties with groups or organizations (2,
veloped measures of network size or social 3). Measures of more qualitative aspects
such as satisfaction with one's social ties
and perceptions of available support have
also shown mixed associations with health
Received for publication August 11,1986; revision
received November 12, 1986. (3, 4, 8, 11, 12). An additional source of
From the Department of Epidemiology and Public variation in these studies is the variety of
Health, School of Medicine, Yale University (T.E.S.) disease outcomes used, including angina
and the Biomedical and Environment Health Sci-
ences, School of Public Health, University of Cali- (12), incidence and prevalence of coronary
fornia, Berkeley (S.L.S.). heart disease (6, 7), cancer incidence and
Address reprint requests to: Dr. Teresa Seeman, mortality (8), and all-cause mortality (2-5).
Department of Epidemiology and Public Health,
School of Medicine, Yale University, 60 College Street, Unfortunately, despite all these re-
New Haven, CT 06510. search efforts, there are no truly compar-
ative data regarding the relative impor- area because of suspected coronary artery disease.
tance for disease etiology of various These hospitals were six of the major Bay Area hos-
structural versus functional approaches to pitals, representing the spectrum of sociodemo-
graphic characteristics of the area. The bulk of the
social network assessment. Indeed, mea- subjects came from two of the larger institutions
sures of the different types and amount of (Merritt Hospital in Oakland, California, and Pres-
support actually derived from network ties byterian Hospital in San Francisco, California). Be-
is strikingly absent from this research. tween them, these two hospitals have a diverse clien-
tele in terms of ethnicity and socioeconomic status.
Clearly, a more thorough understanding Patients included in the study were those scheduled
of the relationship between social ties and for angiography with a diagnosis of 1) angina pec-
host resistance requires that we differen- toris, 2) coronary artery disease, 3) recent myocardial
tiate and compare measures of social net- infarction (within the past 6 months), and/or 4]
asymptomatic coronary artery disease (i.e., suspected
work structure and the functional or sup-
disease due to a positive electrocardiogram or tread-
port characteristics of such ties (13). A major mill test). Angiography patients were excluded if they
strength of the current study is that it goes had had a myocardial infarction more than 6 months
beyond previous research by incorporat- before or had undergone previous cardiac catheter-
ing measures of both structural and func- ization These exclusion criteria were designed to
eliminate patients with a previous known history of
tional aspects of respondents' networks. heart disease in order to avoid 1) possible recall bias
For the first time, we can directly compare from those who already knew the extent of their heart
the relative magnitude of the disease risks disease and 2) possible bias in risk factor data for
associated with these different network these same individuals due to life-style changes they
characteristics. To do this, extensive in- might have instituted subsequent to their earlier an-
giography findings or heart attack. Refusal rates were
formation was obtained from study sub- uniformly low at all hospitals, with a total of 21 re-
jects on network size, types of ties in the fusals out of 182 contacts. Unless otherwise speci-
network, amount of network instrumental fied, all predictor data were gathered via self-admin-
support, and amount of network emo- istered questionnaires completed by study subjects
the day before their cardiac catheterizations.
tional support.
Two additional advantages of this study Measures of social network characteristics fall into
are the availability of covariable infor- two categories; 1) structural measures and 2) mea-
sures of the instrumental and emotional support pro-
mation on an extensive set of standard heart vided by members of the network. The structural
disease risk factors and the direct mea- characteristics of social networks were measured with
surement of coronary atherosclerosis from respect to the presence of four types of social ties: 1)
coronary angiograms. The latter data pro- being married or not; 2) the number of close friends
and relatives seen (or talked to) at least once per
vide us with a continuous measure of the month; 3) regular, weekly church attendance; and 4)
extent of coronary atherosclerosis and thus membership in formal groups. These four measures
a more direct estimate of susceptibility to of social ties were also combined to form a Social
the primary underlying disease process in Network Index, as developed by Berkman and Syme
most cases of coronary heart disease, cor- in the Alameda County study (2). Although this score
is basically a measure of network size, intimate ties
onary atherosclerosis. with a spouse and/or with close friends and relatives
contribute more heavily to the final score than do
more formal ties with a church or other group mem-
METHODS berships.
