The focus for most of the other chapters in this text has been on the person with the wound and the significant psychosocial problems that they may have to confront. However, in this chapter we explore the broader social situation and how this can impact on the individual with the wound and how, in turn, that patient influences it. The concept of social support is outlined, what it is, it’s relationship to health and how this relationship comes about. The relevance to wound care is articulated and how this information can be used to develop social support interventions that can improve concordance, psychological well-being and subsequently wound healing. One specific form of social support- that received from the family and the spouse or partner in particular is explored in detail. Not only are the positive benefits to the individual with the wound detailed but the burden that may result from providing this support outlined. Social support is an important element in wound care and its impact should be harnessed by the health care professional to enhance wound healing and psychological well-being. However, the health care professional should also remember not to neglect the broader family who may all be placed under considerable burden and stress by the presence of an individual with a wound.

Social support can be defined as the existence of people on whom we can rely, people who let us know that they care about, value and love us, and the support they provide for us (Sarason et al. 1983). There is a distinction between the existence of social relationships and the functions provided by these. That is, the structure would be based on ‘how many friends, colleagues, or family relationships’ you have and the functional aspect would refer to what these do.

Essentially you can have lots of friends but have no interaction with them which is not useful to us. Social support can come from a variety of different sources and a variety of types of support (Cohen et al. 2000), for instance, spouses, relatives, friends, neighbours, co-workers, or superiors. But it can also come from professional sources (e.g. the nurse or other health care professional) and this can help in reducing stress, thus becoming a useful and advantageous social interaction. The type and amount of social support an individual receives depends upon their social network but also on various demographic factors such as their age, sex, culture, socio-economic status and so on.

Generally social support comes in one of five types (see Fig. 8.1).

To explore the concepts presented in Fig. 8.1 in more detail:

For the main part, however, social support is frequently divided into either practical support or emotional support: either “help with the shopping”, or a “shoulder to cry on”.

There are a number of methods available to measure social support. Phenomenological studies have investigated social support (Brown 2005a, b; Victor et al. 2002) through a formal methodological interviewing approach. Although this has a number of benefits in terms of getting to the “real data”, it can be subjective and time consuming. In contrast to this interviewing technique there are a number of psychometrically developed questionnaires and scales. For example, the Social Support Questionnaire (SSQ-SF; Sarason 1986; Sarason et al. 1983, 1987). The SSQ-SF is based on two elements: the perception of the number of others available to whom a person can turn to in times of need and the degree of satisfaction with the support available. The Medical Outcomes Study: Social Support Survey (MOS-SSS; Sherbourne and Stewart 1991) is relatively brief (12 item abbreviated version) measure of social support. It assesses four components of perceived availability of social support, including (1) Emotional support/ Informational support, (2) Tangible support (including material support), (3) Positive social interaction (does person have friends that are available to have fun), and (4) Affectionate support (including loving and nurturing relationships). The Multidimensional Scale of Perceived Social (MSPSS; Zimet et al. 1988) is another relatively brief (12 items) measure. The MSPSS assesses both the perceived availability and adequacy of emotional and instrumental social support, across the three factors relating to the source of support (i.e., Family, Friends or Significant others). The Social Provisions Scale (SPS- Russell et al. 1984) assesses six dimensions of social support received within the context of interpersonal relationships: (1) Guidance (receiving advice and/or information), (2) Reliable alliance (feeling assured that one can rely on certain others for concrete assistance if necessary), (3) Reassurance of worth (feeling important to or valued by others), (4) Opportunity for nurturance (feeling needed to provide nurturing attention to others), (5) Attachments (receiving a sense of emotional security from close relationships), and (6) Social integration (feeling a sense of belonging in a group, which includes others with similar interests). All these measures of social support demonstrate both the complexity of social support and the many facets within it.

Finally, Social support has been measured from within the family with the Family Relationship Index (FRI; Moos and Moos 1981). There are also a considerable number of psychometric measures that assess family functioning and support.

There is mounting evidence for the relationship between social support and psychological stress, with a lack of social support potentially increasing a patient’s experiences of stress and consequently potentially affecting wound healing (Brown 2008; Solowiej and Upton 2010a, b). A number of theories have been suggested that support the link between social support, stress and its impact on wound healing.

The main effect hypothesis suggests that the more social support an individual has the better the quality of life, regardless of the person’s level of stress (Helgeson 2003). In other words social support is beneficial to health and it is the absence of social support that is stressful. The more social support you have the better because large social networks provide people with regular positive experiences in terms of both emotional as well as physical support. Hence, social support promotes healthier behaviours such as exercise, eating healthily and not smoking, as well as greater adherence to medical regimes.

