Social support and coronary heart disease: epidemiologic evidence and implications for treatment

Social Support and Access to Health Care Among Older People in Japan: Japan Gerontological Evaluation Study (JAGES)

We investigated cross-sectional associations between social support and access to health care among older Japanese people. From larger cohort datasets of community-dwelling people aged 65 years or older, 23 079 respondents were extracted. We summarized patterns of social support by gender and age group, then analyzed associations between social support and the experience of unmet health care needs, as a negative indicator of access. Adjusting for socioeconomic factors, multiple logistic regression identified that respondents who received instrumental support were less likely to experience unmet health care needs except males aged 65 to 69 years. The effect of receiving instrumental social support was larger than for household income and similar to anxiety about unexpected expenses. In the low-income group, these findings were highlighted among females aged 65 to 69 years and males aged 70 years and older. In addition to redistribution of financial resources, facilitating suitable social support may contribute to alleviating the access gap among older people.

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Background

Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications.

Methods/design

We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care.

Discussion

If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities.

Trial registration

ClinicalTrials.gov, NCT02328326. Registered on 31 December 2014.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2785-2) contains supplementary material, which is available to authorized users.

A conceptual model of social networks and mechanisms of cancer mortality, and potential strategies to improve survival

Women with larger personal social networks have better breast cancer survival and a lower risk of mortality. However, little work has examined the mechanisms through which social networks influence breast cancer outcomes and cancer outcomes more generally, potentially limiting the development of feasible, clinically effective interventions. In fact, much of the emphasis in cancer research regarding the influence of social relationships on cancer outcomes has focused on the benefits of the provision of social support to patients, especially through peer support groups, and only more recently through patient navigation. Though critically important, there are other ways through which social relationships might influence outcomes, around which interventions might be developed. In addition to social support, these include social resources, social norms, social contagion, social roles, and social burdens and obligations. This narrative review addresses how social networks may influence cancer outcomes and discusses potential strategies for improving outcomes given these relationships. The paper (a) describes background and limitations of previous research, (b) outlines terms and provides a conceptual model that describes interrelationships between social networks and relevant variables and their hypothesized influence on cancer outcomes, (c) clarifies social and psychosocial mechanisms through which social networks affect downstream factors, (d) describes downstream behavioral, treatment, and physiological factors through which these subsequently influence recurrence and mortality, and (e) describes needed research and potential opportunities to enhance translation. Though most literature in this area pertains to breast cancer, this review has substantial relevance for cancer outcomes generally. Further clarification and research regarding potential mechanisms are needed to translate epidemiological findings on social networks into clinical and community strategies to improve cancer outcomes.

GENDER DIFFERENCES IN THE ASSOCIATION BETWEEN MARITAL STATUS AND HYPERTENSION IN GHANA

Hypertension is a significant contributor to the global burden of cardiovascular and related target organ diseases such as heart failure, coronary heart disease, stroke and kidney failure, and their associated premature morbidity, mortality and disability. Marital status is an important social characteristic known to predict a range of health outcomes including cardiovascular disease. However, little is known about its impact on hypertension in sub-Saharan Africa. This study explored the relationship between marital status and hypertension among women and men in Ghana. Drawing on data from the 2014 Ghana Demographic and Health Survey (GDHS), descriptive statistics and binary logistic regression models were used to analyse the link between marital status and hypertension. About 13% of women aged 15-49 and 15% of men aged 15-59 were found to be hypertensive. After controlling for lifestyle and socio-demographic covariates, the logistic regression models showed significantly higher odds of hypertension for married (OR=2.14, 95% CI=1.30-3.53), cohabiting (OR=1.94, 95% CI=1.16-3.23) and previously married (OR=2.23, 95% CI=1.29-3.84) women. In contrast, no significant association was found between any of the marital status cohorts and hypertension for men. Other significant predictors of hypertension were age, body mass index and wealth status. The results demonstrate that marital status is an independent risk factor for hypertension in Ghana for women, rather than men. This could have immediate and far-reaching consequences for cardiovascular health policy in Ghana. In particular, the findings could lead to better targeted public health interventions, including more effective risk factor assessment and patient education in clinical settings, which could lead to more effective patient management and improved cardiovascular outcomes.

Determinants of heart rate variability in the general population: The Lifelines Cohort Study

BACKGROUND

Heart rate variability (HRV) is an important marker of heart health, with low values reflecting reduced vagal control of the heart rhythm.

OBJECTIVE

The purpose of this study was to investigate the extent to which a broad range of demographic (age, sex), lifestyle (physical activity, smoking, alcohol use), and psychosocial factors (stress, social well-being, neuroticism) explain individual differences in HRV in the general population.

METHODS

Using baseline data of 10-second electrocardiograms from the Lifelines Cohort Study (n = 149,205; 58.7% female; mean age ± SD: 44.6 ± 13.2 years), we calculated the root mean square of successive differences (RMSSD) between adjacent interbeat intervals as an index of cardiac parasympathetic nervous system activity. We also calculated RMSSD adjusted for its dependency on heart rate (cRMSSD). The association of demographic, lifestyle, and psychosocial factors with RMSSD was assessed using hierarchical linear regression models adjusting for potential confounding effects of medication use, disease, and body mass index.

RESULTS

HRV strongly declined with age and was consistently higher in women. These demographic factors together explained 17.4% of the variance in RMSSD and 21.9% in cRMSSD. Physical activity, alcohol use, and smoking showed some significant associations with RMSSD, but stress, social well-being, and neuroticism did not. Adding lifestyle and psychosocial factors to the model additionally explained <0.50% of the variance.

CONCLUSION

Age and sex were the most important determinants in this very large general population cohort, explaining almost one-fifth of the individual differences in HRV. The additional contribution of lifestyle and psychosocial factors was negligible.

Secular and Religious Social Support Better Protect Blacks than Whites against Depressive Symptoms

Purpose: Although the protective effect of social support against depression is well known, limited information exists on racial differences in this association. The current study examined Black-White differences in the effects of religious and secular emotional social support on depressive symptoms in a national sample of older adults in the United States. Methods: With a longitudinal prospective design, the Religion, Aging and Health Survey, 2001⁻2004, followed 1493 Black (n = 734) and White (n = 759) elderly individuals (age 66 and older) for three years. Race, demographics (age and gender), socio-economics (education and marital status) and frequency of church attendance were measured at baseline in 2001. Secular social support, religious social support, chronic medical conditions and depressive symptoms [8- item Center for Epidemiological Studies-Depression scale (CES-D)] were measured in 2004. Multiple linear regression models were used for data analysis.

