Impact of Emotional and Psychological Factors on Illness Outcomes

Understanding the Links Between Social Support and Physical Health A Life-Span Perspective With Emphasis on the Separability of Perceived and Received Support Bert N. Uchino

University of Utah

ABSTRACT—Social support has been reliably related to

physical health outcomes. However, the conceptual basis

of such links needs greater development. In this article, I

argue for a life-span perspective on social support and

health that takes into account distinct antecedent pro-

cesses and mechanisms that are related to measures of

support over time. Such a view highlights the need to dis-

tinguish measures of perceived and received support and

its links to more specific diseases (e.g., chronic, acute) and

stages of disease development (e.g., incidence). I discuss

both the novel implications of these theoretical arguments

for research on social support and physical health, as well

as the potential intervention approaches that are apparent

from this perspective.

Although social relationships have been extensively studied during

the past decade as independent, intervening, and moderating

variables affecting stress or health or the relationship among them,

almost no attention has been paid to social relationships as de-

pendent variables. The determinants of social relationships, as well

as their consequences, are crucial to the theoretical and causal

status of social relationships in relation to health

—House, Landis, & Umberson, 1988, p. 544

Social support is one of the most well-documented psycho-

social factors influencing physical health outcomes (see reviews

by Berkman, Glass, Brissette, & Seeman, 2000; S. Cohen, 1988;

House, Landis, & Umberson, 1988; Seeman, 1996; Uchino,

2004). Epidemiological studies indicate that individuals with

low levels of social support have higher mortality rates, espe-

cially from cardiovascular disease (Berkman, Leo-Summers, &

Horwitz, 1992; Brummett et al., 2001; Frasure-Smith et al.,

2000; G.A. Kaplan et al., 1988; Orth-Gomér, Rosengren, &

Wilhelmsen, 1993; Rutledge et al., 2004; Williams et al., 1992).

However, there is also evidence linking support to lower mor-

tality rates from cancer (Ell, Nishimoto, Medianski, Mantell, &

Hamovitch, 1992; Hibbard & Pope, 1993; Welin, Larsson,

Svärdsudd, Tibblin, & Tibblin, 1992) and infectious disease

(Lee & Rotheram-Borus, 2001; Patterson et al., 1996).

Given the links between social support and physical health, it

is critical to determine the factors responsible for such links. In

this article, I argue that a life-span perspective highlighting the

factors that influence the development, utilization, and effec-

tiveness of support over time is crucial to understanding such

mechanisms. A life-span approach (e.g., Schulz & Heckhausen,

1996) underscores the developmental context that may influ-

ence social support and, hence, may highlight different mech-

anisms. It is also important to note that chronic diseases follow a

similar life-span trajectory and hence may develop hand in hand

with such psychosocial processes. These psychosocial factors

can potentially place some individuals on positive health tra-

jectories and others on a more negative path and may thus ex-

plain part of the variability often seen in the biological aging

process.

The main goal of this article is to propose a life-span per-

spective on social support and health that elucidates potential

mechanisms and links to differing aspects of support (i.e., per-

ceived and received support) and disease end points (e.g., inci-

dence, course). The distinction between perceived and received

Address correspondence to Bert N. Uchino, Department of Psy- chology and Health Psychology Program, 380 S. 1530 E., Room 502, University of Utah, Salt Lake City, UT 84112; e-mail: bert.uchino @psych.utah.edu.

PERSPECTIVES ON PSYCHOLOGICAL SCIENCE

236 Volume 4—Number 3Copyright r 2009 Association for Psychological Science

support is important, as perceived support has been more

consistently related to beneficial health outcomes than has re-

ceived support (Barrera, 2000; Uchino, 2004; Wills & Shinar,

2000).1 A life-span perspective can inform theoretical models

as to why differences exist between perceived and received

support based on the developmental factors associatedwith these

assessments.

This conceptual framework is illustrated in Figures 1 and 2

and is briefly presented here. As shown in the top portion of

Figure 1, I propose that individuals with positive early family

environments (e.g., parental support, less conflict) develop

‘‘positive psychosocial profiles,’’ including perceived support,

certain personality traits and/or individual differences, social

skills, self-esteem, and feelings of personal control (see also

Flaherty & Richman, 1986; Shaw, Krause, Chatters, Connell, &

Ingersoll-Dayton, 2004). These positive profiles are, in turn,

predicted to be associated with health via distinct mechanisms,

especially proactive coping (Aspinwall & Taylor, 1997), but also

via healthy behavioral choices and cooperation with medical

regimens (DiMatteo, 2004). I also predict that perceived support

should be more strongly linked to chronic disease development

then should received support due to its early familial influences,

stability, and association with other positive profiles.

In contrast to perceived support, received support is more of a

situational factor that arises in response to stressful circum-

stances (see Figure 2; Barrera, 2000; Carver, Scheier, & Wein-

traub, 1989; Thoits, 1986). The health implications of viewing

received support as more of a situational factor is that the an-

tecedent conditions and mediators may differ substantially from

perceived support. As shown in the top half of Figure 2, the

stressor domain and other contextual factors will play a focal

role in the effectiveness of coping options (only one of which

includes receiving support). On the basis of these contextual

processes, it is evident that there are potential psychological

pathways at different points of the coping process. For instance,

the point when support is received may then have influences on

psychological pathways such as alterations in one’s state sense

of esteem and/or control in a positive or negative manner (Bolger

& Amarel, 2007). An additional pathway includes changes in

health behaviors and cooperation with medical regimens that

can co-occur with stress (Testa & Collins, 1997). Finally, I

predict that received support should primarily influence acute

disease susceptibility and the course of diagnosed chronic

disease, and this association may be either positive or negative

depending on the contextual factors detailed above.

Early Family Environment: Parental Affection, Support,

Familial Conflict

General Perceived Support

Physical Health: Chronic Disease Development and

Course, Acute Disease Susceptibility

Social Skills

Personality / Individual Differences Self-Esteem

Feelings of Control

-MECHANISMS - More Effective Coping (e.g., Proactive) / Health Behaviors

Fig. 1. General framework on the antecedent factors influencing perceived support, potential mechanisms, and links to health.

1It is important to note that I will be focusing on general perceptions of support (in contrast to relationship-specific perceptions of support) as this is the dominant approach utilized in epidemiological work on support and physical health.

Volume 4—Number 3 237

Bert N. Uchino

A crucial argument in this article is that perceived support

and received support are separable constructs based on devel-

opmentally salient antecedent processes. As a result, they are

related to different pathways and disease outcomes. In the re-

mainder of this article, I will review the evidence for these

models, along with unique intervention implications and di-

rections for future study. However, I begin with a brief review of

links between social support and health and the measurement of

support that forms the basis for this analysis.

LINKS BETWEEN SOCIAL SUPPORT AND PHYSICAL HEALTH

Morbidity and mortality from disease can be broadly categorized

as acute or chronic. In the early 1900s, acute diseases related to

infectious pathogens were the major causes of morbidity and

mortality. However, changes in sanitation, working situations

(e.g., work hours), and medicine (e.g., vaccination) dramatically

cut mortality from infectious agents (Cacioppo & Berntson,

2007). As a result, chronic diseases are currently the major

causes of morbidity and mortality in the United States and most

industrialized countries. The prototypical chronic disease is

coronary artery disease, because the beginnings of atheroscle-

rosis (e.g., plaque) can be seen in children, and it develops

slowly over time, ultimately cumulating in clinical symptoms for

older adults (e.g., chest pain). This distinction between acute

and chronic conditions is important because psychosocial pro-

cesses such as social support would need to be relatively stable

over time for it to influence the development of such chronic

conditions. On the other hand, more acute conditions could be

related to either stable or stronger fluctuating factors, which then

influence susceptibility to disease.

Measures of social support have been consistently related to

physical health outcomes. Most recent work on social support

conceptualizes it as the functions that are provided by social

relationships. These functions may be separated into perceived

and received dimensions (Tardy, 1985). Perceived support refers

to one’s potential access to social support, whereas received

support refers to the reported receipt of support resources,

usually during a specific time frame (see also Barrera, 1986;

Dunkel-Schetter & Bennett, 1990).2 A majority of studies have

found an association between perceived support and lower

mortality rates even when statistically controlling for baseline

demographic factors and physical health status (e.g., Berkman

et al., 1992; Blazer, 1982; Brummett et al., 2001).

