Social networks and psychosocial support among disabled people

Sot. Sri. Med. Vol. 19, No. 5, pp. 489-497. 1984 Printed in Great Britain. All rights reserved

0277-9536/84 $3.00 + 0.00 Copyright (CI 1984 Pergamon Press Ltd

SOCIAL NETWORKS AND PSYCHOSOCIAL AMONG DISABLED PEOPLE ‘University

MYFANWY MORGAN’, DONALD L. of London, United Medical and Dental

PATRICK’

and

JOHN R.

SUPPORT

CHARLTON’

Schools of Guy’s and St Thomas’ Hospitals, London, England and ‘University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, U.S.A.

Abstract-Analysis of the network characteristics and nature of social ties among physically disabled people living in an inner London borough showed network size rather than network type was related to the availability of psychosocial support, reflecting the important role of both related and non-related people in the provision of this form of support. The study also questioned three commonly held assumptions. Firstly, in contrast to the image of physically disabled people as lacking social ties, those with a high level of disability, although having a lower level of social contact outside the household than other groups, did not differ significantly in other aspects of their network structures and support. Secondly, in contrast to the characterisation of inner city areas as relatively homogeneous and as lacking locally based ties, the inner London area studied comprised a variety of network types with a large proportion of respondents deriving support from people living in close proximity. Thirdly, whereas the presence of household members, and especially a spouse, tend to be equated with the availability of strong emotional support, considerable numbers of married people lacked such support. This suggests measures to promote psychosocial support need to be fairly broadly based and cautions against using marital status as a proxy measure of suppOrt.

INTRODUmION

A social network refers to the individuals’ social ties and relationships, and includes ties with their immediate family, more distant kin, friends and neighbours and more social acquaintances. There is no established way of determining the precise boundaries of an individual’s network. However a distinction is commonly made between a person’s core or personal network, which consists of those people directly important in the individual’s life, and their extended network, which may be defined at its broadest to include potential contacts, who are people known to network members but not to the central individual

VI.

Social networks have been treated both as a dependent variable forming the product of particular types of social and economic conditions and as an independent variable affecting individual behaviour. Classical sociologists paid particular attention to the effects on primary groups of social and economic change, seeing such groups as of declining importance. Durkheim [2] described this in terms of a shift from a society based on organic solidarity to one based on mechanical solidarity, while Tonnies [3] viewed the process as involving a move from Gemeinschaft (community) to Gesselschaft (association). Wirth [4] subsequently depicted the development of urban society as leading to social contacts becoming more impersonal, transitory and segmented. In contrast, Parsons [5] regarded primary group ties as changed not so much by urbanisation as by industrialisation, which reduced the importance of kinship through the need to allocate positions on the basis of

Send all correspondence to: Myfanwy Morgan, Department of Community Medicine. St Thomas’s Hospital Medical School. London SE1 7EH. England.

achieved rather than ascribed characteristics and produced a geographical dispersion of kin through demands for labour force mobility. However empirical studies have pointed to the existence of considerable contact and assistance between kin despite their geographical dispersion, and drawn attention to the role of local ties as sources of sociability and assistance in energency situations [6-81. Thus in contrast to the ‘community lost’ argument portrayed by earlier theories of social change in which social ties are viewed as weak and disorganised, social networks appear to remain real and important. Wellman [9] in one of the few analyses of networks as social wholes described the dominant network type in the East York area of Toronto as conforming most closely to the ‘community liberated’ model, for networks mainly included both kin and non-kin and extended beyond the local area. Of particular importance in promoting such dispersed kin ties has been the availability of cheap effective transportation and communication, which reduces the social cost of spatial distances. Social ties provide the individual with both psychosocial and instrumental support. Psychosocial support consists of the provision of sympathy, encouragement and a sense of belonging, and serves to assure people they are loved, valued and esteemed, whereas instrumental support involves the provision of practical assistance, financial aid, advice and guidance. Of course in many cases these two forms of support overlap, with the provision of practical assistance often serving to assure the individual that he or she is cared about. People may also require both psychosocial and instrumental support in coping with problematic and stressful situations, such as unemployment and bereavement. However the relative importance of these forms of support vary between individuals and at different stages of the individuals coping efforts [lo].

489

490

MYFA.WY MORGAN et al.

