Handbook of Psychology

Psychosocial Factors in Diabetes Management 199

Social Support

There is a general consensus that social support mediates
health-related behaviors and outcomes. Two widely accepted
models by which social support may in”uence health out-
comes have been proposed: a main effect model and a buffer-
ing model (see Cohen & Wills, 1985). The main effect model
postulates that social support has a bene“cial ef fect on health
or well-being regardless of whether individuals are under
stress. The buffering model proposes that social support
lessens the impact of stress on well-being when high levels of
stress are experienced but does not affect health/well-being in
the absence of stress. Social support may insulate patients
from adverse physiologic and behavioral consequences of
stress by modifying their perception of a stressor, thereby
providing them with additional coping resources, or by
modifying the physiological reaction to the stressor, thereby
diminishing the pathological outcome of the stressor.
Social support may play a particularly in”uential role in a
chronic, demanding disease such as diabetes. Because of the
many self-care behaviors involved in diabetes management,
patients with diabetes may be in special need of both instru-
mental and emotional support to allow them to maintain ap-
propriate levels of adherence and psychological adjustment.
The family environment may be especially important in this
patient population. In fact, the family unit has been described
as •the environment in which diabetes management and cop-
ing occurŽ (Newbrough, Simpkins, & Maurer, 1985). A rela-
tionship between family support, regimen adherence, and
metabolic control seems intuitive for two reasons: (a) family
members are often asked to share in the responsibility for
implementation of the diabetic regimen, and (b) family
routines can be disrupted by the diabetes self-care regimen
(B. Anderson & Auslander, 1980; Wishner & O•Brien, 1978).

Impact on Adherence

Research has focused on the role of social support as a deter-
minant of self-care behaviors and/or metabolic control. Links
between social support and regimen adherence have been
documented in adults with diabetes, and some studies have
defended social support•s role in buffering the negative ef-
fects of stress (Glasgow & Toobert, 1988; Schafer, McCaul, &
Glasgow, 1986). Studies have also suggested that diabetes
regimen-speci“c measures of family support may be more
ef“cacious in predicting adherence than general support mea-
sures (Glasgow & Toobert, 1988; W. Wilson et al., 1986).
Research has also focused on speci“c aspects of the social and
family environment that are related to regimen adherence, in-
cluding support ratio (ratio of received to desired amount of

support; Boehm, Schlenk, Funnell, Powers, & Ronis, 1997),

the in”uence of negative versus positive family interactions

(Schafer et al., 1986), aspects of the regimen that are bene“ted

(e.g., diet, medication, exercise; W. Wilson et al., 1986), and

gender differences in the effects of support on adherence

(Goodall & Halford, 1991).

Impact on Metabolic Control

The impact of social support on metabolic control has also

been investigated, with mixed results. Direct, main effects of

support on glycemic control have infrequently been studied

(Klemp & LaGreca, 1987). Of those studies that have

examined the relationship between social support and both

adherence and glycemic control, “ndings have been both

positive (Hanson, Schinkel, DeGuire, & Kolterman, 1995;

Schwartz, Russell, Toovy, Lyons, & Flaherty, 1991) and neg-

ative (Grif“th, Field, & Lustman, 1990; Trief, Grant, Elbert,

& Weinstock, 1998). Again, some “ndings support a stress-

buffering role for social support (Grif“th et al., 1990). It has

been suggested that negative “ndings of a relationship be-

tween social support and glycemic control should not be sur-

prising, given that psychosocial and behavioral variables are

more strongly related to behavioral variables, such as self-

care, than multidetermined physiologic variables, such as

glycemic control (Wilson et al., 1986).

Social Support Interventions

Recent studies have explored the potential role for technology-

based interventions in helping to educate and provide support

to individuals with diabetes. Interventions such as computer/

Internet support groups have reportedly been well received,

actively used, and associated with positive effects. One pro-

fessionally moderated Internet support group for diabetes pa-

tients and their families provided educational and emotional

support to more than 47,000 users over a 21-month period,

with 79% of respondents rating their participation as having a

positive effect on coping with diabetes (Zrebiec & Jacobson,

2001). Other studies using the Internet have focused on both

broad populations of patients with diabetes (McKay, Feil,

Glasgow, & Brown, 1998) and speci“c diabetic populations,

such as rural women (Smith & Weinert, 2000) in providing

education, social support, and other types of information, with

similarly high rates of satisfaction and utilization.

Summary

Although the mixed research “ndings to date suggest that the

in”uence of family and social environment on behaviors of