STRESSOR CONTEXT: Financial, Marital, Health / Job-Related

etc.

Physical Health: Acute Disease Susceptibility or

Chronic Disease Course

-MECHANISMS - Psychological Processes (e.g., Self-Esteem, Control) / Health Behaviors

Received Support:

Type, Support Provider, Anterogatory /

Postrogatory

Other Problem- Focused Coping

Other Emotion- Focused Coping

Fig. 2. General framework on the antecedent factors influencing received support, potential mechanisms, and links to health.

2Received support is typically assessed by recipient self-reports. However, there is good evidence that these ratings correspond to interpersonal exchanges, as correlations are typically high between recipient and provider ratings of received support (e.g., J.L. Cohen, Lakey, Tiell, & Neely, 2005).

238 Volume 4—Number 3

Social Support and Physical Health

The links between perceived support and mortality appear to

be particularly consistent for cardiovascular disease (Berkman

et al., 1992; Brummett et al., 2001; Farmer et al., 1996; Frasure-

Smith et al., 2000; Orth-Gomér, Rosengren, & Wilhelmsen,

1993; Williams et al., 1992). It is important to note that social

support may be linked to cardiovascular problems via its impact

on disease development and/or its clinical course. Although

more research is needed, there are epidemiological links be-

tween perceived support and both the development (Andre-

Petersson, Hedblad, Janzon, & Ostergren, 2006; Orth-Gomér

et al., 1993; Raikkonen, Matthews, & Kuller, 2001; but see

Ikeda et al., 2008) and progression of clinically significant

cardiovascular disease (Berkman et al., 1992; Brummett et al.,

2001; Coyne et al., 2001). These studies suggesting links be-

tween perceived support and cardiovascular disease outcomes

are consistent with research utilizing more ‘‘intermediate’’

physiological outcomes in which the perceived availability of

social support is related to lower plaque buildup (Angerer et al.,

2000; Wang, Mittleman, & Orth-Gomér, 2005), cardiovascular

reactivity (T.W. Smith, Ruiz, & Uchino, 2004; Uchino & Garvey,

1997), ambulatory blood pressure (Linden, Chambers, Maurice,

& Lenz, 1993; Steptoe, Lundwall, & Cropley, 2000), and com-

ponents of the metabolic syndrome (Horsten, Mittleman, Wam-

ala, Schenck-Gustafsson, & Orth-Gomér, 1999).

Of particular relevance for this review, there are a compli-

cated set of findings that emerge when one examines the effects

of received support on physical health, as these studies are quite

variable in their outcome (Uchino, 2004). Indeed, many of these

studies find aspects of received tangible support to be associated

with higher subsequent mortality rates (Forster & Stoller, 1992;

G.A. Kaplan et al., 1994; Krause, 1997; Penninx et al., 1997;

Sabin, 1993). Even the use of a well-validated measure of

general received support (i.e., the inventory of socially sup-

portive behavior; Barrera, Sandler, & Ramsey, 1981) resulted in

inconsistent links with mortality (Oxman, Freeman, & Man-

heimer, 1995). Due to the fact that many of these studies ex-

amine received tangible support, one simple potential

explanation based on the concept of support mobilization is that

individuals who are more dependent on receiving support are

simply more physically impaired to begin with. However, these

studies do not appear to support this explanation, as most con-

sidered the influence of initial health status or limitations in

activities of daily living (G.A. Kaplan et al., 1994; Penninx et al.,

1997). Thus, although perceived support has consistent bene-

ficial influences on health, the influence of received support is

more variable and sometimes associated with negative influ-

ences on physical health outcomes.

THE CONCEPTUALIZATION OF FUNCTIONAL SOCIAL SUPPORT

The epidemiological work points to the importance of distin-

guishing between perceived and received support. This is con-

sistent with broader conceptual work on basic social support

processes. One approach views social support as primarily an

environmental transaction or resource that can be accessed by

the individual (Cobb, 1976). The assumption of this approach is

that social support is interpersonal in nature. A second major

approach views social support as an individual difference factor

that is stable over time and has its roots in early parent–child

interactions (I.G. Sarason, Sarason, & Shearin, 1986). The as-

sumption of this approach is to view adult support as more of an

intrapersonal process that is linked closely to internal, relational

schemas. Of course, as noted by I.G. Sarason and colleagues

(1986), these views are not necessarily competing, but the

challenge is to link these processes to more specific measures

and outcomes.

These conceptual distinctions are also tied to specific mea-

surement approaches. Perceived support refers to one’s poten-

tial access to social support and is more closely linked to the

intrapersonal approach. In comparison, received support refers

to the reported utilization or exchange of support resources and

is more closely related to the interpersonal approach. It is im-

portant to note that these two dimensions do not appear to be

interchangeable as the separability of perceived and received

support is well-documented (Haber, Cohen, Lucas, & Baltes,

2007; Helgeson, 1993; Newcomb, 1990; Wills & Shinar, 2000).

The reasons for the separability of perceived and received

support, however, are still unresolved (Wills & Shinar, 2000)

and reflect the lack of conceptual development regarding what

these measures of support reflect. Although there are other ex-

planations for these differences (see Dunkel-Schetter & Ben-

nett, 1990), one that I expand upon in this article is that they

have different origins (or antecedent processes) that make them

separable and predictably associated with differing outcomes.

As argued by I.G. Sarason, Sarason, and Shearin (1986), mea-

sures of perceived support may have their origins in early fa-

milial transactions. Familial transactions include processes

such as caring, affection, and positive involvement that set the

basis for supportive relational schemas (see also Flaherty &

Richman, 1986). In addition, researchers have found that per-

ceived support is typically stable over time (despite changes in

social circumstances) and linked to reports of parental support

and warmth (Mallinckrodt, 1992; Newcomb, 1990; I.G. Sarason

et al., 1986; Shaw et al., 2004).3 Such individual differences in

perceived support also influence interpretations and reactions to

potentially supportive transactions (Lakey & Cassady, 1990;

L.T. Ross, Lutz, & Lakey, 1999; T.W. Smith et al., 2004).

This conceptual distinction between perceived and received

support on epidemiological physical health work has been

3Of course, it is possible that such stability reflects genetic contributions to social support processes (Kendler, 1997; Kessler, Kendler, Heath, Neale, & Eaves, 1992), such as gene–environment associations (Plomin & Crabbe, 2000). However, future research on the exact nature of these gene–environment interactions for social support processes will be needed to clarify such potential links.

Volume 4—Number 3 239

Bert N. Uchino

minimal. Thus, in this review, I argue for the importance of a life-

span perspective on support that can provide unique insight into

(a) why perceived and received support are related to different

outcomes, (b) potential associations to distinct aspects of

physical health outcomes, and (c) its broader implications for

research and interventions. These issues are elaborated below.

THE DEVELOPMENTAL ANTECEDENTS OF PERCEIVED SUPPORT

The dominant paradigm for examining developmental influ-

ences on relationships is related to attachment styles. The

concept of attachment has its roots in the writings of Dr. John

Bowlby (1982), who argued for the existence of an organized

behavioral attachment system that mediates infant responses to

threat or distress. Because of the dependency of the infant, adult

caretakers become a symbolic ‘‘safety net’’ that the infant relies

on during times of distress. This attachment process develops

over time and is based on repeated interactions with the primary

caretaker. If these interactions are positive, infants can come to

rely on the caretaker as a reliable source of protection and

support and hence develop a secure attachment style. However

if these interactions are inconsistent or negative, infants may

develop more ambivalent or avoidant attachment systems

(Ainsworth, Blehar, Waters, & Wall, 1978).