RESULTS

In the pooled sample, secular and religious social support were both protective against depressive symptoms, net of all covariates. Race interacted with secular (β = −0.62 for interaction) and religious (β = −0.21 for interaction) social support on baseline depressive symptoms (p < 0.05 for both interactions), suggesting larger protections for Blacks compared to Whites. In race-specific models, the regression weight for the effect of secular social support on depressive symptoms was larger for Blacks (β = −0.64) than Whites (β = −0.16). Conclusion: We found Black—White differences in the protective effects of secular and religious social support against depressive symptoms. Blacks seem to benefit more from the same level of emotional social support, regardless of its source, compared to Whites.

Food Insecurity and Obesity: Exploring the Role of Social Support

BACKGROUND

Women are disproportionately affected by both obesity and food insecurity. Food insecurity occurs when there is limited ability to acquire adequate foods. It is unknown whether social support can reduce the effect of food insecurity on increased obesity. This study seeks to determine whether social support modifies the relationship between food insecurity and obesity.

METHODS

We conducted a cross-sectional study in a nationally representative sample of 4672 women aged ≥40 years using National Health and Nutrition Examination Survey (2003-2008). Individual food insecurity was assessed based on the U.S. Department of Agriculture 18-item validated household food security scale. Women were categorized as fully food secure (0 affirmative responses) or food insecure (1-10 affirmative responses). Obesity was defined as body mass index ≥30 kg/m2. Outcomes were analyzed by multivariable logistic regression.

RESULTS

Fourteen percent were food insecure. Women with food insecurity had 1.4 the odds of obesity as those who were fully food secure, adjusting for race/ethnicity and health status (95% confidence interval [CI] 1.22-1.62). Food-insecure women were 80% less likely to report strong social support than women who were fully food secure (95% CI 0.11-0.36). Social support as measured in this study did not modify the association between food insecurity and obesity.

CONCLUSIONS

Women reporting food insecurity reported lower levels of social support and were more likely to experience obesity. Interventions to reduce obesity in women who are food insecure must consider the limited resources available to these women.

Psychosocial Interventions and Wellbeing in Individuals with Diabetes Mellitus: A Systematic Review and Meta-Analysis

Purpose: A number of studies, including systematic reviews, show beneficial effects of psychosocial interventions for people with diabetes mellitus; however, they have not been assessed using meta-analysis. The purpose of this meta-analysis of randomized controlled trials is to investigate the effects of psychosocial interventions on depressive and anxiety symptoms, quality of life and self-efficacy in individuals with diabetes mellitus.

Methods: The databases Pubmed, MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science and SocINDEX were searched with no year restriction. Eligible studies were randomized controlled trials published in English that included individuals diagnosed with diabetes mellitus, aged 18 years or above, who engaged in a psychosocial intervention, with outcome measures addressing depressive or anxiety symptomology, quality of life or self-efficacy. Eligible studies needed to compare the intervention to usual care. Study selection was completed using Covidence and meta-analysis was undertaken using Comprehensive Meta-Analysis software.

Results: Seven studies were included in the meta-analysis. Five studies investigated the effects of psychosocial interventions and showed a medium to large benefit for depressive symptoms (SMD: −0.70; CI: −1.27, −0.13) which persisted at follow up (SMD: −1.54, CI: −2.97, −0.12). Similar results were not seen immediately post-intervention in the three studies that assessed anxiety symptoms (SMD: −0.30; CI: −0.69, 0.10); however, a medium beneficial effect was seen at follow up (SMD = −0.61, CI = −0.92 to −0.31). Small benefits were seen in the three studies assessing quality of life outcomes (SMD: 0.30, CI: 0.06, 0.55). No benefit was seen in the two studies assessing self-efficacy (SMD: 0.23, CI: −0.11, 0.57).

Conclusions: The results of the current study provide preliminary evidence that psychosocial interventions, compared to usual care, reduce depressive symptoms, and may improve quality of life in individuals with diabetes. However, only a few studies were included and the clinical significance of these findings is unknown.

Perceived social support and life satisfaction in drug addicts: Self-esteem and loneliness as mediators

This study was designed to investigate the mediation effects of both self-esteem and loneliness on the relationship between social support and subjective well-being in drug addicts. In all, 110 participants, all drug addicts from Guangdong Fangcun Brain Hospital, completed the questionnaire. Pearson’s correlation analysis showed that perceived social support was positively related to self-esteem and life satisfaction and was negatively correlated with loneliness in drug addicts. Structural equation modeling estimated by the Bootstrap method indicated that loneliness and self-esteem partially mediated the association between perceived social support and life satisfaction. These findings provided insights into the association between perceived social support and life satisfaction in drug addicts.

The Association Between Social Support, Body Mass Index and Increased Risk of Prediabetes: the Cardiovascular Risk in Young Finns Study

PURPOSE

The psychosocial determinants of prediabetes are poorly understood. The aims of our study were (1) to analyse the association between perceived social support in young adulthood and fasting glucose levels and prediabetes in mid-adulthood in a cohort of healthy Finns, (2) to explore whether body mass index (BMI), inflammation or depression mediate this relationship, (3) and to examine the association between social support trajectory groups and fasting glucose.

METHOD

A prospective design was used with an analytic sample of 1250 participants aged 3-18 years at baseline (1980) and aged 12-39 years when social support was measured. Fasting glucose and prediabetes were assessed 32 years after baseline. Linear and logistic regression was used to examine the association between social support and the outcome measures. A bootstrapping technique was used to examine mediation effects.

RESULTS

Social support was associated with future glucose levels in women after adjusting for childhood socioeconomic status (SES) and youth depression (β = -0.136, p = 0.001) and also predicted prediabetes in women after adjusting for childhood SES (β = 1.31, 95 % CI 1.02 to 1.69, p = 0.031). Both associations were attenuated after adjusting for BMI in mid-adulthood. BMI was found to mediate the relationship between social support and prediabetes in women (β for indirect effect β = 0.09, SE = 0.03, CI = 0.03 to 0.16).

CONCLUSION

Low perceived social support in young adulthood is associated with high fasting glucose and prediabetes in mid-adulthood in women but not men. The association between social support and prediabetes in women can be partly explained by BMI.

Adverse childhood experiences (ACEs) and later-life depression: perceived social support as a potential protective factor

OBJECTIVE

To investigate associations between adverse childhood experiences (ACEs) and later-life depressive symptoms; and to explore whether perceived social support (PSS) moderates these.

METHOD

We analysed baseline data from the Mitchelstown (Ireland) 2010-2011 cohort of 2047 men and women aged 50-69 years. Self-reported measures included ACEs (Centre for Disease Control ACE questionnaire), PSS (Oslo Social Support Scale) and depressive symptoms (CES-D). The primary exposure was self-report of at least one ACE. We also investigated the effects of ACE exposure by ACE scores and ACE subtypes abuse, neglect and household dysfunction. Associations between each of these exposures and depressive symptoms were estimated using logistic regression, adjusted for socio-demographic factors. We tested whether the estimated associations varied across levels of PSS (poor, moderate and strong).