The buffer hypothesis proposes that social support buffers the individual against the stressor. Rather than protect a person all the time against the minor hassles and stresses of everyday life, the buffer acts when it is needed most. For example, when a person with considerable social support has a diagnosis of an illness then they appraise it as less stressful because they know people to whom they can turn. In contrast, those with lower social support might be unable to turn to anyone (Cohen et al. 2000). In this way an individual’s social support network, such as friends and family, act as a defence against the negative impacts of stress, which, in turn, can improve wellbeing and consequently the healing of the wound (Solowiej and Upton 2010a, b; Brown 2008). Indeed, Brown (2008) suggests that aftercare to prevent social isolation and potential recurrence of the wound is important.

The social comparison theory suggests that individuals may evaluate their attitudes, beliefs and their abilities against those who are in a similar situation to them. Thus, for example, individuals with a leg wound are much more likely to compare themselves to others with a leg wound in a similar situation. Individuals may either have an upwards or downward social comparison. Those with an upward social comparison can improve the view of themselves, and create a positive perception (e.g. an individual may think that someone else wound may be close to healing and that their wound is similar to theirs). Whereas a downward social comparison occurs when an individual dissociate themselves with others who they consider to be worse off than themselves to make them feel better (e.g. an individual thinking that their wound situation is better than someone else’s wound).

Uchino (2006) outlined a more detailed model that demonstrated the potential pathways between social support and health. One pathway involves behavioral processes including health behaviors and adherence to medical regimens as outlined by social control and social identity theorists (Lewis and Rook 1999 ; Umberson 1987). It is suggested that social support is health-promoting because it facilitates healthier including better adherence to medical regimes.

The other major pathway involves psychological processes that are linked to appraisals, emotions or moods (e.g., depression), and feelings of control (Cohen 1988; Gore 1981; Lin 1986). A variable that has been investigated thoroughly is control – defined as the extent to which a person feels they are able to change their own circumstances. Broadly, the results suggest that the more control you have the less stressful it is (e.g. Troup and Dewe 2002; Gibbons et al. 2011). Obviously, there comes a point where you have more control but also considerable responsibility and this can be stressful as well. This has important considerations when exploring self-management by the patient with the wound. It is obviously important for the health care practitioner to ensure the patient is fully involved in their own wound management and takes control over his or her own condition and treatment. However, this needs to be balanced within the confines of the patient’s ability and circumstances. Responsibility and control without the ability to control leads to increased stress and all the consequences that result.

Finally, it is important for the health care professional to understand how the patient copes with their wound related problems. If the patient uses social support strategies, it may be useful to involve family and friends in their treatment. If a patient prefers a more active approach it may be useful for the patient to be given more information and become more involved with their treatments. In some cases patients may avoid dealing with their wound situation, in this case it may be helpful for the health care professional to help the patient face the facts that their wound needs treatment to heal (Vermeiden et al. 2009). It is important that health care professionals strengthen patients coping strategies as this may reduce stress and potentially improve healing.

Living with a leg ulcer can have a detrimental impact on an individual’s daily life (see Chap.​ 1), which can leave the patient with feelings of being trapped, living a socially restricted life, and on the whole generally feeling socially isolated (Jones et al. 2008a; Parker et al. 2012). Indeed, patients can suffer from extreme social isolation as a consequence of their wound, and this has been linked to a number of factors both psychosocial and medical: including, malodour, lack of mobility, exudate, altered body image, pain and worry over further injury to their leg (e.g. Persoon et al. 2004; Parker et al. 2012; Herber et al. 2007). Furthermore, it has been suggested that patients with chronic leg ulcers often feel as if they are not fully part of society because of poor mobility, and a lack of empathy and peer support from others in their local community (Brown 2005a, b; Maida et al. 2009). Similarly, researchers have suggested that an individual may be embarrassed due to exudate and malodour, which others may perceive as poor hygiene, all of which can result in further social isolation and consequently reduced social support (Douglas 2001; Hopkins 2004a). Overall, this has negative consequences for the individual- including less socialising, which reduces the number of social contacts they may have, which again results in further isolation and a lack of social support.

Research has shown that supportive social relationships can improve health and psychological well-being. This relationship can just be one friend- as long as it is a close and supportive friendship- or a large series of good supportive relationships. Holt-Lunstad et al. (2010) reported that people who were less socially integrated had higher mortality rates. Studies have suggested that those with low levels of social support have higher mortality rates – from cardiovascular disease (e.g. Brummett et al. 2001; Frasure-Smith et al. 2000; Everson-Rose and Lewis 2005) or from cancer (e.g. Hibbard and Pope 1993) and infectious diseases (e.g. Lee and Rotheram-Borus 2001). Furthermore, an overview of longitudinal studies has shown a continuous increased mortality associated with a lack of social support and weak social ties (Quick et al. 1996). Subsequent studies have confirmed that reliable links exist between social support and better physical health (e.g. Uchino 2004; Holt-Lunstad et al. 2010).