The concept of infant attachment has been widely applied to

the adult literature on close interpersonal relationships (Cassidy

& Shaver, 1999; Diamond, 2001). It is thought that these infant–

caretaker attachment processes provide the basis for adult ex-

pectations regarding social relationships. More specifically, it is

proposed that early infant–caretaker interactions provide the

basis for the development of working models of trustworthy and

dependable relationships (Hazan & Shaver, 1987), which is

supported by emerging longitudinal evidence (e.g., Belsky,

Spritz, & Crnie, 1996; Klohnen & Bera, 1998). These links

appear to develop in the context of transactions with early close,

interpersonal relationships that cumulate in positive self–other

representations (Baldwin, 1992). These internalized processes

continue to have an active impact on individuals by influencing

the ‘‘working’’ self-concept and interpretation of subsequent

relationships (Andersen & Berk, 1998; Baldwin, 1992). Studies

do suggest that individuals’ perceptions of their early familial

experiences are related to their subsequent perceptions of

support (Boyce, 1985; Doucet & Aseltine, 2003; Engels,

Dekovic, & Meeus, 2002; Flaherty & Richman, 1986; Mal-

linckrodt, 1992; I.G. Sarason et al., 1986; Shaw et al., 2004). In

one such study, participants completed ratings of their emo-

tional closeness to their parents while in medical school

(Graves, Want, Mead, Johnson, & Klag, 1998). A 30-year follow-

up of these individuals found that these initial ratings of parental

closeness were associated with a greater number of close con-

tacts that individuals perceived were available for social support

at midlife.

If perceived support is linked with attachment security and

develops in the context of early, positive familial interactions,

the question at hand becomes much broader. What else code-

velops in the context of such supportive familial environments

(Shaw et al., 2004)? One possibility is that perceived support

may then be related to personality processes or other individual

difference factors, such as attachment style as noted above.

Studies in this regard suggest that more securely attached in-

dividuals report greater perceived social support (Anders &

Tucker, 2000; Cozzarelli, Sumer, & Major, 1998; Ognibene &

Collins, 1998). In fact, it is clear that perceived support is re-

lated to other personality/individual difference factors, espe-

cially higher trait optimism and extraversion and lower

loneliness, neuroticism, and hostility (Gallo & Smith, 1999;

Pinquart & Sorenson, 2001; T.W. Smith, 1992; Suls & Bunde,

2005; Uchino, Vaughn, & Matwin, 2008).

It is important to note that I focus on the personality/indi-

vidual difference factors above, as they have established links to

physical health outcomes and appear to have significant inter-

personal origins (Cacioppo & Patrick, 2008; Heinrich & Gul-

lone, 2007; T.W. Smith & Gallo, 2001; Suls & Bunde, 2005). For

instance, loneliness is linked, in part, to less secure parental

attachments and lack of positive family involvement (Kerns,

Klepac, & Cole, 1996; Lobdell & Perlman, 1986; Weiss, 1973).

Although earlier work focused on the potential spurious overlap

between perceived support and personality/individual differ-

ences (i.e., biased perceptions of support; Bolger & Eckenrode,

1991), subsequent work suggests that personality was not re-

sponsible for links between perceived social support and more

objective indices of health (e.g., physiological functioning;

see S. Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997; Kiecolt-

Glaser, Dura, Speicher, Trask, & Glaser, 1991; Uchino,

Cacioppo, Malarkey, Glaser, & Kiecolt-Glaser, 1995). As a re-

sult, more recent studies have focused on the moderating role of

personality or other individual differences on perceived support.

This emphasis is consistent with the proposed profile approach

depicted in Figure 1, in that the combination of personality/

individual difference factors (e.g., hostility, loneliness) and

support appear to explain additional variance in health out-

comes (e.g., Knox et al., 2000; Knox et al., 1998; O’Donovan &

Hughes, 2007; Orth-Gomér & Unden, 1990).

The early family environment also influences a broad array of

other psychosocial processes relevant to physical health (Rep-

etti, Taylor, & Seeman, 2002). Infants who are insecurely at-

tached show less effective coping in response to arousing stimuli

(Nachmias, Gunnar, Mangelsdorf, Parritz, & Buss, 1996). These

results appear to generalize to children and adults, as factors

such as low family support have been related to poorer coping

strategies (Hardy, Power, & Jaedicke, 1993; Valentiner, Holo-

han, & Moos, 1994). In addition, children from more conflicted

families have difficulty with self-regulation, as evidenced by

greater emotional reactivity to interpersonal situations (Ballard,

Cummings, & Larkin, 1993; Davies & Cummings, 1998).

240 Volume 4—Number 3

Social Support and Physical Health

Such early familial processes also influence the development

of basic social competencies (Repetti et al., 2002). The devel-

opment of such social skills is critically important as it is related

to positive outcomes such as the formation of supportive social

networks (S. Cohen, Sherrod, & Clark, 1986), and interventions

in children that improve social skills are linked to improvements

in peer acceptance and support (Bierman, 1986; Bierman &

Furman, 1984; Drentea, Clay, Roth, & Mittleman, 2006). In one

relevant study, Landry, Smith, Miller-Loncar, and Swank (1998)

examined mothers’ responsiveness to their infants’ cues. They

found that the mother’s sensitivity to such cues predicted greater

infant growth in social skills over the next several years. These

data are consistent with work linking perceived support to

higher ratings of social skills from independent observers during

social interactions (B.R. Sarason, Sarason, Hacker, & Basham,

1985).

Research on early family environment and links to other

positive psychosocial factors is also consistent with the pro-

posed framework (B.R. Sarason, Pierce, Bannerman, & Sarason,

1993). For instance, a number of theoreticians have argued for

the importance of familial processes on the development of self

and feelings of control (e.g., Bowlby, 1982; Kohut, 1971). These

processes result in an overlap between self–other representa-

tions (e.g., self-concept; Andersen & Berk, 1998; Baldwin,

1992; Ogilvie & Ashmore, 1991). Researchers also found links

between perceived support and feelings of control, self-efficacy,

and self-esteem (Atienza, Collins, & King, 2001; B.R. Sarason

et al., 1993; Shaw et al., 2004; Symister & Friend, 2003). These

associations are important because these psychological factors

appear to have influences on physical health in their own right

(Shaw et al., 2004).

An important question based on this framework is ‘‘What are

the implications for the support and health link?’’ As noted

earlier, I propose that individuals with positive early family

environments (e.g., parental support, less conflict) develop

positive psychosocial profiles. As depicted in the top portion of

Figure 1, these positive profiles include certain personality

traits and/or individual differences, social skills, self-esteem,

and feelings of personal control. Although I use the general term

personality/individual differences, I am referring specifically to

those that have been shown in prior research to be health rele-

vant and linked to perceived support (i.e., secure attachment,

loneliness, low hostility, low neuroticism, high optimism; see

Uchino et al., 2008). As reviewed earlier, the literature that

examines these factors separately in relation to the early family

environment is consistent with such a positive profile (Heinrich

& Gullone, 2007; Repetti et al., 2002; T.W. Smith & Gallo,

2001).

As shown in the middle portion of Figure 1, these positive

profiles are in turn predicted to be associated with health via

distinct mechanisms. That is, such individuals can cope more

effectively, flexibly, and proactively with life stressors. They

have choices and a broader skill/coping set that can be used to

manage and anticipate the challenges in life. For instance, the

simple perception of support or high self-esteem can influence

adaptation to stress by activating more adaptive appraisal pat-

terns and coping behaviors (e.g., challenge appraisals in the

context of more controllable stressors; S. Cohen, 1988). Of

particular importance is that perceived social support may also

be related to greater proactive coping (Aspinwall & Taylor,

1997) and existing longitudinal studies tend to find support to be

related to lower stress exposure (McFarlane, Norman, Streiner,

& Roy, 1983; Russell & Cutrona, 1991; Wills & Cleary, 1996).

This stress prevention pathway is an understudied but important

way by which such psychosocial processes can ultimately in-

fluence health outcomes (Aspinwall & Taylor, 1997).

These positive psychosocial profiles are also predicted to be

related to disease via healthier behavior choices (e.g., diet,

cooperation with medical regimens). For instance, perceived

support has been linked to better health behaviors, including

fruit and vegetable consumption, exercising, and smoking ces-

sation (Reblin & Uchino, 2008). Moreover, at least part of the

link between social support and mortality is explained by such

behavioral pathways (Uchino, 2004). Perceived support is also

linked to better adherence to medical regimens in chronic dis-

ease populations (DiMatteo, 2004).