A major concern evident in functionalist and social policy writings has traditionally been the role of the family and wider kin in providing assistance to elderly and chronically ill people, thus reducing needs for formal services, including intitutional care [l 11. However, increased attention has recently been paid to the positive effects of support in promoting health and feelings of well-being and hence to the possibilities of reducing susceptibility to illness through strengthening and increasing social ties [12, 131. One way in which social ties appear to exert a protective effect on health is through moderating the adverse effects of major life events, such as unemployment, retirement, bereavement, pregnancy and migration and in assisting people cope with more general life stresses [lo, 14, 151. In addition, social ties have been shown to influence the course of illness through their effect on illness behaviour. responses to medical treatment and adjustment to chronic illness [16-181. However although there is now a considerable body of literature pointing to the positive effects of psychosocial support on health and well-being, the measures of support and life events employed have varied widely. This in turn has posed problems in comparing the results of different studies and in assessing their wider implications. The measures of support employed fall into the two broad groups. One group consists of measures which focus on the quality of affective ties, as with Henderson’s notion of ‘attachment’ figures [19] and Brown and Harris’ measure of a ‘close intimate and confiding relationship’ [20]. A second group derives from Durkheim’s anomie theory [21] and focuses on the quantity and diversity of social ties and the extent to which the individual is socially integrated. Examples include Berkman and Syme’s Social Network Index [22] based on four sources of social contact (marriage, contacts with friends and relatives, church membership and informal and formal group associations) and Williams, Ware and Donald’s 9 item measure [23]. Social ties and the support they provide are important at all ages and stages of the life cycle. However one group for whom they are of particular importance are disabled people, who often require assistance with everyday tasks and in coping with the psychological problems associated with their disability. The provision of informal support thus forms a major influence on the quality of life of disabled people, as well as determining whether severely disabled people are able to continue living in the community. In addition, there is evidence to suggest that social ties influence the survival rates of disabled people [22] and their risks of deterioration in functioning [24]. Despite the importance of social ties for disabled people, little is known of the nature of their networks and availability of support beyond fairly broad indicators, such as marital status and household size. Important questions concern the extent to which increasing disability affects network size and the quality of social relationships, whether marital status and household composition form valid indicators of support, the relationship between network structures and the provision of support, and the distribution of different measures of support among the disabled population. This study examines these questions

based on a sample of non-institutionalised disabled people aged 45-75. The disabled respondents all lived in the London Brough of Lambeth, which is an inner city area consisting predominately of semi- and unskilled manual workers. Like many other inner London areas Lambeth has undergone substantial changes over the last 20 years associated with slum clearance and rehousing programmes, the outward movement of young adults to suburban areas and inflow of immigrants of predominately West Indian origin [25]. It is thus an area which is likely to have experienced a break-up of the traditional locally based kin networks and informal support systemscharacteristic of inner London working class communities of the early 1960s [26]. SAMPLE

Physically disabled people living in Lambeth were identified by a postal screening questionnaire sent to a 10% sample of nearly 300,000 non-institutionalised persons living in the borough [27]. Eighty-seven per cent of the sample households returned screening questionnaires. Of these 1100 physically disabled people aged between 16-75 years were sampled for the three-phase interview survey carried out at yearly intervals over the period 1978-198 1 [28]. The analysis of social networks and the provision of psychosocial support was based on data collected at the third interview, as this questionnaire included the most detailed questions on support. The analysis was restricted to people aged 45-75 years due to the relatively small number of younger respondents. This gave a sample of 494 people aged 45-75 years, representing 72% of people in this age range who participated in the first round of interviews. Comparisons were made of the characteristics of those who dropped out between the first and third interview with the remaining sample of 494 people. This showed there to be no statistically significance differences in the variables examined (age, marital status, disability level, household size. and network size), although the dropouts included a slightly higher percentage of people with a high disability level, those living alone and those with a network of less than 6 people. MEASURE

OF DISABILITY

A broad definition of disability was employed in the original postal screen to include not only severely disabled people but also those with relatively minor disabilities who comprise the majority of disabled people in the community. This resulted in a prevalence rate for disability which was double that obtained using Harris’ National Survey definition of disability based on self care capacities [27]. It thus provided a broad cross-section of people with chronic conditions and activity restrictions living in the community, including large numbers of less severely disabled people. In the interview survey disability was measured using the Sickness Impact Profile (SIP) which was adapted for use in Britain by re-wording some of the statements [28, 291. Using multidimensional scaling a global physical disability measure was derived based

491

Social networks and psychosocial support among disabled people

on items relating to ambulation, mobility, body care and moyement, and household management 1301.The global physical disability measure was designed as “/, scores ranging theoretically from a low of 0, or no disability, to a high of 100. Scores of under 20, 2&34 and 35 and over, were used to identify minimal, moderate and severe physical disability and served to distinguish groups which differed in their use of formal services.