In terms of wound healing a series of ground breaking studies in the 1990s and beyond have demonstrated a clear relationship between psychological stress and wound healing (e.g. Kiecolt-Glaser et al. 1995 and see Chap.​ 3). For example, in a classic study Kiecolt-Glaser and colleagues (1995) explored wound healing in two groups: a control group (healthy women) and a group (n = 13) of women caring for a demented relative. The assumption was that the care-givers were under more stress than the control group and this stress would delay wound healing. Wound healing was explored using a punch biopsy- a method used to create a small wound- and the time taken to heal recorded. There was a significant difference between the two groups with those care-givers taking 25 % longer (approximately a week) than the control group. These studies have been repeated on many occasions (Kiecolt-Glaser et al. 2002) and the relationship between stress and wound healing is well recognised.

In contrast to these deleterious effects of stress on wound healing a number of studies have indicated that social support can improve wound healing. However, many of these are with animal models of stress and social support (e.g. Detillion et al. 2004) and the link to relevant human studies, particularly those with chronic wounds is lacking. Charles (2010) did explore the influence of social support on leg ulcer healing. In a group of patients with venous leg ulcers they found that social support through a community nurse was not related to healing. However, although social support was assessed through a questionnaire route, social support was not enhanced or developed. Furthermore, many of the patients were socially isolated due to their leg wounds and the findings appeared to support the suggestion that a visit to an isolated individual by community nurses did not meet the clients’ needs for social support, information exchange and empathy. Consequently, there may be a need for more formal social support interventions (Lindsay 2000, 2008; see next section).

Similarly, supportive social relationships have been demonstrated to be fundamental in patients adapting to illness as well as recovering from it (e.g. Keeling et al. 1996). However, not all social support is equally beneficial and it has been demonstrated that there are sometimes negative consequences of social support- dependency or the inhibition of recovery due to a lack of control and desire to take control of their own illness (e.g. Toshima et al. 1990). Indeed, some health care professionals wonder whether a proportion of patients want to keep their ulcers to maintain contact with their social support- their community nurses- for social contact and support (Brown 2003; Wise 1986; Brown 2005a, b; Moffatt et al. 2009). For instance, it has been suggested that some patients will deliberately delay their wound healing (e.g. take their bandages off after being treated the nurse) so their social contact with the district nurse can continue. However, it is not clear how many patients may do this, and needs to be further explored along with the underlying reasons and potential solutions for any significant problem identified. Furthermore, it has been reported by Charles (2010) that patients do not see nurses as social support contacts nor do they want to keep their ulcers in order to maintain this contact. Finally, it is also important to note that not all social support should be provided by nurses and other health care professionals- the support from significant others, such as family members, friends, or co-workers is also crucial for those suffering with chronic wounds and this will be subject to further discussion later in this chapter.

Health care professionals are usually aware of the benefits of social support interventions for individuals with leg ulcers, even if they understand that the interventions themselves do not produce healing as a direct result (Brown 2010). It has been suggested that health care practitioners should encourage patients to become more involved in self-management, through such social support self-help groups to reduce both pain and the consequent stress it causes (Price et al. 2007; Moffatt et al. 2009; Brown 2010). ‘Leg clubs’ can provide individuals with an environment whereby those with similar problems can socialise in a supporting, information-sharing environment (Edwards et al. 2005). There have been a number of ‘leg club’ interventions set up within a community setting that have been developed which aim to improve an individual’s well-being, some of these include, ‘Lively legs’ programme (Heinen et al. 2012); ‘Look after your legs’ support group (Freeman et al. 2007); and the ‘Lindsay leg club’ ® (Lindsay 2013).

Furthermore, due to the isolation and depression experiences by ulceration patients, the Lindsay Leg Club model of care was established (Lindsay 2004). It is based in a non-medical setting such as a community, church or village hall, where those with leg wounds can have collective treatment and share their experiences, there is also open access, meaning that no appointment is required. Community based interventions also provide patients with information about their wound and how to care for their wound as well as a number of strategies with living with a wound and overcoming practical difficulties from health professionals and other patients who have similar wound related problems (Edwards et al. 2005). Here, the reintegration of leg ulceration sufferers into the social domain is encouraged, whilst the clubs have also proved successful in progressing the removal of the negative stigma associated with such ulcerations. These clubs can conclude in a number of benefits for both the patient and their carer in that not only has treatment concordance been found to improve, but recurrence rates can decrease with overall positive healing outcomes (Lindsay 2004). This club care model supports the assumption that through the fostering of therapeutic relationships, patients can be empowered and encouraged to engage with their care, leading to improved healing rates and overall reduced ulceration reoccurrence. As such, is important for clinicians to incorporate such notions within their would care regime, focusing on patient involvement, communication and health promotion, in turn, enabling patients to become actively involved in their treatment regime.