McEwen, 1996; Uchino et al., 1996). Importantly, studies also indicate negative health effects from social ties when those ties are a source of conflict and criticism (Kiecolt-Glaser, 1999; Kiecolt-Glaser et al., 1994; Seeman and McEwen, 1996).

The limited intervention research to date that attempts to enhance social networks and social support (Glass, 2000) has been disappointing, though this may demonstrate only how complex social relationships are and how difficult it is to alter them. A few studies have targeted patient populations—those recovering from myocardial infarction (Berkman et al., 2003) or stroke (Glass et al., 2000)—or caregivers for those with chronic conditions, such as Alzheimer’s (Pillemer et al., 2000). These studies have shown little evidence of positive effects on subsequent health outcomes, possibly because of the severity of the health problems involved.

The recently completed Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial (a major intervention study designed to assist socially isolated or depressed myocardial infarction patients) exemplifies the difficulties inherent in intervention efforts. The intervention, designed to build social skills and reduce depression, could not be fully implemented. Because of logistical and scheduling problems, participants randomized to the intervention had fewer than half the planned “social/cognitive intervention” sessions, and less than one-third of them actually received group therapy in addition to the initial individual therapy (Powell, 2002). The inability to provide all the group therapy intended may have substantially weakened the trial; preliminary evidence indicates that those who did have a group experience had a lower recurrence rate of fatal or nonfatal myocardial infarction than those who did not, after adjusting for important confounder variables (Saab, 2002).

Intervention efforts such as ENRICHD have largely focused on individual patients or their families, leaving untouched their larger social worlds. As has been shown for other efforts at behavior change, the broad environment constrains people’s ability to maintain behavior change over time (Syme, 2002). Modifying an environment and changing social institutions is of course a substantial task, but for institutions that already play an important role in maintaining health, some interventions may be productive. In recent years, some religious institutions have become important sites for health screening and health interventions. Church-based interventions have increased fruit and vegetable consumption (Resnicow et al., 2001); increased weight loss (McNabb et al., 1997; Oexmann et al., 2001); lowered blood pressure (Oexmann et al., 2001); reduced energy intake, dietary fat, and sodium intake (Yanek et al., 2001); and increased screening for breast, cervical, colon, and prostate cancer (Erwin et al., 1999; Mann et al., 2000). It is not known whether they are more effective at this than other community organizations.



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