RESULTS

23.7% of participants reported at least one ACE (95% CI 21.9% to 25.6%). ACE exposures (overall, subtype or ACE scores) were associated with a higher odds of depressive symptoms, but only among individuals with poor PSS. Exposure to any ACE (vs none) was associated with almost three times the odds of depressive symptoms (adjusted OR 2.85; 95% CI 1.64 to 4.95) among individuals reporting poor PSS, while among those reporting moderate and strong PSS, the adjusted ORs were 2.21 (95% CI 1.52 to 3.22) and 1.39 (95% CI 0.85 to 2.29), respectively. This pattern of results was similar when exposures were based on ACE subtype and ACE scores, though the interaction was clearly strongest among those reporting abuse.

CONCLUSIONS

ACEs are common among older adults in Ireland and are associated with higher odds of later-life depressive symptoms, particularly among those with poor PSS. Interventions that enhance social support, or possibly perceptions of social support, may help reduce the burden of depression in older populations with ACE exposure, particularly in those reporting abuse.

The effect of perceived control on self-reported cardiovascular disease incidence across adulthood and old age

OBJECTIVE

To examine whether rates of change in perceived control are predictive of cardiovascular disease (CVD) incidence across adulthood and old age.

DESIGN

We used the PATH Through Life Project (n = 7103, M = 40, SD = 16; 52% women), a longitudinal panel survey that encompasses three cohorts at Time 1, ages 20-24, 40-44 and 60-64, who have been assessed three times at four-year intervals.

METHOD

We examined whether rates of change in perceived control were associated with CVD incidence over 8 years of time, over and above that of baseline levels of perceived control and known risk factors for CVD.

MAIN OUTCOME MEASURES

Self-reported CVD incidence.

RESULTS

Increases in perceived control over time were associated with decreased likelihood of 8-year incidence of CVD and these effects were independent of socio-demographics, covariates and baseline levels of perceived control. The effects were consistent across young adulthood, midlife and old age and for men and women.

CONCLUSIONS

Findings demonstrate the importance of changes in perceived control as a predictor of CVD incidence across adulthood and old age. We suggest future research using mediation analysis to test reverse causality and mechanisms underlying the effects of perceived control on CVD incidence.

Social Integration and Reduced Risk of Coronary Heart Disease in Women: The Role of Lifestyle Behaviors

RATIONALE

Higher social integration is associated with lower cardiovascular mortality; however, whether it is associated with incident coronary heart disease (CHD), especially in women, and whether associations differ by case fatality are unclear.

OBJECTIVES

This study sought to examine the associations between social integration and risk of incident CHD in a large female prospective cohort.

METHODS AND RESULTS

Seventy-six thousand three hundred and sixty-two women in the Nurses' Health Study, free of CHD and stroke at baseline (1992), were followed until 2014. Social integration was assessed by a simplified Berkman-Syme Social Network Index every 4 years. End points included nonfatal myocardial infarction and fatal CHD. Two thousand three hundred and seventy-two incident CHD events occurred throughout follow-up. Adjusting for demographic, health/medical risk factors, and depressive symptoms, being socially integrated was significantly associated with lower CHD risk, particularly fatal CHD. The most socially integrated women had a hazard ratio of 0.55 (95% confidence interval, 0.41-0.73) of developing fatal CHD compared with those least socially integrated (P for trend <0.0001). When additionally adjusting for lifestyle behaviors, findings for fatal CHD were maintained but attenuated (P for trend =0.02), whereas the significant associations no longer remained for nonfatal myocardial infarction. The inverse associations between social integration and nonfatal myocardial infarction risk were largely explained by health-promoting behaviors, particularly through differences in cigarette smoking; however, the association with fatal CHD risk remained after accounting for these behaviors and, thus, may involve more direct biological mechanisms.

CONCLUSIONS

Social integration is inversely associated with CHD incidence in women, but is largely explained by lifestyle/behavioral pathways.

Correlates of health-related quality of life in patients with myocardial infarction: A literature review

BACKGROUND

By the increasing emphasis on health-related quality of life (HRQoL) in patients with myocardial infarction (MI), it is necessary to explore factors that affect HRQoL in this population.

OBJECTIVES

This study aimed to identify correlates of HRQoL in patients with MI.

DESIGN

A literature review of the factors that affect HRQoL in patients with MI (1995-2016).

DATA SOURCES

Three main databases-CINAHL, MEDLINE and PsychINFO-were searched to retrieve relevant peer-reviewed articles published in English.

REVIEW METHODS

In consultation with a medical librarian, we identified relevant MeSH terms and used them for searching the literature: health-related quality of life/quality of life/HRQoL/QoL, myocardial infarction/heart attack/MI and predict*/factor. Data elements were extracted and narratively described variables synthesised into four categories.

RESULTS

A total of 48 studies met the inclusion criteria and were included in the review. Correlates of HRQoL in patients with MI were identified in the following categories: demographic, behavioural, disease-related, and psychosocial factors. Specific correlates included age and gender-identity for demographic factors; physical activity and smoking for behavioural factors; severity of MI, symptoms, and comorbidities for disease-related factors; anxiety and depression for psychosocial factors.

CONCLUSIONS

Identifying correlates of HRQoL can help identify patients who are at risk for poor HRQoL in the recovery or rehabilitation stage of post-MI. Future intervention should focus on adjustable correlates such as behavioural and psychosocial factors to promote HRQoL among patients after experiencing MI.

Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study

BACKGROUND

Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI.

METHODS

We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction.

RESULTS

One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women.

CONCLUSIONS

Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Depression, social support, and long-term risk for coronary heart disease in a 13-year longitudinal epidemiological study

Depression has been linked with long-term risk for a variety of physical health ailments, including coronary heart disease (CHD). Little is known about resilience factors that may attenuate this relationship. The current study assessed whether social support moderates the long-term risk for CHD associated with this disorder. Data were drawn from the Americans' Changing Lives study, a nationally representative longitudinal survey of adults in the United States. Participants (unweighted n=1636) completed initial assessments of functional social support, body mass index, recent history of major depression, CHD, hypertension, and diabetes. Participants were again assessed for CHD at a follow-up assessment 13 years later. Social support was found to moderate the relationship between depression and the occurrence of CHD 13 years later. Specifically, among individuals with low social support, depression was prospectively associated with CHD. In contrast, depression was not prospectively associated with CHD among individuals with high social support. The results indicate that social support may function as a resilience factor against the long-term cardiovascular risk associated with depression. Clinical interventions focusing on the development of social support systems are important not only for addressing depression itself, but also for associated long-term physical health outcomes.

