Social Networks and Coronary Artery Disease: A Comparison of the Structure and Function of Social Relations as Predictors of Disease

TERESA E. SEEMAN, PHD, AND S. LEONARD SYME, PHD 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, diabetes, 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 covariables (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 object of much epidemiologic interest and debate. Indeed, over the past decade, there has been an explosion of research interest in the role of social ties in health and illness. The result has been a deluge of research with frequently mixed finding [see Broadhead et al. (1) for a review]. One possible explanation for these inconsistent findings is that every study has used different measures of social network ties and/ or support. Thus, some studies have developed measures of network size or social

connectedness by counting various types of social ties (2-8). Others have measured the extent of social activities (9,10). Among these studies, some have shown that greater network size or involvement is significantly associated with decreased mortality risk (2,4, 9,10) while others have not found such strong or consistent associations (3, 5). Results have also varied as to the relative importance of more intimate ties with a spouse or close friends versus more formal ties with groups or organizations (2, 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 (3, 4, 8, 11, 12). An additional source of received November 12, 1986. 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 Sciences, School of Public Health, University of Cali- (12), incidence and prevalence of coronary heart disease (6, 7), cancer incidence and fornia, Berkeley (S.L.S.). Address reprint requests to: Dr. Teresa Seeman, mortality (8), and all-cause mortality (2-5). Department of Epidemiology and Public Health, Unfortunately, despite all these reSchool of Medicine, Yale University, 60 College Street, search efforts, there are no truly comparNew Haven, CT 06510.
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Copyright © 1987 by the American Psychosomatic Society, In Published by Elsovier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017

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ative data regarding the relative importance for disease etiology of various structural versus functional approaches to social network assessment. Indeed, measures of the different types and amount of support actually derived from network ties is strikingly absent from this research. Clearly, a more thorough understanding of the relationship between social ties and host resistance requires that we differentiate and compare measures of social network structure and the functional or support characteristics of such ties (13). A major strength of the current study is that it goes beyond previous research by incorporating measures of both structural and functional aspects of respondents' networks. For the first time, we can directly compare the relative magnitude of the disease risks associated with these different network characteristics. To do this, extensive information was obtained from study subjects on network size, types of ties in the network, amount of network instrumental support, and amount of network emotional support. Two additional advantages of this study are the availability of covariable information on an extensive set of standard heart disease risk factors and the direct measurement of coronary atherosclerosis from coronary angiograms. The latter data provide us with a continuous measure of the extent of coronary atherosclerosis and thus a more direct estimate of susceptibility to the primary underlying disease process in most cases of coronary heart disease, coronary atherosclerosis.

area because of suspected coronary artery disease. These hospitals were six of the major Bay Area hospitals, representing the spectrum of sociodemographic characteristics of the area. The bulk of the subjects came from two of the larger institutions (Merritt Hospital in Oakland, California, and Presbyterian Hospital in San Francisco, California). Between them, these two hospitals have a diverse clientele in terms of ethnicity and socioeconomic status. Patients included in the study were those scheduled for angiography with a diagnosis of 1) angina pectoris, 2) coronary artery disease, 3) recent myocardial infarction (within the past 6 months), and/or 4] asymptomatic coronary artery disease (i.e., suspected disease due to a positive electrocardiogram or treadmill test). Angiography patients were excluded if they had had a myocardial infarction more than 6 months before or had undergone previous cardiac catheterization These exclusion criteria were designed to eliminate patients with a previous known history of heart disease in order to avoid 1) possible recall bias from those who already knew the extent of their heart disease and 2) possible bias in risk factor data for these same individuals due to life-style changes they might have instituted subsequent to their earlier angiography findings or heart attack. Refusal rates were uniformly low at all hospitals, with a total of 21 refusals out of 182 contacts. Unless otherwise specified, all predictor data were gathered via self-administered questionnaires completed by study subjects the day before their cardiac catheterizations. Measures of social network characteristics fall into two categories; 1) structural measures and 2) measures of the instrumental and emotional support provided by members of the network. The structural characteristics of social networks were measured with respect to the presence of four types of social ties: 1) being married or not; 2) the number of close friends and relatives seen (or talked to) at least once per month; 3) regular, weekly church attendance; and 4) membership in formal groups. These four measures of social ties were also combined to form a Social Network Index, as developed by Berkman and Syme in the Alameda County study (2). Although this score is basically a measure of network size, intimate ties 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 memberships. Network instrumental support was calculated by tabulating the frequency with which family and/or friends were reported as sources of assistance for rides, minor household tasks, and financial aid. Net-