Network instrumental support was calculated by
The study population consisted of 119 men and tabulating the frequency with which family and/or
40 women, aged 30-70, who were referred for an- friends were reported as sources of assistance for
giography to six hospitals in the San Francisco Bay rides, minor household tasks, and financial aid. Net-
work emotional support was assessed in two ways. pretation of all films was made by an experienced
One measure is more problem oriented, reflecting cardiologist who remained unaware of risk factor sta-
emotional support from family and/or friends in terms tus and other characteristics of subjects. Evaluations
of advice or information, discussing health and other of the four major coronary arteries were in terms of
personal problems, and helping respondents when 15 subdivisions, with each lesion in these segments
they need to be cheered up. The second measure assessed in terms of the percent occlusion of the ar-
refects a more general, non-problem-oriented sense tery (18).
of emotional support from others, a sense of being The reliability of these evaluations was estimated
loved. Respondents were asked to place themselves by randomly selecting a 10% sample of films to be
on a 6-point scale, ranging from "loved" (6) to "un- reread "blind." Comparisons of these dual evalua-
loved" (1). Because so few people scored below 4, tions yielded correlations of approximately 0.90 for
this item was collapsed to three categories for anal- various summary measures of occlusion.
ysis (See Appendix for further details on components Since it was hypothesized that social network
of instrumental and emotional support scales.) characteristics influence the overall extent of coro-
In addition to the data on network characteristics, nary atherosclerosis, a summary measure of "total
data on standard demographic and heart disease risk occlusion" was developed by totaling the individual
factors were included in multivariate analyses in or- occlusion scores associated with each lesion (20 =
der to estimate the direct independent associations 20% occlusion, 25 = 25% occlusion, 50 = 50% oc-
between the various social network characteristics clusion, 75 = 75% occlusion, 90 = 90% occlusion,
and coronary artery disease. These additional risk 99 = 99%, and 100 = 100%). Other summary mea-
factors were age, sex, income, history of hyperten- sures were also examined but are not presented here,
sion, serum cholesterol above 220 mg/dl, cigarette as they yielded similar findings (e.g., number of ves-
smoking, presence of angina, diabetes, family history sels occluded > 50% or > 75%; number of lesions
of heart disease, Type A behavior pattern, and hos- causing > 50% or > 75% occlusion).
tility. Type A behavior pattern was assessed from the Since the outcome measure of coronary athero-
Structured Interview by interviewers trained by Dr. sclerosis was continuous, regression techniques were
Ray Rosenman. The measure of hostility was also used to assess the associations between network
included in these analyses, as previous research has characteristics and coronary artery disease in uni-
shown a significant association with coronary artery variate and multivariate analyses. A log-transformed
disease (14-16) and such a characteristic might also score for total coronary atherosclerosis was used as
be correlated with fewer social ties and/or less the actual outcome measure in the analyses because
social support. Hostility was measured from the the distribution of raw scores was skewed toward the
Cook-Medley subscale of the MMPI, which is scored lower scores. The regression analyses for this "log-
from 0 to 50 (17). For purposes of these analyses, atherosclerosis" outcome measure yield regression
scores have been dichotomized as in previous an- coefficients indicating the amount of change in "log-
giography studies: 0-10 vs. 11-50 (14). Serum cho- atherosclerosis" associated with a one-unit change
lesterol levels were determined from blood samples in the predictor variable. In order to estimate the
obtained prior to each angiography exam and ana- amount of change in actual atherosclerosis scores,
lyzed by Bio-Science Laboratory, a CDC-standard- one has only to take the antilog of the coefficient.