NETWORK MEASURES

Network size The study aimed to identify the respondent’s core network from among their broad array of social ties. The approach adopted was to ask each respondent whether they had: (1) a spouse, (2) children, (3) siblings, (4) other relatives they usually saw at least once a month, (5) friends and neighbours they usually saw at least once a month and (6) whether there were any other people in whom they would confide. Up to four people cobId be recorded in each of these categories, giving a maximum network size of 21 people. If the respondent had more than four children or siblings, the four selected for inclusion in each case were those who lived closest to the respondent, whereas for friends and neighbours the four recorded were those seen most often. Network types A distinction was made between networks consisting predominately of kin and those containing a high proportion of friends. Networks were designated as ‘kin networks’ if 60% or more of the network members were relatives and ‘friend networks’ if at least 50% were friends. The smaller percentage of friends was adopted in determining network type as the questionnaire allowed for the recording of more related than non-related people. Kin networks were further classified as ‘locally based’ if three or more kin outside the household lived in the same or an adjacent borough as the respondent and ‘dispersed’ if the respondent had fewer network members in close proximity.

SUPPORT MEASURES

Three measures emphasising the psychological dimensions of support were employed. The respondents confiding relationship focuses on the strength of the support received from a single close tie, whereas the measures of network emotional support and social contact reflect the quantity as well as the quality of supportive ties. Confiding relationship The presence of a confiding relationship was determined by asking respondents who they would be most likely to turn to for advice or assurance. Respondents were then asked whether they would confide in this person in the following situations; (a) If someone had done something to hurt or upset them. (b) If they felt that they could not cope with things.

(c) If they felt anxious or under pressure of some kind. (d) If they felt guilty about someone or something they had done. (e) If they had fears over the future. Respondents

were also asked;

(f) If they would expect their main confidant confide in them about these sort of things. On the basis of their answers respondents assigned a score from 0 to 6.

to

were

Network emotional support Respondents were asked whether they felt close to or would confide in each of the members of their personal network. Closeness and confiding could include the provision of information, advice or any kind of perceived intimacy and understanding. An overall score was obtained by summing the number of network members to whom the respondent felt close and the number they confided in, giving a maximum possible score of 42. Social contact This focused on the respondents contacts with their personal network and participation in organisations and activities outside the home. It was based on five areas of life and activities: (1) people in the household; (2) people outside the household seen regularly; (3) employment outside the home; (4) attendance at clubs, societies and religious activities; and (5) use of selected formal services, such as meals-on-wheels, home helps and district nurses. Following Townsend [3 I] scores were assigned to each type of contact with the aim of reflecting the amount of contact obtained from each source. The score for household members thus varied according to the number of people in the household and full-time work received a higher score than part-time employment. Individual scores were summed to provide an overall social contact score for each respondent. FINDINGS

Disability level Using the global physical disability score derived from the SIP, 59% of respondents were classified as having a low level of disability (score under 20), 22% to have moderate disability (score 20-34) and 19% a high disability level (score 35 and over). Increasing disability was associated with higher mean scores for each of the four categories comprising the global physical disability score (Fig. I), although household management was particularly affected by increasing disability. The marital composition of the low and high disability groups was almost identical, although the moderate disability group included a slightly higher percentage of non-married people (single, widowed and divorced)--49% compared with 39 and 36% respectively among the low and high disability groups. As might be expected, married respondents included a higher percentage of men and of younger respondents than other household groups. Increasing disability was also associated with an older age

492

MYFANWY MORGAN et

75 70 65 60 -

.

35ard Physrzol xoie ioverall mean =48

over 2)

E ///

g,*\.

I*

g 35u 300”25-

’ /

\

./’

1’ ‘.’

.