METHODS The study population consisted of 119 men and 40 women, aged 30-70, who were referred for angiography to six hospitals in the San Francisco Bay

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SOCIAL NETWORKS AND CORONARY ARTERY DISEASE work emotional support was assessed in two ways. One measure is more problem oriented, reflecting emotional support from family and/or friends in terms of advice or information, discussing health and other personal problems, and helping respondents when they need to be cheered up. The second measure refects a more general, non-problem-oriented sense of emotional support from others, a sense of being loved. Respondents were asked to place themselves on a 6-point scale, ranging from "loved" (6) to "unloved" (1). Because so few people scored below 4, this item was collapsed to three categories for analysis (See Appendix for further details on components of instrumental and emotional support scales.) In addition to the data on network characteristics, data on standard demographic and heart disease risk factors were included in multivariate analyses in order to estimate the direct independent associations between the various social network characteristics and coronary artery disease. These additional risk factors were age, sex, income, history of hypertension, serum cholesterol above 220 mg/dl, cigarette smoking, presence of angina, diabetes, family history of heart disease, Type A behavior pattern, and hostility. Type A behavior pattern was assessed from the Structured Interview by interviewers trained by Dr. Ray Rosenman. The measure of hostility was also included in these analyses, as previous research has shown a significant association with coronary artery disease (14-16) and such a characteristic might also be correlated with fewer social ties and/or less social support. Hostility was measured from the Cook-Medley subscale of the MMPI, which is scored from 0 to 50 (17). For purposes of these analyses, scores have been dichotomized as in previous angiography studies: 0-10 vs. 11-50 (14). Serum cholesterol levels were determined from blood samples obtained prior to each angiography exam and analyzed by Bio-Science Laboratory, a CDC-standardized laboratory. These values were then dichotomized as high or low risk using 220 mg/dl as the cutoff point. All other covanables were measured from questionnaire data. Other than income (measured in six levels) and age (measured in years), all covariables are dichotomous measures.1 The extent of coronary atherosclerosis was determined from angiographyfilmsfor each subject. Interpretation of all films was made by an experienced cardiologist who remained unaware of risk factor status and other characteristics of subjects. Evaluations of the four major coronary arteries were in terms of 15 subdivisions, with each lesion in these segments assessed in terms of the percent occlusion of the artery (18). The reliability of these evaluations was estimated by randomly selecting a 10% sample of films to be reread "blind." Comparisons of these dual evaluations yielded correlations of approximately 0.90 for various summary measures of occlusion. Since it was hypothesized that social network characteristics influence the overall extent of coronary atherosclerosis, a summary measure of "total occlusion" was developed by totaling the individual occlusion scores associated with each lesion (20 = 20% occlusion, 25 = 25% occlusion, 50 = 50% occlusion, 75 = 75% occlusion, 90 = 90% occlusion, 99 = 99%, and 100 = 100%). Other summary measures were also examined but are not presented here, as they yielded similar findings (e.g., number of vessels occluded > 50% or > 75%; number of lesions causing > 50% or > 75% occlusion). Since the outcome measure of coronary atherosclerosis was continuous, regression techniques were used to assess the associations between network characteristics and coronary artery disease in univariate and multivariate analyses. A log-transformed score for total coronary atherosclerosis was used as the actual outcome measure in the analyses because the distribution of raw scores was skewed toward the lower scores. The regression analyses for this "logatherosclerosis" outcome measure yield regression coefficients indicating the amount of change in "logatherosclerosis" associated with a one-unit change in the predictor variable. In order to estimate the amount of change in actual atherosclerosis scores, one has only to take the antilog of the coefficient. We also considered the possibility of selection bias in a sample such as ours. Such selection bias could occur if cardiologists take "risk factor" characteristics into consideration in deciding whether or not to refer an individual for angiography. For example, if they tend to refer Type As who are otherwise at generally low risk of coronary artery disease (e.g., have few 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 underestimation of the relationship between behavior pattern and disease—there being an overabundance of otherwise low-risk As in the sample. Since the analyses to be presented here are spe-

Mncome categories: <$10,000, $10,000-319,999, $20,000-$29,OO0, $30,000-$39,999, $40,000-$49,999, $50,000 + .

