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AN EXPLORATORY STUDY OF MEASURES. This exploratory study examined: The types and level of social support available to survivors of traumatic spinal cord injury (SCI).The relationships among three major types of social support (perceived, actual and structural) accessed by SCI survivors.. SOCIAL SU

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Gregory Murphy, Ph. D.

School of Public Health

La Trobe University

An exploratory study of measures

This exploratory study examined:

The types and level of social support available to survivors of traumatic spinal cord injury (SCI).

The relationships among three major types of social support (perceived, actual and structural) accessed by SCI survivors.


Social support definition and measurement

“Information leading the subject to believe that he is cared for and loved, esteemed and a member of a network of mutual obligations” (Cobb, 1976).

Although social support is generally understood as the support and assistance provided by others, the research literature lacks consensus over its operationalisation (Chronister et al., 2006).


The social support construct

Social support is a multi-faceted construct that incorporates three broad concepts (Sarason et al., 1987; Schwarzer & Leppin, 1991):

Perceived social support

Actual social support

Structural social support

Although conceptually interconnected, few studies have examined their empirical relationship to each other (Barrera, 1986).


Predicted benefits

Social support reduces and prevents illness (Gore, 1978) and promotes recovery from illness (Sarason et al., 1997).

Social support has been implicated in the successful response to chronic illness (Walker, 2001).

Social support exerts a powerful influence on rehabilitation outcomes following traumatic SCI (Murphy et al., 2009; Murphy & Young, 2006).

Social support provides protection from arthritis, depression, alcoholism, low birth weight and death (Cobb, 1976).

Social support moderates the detrimental effect of unemployment on mental health (Wethington & Kessler, 1986; McKee et al., 2005).



However, the effect of social support on rehabilitation outcomes may vary according to which aspect of social support is assessed (Sarason, et al., 1987; Vaux & Harrison, 1985).

The use of ad-hoc or global measures of social support, which have not been rigorously tested, has contributed to the sometimes conflicting results obtained for the effectiveness of social support on rehabilitation outcomes (Schwarzer & Leppin, 1992).

Social support needs change over the post-injury adjustment process, therefore, different aspects of social support will be more relevant to successful rehabilitation outcomes at different points in time (Wilcox et al., 1994).


Rationale for the present study

Therefore, an examination of the hypothesized connections between the three major types of social support (i.e. perceived, actual and structural) has important implications from both a practitioner and theoretical perspective because it will reveal whether it is appropriate to use these concepts interchangeably.


Perceived social support

Perceived social support is the belief that support is available if required.

Perceived social support is generally considered to be the “crux” of the social support system (Sarason, et al., 1987).

Of the three major types of social support, perceived social support has the strongest relationship to adaptation following adverse health outcomes (Schwarzer & Leppin, 1991).

Therefore, perceived social support may be even more important than actual social support (Antonucci & Israel, 1986).


Actual social support

Actual social support includes emotional, informational and instrumental social support.

Actual social support involves the objective measurement of the frequency and nature of social interactions

Actual social support is thought by some to capture the true meaning of social support (Chronister et al., 2006).

However, actual social support can also be negative in nature. Negative social interactions (e.g. disputes, privacy invasion, embarrassment) can be detrimental to health, particularly for chronic health conditions (Rook, 1984, 1992).


Structural social support

Structural social support measures social embeddedness and refers to the size and density of social networks (Sarason et al., 1987).

A high number of active social ties indicates greater social embeddedness while a lack of social ties results in social isolation (Schwarzer & Leppin, 1991).

Two major types of structural social support exist, however, their scope differs.

Social integration refers to relationships with family, friends, romantic partners, business associates (Whiteneck et al., 2001)

Community Integration refers to more formal interactions at the community group level (Dalgard, 2009).


Limits to each type of social support

Perceived social support involves cognitive appraisal; therefore, interpretations of offered support may differ from those received (Sarason et al., 1987; Vaux & Harrison, 1985).

Actual social support is assumed to be positive but it may be overwhelming in frequency (McDowell, 2006) or profuseness (Sarason et al., 1987), and may reinforce behaviours antithetical to successful rehabilitation.

Structural social support provides an index of potential sources of social support. However, not all sources are able or willing to provide social support (see Barrera, 1986) or appropriate support (Wilcox et al., 1994).


This exploratory study examined:

The types and level of social support available to survivors of traumatic spinal cord injury (SCI).

The relationships among three major types of social support (perceived, actual and structural) accessed by SCI survivors.


Method design

Participants were assessed within one week of discharge from rehabilitation hospital on a range of demographic, injury and social support variables.

Cross-sectional study design

Final sample of 20 participants, who were not dissimilar to the Australian traumatic SCI population in terms of key injury and demographic factors (see Cripps, 2009).



20 traumatic SCI survivors discharged in 2007 from the Royal Talbot Rehabilitation Hospital in Melbourne, Victoria.

Inclusion Criteria: medically stable post-SCI; workforce age (16-65 years); persisting neurological loss.

Exclusion Criteria: require 24-hour ventilation support; significant brain impairment; severe psychiatric co-morbidity.