ized laboratory. These values were then dichoto- We also considered the possibility of selection bias
mized as high or low risk using 220 mg/dl as the in a sample such as ours. Such selection bias could
cutoff point. All other covanables were measured occur if cardiologists take "risk factor" characteristics
from questionnaire data. Other than income (mea- into consideration in deciding whether or not to refer
sured in six levels) and age (measured in years), all an individual for angiography. For example, if they
covariables are dichotomous measures.1 tend to refer Type As who are otherwise at generally
The extent of coronary atherosclerosis was deter- low risk of coronary artery disease (e.g., have few
mined from angiographyfilmsfor each subject. Inter- other risk characteristics such as chest pain or high
cholesterol) more frequently than they refer similarly
low-risk Type Bs, this could lead to an underesti-
mation of the relationship between behavior pattern
Mncome categories: <$10,000, $10,000-319,999, and disease—there being an overabundance of oth-
$20,000-$29,OO0, $30,000-$39,999, $40,000-$49,999, erwise low-risk As in the sample.
$50,000 + . Since the analyses to be presented here are spe-
cifically concerned with possible relationships be- TABLE 1. Frequency Distributions for Sample
tween social network characteristics and coronary Demographic Characteristics
atherosclerosis, the important question is whether
N %
selection/referral bias is likely to occur with respect
to such characteristics. In contrast to the more stan- Sex
dard heart disease risk factors, less established risk Males 120 74.5
factors such as social network characteristics seem Females 41 25.5
unlikely candidates for referral/selection bias. Since
they are not established as risk factors, such char- Age
acteristics are unlikely to influence cardiologists' re- 30-49 39 24.2
ferral decisions (i e., cardiologists are unlikely to re- 50-59 58 36.0
fer an individual on the basis of what are as yet 60-70 62 38 5
"unproven" risk factors). Cardiologists are primarily
concerned with more "biologic" aspects of each case, Income
such as ECG test results and medical history of chest <$10,000 7 4.3
pain and/or presence of other known heart disease $10,000-$19,999 27 16.8
risk factors. However, if social network characteris- $20,000-$29,999 38 23.6
tics covary with the other standard risk factors, se- $3O,OOO-$39,999 24 14.9
lection bias with respect to these latter factors could $40,000-$49,999 22 13.7
presumably lead indirectly to bias with respect to $50,000 + 29 18.0
social network characteristics. Available data from a
community sample, however, show no evidence of Race
such an association between social network ties and White 144 90.6
risk factors such as hypertension, serum cholesterol, Hispanic 5 3.1
or smoking (3). Black 3 1 9
Other 7 4.4
Education
RESULTS <High School 7 4.4
Some high school 23 14 4
As shown in Table 1, the study popu- Completed high 47 29.6
lation was predominantly male, aged 50-70, school
and white. They were fairly evenly spread Some college 42 26.5
Completed 23 14.5
across economic and educational strata. college
Graduate school 17 10.7
Network Structure
Analyses of network structure first ex-
amined the univariate associations of net- disease risk factors was then considered.
work size and the four different types of These additional factors included age, sex,
social ties with extent of coronary athero- income, hypertension, cigarette smoking,
sclerosis. Table 2 presents mean coronary serum cholesterol level above 220 mg/dl,
atherosclerosis scores for different levels family history of heart disease, angina, di-
of the network index as well as for those abetes, Type A behavior pattern, and hos-
with and without specific types of ties. tility. Few if any factors were significant:
Neither network size nor any of the mea- men and subjects with higher incomes were
sure of intimate or formal ties were sig- more likely to be married; subjects who
nificantly associated with extent of ath- smoked and those with a family history of
erosclerosis. heart disease were less likely to attend
Possible covariation with other heart church regularly. Interestingly, neither
Marital status
Not married (0) 490.57 (35)
Married (1) 427.60 (125)
r = -.07, p = 0.37
Memberships in groups
No groups (0) 400.48 (46)
One group (1) 440.08 (48)
Two or more groups (2) 471.02 (66)
r = 0.07, p = 034
Type A behavior pattern nor hostility, the either singly or as a group) and coronary
two more characterologic measures, were atherosclerosis.
significantly associated with the measures
of network structure.2 Adjustment for these
covariables did not alter the estimated as- Network Support
sociations between network size or any of It has been argued that network size was
the four different types of ties (considered found to be associated with morbidity and
mortality in previous studies (2, 5) only
because it serves as a proxy for social sup-
port (i.e., bigger network = more support).