A unique feature of Figure 1 is represented in the bottom box

and includes the predicted links between these processes and

physical health outcomes. This framework predicts that per-

ceived support should be more strongly linked to chronic dis-

ease development then should received support due to its early

familial influences, stability, and association with other positive

profiles. As reviewed earlier, there is evidence of general per-

ceived support’s role in the development of cardiovascular

disease (Orth-Gomér et al., 1993; Raikkonen et al., 2001;

Steptoe et al., 2000; Wang, Mittleman, & Orth-Gomér, 2005). Of

course, given the stability of perceived support, it may also in-

fluence susceptibility to acute diseases via processes such as

impaired immune function that may set the stage for infectious

disease development (Kiecolt-Glaser & Glaser, 1995).

One immediate question that arises as a result of this positive-

profile conceptualization relates to the more precise role of

perceived support as a risk factor. For instance, is it the case that

social support is even necessary to the profile? A comprehensive

profile approach (e.g., latent profile analysis) will be necessary

to more definitively test this possibility on relevant health out-

comes. However, there are several lines of evidence on the im-

portance of social support for understanding such profiles. First,

perceived support is typically correlated with these relevant

personality, individual difference, and psychological factors

(S. Cohen, 1988; Uchino, 2004). Moreover, the magnitude of

these correlations range from .2 to .5, suggesting shared but not

redundant variance (Pinquart & Sorensen, 2001; Procidano,

1992; Symister & Friend, 2003). There are also joint contribu-

tions by perceived support and personality factors on health-

related outcomes (Knox et al., 1998; O’Donovan & Hughes,

Volume 4—Number 3 241

Bert N. Uchino

2007; Unden, Orth-Gomér, & Elofsson, 1991), which is con-

sistent with the profile approach. For instance, the combination

of high hostility and low support appears to be associated with

greater underlying coronary calcification (Knox et al., 2000).

Using latent profile analyses, Ko, Berg, Butner, Uchino, and

Smith (2007) also found that both personality and perceived

support contributed meaningfully to aspects of successful aging.

Thus, social support appears important to understanding the

nature and health relevance of these positive profiles, although

future research will provide more definitive tests of this con-

ceptual framework.

THE SITUATIONAL NATURE OF RECEIVED SUPPORT

In contrast to perceived support, received support is less likely

to represent early developmental (e.g., parental) influences.

This is not to say that there are no early familial influences on

received support or situational influences on perceived support

(Lakey, in press). I will return to such links later in the article.

However, received support is more likely to represent a situa-

tional factor that is sought or provided in response to stress

(Barrera, 2000). This conceptualization is consistent with vari-

ous coping models that include support seeking as a potential

resource (Carver et al., 1989; Thoits, 1986). Of course, when we

are under stress, network members may also spontaneously offer

support in an attempt to help us cope. Bolger and Amarel (2007)

have termed this an anterogatory process (prior to seeking sup-

port) in contrast with a postrogatory process (after decision to

seek support). However, most existing received support mea-

sures (including those used in epidemiological work) do not

separate these processes. I will return to a discussion of this

issue later in the review.

A main point of this conceptualization of received support is

that it is only one of many coping options available to the in-

dividual and its effectiveness may depend heavily on the context

(Berg & Upchurch, 2007; Suls & Fletcher, 1985). For instance,

problem-focused coping strategies are more beneficial for rel-

atively controllable forms of stress. This perspective is also

found in the matching hypothesis of support, which predicts that

stress-buffering is most effective when the type of support

matches the needs or challenges of the stressful event. More

specifically, the matching hypothesis predicts that informational

and tangible support should be most effective for controllable

events (e.g., preparing for a job interview), whereas emotional

and belonging support should be most effective for uncontrol-

lable events (e.g., job layoff; Cutrona & Russell, 1990). Simi-

larly, Horowitz and colleagues (2000) argue that the person

seeking support wants something (i.e., has a goal) and that more

beneficial influences might be obtained if the support provider is

able to understand such goals and the appropriate response

(e.g., action-facilitating support for agentic problems). Thus,

received support can have either positive or negative influences

depending on the context.

The literature on received support suggests negative reactions

to some support attempts (Bolger, Zuckerman, & Kessler, 2000;

Helgeson, 1993; Newsom, 1999), which is consistent with the

argument. In one study, Lehman, Ellard, and Worthman (1986)

examined this possibility in a sample of bereaved participants.

They found that bereaved participants were readily able to recall

support attempts that were both helpful and unhelpful. Actions

such as expressing concern and contact with similar others were

viewed as helpful, whereas giving advice and encouraging re-

covery were seen as unhelpful. It has also been found that the

receipt of informational and tangible support tends to be viewed

as less nurturant andmore controlling than is either emotional or

belonging support (Trobst, 2000). These data suggest that the

type of support received in a particular stressor context is im-

portant and may be responsible for some conflicting findings on

received support (Helgeson, Cohen, Schulz, & Yasko, 2000).

One important issue that bears on the present argument is

that if there are circumstances under which received support

is less effective, why do such negative effects sometime occur?

One possible explanation is based on the finding that stressful

circumstances are usually associated with increased support-

seeking. Those who report greater levels of received support

are actually under more severe stress (Barrera, 1986). One im-

plication of this argument is that researchers may need to follow

the effects of received support in stressed populations over

longer periods of time because initially it may represent an in-

dividual’s attempt to mobilize support. Only over time may re-

ceived support eventually help one resolve the stressor (Barrera,

1986).

A second reason why received support may sometimes fail is

related to the provider of support. Anxiety on the part of the

support provider may interfere with the retrieval of effective

support skills (Gottlieb, 2000). Lehman and colleagues (1986)

reported that nonbereaved individuals’ reports of effective

support matched well with that of the bereaved sample. If people

know what to do than why did so many bereaved individuals

report unhelpful support attempts by individuals in their net-

work? The authors hypothesized that people interacting with

someone undergoing such a stressful event feel anxious about

these interactions because they would not want to do or say

anything that would upset the individual. Ironically, this anxiety

makes it difficult to be an effective support provider as indi-

viduals may slip into more automatic or casual modes of support

provision that may then be viewed as unhelpful.

A third reason is based on the possibility that conflict in re-

lationships can undermine the effectiveness of received support.

We have shown in a number of laboratory studies that the co-

existence of positivity and negativity in relationships can de-

crease the efficacy of received support (Holt-Lunstad, Uchino,

Smith, & Hicks, 2007; Uno, Uchino, & Smith, 2002). For in-

stance, Holt-Lunstad and colleagues (2007) randomly assigned

participants to interact with an ambivalent (containing both

positive and negative aspects) or supportive (containing pri-

242 Volume 4—Number 3

Social Support and Physical Health

marily positive aspects) friend. Individuals receiving support

from an ambivalent friend did not appear to benefit from the

support, as evidenced by their higher levels of distress and

systolic blood pressure reactivity during a disclosure task.

A final possible explanation for why received support may not

be beneficial is related to the possibility that it is associated with

a drop in self-esteem or threat to one’s sense of independence

(Bolger et al., 2000; Martire, Stephens, Druley, & Wojno, 2002;

Nadler & Fisher, 1986). These changes may in turn offset any

benefits of received support. This point is illustrated in work by

Niall Bolger and his colleagues (2000), who have argued that the

best form of received support may be those acts that are not

actually noticed by the recipient as supportive. In one intriguing

study on what is termed invisible support, Bolger and colleagues

(2000) followed couples in which one member was preparing to

take the stressful New York State Bar Exam. Diaries on received

support were completed over a 1-month period. The results of

the study revealed that there were many instances in which the

partner reported providing support that was not noticed by the

recipient. Further, the provision of invisible support was asso-

ciated with the lowest levels of depression during the study

period (also see Bolger & Amarel, 2007; but see Gable, Reis, &

Downey, 2003).

More recent research on invisible support is starting to clarify

why received support might have detrimental influences under

some situational contexts (Bolger &Amarel, 2007). In a series of

laboratory studies, Bolger and Amarel (2007) found that invis-

ible support (posed as a coping question aimed at the experi-

menter instead of the participant during an upcoming stressor)

was associated with smaller increases in distress. They also

found that these effects were mediated by individuals commu-

nicating a sense of inefficacy to the person about to undergo

stress. These findings suggest that eliminating the possible

negative effects on a person’s sense of esteem may reveal ben-

eficial influences of received support (e.g., perhaps emphasizing

the normative nature of the support), providing the support

meets the needs of the situation.