Social Relationships and Inflammatory Markers in the MIDUS Cohort: The Role of Age and Gender Differences

OBJECTIVE

To better understand age and gender differences in associations of social relationships with chronic inflammation.

METHOD

Using a sample of middle-aged and older adults ( N = 963) from the Midlife Development in the United States (MIDUS) biomarker project, we examined interactions of age and gender with structural and functional social network measures in predicting interleukin-6 (IL-6) and C-reactive protein (CRP).

RESULTS

Significant interactions involving age and gender showed that social support was associated with lower IL-6 in older women, whereas perceived positive relationships and social integration were related to lower IL-6 in both men and women of advanced age. Functional measures were associated with higher CRP in both men and women after adjustment for health conditions and behaviors, with some further variation by age.

DISCUSSION

Greater social support may be related to lower IL-6 in older women. Further research is needed to understand observed associations of social support with higher CRP.

Lifestyle Modification in Secondary Prevention: Beyond Pharmacotherapy

Despite significant advances in medical technology and pharmacology, cardiovascular disease (CVD) remains a major contributor to health care expenses and the leading cause of death in the United States. Patients with established CVD and their health care providers are challenged with achieving cardiovascular risk reduction to decrease the likelihood of recurrent cardiovascular events. This "secondary prevention" can be achieved, in part, through adherence to prescribed pharmacotherapies that favorably modify major coronary risk factors (ie, hypertension, hypercholesterolemia, diabetes, and obesity). However, lifestyle modification can also be helpful in this regard, providing independent and additive benefits to the associated reductions in cardiovascular morbidity and mortality. Accordingly, physicians and other health care providers should routinely counsel their coronary patients to engage in structured exercise and increased lifestyle physical activity, consume a heart-healthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial stressors that may elevate cardiovascular risk. These lifestyle interventions, either as an adjunct to medication therapy or independently in those patients where medications may be poorly tolerated, cost prohibitive, or ineffective, can significantly decrease cardiovascular mortality and the risk of recurrent cardiac events.

Factors predicting quality of life for coronary artery disease patients after percutaneous coronary intervention

Background: A clear understanding of factors affecting patients’ perception of quality of life (QOL) would be useful for improving continuous care in coronary artery disease (CAD) patients.

Objective: To examine the causal relationships between cardiac self-efficacy, social support, left-ventricular ejection fraction (LVEF), angina, dyspnea, depression, vital exhaustion, functional performance, and QOL in CAD patients experiencing postpercutaneous coronary intervention (post-PCI).

Methods: We used a research survey for causal analysis design to explore the theoretical linkage, guided by the revised Wilson and Cleary model, between QOL interest variables and patient QOL. The 303 subjects were all post-PCI CAD patients. All participants completed the following surveys: (1) a demographic data questionnaire, (2) a QOL Index (Cardiac version IV), (3) the Center for Epidemiologic Studies Depression Scale, (4) the Cardiac Self-efficacy Scale, (5) the Social Support Questionnaire, (6) the Rose Questionnaire for angina, (7) the Rose Dyspnea Scale, (8) the SF-36: vitality subscale, and (9) the Functional Performance Inventory Short-Form, with reliability ranging from 0.72 to 0.98. Data were analyzed using a linear structural relationship analysis.

Results: The postulated model was found to fit the empirical data and explained 54% of the variance in quality of life (χ2 = 1.90, df = 3, p = 0.59, χ2/df = 0.63, root mean square error of approximation = 0.00, Goodness of Fit Index = 0.99, Adjusted Goodness of Fit Index = 0.98). Social support, depression, and vital exhaustion were found to significantly and directly affect the QOL of post-PCI CAD patients. Cardiac self-efficacy was the only variable that had an indirect effect on quality of life (β = 0.21, p < 0.001).

Conclusion: Health care providers should be aware of the significant effects of social support, depression, vital exhaustion, and self-efficacy on QOL, and develop appropriate nursing interventions to improve quality of life in post-PCI CAD patients.

Social support and networks: cardiovascular responses following recall on immigration stress among Chinese Americans

Social support has been shown to act as a buffer for cardiovascular responses to stress. However, little is known about how social support and networks are related to cardiovascular responses to immigration stress recall. The current study evaluated the impact of structural and functional support on cardiovascular reaction following immigrant stress recall provocation as well as the moderation effect of interdependent self-construal among first-generation Chinese immigrants. One hundred fifty Chinese immigrants were recruited in the New York Chinatown area. Participants completed questionnaires assessing their levels of social support and networks, and interdependent self-construal. Following adaptation, participants recalled a recent post-immigration stress-provoking situation. Cardiovascular measures were taken during adaptation, stressor task, and recovery period. Hierarchical multiple regression analysis was performed. Social network size and type, as well as perceived emotional support were positively predictive of systolic blood pressure (SBP) reactivity changes. Instrumental support seeking was a positive predictor of SBP and diastolic blood pressure (DBP) reactivity. The moderation effect between instrumental support seeking and interdependent self-construal were significantly predictive of DBP reactivity and recovery, suggesting that perceptions about themselves in relation to others is a crucial factor for determining whether support seeking is beneficial or not. Social support was not a direct buffer on cardiovascular responses to stress among Chinese immigrants. Chinese values of interdependence and collectivism may partly explain the disconfirming results. Still, when interdependent self-construal was taken into account, Chinese immigrants who had less interdependent self-construal, but solicited more instrumental support, had faster adaptation to stress over the long term.

Relationship between health-related quality of life, perceived family support and unmet health needs in adult patients with multimorbidity attending primary care in Portugal: a multicentre cross-sectional study

BACKGROUND

Multimorbidity has a high prevalence in the primary care context and it is frequently associated with worse health-related quality of life (HRQoL). Few studies evaluated the variables that could have a potential effect on HRQoL of primary care patients with multimorbidity. The purpose of this study, the first of its kind ever undertaken in Portugal, is to analyse the relationship between multimorbidity, health-related quality of life, perceived family support and unmet health needs in adult patients attending primary care.

METHODS

Multicentre, cross-sectional survey conducted among primary care patients with multimorbidity. It included 521 participants (64.1 % females) who met the inclusion criteria. HRQoL was evaluated using the Portuguese Short Form-12 Health Status Questionnaire. The Portuguese Family APGAR was used to measure the perceived family support. A patients' unmet health needs questionnaire was used. The unmet needs for medical, surgical and dental care; prescription medications; mental healthcare or counselling; and eyeglasses or other technical aid was assessed. Descriptive and multivariate analyses were performed.