Body care and movement

Fig.

score 20-34 meon = 27 1)

/

\ \

20 -

Physical IOverall

/

/ /.\\

1. Profiles

Ambularlca

Mob~My

Physical

score

ioverall

meon = 731

O-19

Household ma”D+Tle”f

of mean category scores for respondents three physical categories.

in

distribution with this holding for both married and non-married people. NETWORK

STRUCIWRE

The majority of respondents identified a network of people known intimately of between 4 and 9 members (mean 7.2), with only 11% having a network of less than four people. As Table 1 shows, small networks were most common among non-married people living alone and were also more evident among the highest disability group which largely reflected their older age distribution. About three-quarters of all networks were kin networks, although only 21% consisted exclusively of kin. The further differentiation between kin networks on the basis of the proximity of network members showed dispersed kin networks formed the dominant

al.

network type (619;). However, locally based kin networks which have formed an important feature of working class communities still existed and comprised 16% of all networks. These were rather larger than dispersed kin networks, with 637; consisting of ten or more people compared with 290,; of dispersed kin networks. Predominantly friend networks comprised 23% of all networks and were as a group the smallest in size, with only 5s; consisting of ten or more people. However friend networks were characterised not merely by a deficiency of kin but also by the positive inclusion of friends; 60”,$included four or more friends, compared with only 23”,/, of locally based kin networks and 15% of dispersed kin networks. Friend networks were most common among people living alone (Table 2). They were also more common among moderately disabled people than among other disability groups, reflecting the higher proportion of non-married people living alone among the moderately disabled. The distribution of locally based kin networks among both household groups and disability groups was remarkably similar, and also showed little variation by age, sex or social class. People from outside the U.K. were however significantly ( < 0.05) more likely to have a locally based kin network than the U.K. born population, with the percentages being 26 and 15% respectively. This difference in network type by place of birth held even when age, sex and social class were controlled in a regression analysis. Availability of support

Married people as a group were most likely to experience a high level of support and non-married people living alone the lowest. However there was a considerable spread of support scores among each household group (Table 3). Within each household group men had rather higher levels of social contact than women, reflecting their higher employment rates, whereas women reported a higher level of

Table I. Network size by household group and by disability level Household group Married Network size (%) O-3 -_____ 7 23 4-6 34 l-9 23 IO-12 Over I2 I4 Total % (Nj

Non-married lives with others (%) IO 30 26 22 II

--__ Non-married lives alone (%) 22 38 29 9 2

100 (105)

100 (133)

100 (256)

Disability level

Low (under 20) 0,) 10 26 32 I9 ‘I2

Moderate (20-34) (x) 9 29 30 22 IO

High (35 and over) _. (%) 19 34 29 I3 5

100 (2921

100 (110)

100 1921

Table 2. Network type by household group and by disability level Household group

Network size Locally based kin Dispersed kin Friend network Unclassified Total % (N)

Married WJ 16 69 9 6

Non-married lives with others (%) 17. 60 I8 5

100 (256)

IO0 (105)

-...-

Non-married lives alone (%) I6 39 39 6

Disability level Low Moderate (under 20) (20-34) (%) __.~_D_0’) I4 I9 60 54 I8 23 8 4 100 (110)

High (35 and over) (“‘) ID I8 62 I7 2 100 (92)

493

Social networks and psychosocial support among disabled people Table 3. Support scores by household group and by disability level Disability level

Household group

Support scores

Married (%)

Non-married lives alone (%)

Network emotional support O-4 5-9 10 or more

13 32 55

Confiding relationship 0 1-3 4-5 6

3 6 16 75

24 58

Social contact O-25 26-50 Over 50

20 54 25

30 53 16

20 21 53 9’

Non-married lives alone (“/,)

Low (under 20) (“/,)

19 32 49

19 30 51

21 36 37

21 18 22 39

8 10 22 60

10 II 12 67

14 6 21 59

86 13

33 46 21

42 49 9

60 36 4

men and women and for each age broad age group (45-64 and 65-74). Table 4 presents the distribution of each item comprising the social contact score. The low level of social contact among people living alone is shown to reflect both the absence of household members and less frequent contacts with people outside the household, which were only partly compensated for by their greater receipt of formal services. The relatively low social contact scores among the most severely disabled was mainly due to their lower rates of

Table 4. Percentages of people reporting different forms of social contacts and participation by level of disability

by household group and

Household group

Source of social contact

Married (%)

High (35 and over) (%)

35 37 28

I

emotional support. However, the broad differences between household groups shown in Table 3 held for both men and women considered separately. The most severely disabled respondents had a slightly lower level of each form of support than other disability groups. In the case of network emotional support and the strength of the main confiding relationship this was largely accounted for by differences in the age distribution of respondents. However, the relationship between social contact and disability held for each household group, for both

Moderate (2G34) (%)

Non-married lives with others (%)

Disability level

Non-married lives alone (%)

. High

Low (%)

Moderate (%) 31 41 17 II

34 39 11 16

(%)