It should be noted that laboratory studies do document ben-

eficial influences of received support on physiological reactivity

during acute stress (Gerin, Pieper, Levy, & Pickering, 1992;

Lepore, Allen, & Evans, 1993). In these laboratory studies, ei-

ther a friend or the experimenter provides the participant with

support while they are undergoing a standardized stress task

(e.g., speech). The most common support provided has been

emotional support conveyed in a nonthreatening manner that

matches the needs of the current situation (e.g., esteem-

building). In fact, the receipt of emotional support is typically

viewed as more nurturant and less controlling than either in-

formational or tangible support (Trobst, 2000). Again, these data

make clear that the effectiveness of received support may de-

pend heavily on the context, with beneficial influences more

likely when there is a match between the type of received sup-

port and the context (Berg & Upchurch, 2007).

The health implications of viewing received support as more

of a situational factor is that the antecedent conditions and

mediators may differ substantially from perceived support (see

Figure 2). As shown in the top half of the model, the stressor

context will play a focal role in the effectiveness of coping op-

tions. These coping options include receiving support (sought or

offered), as well as other emotional- (e.g., spirituality) and

problem-focused (e.g., planning) coping behaviors.

This framework also highlights the importance of specifying

contextual factors that may influence the effectiveness of re-

ceived support (e.g., type of support, relationship characteris-

tics, timing of the received support). As reviewed earlier, the

type of support received is predicted to be critical to its effec-

tiveness within a particular stressor context according to the

matching hypothesis (Cutrona & Russell, 1990) and other goal-

seeking approaches (Horowitz et al., 2000; Stroebe & Stroebe,

1996). The epidemiological work also points to the possible

detrimental influence of received tangible support (e.g., Sabin,

1993). In addition, the presence of conflict in an existing rela-

tionship may undermine the effects of received support (Holt-

Lunstad et al., 2007). The type of relationships (i.e., familial tie,

friendship) also needs consideration, as conflict in involuntary

relationships may be particularly harmful (Krause & Rook,

2003).

Finally, the timing of when support is received is also an

important contextual factor. According to Bolger and Amarel

(2007), if support is received during the anterogatory period, it is

more likely to have negative influences on the proposed psy-

chological mechanisms than it would during the postrogotory

period, when the decision to seek support has already been

made. Also invisible received support is expected to be espe-

cially beneficial during the anterogatory period, as it does not

negatively impact the mechanisms outlined in the model. In

summary, the top half of Figure 2 highlights the contexts and

ways that received support can go ‘‘right’’ or ‘‘wrong’’ as a coping

mechanism.

The middle of Figure 2 highlights the mechanisms that are

salient from the present view of received support. Potential

psychological pathways include more state alterations in one’s

sense of esteem/control in a positive or negative manner, as

reviewed earlier. That is, if there is a good match between the

stressor context and support received, then more positive out-

comes are likely via such mechanisms (Bolger & Amarel, 2007;

Cutrona & Russell, 1990; Horowitz et al., 2000). Moreover,

health behaviors may also serve as mechanisms. For instance, if

received support helps individuals cope with their stress, then

more positive health behaviors are likely (e.g., less smoking,

better sleep; Stetson, Rahn, Dubbert, Wilner, & Mercury, 1997;

Testa & Collins, 1997).

As shown in the bottom box of Figure 2, I also predict that

received support should primarily influence acute disease sus-

ceptibility and the course of diagnosed chronic disease. How-

ever, this association can be either positive or negative (i.e.,

Volume 4—Number 3 243

Bert N. Uchino

healthy or unhealthy), depending on the contextual processes

outlined above. Of course, it is also predicted that ongoing at-

tempts at coping with such diseases can influence received

support and coping more generally (Bolger, Foster, Vinokur, &

Ng, 1996). For instance, Bolger and colleagues (1996) found

that although support was initially mobilized in response to the

diagnosis of cancer, the patients’ distress was related to an

erosion of received support from the spouse over time.

Figure 2 shows several issues in need of further discussion.

The first issue is related to the influence of received support on

more long-term stress, as chronic stress appears to also influence

the development of cardiovascular disease (Ming et al., 2004;

Rosengren et al., 2004). A second point is that received support

draws, in part, from relationships that are stable over time (e.g.,

family) and hence might in this way be related to the develop-

ment of chronic diseases. However, the influence of these pro-

cesses on the link between received support and chronic disease

development should be attenuated because of the potential of

chronic stress to erode support (even from close relationships),

because the variability associated with the effectiveness of re-

ceived support in coping with stress, and because it is just one

of many coping options. Basically, the presence of chronic stress

or stable relationships does not guarantee that the quantity or

quality of support received will be beneficial. Nevertheless,

these are important empirical questions, as I am unaware of any

epidemiological studies that have examined whether received

support measured at an earlier point in time predicts the de-

velopment of cardiovascular disease.

CONCEPTUAL AND METHODOLOGICAL IMPLICATIONS

I have argued that a life-span perspective has important impli-

cations for research linking social support to physical health

outcomes. This framework begins to link relevant support pro-

cesses/measures to more specific aspects of disease (i.e., acute,

chronic disease development or course). This model predicts

that perceived support should bemore strongly linked to chronic

disease development than should received support due to its

early familial influences, stability, and association with other

positive profiles. In comparison, given that received support is

more of a situational variable, its influence may depend more

heavily on its match to the situational (stressor) context. I be-

lieve that this framework has unique research and intervention

implications. Due to the life-span perspective, I first start with a

consideration of its implications for older adult populations.

Implications for an Aging Population

The relevance of this framework for older adults is of particular

importance as they represent one of the fastest growing segments

of the population (Centers for Disease Control and Prevention,

2003). In the U.S. alone, the proportion of individuals over

age 65 will increase from 12.4% in 2000 to 19.6% in 2030. There

will be an almost doubling of older adults over age 65 worldwide

by 2030 (Centers for Disease Control and Prevention, 2003).

These trends are of particular importance due to age-related

changes in functional health status (Kart, Metress, & Metress,

1992), as older adults may have to rely on received support as

coping mechanisms more than younger adults do (van Tilburg,

1998).

It is important to note that the life-span literature on the well-

being of older adults also suggests variability in outcomes as-

sociated with received support. For instance, Liang, Krause, and

Bennett (2001) examined an older adult population and found

received support to be related to higher levels of depression,

whereas no direct effect was found in another study of older

adults (Krause, Liang, & Keith, 1990). Other research has

similarly found received tangible support to be associated with

reduced well-being, whereas received emotional support was

associated with positive influences or none at all (Penninx et al.,

1998; Reinhardt, Boerner, & Horowitz, 2006).

The variable outcomes associated with received support in

older adults reflect the unique circumstances associated with

aging that impact the contextual factors shown in Figure 2. Ac-

cording to socioemotional selectivity theory, there are age-related

differences in the social networks of older adults due to the sa-

lience of emotional goals (Carstensen, Isaacowitz, & Charles,

1999). As a result, close, familial ties are maintained, whereas

more peripheral ties are less prevalent (Antonucci & Akiyama,

1987; Carstensen et al., 1999). One implication is that there are

more involuntary relationships (e.g., relationships one cannot

easily choose to exit) in the social network of older adults (Krause,

2001). This is important because prior work suggests that some of

these involuntary ties are a source of conflict for older adults

(e.g., Birditt, Fingerman, & Almeida, 2005). In fact, there is

considerable stability in the conflict associated with the social

networks of older adults (Krause&Rook, 2003), and such conflict

may undermine the effects of received support (Liang et al.,

2001).

It is also clear that older adults face a number of health-

related biological challenges that they may find threatening.

The need for received support has the potential to further

threaten their sense of independence and control (M.M. Baltes,

1995; P.B. Baltes, 1997; Martire & Schulz, 2007; Schulz &

Heckhausen, 1996). Moreover, a distinction is typically drawn

between receiving autonomy-enhancing and autonomy-de-

creasing support (M.M. Baltes, 1995; Martire & Schulz, 2007;

Rowe & Kahn, 1987). M.M. Baltes (1995) in particular argues

that older adults appear to be subject to the ‘‘dependency-sup-

port script,’’ in which their dependent behavior is reinforced. In

contrast, the independent behavior of the older adult is more

likely to be ignored (i.e., ‘‘independence-ignore script’’). It is

important to note that it is the autonomy-enhancing nature of

received social support that may be beneficial (Martire &

Schulz, 2007), and hence its absence is particularly detrimental

to older adults.