RESULTS

The sample had an overall average of 4.5 chronic health problems. Increased multimorbidity levels were linked to worse health-related quality of life, particularly the physical health. Some variables were confirmed as playing a role on health-related quality of life. Male patients with high monthly incomes and highly functional families had better physical and mental health. High levels of education and the presence of asthma were also associated with better physical health. Contrariwise, elderly patients with high levels of multimorbidity and with osteoarthritis had lower physical health. The majority of the patients did not have unmet health needs. When health needs were stated they were mostly for generalist medical care, dental care, and eyeglasses/other technical aid. Financial insufficiency was the primary reason for not fulfilling their health needs.

CONCLUSION

To improve the quality of life of multimorbid patients, within primary care practices and health delivery systems, one should take into special account the sex of the patient, the perceived family support and the self-perceived economic status because of their relationship with both physical and mental health. Limitations and recommendations are discussed.

Association between social capital and the prevalence of gestational diabetes mellitus: An interim report of the Japan Environment and Children's Study

BACKGROUND

Social capital is generally defined as the quality and frequency of social interactions with relatives, neighbors, and society. Social capital refers to broad concepts of social interactions and structures in individuals, communities and societies such as trust (e.g., neighborhood trust, which is social cohesion with neighbors) and social support (e.g., emotional support, which is the level of the feeling of being loved). Studies during the last few decades have shown that there is a significant inverse association between social capital and the prevalences of diseases such as depression and acute coronary syndrome. Significant inverse associations between trust, social support and the prevalence of diabetes have also been shown. However, associations between social capital and the prevalence of gestational diabetes mellitus (GDM) are less clear.

METHODS

We used the primary dataset of the Japan Environment and Children's Study (JECS), including 10,228 mothers with recorded obstetric outcomes from January to December 2011. In this study, we included 8874 the 10,228 participants. Diagnosis of GDM was determined using the criteria of the Japan Diabetes Society (JDS). The quality and quantity of social capital were measured with nine questions on a self-administered questionnaire during the second or third trimester. Using principal component analysis (PCA), we distinguished the following three components (indices) of social capital: (A) index of all nine questions about social capital, (B) index of emotional support and neighborhood trust and (C) index of generalized trust. The high factor loading variants of indices were as follows; (A) all nine variants, (B) five variants about emotional support and neighborhood trust and (C) two variants about generalized trust. Multivariate random effect modeling was used to calculate the odd ratios (ORs) for evaluating the association between these indices of social capital and the prevalence of GDM. This model was adjusted for baseline characteristics such as family income, BMI before pregnancy and smoking during pregnancy.

RESULTS

Of the 8874 participants, 204 women developed GDM (2.30%). Multivariable logistic regression analysis showed that index B, the index of emotional support and neighborhood trust (adjusted OR: 0.651, 95% CI: 0.429, 0.987) was significantly and independently associated with the prevalence of GDM.

CONCLUSIONS

We found that the 5-question index of emotional support and neighborhood trust is significantly associated with the prevalence of GDM during pregnancy.

High perceived social support protects against the intergenerational transmission of obesity: The Cardiovascular Risk in Young Finns Study

AIMS

Our aims were to assess whether offspring social support moderates the relationship between parental body mass index (BMI) and offspring BMI.

METHODS

A prospective design was used with an analytic sample of 1049 participants from Finland (the offspring) who were 35-50years old in 2012 when adulthood BMI was measured. Parental BMI was self-reported at baseline in 1980. Offspring social support was measured in 2007 when participants were 30-45years old. Linear and logistic regression was used to examine whether there was an interaction between parental BMI and offspring social support when predicting offspring BMI in adulthood. An analysis of simple slopes and multilevel growth curve modeling were used to further examine the interaction.

RESULTS

The interaction between maternal BMI and offspring social support was significantly and negatively related to offspring BMI in adulthood (β=-0.068, R(2) change=0.005, p=0.015) in the fully adjusted model which also adjusted for parental occupational status and offspring depressive symptoms. The logistic regression supported these results, with the interaction between maternal overweight (BMI≥25kg/m(2)) and offspring social support negatively associated with offspring overweight in adulthood (odds ratio=0.74, 95% confidence interval, 0.56 to 0.98). The growth curve analysis further demonstrated that high maternal BMI predicts more rapidly rising offspring BMI in those reporting low social support compared to high social support.

CONCLUSIONS

Our results suggest that social support protects against the intergenerational transmission of obesity and therefore presents an important opportunity for obesity prevention efforts.

A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study

Background

Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.

Objective

To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.

Methods

We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants’ feedback was used to develop a family-centered self-management program called “SUCCEED: Self-management Using Couples’ Coping EnhancEment in Diseases.” The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants’ program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.

Results

Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED’s sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.

Conclusion

In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

Source-specific workplace social support and high-sensitivity C-reactive protein levels among Japanese workers: A 1-year prospective cohort study

BACKGROUND

This study investigated the prospective association between source-specific workplace social support and high-sensitivity C-reactive protein (hs-CRP) levels in workers in Japan.

METHODS

We conducted a 1-year prospective cohort study with 1,487 men and 533 women aged 18-65 years. Participants worked at two manufacturing worksites in Japan and were free of major illness. We used multivariable linear regression analyses to evaluate the prospective association between supervisor and coworker support at baseline, and hs-CRP levels at follow-up. We conducted the analyses separately for men and women.

RESULTS

For women, high supervisor support at baseline was significantly associated with lower hs-CRP levels at follow-up (β = -0.109, P < 0.01), whereas coworker support at baseline was not significantly associated with hs-CRP levels at follow-up. Associations between supervisor and coworker support and hs-CRP levels were not significant for men.

CONCLUSIONS

Supervisor support may have beneficial effects on inflammatory markers in working women. Am. J. Ind. Med. 59:676-684, 2016. © 2016 Wiley Periodicals, Inc.

Psychosocial Screening and Assessment Practice within Cardiac Rehabilitation: A Survey of Cardiac Rehabilitation Coordinators in Australia

BACKGROUND

Many cardiac rehabilitation (CR) guidelines and position statements recommend screening for psychosocial risk factors, although there is wide variation in the recommended factors and recommended screening tools. Little is known about screening in CR in Australia.

METHODS

Cardiac rehabilitation coordinators at the 314 CR programs operating across Australia, drawn from the 2014 Australian Directory of Cardiac Rehabilitation Services were invited to participate in an online survey.

RESULTS

Of 165 complete responses, 157 (95%) CR coordinators indicated that they screened at entry with 132 (80%) screening on exit. At CR entry, programs screened for - depression (83%), anxiety (75%), stress (75%), and sleep disturbance (57%). The use of standardised instruments by those screening at entry varied from 89% for depression to only 9% for sleep disturbance. Organisational, resource and personal barriers inhibited the routine screening for many psychosocial factors.