Household size 1 2 3 4 or more

56 44 -

I

-

94

-

23 42 16 19

Network members outside household se-enlast week 0 l-3 4-6 7 or more

26 41 33

36 33 31

9 48 33 10

3: 36 29

284 43 25

49 34 17

Employment Not working Part-time work Full time work (30 hours or more)

68 2:

82 3 15

88 2 10

66 5 29

‘84 7 9

99 1 -

Social activities in last month* Went out socially (club, pub, bingo, visiting friends) Attending church/religous activities

61

61

55

71

54

28

19

27

14

21

12

14

5 5

2 12

3 37

-

4 20

13 37

Receipt of formal services* in last 14 days District nurse Home help Meals on wheels, Luncheon club, day centre, self help group No. of respondents *These categories are not mutually exclusive.

5

3

3

256

105

100 -

6

14

6

113 ___

792 __-

7 Ill-l ..”

5 QI) ,_

494

MYFANWY MORGAN et al. Table 5. Logistic regression analyses of probability of having a low level of psychosocial support on three measures of support (high value indicates greater probability of having a high level of support) Dependent variabiest Independent variables

Network emotional support

Confiding relationship

-__. Social contact

- 1.31

0.47

- 3.18

- 0.38 -0.88’

- 0.718 - I .54**

Reference mean (All variables at level 1): Household group Non-married lives with others Non-married lives alone Network size (large)

0.63**

0.08*

- 0.09 - 3.19** 0.54**

Network type Dispersed kin Friend

- 1.08 - 0.82

- 0.54 -0.13

0.75 0.98

Disability (20 or over)

- 0.22

- 0.21

- 0.58*

*Significant at 0.05 level. **Significant at 0.01 level. tDichotomous groups of high and low levels of support were employed in the analysis owing to the skewed distribution of support scores and because the importance to the individual of increasing levels of support is unlikely to form a continuous ratio scale. Low support was defined as: network emptional support score O-%; confiding relationship Score &5; and social contact score G25. fvariables at level 1: household group (married), network type (locally based kin), network size (O-6). disability (under 20). age (25-44). sex (men), social class (non-manual). place of birth (U.K.).

employment and participation side the home. Network

structure

in other activities out-

and support

Three network characteristics-a small network size, a friend network and living alone-were each significantly associated with a low level of support. However these factors were themselves closely interrelated, as those living alone were more likely to have a small and predominantly friend network. The independent contribution of these factors to level of support was examined using logistic regression analysis [32]. This indicated that both a small network size and living alone significantly increased the probability of having a low level of each measure of support and contributed separately to explaining level of support (Table 5). Network type was not significantly associated with level of support when other variables were controlled, although locally based kin networks were rather more likely than other network types to be associated with a high level of network emotional support and low level of social contact. As Table 5 shows, a high level of disability was still significantly associated with a low level of social contact when other variables were controlled. Relationship

between measures

Despite a fairly high correspondence in the ranking of people as high or low on different measures of support, considerable numbers of people with a high level of one measure of support did not have a high level on another measure. For example, 31% of respondents with a network emotional score of 5 or more did not have a single strong confiding relationship (score of 6) and conversely, 12% of those with a strong confiding relationship had a network emotional score of less than 5. This draws attention to the difference between the quantity and quality of supportive ties. It is also notable that despite the strong relationship between household group and level of support, one-quarter of married people scored less than 6 on the measure of the strength of their main confiding relationship, compared with

42% of non-married people living with others and 61% of people living alone. Estimates were derived of the prevalence of high and low levels of support among all disabled people in Lambeth aged 45-75 years by reweighting the sample figures to take account of the sampling and the bias in the sample characteristics due to the drop-outs between the initial screen and third round of interviews. Although non-married people have the greatest probability of having a low level of support, large numbers of married people in the community were shown to have low levels of support and to comprise a significant proportion of the low support group. For example, married people comprised 29% of disabled people in the community lacking a strong confiding relationship, whereas non-married people living with others and these living alone comprised 32 and 38% respectively. Provision of support

Friends and neighbours appeared to play an important role in the provision of supportive ties with 79% of networks including such non-related people. However, kin were most likely to be identified as the main confidant; 76% of respondents identified a related person as their main confidant, 14% a friend or neighbour and 3% a non-related person such as a home help or general practitioner, while 6% did not feel they had anyone in whom to confide. Married people were most likely to identify a main confidant and generally confided in their spouse, although 19% of married people identified a person other than their spouse as their main confidant and 3% felt they had no one in whom to confide. Non-married people living alone were both least likely to identify a main confidant and most likely to rely on friends and neighbours for such support (30%). The percentages identifying friends and neighbours as their main confidant was 18% for non-married people living with others and 5% for married people. Besides being asked who they would be most likely to confide in respondents were also asked who they would be most likely to depend on for help. The