244 Volume 4—Number 3

Social Support and Physical Health

This conceptualization also has implications for links be-

tween perceived support and health in the aging adult (see

Figure 1). First, older adults with high perceived support are

predicted to have lower rates of chronic disease development.

Thus, they are more likely to have successfully aged in terms of

their physical health (Horsten et al., 1999; Wang, Mittleman, &

Orth-Gomér, 2005). In a series of studies, researchers found that

perceived support moderated age-related differences in resting

blood pressure (Uchino et al., 1995; Uchino, Holt-Lunstad, Uno,

& Betancourt, 1999). That is, older adults with high perceived

support had resting blood pressure levels that were comparable

with individuals almost 50 years younger (Uchino et al., 1995).

An important point here is that individuals with high perceived

support are likely to have more disease-free years than those

with low perceived support, with corresponding influences on

the quality of their lives and relationships.

Rowe and Kahn (1998) have also distinguished between

social, cognitive, and physical health components of successful

aging. The proposed framework suggests that, to the extent that

perceived support is measured as a component of social en-

gagement, there should be some ‘‘evenness’’ in terms of its

links to the other profile (i.e., cognition and physical health; see

Ko et al., 2007). However, this framework also points to how

unevenness might occur. For instance, measures of received

support cannot be assumed to be the same as measures of per-

ceived support, and its inclusion might introduce discrepancies

due to the variability often found in the effectiveness of received

support. Of course, increased variability is also likely in a

sample of older adults, as individuals engage in selection, op-

timization and/or compensation strategies (P.B. Baltes, 1997).

Nevertheless, the current perspective helps in understanding

how different measures of support may impact questions sur-

rounding aging constructs that have support processes as an

important component.

Links Between Perceived and Received Support

The frameworks depicted in Figures 1 and 2 assume a separa-

bility of perceived and received support, which is consistent

with the available literature (Wills & Shinar, 2000). The sepa-

rability argument is based on the assumption of distinct

antecedent processes and not necessarily its statistical inde-

pendence (Cacioppo & Bernston, 1994). Although separable,

perceived and received support are conceptually related under

some conditions and may interact in potentially important ways.

As noted earlier, I do not believe that perceived support re-

flects a total lack of situational influences nor do I believe that

received support reflects a total lack of any developmental in-

fluences (Lakey, in press). The argument is a relative one, and a

statistical link between perceived and received support is

consistent with the results of research suggesting that each may

influence the other under some contexts (e.g., Haber et al.,

2007). For instance, Lakey and Cassady (1990) have argued

from a social-cognitive perspective that perceptions of support

may act as a schema that influences one’s interpretation of

supportive behaviors. They found that individuals high in per-

ceived support interpreted videotaped support interactions

more positively. These studies are consistent with broader so-

cial-cognitive work on links between relationship constructs

and the interpretation of schema-relevant information (Baldwin,

1992; Holmes, 2000). Likewise, received support can influence

perceptions of support, especially during stressful events that

more broadly influences one’s social network (e.g., natural di-

sasters; Norris & Kaniasty, 1996). In fact, chronic disease pa-

tients or victims of natural disasters have a greater need for

received support (Nicassio & Smith, 1995; Norris & Kaniasty,

1996). Such situations allow for greater opportunities for each

construct to influence the other (e.g., whether the high perceived

support actually materializes when called upon).

Nevertheless, this theoretical analysis makes it clear that

these are not redundant constructs. There is an interesting

question that arises here: ‘‘What are the consequences of re-

ceiving support for individuals who are low versus high in per-

ceived support (i.e., interactions between perceived and

received support)?’’ There is very little research that examines

this issue, perhaps due to the conceptual overlap that is assumed

between these two support measures. One interesting possibility

is that, given their more positive interpersonal schemas, indi-

viduals with high perceived support may be more receptive and

thus benefit more from received support. In comparison, this

review suggests an alternative prediction. That is, because of the

codevelopment of other positive psychosocial factors (e.g., self-

esteem), when support is simply provided, individuals with high

support may not benefit because it is deemed unnecessary

(discounted) or because it could threaten their codeveloped

sense of esteem or control. In one of the few studies that tested

this interaction between perceived and received support, I.G.

Sarason and Sarason (1986) gave individuals experimentally

provided support by telling them that the experimenter would be

able to help them during an anagram task if needed. In general,

individuals who were provided with a sense of support per-

formed better on the task. However, this performance boost was

mostly evident for individuals with low perceived support (see

also Lindner, Sarason, & Sarason, 1988).

The present analysis would also predict at what phase in the

support process such null or negative influences for received

support would occur for individuals with high perceived

support. All else being equal, received support is likely to be

beneficial after individuals with high perceived support have

decided (and hence are receptive) to seek support. The support

processes is a complex one, and the decision to actually seek

support depends on a number of factors. Barbee, Gulley, and

Cunningham (1990) have argued that the person under stress

must decide to seek support on the basis of their emotions

(do they feel embarrassed about the problem?), thoughts (can

they handle the problem on their own?), and the quality of their

Volume 4—Number 3 245

Bert N. Uchino

existing relationships (is there someone that they can turn to

about this problem?). As noted earlier, Bolger and Amarel

(2007) have distinguished between anterogatory (prior to seek-

ing support; e.g., appraisal) and postrogatory (after deciding to

seek support) processes. According to the present analysis, the

anterogatory processes for individuals with high perceived

support make them more effective at avoiding and coping with

stress and, thus, less likely to rely on received support during

stress. Hence, issues raised earlier that can influence the

effectiveness of received support, such as receiving support

from conflicted network members, may not be as applicable.

Moreover, in the absence of seeking support, received support

may be discounted or it may conflict with the self-esteem of

individuals with high perceived support. Note that invisible

support should be especially beneficial for these individuals so

that it does not threaten their codeveloped self-esteem (Bolger &

Amarel, 2007). These ‘‘moderational’’ predictions may explain

some of the inconsistencies found in studies of received support

and health.

Measurement and Data Analytic Implications for the

Physical Health Domain

The present conceptualization can be used to guide measure-

ment strategies regarding perceived or received support de-

pending on the research question and disease context. A typical

approach in prior work has been to measure either perceived or

received support and to examine its association to health out-

comes (Uchino, 2004). I believe that this reflects the assumed

overlap between these measures in epidemiological work. Thus,

there is much less research measuring both components and

linking them to relevant outcomes. A more comprehensive ap-

proach is important because these are not redundant measures/

constructs and because epidemiological work linking received

support to mortality suggests some negative influences on health

(e.g., Sabin, 1993). It is important to note that the framework can

also be used in the measurement of mediators or contextual

processes that can be used to clarify the nature of such associ-

ations as reduced self-esteem or conflict in relationships.

The framework proposed in this article also suggests alter-

native analytical approaches to examining these questions.

What other factors codevelop in the context of such supportive

familial environments (Shaw et al., 2004)? The identification of

such positive profiles can be performed via a number of estab-

lished analytical procedures including cluster, factor, and/or

latent profile analyses (e.g., Gallo & Smith, 1999; Ko et al.,

2007). These profile scores can then be used in the prediction of

physical health outcomes and contrasted with the more tradi-

tional approach of examining perceived support as the main

predictor of health outcomes. In addition, perceived support

may be used as one mediator (or part of a profile) of links be-

tween early family environment and long-term health outcomes

(Shaw et al., 2004).

In contrast to such a profile approach to perceived support,

past research has typically examined these related personality

or psychological factors as independent from support by sta-

tistically controlling for them (Uchino, 2004). Such an approach,

although perhaps necessary in early work, does not reflect the

recent conceptual work linking social support to these factors

(Gallo & Smith, 1999; Shaw et al., 2004; T.W. Smith & Gallo,

2001). For instance, it is clear that personality factors have

significant interpersonal origins and reflect, in part, the per-

ception that one is socially valued (Gallo & Smith, 1999; Leary,

1999). In addition, perceived control can be a cause, conse-

quence, or evidence reciprocal links to perceived support

(Krause, 2001).