CONCLUSIONS

Surveys such as this are useful for monitoring the rate of adoption of guideline recommendations and identifying barriers to implementation. Findings can also inform discussions about what should be included in minimum data sets for CR programs, and the identification of brief screening tools that have been validated not just in the general population but in cardiac patients.

Sexual activity and concerns in people with coronary heart disease from a population-based study

Objective

Sexual activity is a central component of intimate relationships, but sexual function may be impaired by coronary heart disease (CHD). There have been few representative population-based comparisons of sexual behaviour and concerns in people with and without CHD. We therefore investigated these issues in a large nationally representative sample of older people.

Methods

We analysed cross-sectional data from 2979 men and 3711 women aged 50 and older from the English Longitudinal Study of Ageing. Sexual behaviour and concerns were assessed by validated self-completion questionnaire and analyses were weighted for non-response. Covariates included age, partnerships status and comorbidities.

Results

There were 376 men and 279 women with CHD. Men with CHD were less likely to be sexually active (68.7% vs 80.0%, adjusted OR 0.62, 95% CI 0.47 to 0.81), thought less about sex (74.7% vs 81.9%, OR 0.72, CI 0.54 to 0.95), and reported more erectile difficulties (47.4% vs 38.1%, OR 1.46, CI 1.10 to 1.93) than men without CHD. Effects were more pronounced among those diagnosed within the past 4 years. Women diagnosed <4 years ago were also less likely to be sexually active (35.4% vs 55.6%, OR 0.44, CI 0.23 to 0.84). There were few differences in concerns about sexual activity. Cardiovascular medication showed weak associations with erectile dysfunction.

Conclusions

There is an association between CHD and sexual activity, particularly among men, but the impact of CHD is limited. More effective advice after diagnosis might reverse the reduction in sexual activity, leading to improved quality of life.

Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country

BACKGROUND

Patients' engagement in mobile health (m-health) interventions using interactive voice response (IVR) calls is less in low- and middle-income countries (LMICs) than in industrialized ones. We conducted a study to determine whether automated telephone feedback to informal caregivers ("CarePartners") increased engagement in m-health support among diabetes and hypertension patients in Bolivia.

MATERIALS AND METHODS

Patients with diabetes and/or hypertension were identified through ambulatory clinics affiliated with four hospitals. All patients enrolled with a CarePartner. Patients were randomized to weekly IVR calls including self-management questions and self-care education either alone ("standard m-health") or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ("m-health+CP").

RESULTS

The 72 participants included 39 with diabetes and 53 with hypertension, of whom 19 had ≤6 years of education. After 1,225 patient-weeks of attempted IVR assessments, the call completion rate was higher among patients randomized to m-health+CP compared with standard m-health (62.0% versus 44.9%; p < 0.047). CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy (p < 0.001 for both). M-health+CP patients were more likely to report excellent health via IVR (adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI], 1.07, 6.32) and less likely to report days in bed due to illness (AOR = 0.42; 95% CI, 0.19, 0.91).

CONCLUSIONS

In this study we found that caregiver feedback increased engagement in m-health and may improve patients' health status relative to standard approaches. M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs.

Key Role of Social Supports in a Cardiac Transplant Treatment Team

Only a limited literature focuses on solid organ transplant outcomes using an integrated care approach connecting the transplant team with psychiatry, other medical specialties, and importantly, the patient's social supports. We present the case of a man with heart failure whom we treated for symptoms of anxiety and depression both precardiac and postcardiac transplant. The patient was managed by a multidisciplinary team for his complex medical, psychiatric, family, and social issues. Most notably, the role and involvement of his primary caregiver at home changed during the crucial period between his pretransplant evaluation and clinical care during the year following his cardiac transplant. Unfortunately our patient succumbed to a poor outcome both socially and medically, dying 1 year posttransplant. Our experience with this patient led us to explore the cardiac transplant presurgical and postsurgical assessment and management process, focusing on the key role of social support in the patient care team.

Social support and management of hypertension in South-west Nigeria

INTRODUCTION

Social support can facilitate compliance or adherence to recommended treatment regimens, especially for chronic disease management. There is little data from Africa on the role of social support in the management of chronic disease.

OBJECTIVE

The current study investigated the relationship between social support for treatment compliance among hypertensive subjects in a poor urban community in southwest Nigeria. A second objective was identifying the correlates of social support in the study sample.

METHODS

The study was a community-based, cross-sectional and descriptive study of 440 community residents (mean age 60 years, 65.2% women) from Idikan community, Ibadan, Nigeria who had hypertension.

RESULTS

Most subjects (˜ 93%) reported receiving some social support from family members and approximately 55% reported receiving social support from friends. Social support from friends (p < 0.0001) but not from family (p = 0.162) was significantly associated with good compliance with treatment for hypertension. Factors associated with receiving significant support from both family and friends included marital status and religion, while age and educational level were associated with receiving significant support from family members only. Gender was not significantly associated with receiving social support.

CONCLUSION

We concluded that social support is strongly associated with hypertension treatment compliance in this community in south-west Nigeria. These findings suggest a need for exploring the promotion of social support as a useful tool in chronic disease treatment programmes.

Effects of stress, health competence, and social support on depressive symptoms after cardiac hospitalization

Little is known about the role of stress on the psychological well-being of patients after cardiac hospitalization or about factors that protect against or exacerbate the effects of stress. We use prospective data from 1542 patients to investigate the relationship between post-discharge stress and changes in depressive symptoms, and whether the level of prior depressive symptoms, health competence, and perceived social support moderate this relationship. Net of depressive symptoms in the 2 weeks prior to hospitalization, higher levels of post-discharge stress significantly increase depressive symptoms 30 days after discharge. The level of prior depressive symptoms moderates the effect of stress. On the other hand, perceived health competence and social support buffer the negative effects of post-discharge stress. Knowing which patients are particularly vulnerable to experiencing stress and a subsequent increase in depressive symptoms can help trigger interventions prior to discharge and possibly ameliorate the prevalence of depression.

Early Adolescent Peer Foundations of Late Adolescent and Young Adult Psychological Adjustment

The long-term impacts of failing to establish autonomy and relatedness within close friendships are poorly understood. Adolescent behaviors undermining autonomy and relatedness in friendships at 13 were examined as predictors of friendship competence at 18 and depressive symptoms and social withdrawal at 21. A diverse community sample of 184 adolescents participated in self, peer, and observational assessments. Teens' inability to establish autonomy and connection with friends at 13 predicted decreases in friendship competence at 18 (ß=-.20, p=.02). Direct links to increases in depressive symptoms (ß=.34, p<.001) and social withdrawal (ß=.18, p=.03) were observed, with friendship competence partially mediating these relations. Results highlight the importance of problematic adolescent peer relationships as risk factors for the development of young adult internalizing symptoms.