2 However, others have argued that some
A complete correlation matrix for all variables
included in the analyses of network structure and network ties may not provide support
support is available on request from the first author. (19-21). If so, this will tend to weaken
associations between size and levels of ily or friends with those reporting such
support and underscores the importance support from family and friends in all three
of differentiating among such network "instrumental" situations revealed sub-
characteristics in assessing the possible stantial differences in coronary athero-
health effects of social ties (13). sclerosis between the two groups: those
Interestingly, inspection of the relation- with no network instrumental support had
ship between network size and our mea- approximately 1.74 times more athero-
sures of network support reveals no as- sclerosis. As with the analyses of network
sociation between network size and levels structure, we examined possible con-
of network instrumental support (r = founding from associations with 11 cov-
-0.08;p = 0.31), though there are modest ariables. Only age showed a significant and
associations with "problem-oriented" net- negative association with instrumental
work emotional support (r = 0.20; p = 0 support (r = - 0.28; p<0.001). Again, nei-
.01) and with feeling loved (r = 0.19; p = ther Type A behavior pattern nor hostility
0.02). These data suggest that network size was associated with levels of instrumental
is not a universally good proxy for network support. Multivariate adjustment for all 11
support. As a result, although network size covariables did reduce the negative asso-
was not associated with degree of coronary ciation between network instrumental
atherosclerosis, the question remains support and coronary atherosclerosis
whether our direct measures of network somewhat, although it remains significant
instrumental and emotional support are (see Table 4, Model II, for instrumental
more strongly associated with suscepti- support).
bility to coronary artery disease. Thus, network instrumental support ap-
As shown in Table 3, network instru- pears to have an independent and direct
mental support did show a strong and sig- effect on coronary atherosclerosis, an ef-
nificant negative association with coro- fect that is not confounded or mediated by
nary atherosclerosis: subjects with greater these standard risk factors. A sense of the
network instrumental support tended to relative magnitude of the effect can be
have less atherosclerosis (r = 0.25, p = gained from comparisons of the standard-
0.002). Comparisons of individuals re- ized regression coefficient for network in-
porting no instrumental support from fam- strumental support ( - 0.19) with those for
such standard risk factors as age and sex.
[Note: The coefficient for instrumental
support (-0.10) given in Table 4 is the
TABLE 3. Mean Coronary Atherosclerosis (CAD) unstandardized rather than the standard-
Scores by Network Instrumental Support ized coefficient.] Comparisons of the stan-
Network
dardized coefficients indicate that the
Instrumental Mean CAD strength of the association between coro-
Support Scores N nary atherosclerosis and network instru-
0 (Low) 557.17 (30)
mental support is in the range of those for
1 500.15 (33) age (standardized coefficient = 0.11) and
2 483.14 (35) sex (male = 1 and female = 2; standard-
3 292.22 (27) ized coefficient = -.25).