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cifically concerned with possible relationships between social network characteristics and coronary atherosclerosis, the important question is whether selection/referral bias is likely to occur with respect to such characteristics. In contrast to the more standard heart disease risk factors, less established risk factors such as social network characteristics seem unlikely candidates for referral/selection bias. Since they are not established as risk factors, such characteristics are unlikely to influence cardiologists' referral decisions (i e., cardiologists are unlikely to refer an individual on the basis of what are as yet "unproven" risk factors). Cardiologists are primarily concerned with more "biologic" aspects of each case, such as ECG test results and medical history of chest pain and/or presence of other known heart disease risk factors. However, if social network characteristics covary with the other standard risk factors, selection bias with respect to these latter factors could presumably lead indirectly to bias with respect to social network characteristics. Available data from a community sample, however, show no evidence of such an association between social network ties and risk factors such as hypertension, serum cholesterol, or smoking (3).

TABLE 1. Frequency Distributions for Sample Demographic Characteristics N Sex Males Females Age 30-49 50-59 60-70 Income <$10,000 $10,000-$19,999 $20,000-$29,999 $3O,OOO-$39,999 $40,000-$49,999 $50,000 + Race White Hispanic Black Other Education <High School Some high school Completed high school Some college Completed college Graduate school 120 41 % 74.5 25.5

39 58 62

24.2 36.0 38 5

7 27 38 24 22 29

4.3 16.8 23.6 14.9 13.7 18.0

144 5 3 7

90.6 3.1 1 9 4.4

RESULTS As shown in Table 1, the study population was predominantly male, aged 50-70, and white. They were fairly evenly spread across economic and educational strata. Network Structure Analyses of network structure first examined the univariate associations of network size and the four different types of social ties with extent of coronary atherosclerosis. Table 2 presents mean coronary atherosclerosis scores for different levels of the network index as well as for those with and without specific types of ties. Neither network size nor any of the measure of intimate or formal ties were significantly associated with extent of atherosclerosis. Possible covariation with other heart
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7 23 47 42 23 17

4.4 14 4 29.6 26.5 14.5 10.7

disease risk factors was then considered. These additional factors included age, sex, income, hypertension, cigarette smoking, serum cholesterol level above 220 mg/dl, family history of heart disease, angina, diabetes, Type A behavior pattern, and hostility. Few if any factors were significant: men and subjects with higher incomes were more likely to be married; subjects who smoked and those with a family history of heart disease were less likely to attend church regularly. Interestingly, neither
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TABLE 2. Mean Coronary Atherosclerosis Scores (CAD) by level of Social Connections Social Network Index (collapsed by quartiles) 1 (smallest networks) 2 3 4 (largest networks) Mean CAD 442.17 471.50 443.81 451.73 N (58) (14) (36) (44) r = 0.02,

p = 0.78

Marital status Not married (0) Married (1)

490.57 427.60

(35) (125) r = -.07, p = 0.37

Contacts with friends and relatives Few (1) Some (2) Many (3)

432.60 442.47 475.61

(42) (72) (38) r = 0.06,

p = 0.43

Regular church attendance No (0) Yes (1)

432.76 466.51

(118) (41) r = 0.03,

p = 0.73

Memberships in groups No groups (0) One group (1) Two or more groups (2)

400.48 440.08 471.02

(46) (48) (66) r = 0.07,

p = 034

Type A behavior pattern nor hostility, the two more characterologic measures, were significantly associated with the measures of network structure.2 Adjustment for these covariables did not alter the estimated associations between network size or any of the four different types of ties (considered

either singly or as a group) and coronary atherosclerosis. Network Support It has been argued that network size was found to be associated with morbidity and mortality in previous studies (2, 5) only because it serves as a proxy for social support (i.e., bigger network = more support). However, others have argued that some network ties may not provide support (19-21). If so, this will tend to weaken
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2 A complete correlation matrix for all variables included in the analyses of network structure and support is available on request from the first author.