Social support attenuates the harmful effects of stress in healthy adult women

OBJECTIVE

The purpose of this study was to test the hypothesis that social support buffers the effects of perceived stress on physical symptoms in healthy women.

METHODS

The study was conducted in the Southwest United States and data were collected from 2006 to 2010. Participants were 52 healthy adult women who completed a baseline questionnaire and a 21-day daily diary. Social support was assessed in the baseline questionnaire and perceived stress and physical symptoms were assessed in the daily diary. Multilevel analyses were used to predict both same day and next day physical symptoms from baseline social support and daily perceived stress.

RESULTS

The hypotheses were supported when predicting both same and next day physical symptoms. For the same day, perceived stress and the social support × perceived stress interaction were both related to physical symptoms. For the next day, the social support × perceived stress interaction but not perceived stress was related to physical symptoms when controlling for previous day physical symptoms. The interactions were such that women higher in social support had smaller increases in same and next day physical symptoms on days of higher perceived stress than women lower in social support.

CONCLUSIONS

Social support may buffer the effects of daily perceived stress on physical symptoms in healthy women. Future research should investigate what aspects and in what contexts social support may reduce the effects of perceived stress on physical symptoms and examine how social support may affect the development of long-term health problems through increases in daily physical symptoms.

Psychosocial interventions for patients with coronary heart disease and depression: A systematic review and meta-analysis

INTRODUCTION

Depression is common in patients with coronary heart disease, and together these conditions significantly affect health outcomes. Impaired social support is also considered an important predictor of coronary heart disease prognosis and, as there is a complex interplay between social isolation and depression, interventions to address both may be required. This review aimed to assess the effectiveness of psychosocial interventions addressing both depression and social support for people with coronary heart disease and depression.

METHODS

PRISMA guidelines were used to search major health databases to identify randomised controlled trials that evaluated psychosocial interventions compared with usual care in patients with coronary heart disease and depression; the primary outcome was depressive symptoms and secondary outcomes were mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety, social support and quality of life. Data, when suitable, were pooled using a random-effects meta-analysis model.

RESULTS

Five studies (n=1358 participants) were eligible and included. The psychosocial intervention group had significantly lower levels of depressive symptoms (standardised mean difference (SMD) -0.15, 95% confidence interval (CI) -0.27 to -0.03; P=0.02) and higher levels of social support (SMD 0.17; 95% CI 0.04 to 0.30; P=0.01) but no differences were found for mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety or quality of life.

CONCLUSIONS

Psychosocial interventions for patients with coronary heart disease and depression result in modest reductions in depressive symptoms and improvements in social support. However, caution is warranted in view of the small number of studies included in the review and potential heterogeneity in outcomes and in differences in treatment.

Can We Improve Our Physical Health by Altering Our Social Networks?

Persons with more types of social relationships live longer and have less cognitive decline with aging, greater resistance to infectious disease, and better prognoses when facing chronic life-threatening illnesses. We have known about the importance of social integration (engaging in diverse types of relationships) for health and longevity for 30 years. Yet, we still do not know why having a more diverse social network would have a positive influence on our health, and we have yet to design effective interventions that influence key components of the network and in turn physical health. Better understanding of the role of social integration in health will require research on how integrated social networks influence health relevant behaviors, regulate emotions and biological responses, and contribute to our expectations and worldviews.

Social support and the consequences of heart failure compared with other cardiac diseases: The contribution of support received within an attachment relationship

BACKGROUND

Interpersonal support is protective in heart disease, but sources of support and the quality of support may change over time, especially with aging and disease progression.

AIMS

To determine if support received within an attachment relationship with a spouse is more protective than other types.

METHODS

Subjects were sex- and age-matched cardiac outpatients with (n=40) or without (n=43) heart failure; they were studied with an observer-rated measure of attachment and self-report measures of other variables.

RESULTS

Having heart failure was associated with more depressive symptoms and illness intrusiveness. Although perceived social support did not differ in people with or without heart failure, those with heart failure had a spouse as the primary source of attachment functions less frequently than those without heart failure (50% vs 79%; P=0.006). Not having a spouse as the main provider of attachment functions was a partial mediator of the relationship between disease type (heart failure or no heart failure) and depressive symptoms (β=-0.24, t=-2.2; P=0.03) and deficits in non-attachment support made a further independent contribution (β=-0.24, t=-2.4; P=0.02). Neither perceived social support nor having a spouse serving attachment needs made a significant contribution to illness intrusiveness.

CONCLUSION

Having someone other than a spouse to provide attachment support is more common in cardiac patients who have heart failure and is associated with an increased risk of depressive symptoms.

A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial

Background

Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers’ needs for information about the patient’s status or how the caregiver can help.

Objective

We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach.

Methods

We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a “CarePartner” outside their household. Patients randomized to “standard mHealth” (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients’ responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to “mHealth+CP” (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient’s status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments.

Results

Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls.

Conclusions

Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients’ medication adherence and caregiver communication. mHealth+CP may also decrease patients’ risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys.

Trial Registration

ClinicalTrials.gov NCT00555360; https://clinicaltrials.gov/ct2/show/NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).

Role of social factors on cell death, cerebral plasticity and recovery after stroke

Stroke is a serious global health care problem. It is now is the fourth leading cause of death and the primary cause of adult disability in the United States. Substantial evidence from both experimental and clinical studies has demonstrated that social isolation (SI) can increase stroke incidence and impair recovery. Epidemiological studies demonstrate that an increasing number of patients are living alone, and as the aging population increases, loneliness will only increase in prevalence. SI is increasingly identified as an independent risk factor for all-cause mortality. In contrast, individuals with high levels of social support exhibit more rapid and extensive functional and cognitive recovery after a wide variety of pathological insults, including stroke. Clinical data suggests that SI is an important risk factor for increased mortality and delayed functional recovery following ischemic stroke. Attesting to the importance of mortality and behavioral factors in stroke outcome is that these same effects can be reproduced in animal models of experimental stroke. This has allowed researchers to identify several mechanistic changes that occur with affiliative interactions. These include decreased systemic inflammation, elaboration of growth factors including brain derived neurotropic factor (BDNF), enhanced neurogenesis, and improved neuroimmune responsiveness in group housed animals. These may mediate the beneficial effects of social interaction on improving stroke recovery and reducing neuronal death. In this review we provide an overview of the effects of SI on ischemic injury and recovery and discuss their clinical and therapeutic implications.