4 (High) 317.21 (24) Turning to a similar examination of our
(r= -0.25; p = 0.002)
more problem-oriented measure of net-
Model II
(1 + 10 heart risk factors)
Support Scale -0.06b -0.01 -0.11 1 1
Age 0.006 0.009c 0.008c
Sex (M = 1; F = 2) -O.35 d -O.37 d -035d
Income -0.04 -0.04 -0.04
Angina6 0.20b O.23a 0.20a
History of Hypertension 0.186 cis* 0.17C
Serum Cholesterol (>220 0.0009 0.0008 0.0008
mg/dl)
Smoking 0.05 0.05 0.01
Diabetes 0.20 0.20 0.19
Family History of CHD 0.03 0.02 0.01
Type A behavior 0.236 0.24a -0.196
Hostility' 0 03 0.01 0.01
work emotional support, we found little tional support from family or friends, who
association with extent of coronary ath- showed an unexpectedly low mean level
erosclerosis (r = -0.12, p = 0.15). How- of coronary atherosclerosis.
ever, though this association was nonsig- As in earlier analyses, we also examined
nificant, mean coronary atherosclerosis possible associations between problem-
scores for those with different amounts of oriented emotional support and 11 pos-
such network emotional support did show sible confounders. Again, only age showed
a general pattern of increasing atheroscle- a significant, negative association
rosis with decreasing levels of network ( r = - 0 . 1 6 ; p = 0.05). Multivariate anal-
emotional support (see Table 5). The only yses adjusting for age and the other co-
exception was the group reporting no emo- variables did not change the pattern of
situation suits them (i.e., they do not wish these other studies each included over 2500
for or need such support). This possibility subjects (6928 in the Alameda sample and
was examined using ancillary data on per- 2754 in Tecumseh). With these larger sam-
ceived loneliness and desire for more ple sizes, the latter two studies had the
friends. The data suggest that individuals statistical power to detect significant risk
in the group reporting no problem-ori- factor associations of smaller magnitude.
ented emotional support are not unduly As discussed earlier, if network support is
unhappy about that situation; their re- the critical factor in host resistance to dis-
ported frequency of "feeling lonely" and ease, measures of social network size may
"wishing for more close friends," for ex- show weaker associations with disease
ample, is lower than that of those with a susceptibility since they are only "indi-
score of " 1 " on the emotional support scale rect" indicators of network support (i.e.,
(58% reporting occasional or frequent being good proxies only to the extent that
loneliness among those with a score of "0" more ties = more support). To the extent
versus 75% among those with a score of that certain network ties are not sources
"1"). Comparable figures for these two of support, a measure of network size will
groups regarding "wishing for more close be less strongly associated with disease
friends" are 50% and 75%, respectively. susceptibility. The sample sizes in the
As one would expect, those who report the Alameda and Tecumseh studies were per-
highest levels of network emotional sup- haps sufficiently large to detect this weaker,
port (i.e., with scores of 4 or more), also "indirect" association while the smaller
report lower frequencies of feeling occa- sample of angiography patients examined
sionally or frequently lonely (48%) or here was not. In fact, those with few ties
wishing for more close friends (46%). had 0.98 times the relative degree of cor-
Our more general measure of feeling onary atherosclerosis as those with many
loved, however, was a significant predic- ties (i.e., somewhat less disease). By com-
tor of coronary atherosclerosis. Additional parison, the estimated relative mortality
evidence from another recent study of an- risk from the Alameda County study was
giography patients also suggests that net- 2.14 (adjusted for age, sex, race, socioeco-
work emotional support may, in fact, be nomic status, health status, and health
negatively related to extent of coronary practices) (22). Similar sex-specific results
atherosclerosis (11). This association was from the Tecumseh study give estimated
particularly strong among their Type As, relative mortality risks of 1.23 (males) and
a pattern not seen in our own data. Clearly, 1.09 (females) (3). Thus, it would appear
network emotional support will bear fur- that measures of network size are more
ther investigation as a potential protective strongly related to mortality than the ex-
factor. tent of disease. Perhaps, an indirect mea-
The lack of significant association for sure of support such as network size is
network size is in striking contrast to the only able to differentiate major differences
significant, negative associations with in health outcomes (e.g., dead versus alive)
mortality found, for example, in the Ala- but cannot discriminate among finer gra-
meda and Tecumseh studies. One possible dations of disease such as "amount of cor-
explanation for these differences is the ex- onary atherosclerosis." It is only when we