Social networks and psychosocial support Table

6. Relationship

of main confidant

Relatmnship

Person would depend on for help

No one Spouse, ex-spouse, cohabitee Child Sibling Other relative Friend/ neighbour Other No answer Total ;; (NJ

No one C”)

Spouse, ex-spouse. cohabitee (?b)

55

I

I9

95

6

2

-

I

3 13 3

-

100 (31)

100 (209)

Child (‘:,)

495

among disabled people and main

helper

of main confidant

Sibling (:‘,)

Other relative (“‘) /”

Friend/ neighbour (“‘J /D

Other f%

No answer (“:,)

7

10

21

31

II

15

14

I6

31

72 3 l

7 61 5

14 7 38

8

5

3

5

2

IO 7

51 2 -

5 32

50

100 (41)

100 (29)

100 (63)

loo (19)

loo (2)

7

3 3 -

extent to which different categories of people acted as the respondents main confidant and main helper is summaiised in Table 6. Although this table groups people into broad categories rather than distinguishing between individuals, it indicates that with the exception of a spouse and a lesser extent children, people identified as the main confidant were often not identified as the main helper. This suggests that many people rely on different categories of people for different types of support. In general, both married and non-married people were more likely to depend on a relative for help than they were to identify a relative as their main confidant. DISCUSSION

The dominant network type among disabled people in Lambeth was a dispersed kin network, which although often including local ties consisted predominately of ties with people living outside the local area. This is consistent with Wellman’s analysis of social networks in the East York area of Toronto [9] and with an analysis based on national survey data for the U.S.A. [33]. However, although communities can be characterised in terms of a dominant network pattern, important variations may exist among subgroups of the population. A distinctive feature of social networks among disabled people in Lambeth was the greater tendency for foreign born people, predominately of West Indian origin, to have locally based kin networks. This type of network was shown to provide a rather higher level of emotional support than other network types, although this difference might have been greater if the strength of the respondents relationship with network members had been examined. This is because close proximity and more frequent contact may have been associated with stronger emotional bonds and thus a greater likelihood that individual network members would have provided a strong confiding relationship. The existence of locally based kin networks accords with what Wellman termed the ‘community saved’ hypothesis. This came into prominence with Gans’ study [34] of an urban village and suggests that densely knit, locally based networks often emerge in initially sparse neighbourhoods, an important

50 -

impetus for their formation being the needs of poorer sections of the population and ethnic minorities to rely on informal ties for assistance in finding accommodation and housing and adjusting to the general demands of life in unfamiliar surroundings. This in turn draws attention to the rather artificial characterisation of communities when described in terms of a single community type and the difficulty often experienced by researchers in identifying a fit between the characteristics of the community they studied and a hypothetical community type [9, 331. These differences in the experiences, needs and resources of sub-groups in the population also pose problems for area based policies, as a large proportion of the deprived population generally live outside areas designated as deprived or as ‘action’ areas [35]. The image of disabled people as a group of isolated, alienated people with few close ties has been conveyed by studies of patients admitted to institutional care [36,373 and comparisons of psychiatric and normal population [19]. Skidrow populations have also been shown to include a high proportion of disabled people, reflecting either the effects of health in producing downward drift, or forming the outcome of a lack of supportive ties on health and life styles [38]. Another important influence responsible for the image of disabled people as lacking close social ties has been research on stigmatised populations. Such studies have drawn attention to the way in which people suffering from negatively valued conditions are socially handicapped as a result of the social responses to their condition, which often involved avoidance and exclusion by ‘normals’ [39,40]. The present study provided evidence of greater social isolation with increasing disability. However it also drew attention to the wide range of support scores among each disability group and suggested that increasing physical disability had little effect on the availability of close confiding relationships. The smaller difference between disability groups in the availability of support than might have been expected may be due to three main factors. Firstly, the study population represented a broad cross section of chronically ill people in the community, and in most cases their conditions are not likely to have been highly stigmatised or socially obtrusive. Secondly,

496

MYFANWYMORGANet al.