An approach that is also gaining in popularity is the examina-

tion of psychological factors (e.g., esteem, control) as potential

mediators of links between social support and health. This ap-

proach is especially evident in work examining links between

social support and mental health outcomes (Atienza et al., 2001;

Symister & Friend, 2003). For instance, in a recent prospective

study, Symister and Friend (2003) found that self-esteem was a

partial mediator of links between perceived support and depres-

sion. However, the salient question that arises from this concep-

tual perspective is whether self-esteem was a partial mediator or

part of a positive profile (with reciprocal links and/or overlapping

variance) that includes perceived support (see Holahan &

Holahan, 1987). Future research will be needed that can simul-

taneously examine alternative models (e.g., meditational, profile).

Nevertheless, I predict that different mediators and processes are

salient when examining measures of received support.

However, there are situations in which one might find the

psychological factors of self-esteem and control mediating links

between perceived support and health. As noted earlier, some

situations allow for greater reciprocal links between perceived

and received support (e.g., chronic disease patients or victims of

natural disasters; Nicassio & Smith, 1995; Norris & Kaniasty,

1996) and thus may result in such meditational effects. Never-

theless, I still predict that these meditational results reflect the

influence of received support that either alters perceived sup-

port to more closely reflect situational influences (Norris &

Kaniasty, 1996; Wethington & Kessler, 1986) and/or mobilizes

other psychosocial factors to deal with the upcoming challenges

of potent stressors. Thus, testing such models will require the

simultaneous assessment of perceived support, received sup-

port, and relevant psychosocial factors in a health context over

time. In short, one important implication of this framework is

that perceived and received support are not redundant con-

structs and, hence, questions and models regarding their sepa-

rable and joint influences are in need of greater consideration.

Intervention Implications

There is now strong evidence linking social support to physical

health outcomes (Berkman et al., 2000; S. Cohen, 2004; Uchino,

246 Volume 4—Number 3

Social Support and Physical Health

2004). These findings highlight the potential of support inter-

ventions to foster positive health outcomes. In fact, there have

been hundreds of support interventions in various populations

aimed at helping individuals utilize their relationships for such

benefits (Hogan, Linden, & Najarian, 2002). Most of these

interventions are based in chronic disease populations in an

attempt to foster better mental and possibly physical health

outcomes (Uchino, 2004). The source of support varies

from a new relationship (e.g., physician) to established network

ties. In addition, the intervention setting can include either a

group (e.g., support groups) or one-on-one setting (Gottlieb,

1988).

I will not attempt to provide a comprehensive review of this

large literature (see Hogan et al., 2002; Martire, Lustig, Schulz,

Miller, & Helgeson, 2004). However, I will attempt to discuss

important issues for future support interventions based on the

current framework. As noted by others (e.g., Neely et al., 2006),

one important assumption of support intervention is that re-

ceiving support is a key factor responsible for links to health.

Although perceived support consistently shows such stress-

buffering influences, there is much greater variability in stress-

buffering studies that examine received support (Barrera, 2000;

Uchino & Birmingham, 2008). The present analysis suggests

that interventions that conceptualize support in this fashion will

need to look more closely at the literature on received support

and the importance of considering the stressor context (see Berg

& Upchurch, 2007). Although it may be possible for such in-

terventions to increase perceptions of support, the more proxi-

mal goal should be to influence needed support that is provided

in an effective manner. The possibility that received support is

simply one of many coping options is also important, and broader

approaches may be necessary to supplement support interven-

tions (e.g., cognitive–behavioral interventions).

The present framework also suggests the need for more

comprehensive assessments prior to performing support inter-

ventions. Are these individuals with high or low perceived

support? Are they experiencing deficits in received support?

These questions are important because they might result in more

specific interventions depending on such assessments. For in-

stance, individuals with low perceived support might be better

candidates for more general cognitive behavioral intervention

that focus on a wider set of psychosocial processes that they may

lack (e.g., support seeking skills, perceptions of control).

However, those with high perceived support might be provided

with choices regarding more specific interpersonal exchanges

and information that fosters their general understanding of the

stressor of interest (e.g., support groups for cancer patients). It

may also be important to match particular persons with specific

network members to create support dyads that best meet the

demands of the situation (Lakey, in press).

It is also clear that most social support interventions focus on

individuals who are most at-risk or those who already have

psychological, behavioral, or medical problems. An alternative

way of thinking about support interventions is as a form of pri-

mary prevention that focuses on healthy individuals. Primary

prevention refers to attempts to reduce the probability of a

health problem developing (R.M. Kaplan, 2000). Examples in-

clude interventions to increase exercise or prevent smoking in

healthy individuals. In a compelling analysis, R.M. Kaplan

(2000) argued for the promise of primary prevention efforts,

especially in light of the more limited public health benefits that

seem to arise from secondary prevention efforts that simply focus

on the identification and treatment of disease.

Given that many chronic diseases have a long-term etiology

and develop over decades (e.g., coronary artery disease), pri-

mary prevention efforts in social support interventions may be

particularly important to consider. For instance, given the de-

velopmental antecedents of perceived support, it is clear that

early familial interventions are an important starting point. Such

interventions have mostly been conducted in at-risk populations

and show promise in fostering more positive child outcomes

(Alexander, Sexton, & Robbins, 2002).

This perspective on perceived support also raises the inter-

esting possibility that social support interventions may be use-

fully applied early in children and adolescents to help them

develop positive profiles that then place them on healthier tra-

jectories (e.g., Eggert, Thompson, Herting, Nicholas, & Dicker,

1994). This literature has also focused on a different set of

outcomes (e.g., social interactions, grade point average); how-

ever, existing studies suggest that social skills training in ado-

lescents results in positive social and academic outcomes

(Dirks, Treat, & Weersing, 2007), although the long-term nature

of such interventions need further evaluation (Beelmann,

Pfingsten, & Losel, 1994). One strength of the current framework

for support interventions is that it highlights differing potential

entry points, as well as approaches, depending on whether one is

focusing on perceived or received support.

FUTURE RESEARCH DIRECTIONS

Based on the present framework, there are a number of issues

that I see as being particularly important to address in future

studies linking social support to physical health. The first

and most general is the need to incorporate a life-span approach

that considers the antecedent processes responsible for distinct

measures of support and how they emerge and change over time

to influence risk for disease. For instance, early familial

processes appear to cast long shadows on perceived support

that only become apparent from such a vantage point (Graves

et al., 1998). In addition, the support needs of older adults

need stronger consideration given developmental changes in

social networks and functional health status. However, there

is a lack of theoretical and empirical work that highlights such

antecedent processes, despite their potential usefulness to the

design of relevant interventions (House et al., 1988; G.A.

Kaplan, 1995).

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Bert N. Uchino

It should also be noted that perceived and received support

may differ on other dimensions besides the ones being cur-

rently examined (i.e., intra- and interpersonal). For instance,

perceived support is more abstract and subjective, whereas re-

ceived support tends to be more concrete and objective (e.g., a

specific time frame). In addition, although perceived support is

more stable than received support, received support may also be

stable under some circumstances (e.g., Lakey, in press). Thus,

although I have focused on one important difference between

these assessments, given the lack of conceptual work that has

addressed this issue, more research is needed on other potential

meaningful distinctions and its implications for the present

model and social support theory more generally.

Another important research question relates to links between

the concepts presented in this framework and other indices of

support. General perceived support and received support are the

dominant approaches in epidemiological work, so a focus on

these measures is necessary (Uchino, 2004). However, there are

other measurement approaches that are important to consider,

such as relationship-specific measures of perceived support.

Research by Lakey and colleagues (e.g., Lakey, McCabe, Fisi-

caro, & Drew, 1996; Lakey & Scoboria, 2005) suggest that these

measures are related, but distinct from general perceptions of

support (see also Davis, Morris, & Kraus, 1998; Pierce, Sarason,

& Sarason, 1991). Moreover, relationships-specific assessments

appear to more strongly reflect Trait � Situational influences (Lakey et al., 1996). This suggests that relationship-specific

measures of perceived support may be reflective of processes

operating in both Figures 1 and 2. Studies that focus on the

quality of marital relationships suggest more general links to

disease development and its course (Kiecolt-Glaser & Newton,

2001). Of course, for such measures to have an impact on health,

it is probably necessary for the relationship to be an important

one (e.g., parents, spouse, children). Future research will be

needed to test these possibilities, along with the possible impact

of support erosion or conflict on such relationship-specific

processes (Bolger et al., 1996; Manne & Glassman, 2000).