treme differences in sample size. The pre- look at more direct measures of network
sent study included only 159 subjects while instrumental support and feeling loved that
we see significant associations with degree eralizability of findings from this sample
of coronary atherosclerosis. to other populations. A sample of angio-
graphy patients such as this is certainly
not a representative sample of the general
SUMMARY population. Rather, this sample generally
represents individuals at high risk for cor-
The data from this study are unique in onary artery disease by virtue of existing
several respects. They offer one of the first chest pain and/or risk status on standard
opportunities to examine and compare both heart disease risk factors such as smoking
structural and functional aspects of social or having a history of hypertension. In-
networks in relation to coronary artery dis- deed, analyses for these angiography pa-
ease. Use of a sample of men and women tients can be seen as somewhat analogous
undergoing angiography further provides to a stratified analysis that focuses pri-
a unique and valuable outcome, a direct marily on the highest risk strata. As an-
and continuous measure of actual coro- giography examinations are currently the
nary atherosclerosis. This outcome mea- only feasible means of directly assessing
sure allows us to more accurately estimate coronary atherosclerosis and are also per-
the extent of disease than do the usual, formed only when "indicated" (i.e., when
dichotomous measures of disease. Also, coronary disease is suspected), the top risk
these latter classification schemes depend stratum is currently the only one for whom
on evaluating disease from such indirect analyses such as these are possible. As less
indicators as results of electrocardiograms invasive means of assessing coronary ath-
and/or reports of anginal chest pain whereas erosclerosis become more widely avail-
our measure is obtained from direct vis- able, it will be possible to investigate
ualization of the extent of coronary ath- whether the same risk factor relationships
erosclerosis in the major coronary blood between social network characteristics and
vessels. atherosclerosis hold true in "lower risk"
Our findings indicate that the function strata of the general population.
or content of network ties is more strongly The data presented here do confirm the
associated with coronary atherosclerosis importance of social ties for physical well-
than is the mere presence of social ties. As being, particularly the importance of cer-
originally suggested by Cassel [23], it seems tain "support" characteristics of these ties.
that the "feedback" or support received The precise mechanisms for these effects
from network ties is most strongly and remain to be clarified. Our data, as well as
negatively associated with extent of cor- evidence from the Alameda County Study
onary artery disease. These results also in- indicate that the association is not simply
dicate the importance of differentiating a function of positive associations be-
between network characteristics such as tween support or social ties and better risk
network size and various types of network profiles or health practices (22). Indeed,
support. It is only through specifying dif- we find few if any associations between
ferent social network characteristics for support or social ties and standard risk
study that those that most strongly influ- factors such as hypertension, serum cho-
ence host resistance to disease can be clar- lesterol, or smoking. Perhaps, as Bovard
ified. (24-26), and Jemmott and Locke (27) have
There is, of course, the question of gen- suggested, it is through the neuroendo-
crine and immune systems that stimuli as- been and may continue to be conveyed by
sociated with social support influence man's social ties with others: that social
health. network ties, and in particular the instru-
That social ties, particularly the support mental support and sense of being loved
they provide, influence host resistance to that these ties can provide, may serve to
disease should not be too surprising. Man promote host resistance to disease, thereby
has evolved as a social animal because liv- increasing survival,
ing in groups conveyed survival advan-
tages (28-30). The results of this study are This research was supported in part by
consistent with the idea that more subtle NIH Grant #ROl-HL27143 and by the
physiologic survival advantages may have MacArthur Program on Successful Aging.
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When you're worried about personal (Please describe yourself in terms of the
problems (family, work) following word pairs by checking that
When you need cheering-up portion of the line between the words
which most accurately describes you).
(final scoring collapses 6-8 due to
small numbers) Loved Unloved
II. Non-problem-oriented Emotional Sup-
port (scores were collapsed into thirds)