El deber de evitar delitos graves previsibles contra personas concretas: el test Osman

Having considered family relationships in this review, it is also necessary to evaluate the importance of other social supports. These may be many and varied, and previous studies have identified a relationship with both the onset and the clinical course of disease. There has been a diversity of measures of social support and some studies have focussed on the availability of social ties or support in times of crises (Henderson 1984, Sarason et al 1983). It may be important to differentiate between actual social support (in times of crisis) and feelings of attachment and dependency (O’Connor and Brown 1984). A recent study found that the risk of depression was significantly related to the absence of social supports in times of crisis (Brown et al 1986).

There have been two main categories of measurement; those instruments that measure the quantity of support and interaction, and those that measure qualitative aspects such as the functions and adequacy of supports. Studies such as the Alameda County study (Berkman and Syme 1979) used quantitative methods and a prospective design, and demonstrated a relationship between a sparse social network and increased mortality. Qualitative studies such as those by Henderson (1984) and Bell et al (1982) have measured the functional aspects of social support and the perceived availability

of supports in times of crisis. Henderson (1984) argued that in his study the crucial factor was not the level of support provided but rather its perceived adequacy in the eyes of the respondent.

More recently there have been several attempts to measure both quantitative and qualitative aspects of social support in the same investigation (Sarason 1983, Funch et al 1986). Both groups of instruments have been reviewed by Orth-Gomer and Unden (1987), who have concluded that the quantitative measures were more easily applicable, the questions more easily understood, and their predictive capacity for chronic illness fairly well established. The qualitative instruments were the most carefully tested for psychometric properties but their capacity to predict the onset of illness was less well examined. Finally, they concluded that they

could not identify any instrument which satisfied all desirable requirements. This may however, be dependent upon the needs of the study in question, ie. whether it is necessary to collect in-depth information or whether a simple count of the number of contacts is required. If the nature or quality of social support is found to be important in the study of either the onset or the course of disease, then qualitative instruments will need to be refined so that they are of more use.

Apart from the issue of measurement, there has been a plethora of studies investigating how and why social supports influence the

impact of illness. Both a preventive role and a buffering one have been suggested. The degree of social support may mediate the impact of stress on individuals (Kaplan et al 1977, Bruhn and Philips 1983, Cassel 1976). Social supports may act as a buffer against disease in times of psychosocial stress, or could act as the stressor itself

The loss or absence of social supports has been linked to both morbidity and mortality of various conditions, such as heart disease, cancer, and mental health problems, suggesting a possible preventive role for social supports (Pilisuk and Froland 1978, Lin

et al 1981, Bruhn and Philips 1983). Migration, mobility, social change and other phenomenon have been shown to have a strong influence on the ability to maintain enduring and effective ties so that people find themselves isolated, and in these situations social supports, or rather the lack of them, are the stressors. The absence of a close, confiding relationship has been shown to be associated with greater risk of depression in the presence of other adverse events (Brown 1975).

Social isolation has been associated with increased mortality (Berkman and Syme 1979, Schoenbach et al 1986, House et al 1982), however most of these studies only have data on Caucasian groups, and few compare men with women (Berkman 1986). Those who are not married, and therefore do not have this most intimate relationship (whether single, separated, widowed or d i v o r c e d ) , have been shown to experience higher mortality rates compared to married people (Berkman 1981). There may also be an association between lack of social bonds and the presence of neurotic symptoms (Henderson et al 1978).

Social support has been associated with level of self-esteem. In a

study by Brown and colleagues (1986), the authors linked low self­ esteem and lack of social supports, especially in times of crises, with a greatly increased risk of subsequent depression once a stressor had occurred.

Physically disabled people with a high level of support may have higher levels of self-esteem compared to those with low levels of support, and this could help them to cope with the everyday problems of being disabled (Patrick et al 1986). Social support may encourage problem-solving and may also reduce the impact of further stresses for those with a pre-existing illness. In Patrick's study (1986), a low level of social contact was associated with a deterioration in emotional functioning, but only in the presence of adverse life- events such as a major illness or financial difficulty, confiding relationships did not appear to be important for adults who had a

pre-existing illness and were not at a significant risk of developing stress-related conditions. The authors suggested that these relationships may be more important for those who have a psychiatric condition.

The relationship between social support and the onset or course of chronic disease is a complex one. Stress may be deflected by the presence of social supports, protecting the individual from illness that might otherwise occur. Alternatively, there may be a reciprocal relationship between stress and social support (McFarlane et al 1983) or chronic illness may influence the ability or desire to maintain social ties. This may be because of the feared stigma of

Both family and peer supports have been associated with adjustment in children with IDDM aged 6 to 16 years, although peer support was more important in the older subjects (Varni 1989). This age effect was not detected in a study of hypertension in older adolescents aged between 12 and 19 years (Greenberg 1983). It ma y be that once

the difficulties associated with the adolescent period are coming to an end, parental support becomes more welcome.

There ma y also be important effects of social support on adjustment in older people with diabetes (Carpenter et al 1983). In a study of people over the age of 15 years, Carpenter found that the perception of being positively supported by others, the quality of supports and overall satisfaction with relationships were all related to the process of adjusting to their condition.

There is some evidence to suggest that support from peers and from family should be investigated separately (Lyons 1988). In a study of adults with diabetes compared to a sample of psychiatric patients and a group of college under-graduates, Lyons (1988) measured the level of support received from both family and friends. He found no differences in the perceived level of family support between the college sample and those with diabetes, however those with psychiatric illness did report lower levels of family support. College students appeared to have more peer support than the

psychiatric patients, but did not differ this wa y from the subjects with diabetes. In the same study, the author found that those with diabetes who reported higher perceived support from friends, also reported feeling healthier.

Kelleher (1988a) has described how friendships with peers helped adolescents with diabetes to see themselves as 'normal1. At the same time, he suggested that many teenagers with diabetes experienced in an extreme form, the opposing pressures involved in trying to lead as normal a life as possible with all the associated risks.

Social relationships ma y be an important source of both practical and emotional help for the young adult with diabetes, but little research has been carried out in this section of the population to evaluate this. Young adults may have different needs compared to younger patients, and there is sparse information to date, on how the disease itself impacts on the development of relationships outside the family. Degree of social isolation, or whether or not young people are able to maintain close relationships, m a y be associated with degree of metabolic control and ultimately to the serious development of the complications of diabetes. In the vast literature on social support there is little to confirm or dispute these issues.