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associations between size and levels of support and underscores the importance of differentiating among such network characteristics in assessing the possible health effects of social ties (13). Interestingly, inspection of the relationship between network size and our measures of network support reveals no association between network size and levels of network instrumental support (r = -0.08;p = 0.31), though there are modest associations with "problem-oriented" network emotional support (r = 0.20; p = 0 .01) and with feeling loved (r = 0.19; p = 0.02). These data suggest that network size is not a universally good proxy for network support. As a result, although network size was not associated with degree of coronary atherosclerosis, the question remains whether our direct measures of network instrumental and emotional support are more strongly associated with susceptibility to coronary artery disease. As shown in Table 3, network instrumental support did show a strong and significant negative association with coronary atherosclerosis: subjects with greater network instrumental support tended to have less atherosclerosis (r = 0.25, p = 0.002). Comparisons of individuals reporting no instrumental support from fam-

ily or friends with those reporting such support from family and friends in all three "instrumental" situations revealed substantial differences in coronary atherosclerosis between the two groups: those with no network instrumental support had approximately 1.74 times more atherosclerosis. As with the analyses of network structure, we examined possible confounding from associations with 11 covariables. Only age showed a significant and negative association with instrumental support (r = - 0.28; p<0.001). Again, neither Type A behavior pattern nor hostility was associated with levels of instrumental support. Multivariate adjustment for all 11 covariables did reduce the negative association between network instrumental support and coronary atherosclerosis somewhat, although it remains significant (see Table 4, Model II, for instrumental support). Thus, network instrumental support appears to have an independent and direct effect on coronary atherosclerosis, an effect that is not confounded or mediated by these standard risk factors. A sense of the relative magnitude of the effect can be gained from comparisons of the standardized regression coefficient for network instrumental 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 unstandardized rather than the standardized coefficient.] Comparisons of the standardized coefficients indicate that the strength of the association between coronary atherosclerosis and network instrumental support is in the range of those for age (standardized coefficient = 0.11) and sex (male = 1 and female = 2; standardized coefficient = -.25). Turning to a similar examination of our more problem-oriented measure of netPsychosomatic Medicine 49:341-354 (1987)

TABLE 3. Mean Coronary Atherosclerosis (CAD) Scores by Network Instrumental Support
Network Instrumental Support 0 (Low) 1 2 3 4 (High) Mean CAD Scores 557.17 500.15 483.14 292.22 317.21

N (30) (33) (35) (27) (24) (r= -0.25; p = 0.002)

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TABLE 4.

Univariate and Multivariate Regression Analyses for Network Instrumental and Emotional Support Regression Coefficients Network Instrumental Support Network Emotional Support Problem Oriented Feeling Loved

Model 1 (simple linear regression) Support Scale R2 F Model II (1 + 10 heart risk factors) Support Scale Age Sex (M = 1; F = 2) Income Angina6 History of Hypertension Serum Cholesterol (>220 mg/dl) Smoking Diabetes Family History of CHD Type A behavior Hostility'
R2 F
a 6 c

-0.10a (0.06) 10.1 a

- 0 . 0 3 (p = 0.15) (0.01) 2.13

-0.13 f a (0.03) 5.12b

-0.06b 0.006 -O.35 d -0.04 0.20b 0.186 0.0009 0.05 0.20 0.03 0.236 0 03 (0 26) 3.94"

-0.01 0.009c -O.37 d -0.04 O.23a cis* 0.0008 0.05 0.20 0.02 0.24a 0.01 (0.24) 3 51

-0.11 1 1 0.008c -035d -0.04 0.20a 0.17C 0.0008 0.01 0.19 0.01 -0.196 0.01 (0.23) 3.39d

0.001 < p < 0 01. 0.01 < p < 0.05. 0.05 < p < 0.10. d p < 0.001. e AII subsequent risk factors coded: No = 0/Yes = 1 unless otherwise specified. 'Coded as per Williams etal. (14): 0-10 = 0 (low), 11-50 = 1 (high).