The majority of participants were:

Male (90%, n=18).

Employed full-time pre-injury (80%, n=16).

Received post-injury compensation e.g. TAC, workers’ compensation (65%, n=13).


Social support instruments

Data for the three major forms of social support were collected using psychometrically sound instruments.

Perceived Social Support Scale (PSS) (Sarason et al., 1983) which measures perceived social support.

RAND Social Health Battery (Donald & Ware, 1982) which measures actual social support.

Community Integration Measure(CIM) (McColl et al., 2001) and the Social Integration Measure (SI) (Whiteneck et al., 1992) which measure two key aspects of structural social support.


Perceived social support pss

The PSS scale (Sarason et al., 1987) focuses on two key aspects of perceived social support:

The number of people to whom a person can turn in specified situations (i.e. availability of social support).

The level of satisfaction with the social support provided.

(Higher scores on the PSS scale indicate higher levels of perceived social support).


Actual social support1

RAND social health battery (Donald & Ware, 1982).

Evaluates the level of social support and frequency of different types of social interactions

Unlike other instruments, it acknowledges the negative impact of excessive social interactions as well as the beneficial aspects of social interactions (McDowell, 2006).

(Higher scores on the RAND indicate higher levels of actual social support).


Structural social support 1

Two key types of structural social support were measured (community integration and social integration).

Community Integration Measure (CIM) assesses the extent of community participation and integration (McColl et al., 2001). Unlike other measures, it does not posit an hierarchical view of the importance of different types of community interactions (Radomski & Latham, 2007).

(Higher scores on the CIM scale indicate higher levels of community integration).


Structural social support 2

Social Integration scale is a subset of the Craig Handicap Assessment Reporting Technique (CHART) (Whiteneck et al., 1992).

The social integration scale assesses participation in, and maintenance of, an array of social relationships including family, housemates, friends, business associates and strangers (Whiteneck, 2001).

(Higher scores on the SI scale indicate higher levels of social integration).


Results descriptives for the four social support measures

RESULTS: Descriptives for the Four Social Support Measures

Level of social support among sci survivors

High levels of perceived social support were reported, indicating satisfaction with available social support which adequately met SCI survivor needs.

The level of structural social support differed according to network type: social integration levels were high but community integration levels were low. Thus, social support from closer networks (friends and family) seems more salient in the early stages of rehabilitation while the more distant and formal community networks are not.


Results associations among the four types of social support


RESULTS: Associations among the Four Types of Social Support

Bivariate analyses 1

Frequent, high quality social interactions (i.e. actual social support) were significantly associated with greater social integration (i.e. structural social support) (r=.64, p<.01, n=20, 2-tailed) and higher perceived social support (r=.50, p<.05, n=20, 2-tailed).


Results cont

Thus, SCI survivors who experienced frequent, higher quality social interactions (i.e. actual social support) were more likely to become socially integrated and to be satisfied with the social support received (i.e. perceived social support).


Bivariate analyses 2

However, community integration and social integration, which measure different aspects of structural social support, were essentially unrelated

(r=-.26, p>.05, n=20, 2-tailed).


Results cont1

Therefore, the two key forms of structural social support (community integration and social integration) are independent, at least in the early stages of rehabilitation, and the terms cannot be used interchangeably.

Measures of both may be called for in certain situations.



Small sample size (n=20).

However, as the sample was quite representative and effect sizes were large, results may be fairly robust.

Design (the timing of the measurement of social support - shortly after discharge).

However, the intention was early identification of those at risk of social isolation (which is a frequent sequela of SCI), and to map the stability of social support needs over the first 12-months.


Future directions

Due to the dynamic nature of social support and recovery (Wilcox et al, 1994), relationships among the three major types of social support need to be measured at different points post-injury, as needs change in the adjustment process.

To effectively match SCI survivor needs, the types of social support that best predict successful rehabilitation outcomes need to be identified.

The exponential growth in e-communications has opened another form of structural social support. Research could examine the role of e-networks (i.e. virtual communities) on rehabilitation outcomes, either as a distinct form of structural support or an adjunct to either social or community integration.



Actual social support influences perceptions of social support as well as the level of social integration.

Theoretically, these results suggest that actual social support influences the two main opposing models used to explain the relationship between social support and well-being; the Stress Buffering Model (for perceived social support) and the Main Effect Model (for structural social support or embeddedness) (Cohen & Wills, 1985).


Conclusions cont

From a researcher and practitioner perspective, the use of well-defined, psychometrically sound measures of social support is critical to the attempt to better understand the influence of social support on rehabilitation outcomes.



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Cohen, S., & Wills, T.A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357.

Cripps, R. (2009). Spinal cord injury, Australia, 2006-07. Catalogue No. INJCAT 119. Canberra: AIHW.

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Donald, C. A., & Ware, J. E. (1982). The quantification of social contacts and resources. (R-2937-HHS). Santa Monica, CA: RAND Corporation.

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Gregory Murphy, Ph. D.

School of Public Health

La Trobe University