It is also the case that multidimensional assessments of social

support have conceptual advantages over aggregate indices of

support (Cutrona & Russell, 1990). However, most of the prior

work on social support and health has focused on such aggregate

measures (Uchino, 2004). The few epidemiological studies that

focus on distinct components of perceived support do not sug-

gest differences as a function of support type (i.e., perceived

emotional support; Berkman et al., 1992; Blazer, 1982; Falk,

Hanson, Isacsson, & Östergren, 1992). However, epidemiolog-

ical studies on received support appear to show the most neg-

ative influences for received tangible support (Forster & Stoller,

1992; G.A. Kaplan et al., 1994; Sabin, 1993), and hence, sup-

port type was included as a contextual factor in Figure 2. Very

few studies contrast the health effects of different support types

within the same study, so it will be important for future research

to more fully examine its impact on the proposed models.

In general, this life-span perspective raises questions about

the dominant single risk factor approach seen in the literature.

The present framework highlights the need to examine multiple

psychosocial risk factors in combination (see Gallo & Smith,

1999; G.A. Kaplan, 1995; Williams, Barefoot, & Schneiderman,

2003) in order to supplement the more traditional approach of

focusing on single risk factor models. The later approach is more

tractable, but it ignores considerable research on how these

factors may codevelop and have significant early family origins

(Repetti et al., 2002; Shaw et al., 2004; T.W. Smith & Gallo,

2001). In fact, the present analysis suggests that the adoption of

a profile approach may explain more of the variance in health

outcomes and better reflect the phenomenon of interest. The

need for such an approach was foreshadowed by early work on

successful aging in which the combination of social support and

feelings of control were identified as important psychosocial

factors influencing the biological aging process (Rowe & Kahn,

1987). It is important to note that this line of research has started

to incorporate more of a profile analysis to examine aspects of

successful aging (Ko et al., 2007; J. Smith & Baltes, 1997). Of

course, such an approach lacks the specificity often seen in

single risk factor modeling, but it may provide a more compre-

hensive analysis of complex health outcomes (G.A. Kaplan,

1995). Provided that a broad range of measures are available,

these two approaches can be simultaneously modeled to

examine their fit to the data (e.g., Shaw et al., 2004).

A life-span perspective also highlights the need to better

understand the stage of disease potentially impacted by social

support. There is evidence of perceived support’s role in the

development and course of cardiovascular disease, as well as

susceptibility to infectious illnesses (Berkman et al., 2000;

Uchino, 2004). The present framework makes unique predic-

tions about the relative role of perceived and received support

on chronic disease development. Although more research is

needed, there is evidence suggesting that perceived support

plays a role in lower cardiovascular disease incidence (Andre-

Petersson et al., 2006; Orth-Gomér et al., 1993; Raikkonen

et al., 2001; but see Ikeda et al., 2008). However, I know of no

research examining links between received support and the

development of cardiovascular disease, even in more chroni-

cally stressed populations. More generally, research on social

support and health (including my own) has typically examined

either perceived or received support, with little theoretical

justification for its link to specific stages of disease. Therefore,

future epidemiological and clinical/laboratory work will be

needed to test these predictions regarding the stage of disease

impacted by distinct measures of support.

In this life-span model, I have highlighted the health-relevant

factors that appear to codevelop in the context of supportive,

early family environments. These factors were chosen mostly

because of existing evidence that also links them to physical

health outcomes (Krause, 2001; Shaw et al., 2004; T.W. Smith

& Gallo, 2001). Future research will be needed to determine

248 Volume 4—Number 3

Social Support and Physical Health

the more precise combination of factors that in turn influence

health at both the idiographic and nomothetic levels of analysis.

Identification of other relevant factors may further clarify

processes outlined in the model. For instance, there is a small

but intriguing literature on the physical health benefits of being

a support provider (Brown, Nesse, Vinokur, & Smith, 2003).

Given evidence for early familial influences on prosocial be-

havior (e.g., Knafo & Plomin, 2006), being a support provider

may be another behavioral pathway associated with perceived

support that has corresponding health-relevant affective

and physiological correlates (Brown & Brown, 2006). Received

support, in comparison, is more clearly related to support pro-

vision (Gleason, Iida, Bolger, & Shrout, 2003; Liang et al., 2001;

Sprecher, 2001). Researchers have found that equity between

received and provided support (i.e., under- or overbenefitting)

may be important in considering the overall links between re-

ceived support and various outcomes (Gleason et al., 2003;

Sprecher, 2001), which is consistent with a contextual approach.

However, more work is needed on the separable and joint

contributions of these support constructs in a physical health

context.

There is also a pressing need to elucidate the mechanisms

responsible for social support and health links (House, 2001).

Proposed mediators are evident at multiple levels of analysis

and include psychosocial (e.g., appraisals) and behavioral (e.g.,

health behaviors) factors (Berkman et al., 2000). The present

framework makes unique predictions about the more proximal

pathways linking different aspects of support to health out-

comes. For instance, proactive coping is proposed to be an im-

portant mechanism linking perceived support to longer term

health outcomes (Aspinwall & Taylor, 1997), whereas more

‘‘reactive’’ coping (i.e., coping in response to stress) is thought to

be partly responsible for received support influences. Thus, the

model encourages the simultaneous consideration of differing

pathways and makes competing predictions about such in-

fluences.

Finally, there are differing levels of analysis when examining

links between social support and health (Berkman et al., 2000).

This framework hasmostly focused on relevant psychosocial and

behavioral processes. However, there are both broader and more

specific levels of analysis that need modeling in social support

and health work. For instance, cultural processes influence the

seeking of support, so the effects of received support may vary

accordingly. Asian Americans appear more reluctant than Eu-

ropean Americans to seek support during stress due to relational

concerns (Taylor et al., 2004). These data suggest that important

antecedent processes linking received support to positive or

negative outcomes can differ as a function of culture (i.e., re-

lationship concerns versus threats to independence), although

the health consequences of such cultural differences need fur-

ther study.

Likewise, more microlevel biological processes are an im-

portant level of analysis and can vary depending on the stage of

disease. For instance, the role of social support in buffering

stress reactivity during the development of disease highlights

the role of endothelial injury due to mechanical (e.g., shear

force) or chemical (e.g., catecholamines) factors as important

precipitating events (Krantz & Manuck, 1984). More recent

research is focusing on the possibility that inflammatory

processes following endothelial injury are crucial due to the

migration of macrophages and/or T-cells and the release of

cytokines (Libby, 2002; R. Ross, 1999). In comparison, the

mechanisms linking low support to the clinical course of diag-

nosed cardiovascular disease may be related more to the

induction of myocardial ischemia, arrhythmias, and thrombosis

(Rozanski, Blumenthal, & Kaplan, 1999). This level of analysis

thus highlights the need to model different biological path-

ways depending on the support measure and relevant stage of

disease (e.g., perceived support and cardiovascular disease

development).

CONCLUSIONS

In the present analysis, I have argued for the importance of a

life-span approach to the examination of the physical health

effects of general perceived and received social support. This

framework highlights the factors that influence the development,

utilization, and effectiveness of support over time. More spe-

cifically, the separability of perceived and received support is

highlighted by focusing on distinct antecedent processes and

mechanisms. This framework also makes unique predictions

about the type and stage of disease potentially impacted by these

distinct support measures. The benefits of this framework are

most evident in the generative nature of the proposed predic-

tions for the literature linking social support to physical health.

Prior epidemiological work makes a strong case for the tre-

mendous potential for relationships to influence physical health

outcomes. To realize this potential, the complexities of the

phenomena from an interdisciplinary perspective need to be

modeled. This framework is an attempted step in this direction of

fostering social support theory in the health domain and its

potentially novel research/intervention implications.

Acknowledgments—Support for this review was generously

provided by the National Heart, Lung, and Blood Institute (R01

HL085106) and by the National Institute on Aging (R21

AG029239). This article has also benefitted from the extremely

helpful suggestions of Cynthia Berg, Lisa Diamond, Brian La-

key, and Timothy Smith. Of course, all errors of fact or emphasis

are mine.

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