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 nonsigAs in earlier analyses, we also examined nificant, mean coronary atherosclerosis possible associations between problemscores for those with different amounts of oriented emotional support and 11 possuch 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 analemotional support (see Table 5). The only yses adjusting for age and the other coexception was the group reporting no emo- variables did not change the pattern of
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coefficients remain unchanged: network instrumental support remains a significant predictor and network emotional support Network remains a nonsignificant one. Mean CAD Emotional N Support However, when we turn to the more Scores general, non-problem-oriented measure of (12) 0 (Low) 398.92 "feeling loved," we do find a significant 1 (12) 674.75 (19) 2 493.79 pattern of increasing coronary atheroscle3 (28) 487.93 rosis with decreasing feelings of being loved 402.64 4 (25) (r= -0.18; p = 0.02). Those who feel least (20) 5 332.00 loved have approximately 1.5 times greater 6 (High) (33) 393.91 mean atherosclerosis (Table 6). Looking at (r = -0.12; p = our 11 covariables, we again find no sig0.15) nificant associations with feeling loved and multivariate adjustments for these covariables did not alter the association benonassociation between network emo- tween feeling loved and having less cortional support and coronary atheroscle- onary atherosclerosis (Table 4). rosis (see Table 4, Model II, for problemoriented emotional support). Sex-Specific Analyses The lack of association for this measure of network emotional support was someSince some studies have found eviwhat unexpected in view of its significant dence of sex differences in patterns of aspositive association with the measure of sociation for network ties and health (3,5, instrumental support (r=0.51, p<0.001) 8), we also examined sex-specific models and the significant, negative association for each of our network measures. Netbetween such instrumental support and work size showed a positive trend of ascoronary atherosclerosis. The positive as- sociation with greater coronary atherosociation between network instrumental sclerosis for men but a negative trend for and emotional support, however, does not the women. Neither of these trends, howappear to influence their individual as- ever, reached statistical significance in sociations with atherosclerosis. If we in- either the univariate or multivariate clude both instrumental and emotional regression models. The analyses of netsupport in a single regression model of work support revealed that neither instrucoronary atherosclerosis, their respective mental nor either of the measures of emotional support was related to coronary atherosclerosis among the women in either univariate or multivariate models. For the TABLE 6. Mean Coronary Atherosclerosis (CAD) men, network instrumental support was Scores by Degrees of Feeling "Loved" significantly associated with lesser degrees of coronary atherosclerosis (regresFeeling Loved Mean CAD (N) Scores sion coefficient = -0.11, p = 0.002). FurHigh 393.53 (91) ther multivariate adjustments for the 11 Medium 458.21 (39) demographic and heart disease risk factors Low 573.24(21) (r = -0.18; p = 0.02) did not substantially alter the association
TABLE 5. Mean Coronary Atherosclerosis (CAD] by Network Emotional Support 348 Psychosomatic Medicine 49:341-354 (1987)

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(regression coefficient = - 0.08; p = 0.03). Feelings of being loved also continued to show a significant association with lesser atherosclerosis for the men in both univariate (regression coefficient = -0.17; p = 0.009) and multivariate analyses (regression coefficient = -0.18; p = 0.007). Despite these apparent sex differences, it is important to note that regression models fit with sex-by-network support interaction terms for instrumental and emotional support failed to show any evidence of significant sex differences in the associations of these types of network support with coronary atherosclerosis. One possible reason for both the mixed patterns of association and the lack of significant interactions is the small number of the women in these analyses (N = 40). Because of their small number, a great deal of uncertainty is attached to estimates for this group, making it difficult to detect not only associations within this group but also any differences in comparisons with the males.

DISCUSSION The analyses presented here have shown that measures of network instrumental support and emotional support (in the sense of feeling loved) were more strongly associated with extent to coronary atherosclerosis than were structural measures of network size and the presence of specific types of network ties. This pattern of association holds true independent of a set of standard biomedical and demographic risk factors. These differential findings provide support for the hypothesis that it is the network's supportive /unction rather than its structural characteristics that most influences the development of coronary atherosclerosis. The lack of significant association for
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the measure of problem-oriented emotional support was puzzling, particularly in light of the strong, positive association between this type of network emotional and our measure of similarly problem-oriented instrumental support. Further consideration suggested that greater measurement error associated with assessing such network emotional support may have contributed to the differential pattern of findings for the two types of network support. Greater social desirability, for example, may be attached to reporting that emotional support is available from family and/or friends than is the case for reporting of instrumental support. The possibility of such bias was further suggested by the fact that only 8% of the sample reported no such network emotional support as compared with some 20% reporting no network instrumental support. Another possible source of measurement error associated with assessing such network emotional support is its less tangible nature. Perhaps people can more accurately report network instrumental support because instances of such support are by definition more "tangible" and perhaps easier to recall and report accurately than is "emotional" support. Both of these types of measurement bias would tend to weaken the observed association between reported levels of problem-oriented emotional support and extent of coronary atherosclerosis. Also, as noted earlier, subjects reporting less problem-oriented emotional support actually did have more atherosclerosis with one exception: those reporting no such support had very little disease. One possible explanation for this unexpected pattern may be the idea of "person-envisionment fit." Perhaps this latter group shows little disease, despite their apparent lack of emotional support, because in fact this 349