Psychosocial factors are preventive against coronary events in Japanese men with coronary artery disease: The Eastern Collaborative Group Study 7.7-year follow-up experience

Background

The Japanese Coronary-prone Behaviour Scale (JCBS) is a questionnaire developed by the Eastern Collaborative Group Study (ECGS), a multi-centre study of coronary-prone behaviour among Japanese men. Subscale C of the JCBS consists of 9 items that have been independently associated with the presence of coronary artery disease (CAD) in patients undergoing coronary angiography (CAG). There have been no reports of a relationship between any behavioural factor and the prognosis of CAD in Japan. The purpose of the current study was to investigate behavioural correlations with the prognosis of CAD as a part of the ECGS.

Methods

We examined the mortality and coronary events of 201 men (58 ± 10, 27-86 years) enrolled in the ECGS from 1990 to 1995, who underwent diagnostic coronary angiography and were administered the JCBS and the Japanese version of the Jenkins Activity Survey (JAS) Form C. Their health information after CAG was determined by a review of their medical records and by telephone interviews that took place from 2002 to 2003.

Results

Cardiac events during the follow-up period (7.7 ± 4.2 years) included 13 deaths from CAD, 25 cases of new-onset myocardial infarction, 26 cases of percutaneous coronary intervention, and 19 cases of coronary artery bypass graft surgery. There was no difference in established risk factors between groups with and without cardiac events. Seven factors were extracted by principal component analysis in order to clarify which factors were measured by the JCBS. Stepwise multivariate Cox-hazard regression analysis, in which 9 standard coronary risk factors were forced into the model, showed that Factor 4 from the JCBS (namely, the Japanese spirit of ‘Wa’) was independently associated with coronary events (hazard ratio: 0.21; p = 0.01). By other Cox-hazards regression analyses of coronary events using each set of JAS scores and the JCBS Scale C score instead of Factor 4 as selectable variables, the JAS scores or the JCBS Scale C score were not entered into the models.

Conclusion

The Japanese spirit of ‘Wa’ is a preventive factor against coronary events for Japanese men with CAD.

Association of living alone and hospitalization among community-dwelling elders with and without dementia

BACKGROUND

Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors-for example, living alone-may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+).

OBJECTIVES

To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation.

MAIN MEASURES

Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data.

KEY RESULTS

At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR = 0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR = 0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR = 0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations.

CONCLUSION

Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.

Social integration and mortality in patients with coronary heart disease: findings from the Heart and Soul Study

OBJECTIVE

To determine why lower social integration predicts higher mortality in patients with coronary heart disease (CHD).

METHODS

The association between social integration and mortality was examined prospectively in 1019 outpatients with stable CHD from the Heart and Soul Study. Baseline social integration was assessed with the Berkman Social Network Index. Cox proportional hazards models were used to determine the extent to which demographic and disease-relevant confounders and potential biological, behavioral, and psychological mediators explained the association between social integration and mortality.

RESULTS

During a mean (standard deviation) follow-up period of 6.7 (2.3) years, the age-adjusted annual rate of mortality was 6.3% among socially isolated patients and 4.1% among nonisolated patients (age-adjusted hazard ratio [HR] = 1.61, 95% confidence interval [CI] = 1.26-2.05, p < .001). After adjustment for demographic and disease-relevant confounders, socially isolated patients had a 50% greater risk of death than did nonisolated patients (HR = 1.50, 95% CI = 1.07-2.10). Separate adjustment for potential biological (HR = 1.53, CI = 1.05-2.25) and psychological mediators (HR = 1.52, CI = 1.08-2.14) did not significantly attenuate this association, whereas adjustment for potential behavioral mediators did (HR = 1.30, CI = 0.91-1.86). C-reactive protein and hemoglobin A1c were identified as important biological and omega-3 fatty acids, smoking, and medication adherence as important behavioral potential mediators, with smoking making the largest contribution.

CONCLUSIONS

In this sample of outpatients with baseline stable CHD, the association between social integration and mortality was largely explained by health-related behavioral pathways, particularly smoking.

Effect of low perceived social support on health outcomes in young patients with acute myocardial infarction: results from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study

Background

Social support is an important predictor of health outcomes after acute myocardial infarction (AMI), but social support varies by sex and age. Differences in social support could account for sex differences in outcomes of young patients with AMI.

Methods and Results

Data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, an observational study of AMI patients aged ≤55 years in the United States and Spain, were used for this study. Patients were categorized as having low versus moderate/high perceived social support using the ENRICHD Social Support Inventory. Outcomes included health status (Short Form‐12 physical and mental component scores), depressive symptoms (Patient Health Questionnaire), and angina‐related quality of life (Seattle Angina Questionnaire) evaluated at baseline and 12 months. Among 3432 patients, 21.2% were classified as having low social support. Men and women had comparable levels of social support at baseline. On average, patients with low social support reported lower functional status and quality of life and more depressive symptoms at baseline and 12 months post‐AMI. After multivariable adjustment, including baseline health status, low social support was associated with lower mental functioning, lower quality of life, and more depressive symptoms at 12 months (all P<0.001). The relationship between low social support and worse physical functioning was nonsignificant after adjustment (P=0.6). No interactions were observed between social support, sex, or country.

Conclusion

Lower social support is associated with worse health status and more depressive symptoms 12 months after AMI in both young men and women. Sex did not modify the effect of social support.

Characteristics and well-being of informal caregivers: Results from a nationally-representative US survey

OBJECTIVES

Given ongoing concerns about high levels of burden reported among some informal caregivers, the goal of this study was to characterize their sociodemographics, health, and well-being.

METHODS

Using cross-sectional data from a large nationally representative survey in the United States (N = 438,712) we identified adults who provided informal care to friends or family members with a health problem, long-term illness, or disability. Descriptive statistics and propensity matching were used to characterize caregivers and compare their health and social support to sociodemographically-similar adults who were not caregivers. Logistic regression models examined associations between caregiving and respondents' mental health, general health, perceived social support, and sleep problems.

RESULTS

A total of 111,156 (25.3%) participants reported being caregivers, most of whom reported good mental health (90%) good general health (83%), and adequate social support (77%). After adjusting for respondents' gender, caregivers reported worse mental health than non-caregivers (odds ratio (OR) = 1.35, 95% confidence interval (CI) = 1.31-1.39 for >15 days poor mental health in the past month) but better general health (OR = 0.96, 95%CI = 0.94-0.98 for fair or poor health). Men caregivers reported somewhat worse overall health than non-caregivers (OR = 1.09, 95%CI = 1.05-1.13) whereas women reported better overall health.

DISCUSSION

Although reporting good overall well-being, caregivers remain vulnerable for worse outcomes than non-caregivers. Caregiving is associated with poor mental health, and may have additional impacts on the physical health of caregiving men.