social ties are known to exert a selective effect, with those with the lowest levels of informal support being most likely to enter institutional care or otherwise be excluded from the study population. Thirdly, psychiatric disorders may have a greater effect than physical disability on an individuals ability to create and maintain close confiding relationships and their perceptions of support. This in turn draws attention to the need to be aware of the selective effects of social processes in undertaking cross-sectional and essentially static analyses, and to the important differences which may exist among particular segments of ‘the disabled population’, as in the community as a whole. The identification of network structures and the measurement of support poses a number of methodological problems. However, although the criteria adopted in delineating networks is fairly arbitrary, this presents fewer problems if the main concern, as in this paper, is to compare the network characteristics of different groups in the population rather than to make precise estimates of the prevalence of different network sizes or types. Similar difficulties are apparent in relation to the measurement of support. However an important finding was the lack of correspondence between the high and low support groups on different measures of support. This suggests that people classified as having a low level of support in studies of the relationship between support and health may vary according to the particular measure employed, thus contributing to the differing assessments of the protection afforded by social ties [14]. However little is known of the extent to which particular forms of support may compensate for each other, or even of the adequacy of the traditional approach of assessing support using objective measures and standard criteria. This approach assumes individuals have similar needs for support, whereas people who have always experienced a fairly low level of support and small number of social ties may respond differently to this situation than someone who has experienced a recent loss of social ties [51]. People may also differ in their needs to be part of a network of reciprocal obligations associated with differences in their age or personality characteristics [42,43]. Other aspects of social ties which tend to be overlooked in epidemiological studies are the conflicts and strains which may characterise social relationships and which have been well documented in studies of families caring for a dependent relative [7,44,45]. A further question is whether the low level of support identified among segments of the married population, particularly the fairly large proportion who did not have a strong confiding relationship with their spouse, is representative of the general population or is associated with the experience of disability. Some writers have suggested that severe, life threatening illness, serves to draw marital partners closer together, whereas others have postulated the stresses of illness are essentially disruptive and tend to damage the marital relationship. However, the precise effect may depend both on the nature and duration of the illness and the strength of the marital relationship prior to illness [46]. The ways in which the social ties of physically disabled people should be strengthened and increased

depends on issues which are as yet unclear concerning their perceived needs for informal support, and whether certain forms of support are most beneficial in relation to specific types of conditions and situations. However this study suggests an area which may be of particular importance to physically disabled people, and especially to those who live alone. is their relatively limited contact and participation outside the home, which is likely to increase feelings of loneliness. This draws attention to the importance of transportation and home-visiting schemes to reduce social isolation and provide opportunities for strengthening and increasing social ties. The wide distribution of low levels of support among different groups in the production also suggests that whereas the provision of community services, such as home helps and meals-on-wheels, has in practice been

largely concentrated among those who live alone, it is important to ensure that schemes to provide psychosocial support are more broadly based. Acknowledgements-The

research was supported by the Department of Health and Social Security and the Special Trustees of St Thomas’ Hospital. We are also grateful to our colleagues in the Department of Community Medicine at St Thomas’ for their helpful comments. REFERENCES 1. Hammer M. ‘Core’ and ‘extended’ social networks in relation to health and illness. Sot. Sci. Med. 17, 405-411, 1983. Durkheim E. The Division of Labour in Society. Macmillan, London, 1934. Tonnies F. Gemeinschaft and Gesselschaft. Routledge & Kegan Paul, London, 1955. Wirth L. Urbanisation as a way of life. Am. J. Social. 44, 3-24,

1973.

Parsons T. (Ed.) The kinship system of the contemporary United States. In Essays in Sociological Theory. Collier Macmillan, London, 1964. Croog S. H., Lipson A. and Levine S. Help patterns in severe illness. J. Marr. Fum. 1. 3241. 1972. Hunt A. The Elderly at Home. Office of Population Censuses and Surveys, HMSO, London, 19791 Bavlev M. Mental Handicap and Community Care. Routledge & Kegan Paul, London, 1973. _ Wellman B. The community question: the intimate networksof East Yorkers. Am. J. Social. 84,1201-1231, 1979. 10. Gerhart U. Coping and social action: theoretical reconstruction of the life event approach. Social. Hlth Ill. 1,

195-225, 1979. II. Moroney R. The Family and the State. Longmans, London, 1976. 12. Kaplan B., Cassel J. and Gore S. Social support and health. Med. Care 15, SULXJI.45-57, 1977. 13. Pilisuk M. and Froland C. Kinship, social networks, social SUDDOI~ and health. Sot. Sci. Med. 128.273-280, 1978. 11 14. Broadhead W., Kaplan B., James S. et al. The epidemiologic evidence for a relationship between social support&d health. Am. J. Epid. 117; 521-537, 1983. IS. Macfarlane A.. Norman G., Striener D., Roy R. and Scott D. A longitudinal study of the influence of the psychosocial environment on health status. J. Hlrh sot. Behao. 21, 124-133, 1980. 16. Berkanovic E., Telesky C. and Reeder S. Structural and social psychological factors in the decision to seek medical care for symptoms. Med. Care 14, 693-709, 1981.