T. E. SEEMAN and S. L. SYME

situation suits them (i.e., they do not wish for or need such support). This possibility was examined using ancillary data on perceived loneliness and desire for more friends. The data suggest that individuals in the group reporting no problem-oriented emotional support are not unduly unhappy about that situation; their reported frequency of "feeling lonely" and "wishing for more close friends," for example, is lower than that of those with a score of " 1 " on the emotional support scale (58% reporting occasional or frequent loneliness among those with a score of "0" versus 75% among those with a score of "1"). Comparable figures for these two groups regarding "wishing for more close friends" are 50% and 75%, respectively. As one would expect, those who report the highest levels of network emotional support (i.e., with scores of 4 or more), also report lower frequencies of feeling occasionally or frequently lonely (48%) or wishing for more close friends (46%). Our more general measure of feeling loved, however, was a significant predictor of coronary atherosclerosis. Additional evidence from another recent study of angiography patients also suggests that network emotional support may, in fact, be negatively related to extent of coronary atherosclerosis (11). This association was particularly strong among their Type As, a pattern not seen in our own data. Clearly, network emotional support will bear further investigation as a potential protective factor. The lack of significant association for network size is in striking contrast to the significant, negative associations with mortality found, for example, in the Alameda and Tecumseh studies. One possible explanation for these differences is the extreme differences in sample size. The present study included only 159 subjects while
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these other studies each included over 2500 subjects (6928 in the Alameda sample and 2754 in Tecumseh). With these larger sample sizes, the latter two studies had the statistical power to detect significant risk factor associations of smaller magnitude. As discussed earlier, if network support is the critical factor in host resistance to disease, measures of social network size may show weaker associations with disease susceptibility since they are only "indirect" indicators of network support (i.e., being good proxies only to the extent that more ties = more support). To the extent that certain network ties are not sources of support, a measure of network size will be less strongly associated with disease susceptibility. The sample sizes in the Alameda and Tecumseh studies were perhaps sufficiently large to detect this weaker, "indirect" association while the smaller sample of angiography patients examined here was not. In fact, those with few ties had 0.98 times the relative degree of coronary atherosclerosis as those with many ties (i.e., somewhat less disease). By comparison, the estimated relative mortality risk from the Alameda County study was 2.14 (adjusted for age, sex, race, socioeconomic status, health status, and health practices) (22). Similar sex-specific results from the Tecumseh study give estimated relative mortality risks of 1.23 (males) and 1.09 (females) (3). Thus, it would appear that measures of network size are more strongly related to mortality than the extent of disease. Perhaps, an indirect measure of support such as network size is only able to differentiate major differences in health outcomes (e.g., dead versus alive) but cannot discriminate among finer gradations of disease such as "amount of coronary atherosclerosis." It is only when we look at more direct measures of network instrumental support and feeling loved that
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we see significant associations with degree of coronary atherosclerosis.

SUMMARY

The data from this study are unique in several respects. They offer one of the first opportunities to examine and compare both structural and functional aspects of social networks in relation to coronary artery disease. Use of a sample of men and women undergoing angiography further provides a unique and valuable outcome, a direct and continuous measure of actual coronary atherosclerosis. This outcome measure allows us to more accurately estimate the extent of disease than do the usual, dichotomous measures of disease. Also, these latter classification schemes depend on evaluating disease from such indirect indicators as results of electrocardiograms and/or reports of anginal chest pain whereas our measure is obtained from direct visualization of the extent of coronary atherosclerosis in the major coronary blood vessels. Our findings indicate that the function or content of network ties is more strongly associated with coronary atherosclerosis than is the mere presence of social ties. As originally suggested by Cassel [23], it seems that the "feedback" or support received from network ties is most strongly and negatively associated with extent of coronary artery disease. These results also indicate the importance of differentiating between network characteristics such as network size and various types of network support. It is only through specifying different social network characteristics for study that those that most strongly influence host resistance to disease can be clarified. There is, of course, the question of genPsychosomatic Medicine 49:341-354 (1987)

eralizability of findings from this sample to other populations. A sample of angiography patients such as this is certainly not a representative sample of the general population. Rather, this sample generally represents individuals at high risk for coronary artery disease by virtue of existing chest pain and/or risk status on standard heart disease risk factors such as smoking or having a history of hypertension. Indeed, analyses for these angiography patients can be seen as somewhat analogous to a stratified analysis that focuses primarily on the highest risk strata. As angiography examinations are currently the only feasible means of directly assessing coronary atherosclerosis and are also performed only when "indicated" (i.e., when coronary disease is suspected), the top risk stratum is currently the only one for whom analyses such as these are possible. As less invasive means of assessing coronary atherosclerosis become more widely available, it will be possible to investigate whether the same risk factor relationships between social network characteristics and atherosclerosis hold true in "lower risk" strata of the general population. The data presented here do confirm the importance of social ties for physical wellbeing, particularly the importance of certain "support" characteristics of these ties. The precise mechanisms for these effects remain to be clarified. Our data, as well as evidence from the Alameda County Study indicate that the association is not simply a function of positive associations between support or social ties and better risk profiles or health practices (22). Indeed, we find few if any associations between support or social ties and standard risk factors such as hypertension, serum cholesterol, or smoking. Perhaps, as Bovard (24-26), and Jemmott and Locke (27) have suggested, it is through the neuroendo351

T. E. SEEMAN and S. L. SYME

crine and immune systems that stimuli associated with social support influence health. That social ties, particularly the support they provide, influence host resistance to disease should not be too surprising. Man has evolved as a social animal because living in groups conveyed survival advantages (28-30). The results of this study are consistent with the idea that more subtle physiologic survival advantages may have

been and may continue to be conveyed by man's social ties with others: that social network ties, and in particular the instrumental support and sense of being loved that these ties can provide, may serve to promote host resistance to disease, thereby increasing survival, This research was supported in part by NIH Grant #ROl-HL27143 and by the MacArthur Program on Successful Aging.

REFERENCES
1. Broadhead WE. Kaplan BH, James SA, et al: The epidemiologic evidence for a relationship between social support and health. Am J Epidemiol 117:521-537, 1983 2. Berkman LF, Syme SL: Social networks, host resistance, and mortality: A nine-year follow-up of Alameda County residents. Am J Epidemiol 109:186-204, 1979 3. House JS, Robbins C, Metzner HL: The association of social relationships and activities with mortality: Prospective evidence from the Tecumseh Community Health Study. Am J Epidemiol 116:123-140,1982 4. Blazer DG: Social support and mortality in an elderly community population. Am J Epidemiol 115:684-694, 1982 5. Schoenbach VJ, Kaplan BH, Kleinbaum DG, et al: Social ties and mortality. Paper presented at APHA annual meeting, Dallas, 1984 6. Joseph J: Social affiliation, risk of factor status and coronary heart disease. Ph.D. dissertation, Department of Biomedical and Environmental Health Sciences, University of California, Berkeley, 1980 7. Reed D, McGee D, Yano K, Feinleib M: Social networks and coronary heart disease among Japanese men in Hawaii. Am J Epidemiol 117:384-397, 1983 8. Reynolds P, Kaplan G: Social connections and cancer: A prospective study of Alameda County residents. Paper presented at the Society for Behavioral Medicine annual meeting, March 1986 9. Welin L, Tibblin G, Svardsudd K, et al: Prospective study of social influences on mortality. Lancet i:915-918, 1985 10. Ruberman W, Weinblatt E, Goldberg JD, Chaudhary BS: Psychosocial influences on mortality after myocardial infarction. N Engl J Med 311:552-559, 1984 11. Burg MM, Blumenthal JA, Barefoot JC, Williams RB, Haney TL: Social support as a buffer against the development of coronary artery disease. Paper presented at the Society for Behavioral Medicine annual meeting, March 1986 12. Medalie JH, Goldbourt U: Angina pectoris among 10,000 men: II. Psychosocial and other risk factors as evidenced by a multivariate analysis of afive-yearincidence study. Am J Med 60:910-921, 1976 13. House JS, Kahn RL: Measures and concepts of social support. In Cohen S and Syme SL (eds), Social Support and Health. New York, Academic, 1985, pp 83-108 14. Williams RB, Haney TL, Lee KK, et al: Type A behavior, hostility and coronary atherosclerosis. Psychosomatic Med 42:539-549, 1980 15. Barefoot JC, Dahlstrom WG, Williams RB: Hostility, CHD incidence, and total mortality: A 25-year follow-up study of 255 physicians. Psychosomatic Med 45:59-63, 1983 16. Matthews KA, Haynes SG: Type A behavior pattern and coronary disease risk. Am J Epidemiol 123:923-960, 1986 17. Cook WW, Medley DM: Proposed hostility and pharisaie virtue scales for the MMPI. J Appl Psychol 38:414-418, 1954 352 Psychosomatic Medicine 49:341-354 (1987)