Social networks and psychosocial support among disabled people 17. Dimatteo M. and Hays R. Social support and serious illness. In Social Networks and Social Support (Edited by Gottlieb B.). Sage, New York, 1981. 18. Smith R. T: Rehabilitation of the disabled: the role of social networks in the recovery process. ht. Rehab. Med. 1, 63-72, 1979. 19. Henderson S., Duncan-Jones P., McAuley H. and Ritchie R. The patients primary group. Br. J. Psychiut. 132, 7486,

1978.

20. Brown G. W. and Harris T. The Social Origins of Depression. Tavistock, London, 1978. 21. Durkheim E. Suicide. The Free Press, New York, 1951. 22. Berkman L. and Syme L. Social networks, host resistance and mortality: a nine year follow-up study of Alameda County residents. Am. J. Epid. 109, 186-204, 1979. 23. Williams A., Ware J. and Donald C. A model of mental health, life events and social support applicable to general populations. J. Hlth sot Rehuc. 22, 324-336, 1981.

24. Morgan

M. Social ties, support

and well-being.

In

Disablement in the Community (Edited by Patrick D.

and Peach H.). University Press, Oxford, 1984. In press. 25. St Thomas’ Health District. District Profile, 1978. 26. Young M. and Wilmott P. Family and Kinship in East London. Penguin Books, Middlesex, 1957. 27. Patrick D., Darby S., Green S., Horton G., Locker D. and Wiggins R. Screening for disability in the inner city. J. Epid. Communit. Hlth 35, 65-70,

1981.

28. Patrick D. (Ed.) Health and Care of the Physically Disabled in Lambeth: Phase I Report. Department of Community Medicine, St Thomas’ Hospital Medical School. London. 1982. 29. Bergner M. and Gibson B. The sickness impact profile. In The Relevance of Social Science to Medicine (Edited by Eisenberg L. and Kleinman A.). Riedel, Holland, 1981. 30. Charlton J., Patrick D. and Peach H. Use of multivariate measures of disability in health surveys. J. Epid. Communit. Hlth 37, 296304,

1983.

497

31. Townsend P. The Familv Life of Old People. Penguin Books, Middlesex, 1963: _ 32. COXD. The Analvsis __ ofI?inurv_ Data. Methuen. London. 1971. 33. Tsai Y. and Sigelman Y. The community question: a perspective from national survey data-the case of the U.S.A. Er. J. Social. 4, 579-588, 1982. 34. Gans H. The Urban Villagers. Free Press, Glencoe, IL, 1962. 35. Hall P. and Lawrence S. Deprivation in the inner city. In The Inner City in Context (Edited by Hall P.). Heinemann, London, 198I. 36. Blaxter M. The Meaning of Disability. Heinemann, London, 1976. 37. Townsend P. The Last Refuge: A Survey of Residential Institutions and Homes for the Disabled- in England and Wales. Routledge & Keaan Paul, London. 1980. 38. Bogue D. Skid-Row in American Cities. University of

Chicago Press, Chicago, 1963. 39. Goffman E. Stigma: Notes on the Management of a Spoiled Identity. Prentice-Hall, New York, 1963. of 40. Davis F. Deviance disavowal: the management strained interaction by the visibly handicapped. Social Problems 9, 120-132, 1961.

41. Lowenthal M. and Boler D. Voluntary vs involuntary social withdrawal. J. Geront. 20, 363-371, 1965. 42. Rosow I. Social Integration of the Aged. The Free Press, New York, 1967. 43. Dowd J. Ageing as exchange. J. Geronr. 30, 584-594. 1975. 44. Nissel M. and Bonnerjea L. Family Care of the Handicapped Elderfv: Who Pavs? Policv Studies Institute, London, 1982. 45. Sainsbury P. and Grad de Alarcon J. The cost of community care and the burden on the family of treating the mentally ill at home. In Impairment, Disability and Handicap (Edited by Lees D. and Shaw S.). Heinemann, London, 1974. 46. Croog S. and Levine S. Lge After a Heart Attack. Human Science Press, New York, 1982.