SOCIAL NETWORKS AND CORONARY ARTERY DISEASE
18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. Gensini GG: Coronary Arteriography. New York, Futura, 1975 Wellman B: Applying network analyses to the study of support. In Gottlieb BH (ed), Social Networks and Social Support. Beverly Hills, Sage, 1981, pp 171-200 Hall A, Wellman B. Support and non-support: A network analytic approach. Paper presented at American Sociological Association meeting, San Francisco, September 1982 Croog SH: The family as a source of stress. In Levine S, Scotch NA (eds), Social Stress. Chicago, Aldine, 1970 Berkman LF, Breslow L: Health and Ways of Living: The Alameda County Study. New York, Oxford University Press, 1983 Cassel J: The contribution of the social environment to host resistance. Am J Epidemiol 104:107-123, 1976 Bovard EW: The effects of social stimuli on the response to stress. Psychol Rev 66:267-277, 1959 Bovard EW: A concept of hypothalamic functioning. Perspect Biol Med 5:52-60, 1961 Bovard EW: The balance between negative and positive brain system activity. Perspect Biol Med 6:116-127, 1962 Jemmott JB, Locke SE: Psychosocial factors, immunologic mediation, and human susceptibility to infectious diseases: How much do we know? Psychol Bull 95:78-108, 1984 Alcock J, Animal Behavior: An Evolutionary Approach. MA, Sinauer, 1983 Goldschmidt W: Man's Way. Cleveland, World, 1959. Washburn SL: Social Life of Early Man. Chicago, Aldine, 1961

APPENDIX: NETWORK SUPPORT SCALES

I. Problem-oriented Network Instrumental and Emotional Support Scales were developed from answers to the following stem question: "We would like you to think about the types of people you talked to or went to for different kinds of help BEFORE YOUR CHEST PAIN OR DISCOMFORT BEGAN. For each of the following situations, please indicate all the people you usually talked to or went to for help. Mark an "X" in as many categories as apply. [Answer Categories: rely on myself, turn to friends, turn to family, pay for service (e.g. taxi, doctor), do nothing] A. Network Instrumental Support (scores = 0-6):
Psychosomatic Medicine 49:341-354 (1987)

(one point for each answer of using family and/or friends for help in these situations): Help with minor household tasks or repairs When you need a ride When you need a loan of money (final scoring collapses 4-6 due to small numbers) B. Network Emotional Support (scores = 0-8): (again, one point for each answer of using family and/or friends for help in these situations): When you need advice or information When you're worried about your health
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T. E. SEEMAN and S. L. SYME

When you're worried about personal problems (family, work) When you need cheering-up (final scoring collapses 6-8 due to small numbers) II. Non-problem-oriented Emotional Support Feeling Loved—measured from adjective checklist

(Please describe yourself in terms of the following word pairs by checking that portion of the line between the words which most accurately describes you). Loved Unloved

(scores were collapsed into thirds)

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Psychosomatic Medicine 49:341-354 (1987)

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