EFFECTS OF SOCIAL SUPPORT ON INDIVIDUALS’ RESULTS OF 12-WEEKS OF CARDIAC REHABILITATION

PURPOSE: The purpose of this study was to analyze the effects of social support on an individual’s result of 12-weeks of cardiac rehabilitation. Specifically, this study investigated whether or not participants decreased their body mass index, increased their stress test duration, showed greater changes in their maximum attained heart during their stress test and overall improvements in health through their SF-36 scores. METHODS: Fifty-five men and women from Rhode Island were recruited from The Miriam Hospital Center for Cardiac Fitness. All participants were currently participating in cardiac rehabilitation. They completed all twelve weeks, completed all necessary paperwork and completed a treadmill stress test. This was a descriptive study design that used pre and post testing physiological measurements. The ENRICHD Social Support Instrument (ESSI) was given after the participant completed the consent form. The majority of these participants had high levels of social support (N= 49). Individuals were considered to have high social support if they had a minimum score of 28 out of 34 and were considered to have low social support if they scored at or below 27 out of 34. Pre test measurements included anthropometrics (body mass index (kg/m): high social support= 28.81± 5.07, lower social support= 26.70± 3.85, stress test measurements (resting systolic pressure (mmHg): high social support= 123.10± 16.91, lower social support= 115.60± 15.06; resting diastolic pressure (mmHg): high social support= 73.35± 8.48, lower social support= 70.00± 9.06; total time on treadmill (sec): high social support= 418.83± 126.07, lower social support= 391.80± 75.74; maximum attained heart rate (bpm): high social support= 119.00± 16.66 , lower social support=116.00± 19.16) and questionnaires (SF-36 mental composite score: high social support= 53.08± 10.53, lower social support= 50.67± 11.68; physical composite score: high social support= 39.19± 7.63, low social support= 36.67± 3.76). RESULTS: The level of social support did not have an impact upon changes in weight, BMI, stress test time and maximum attained heart rate over the course of cardiac rehab enrollment. A generalized linear model showed that those with higher social support reported higher scores on the overall physical composite score (P= 0.000); as well as, the physical functioning (P= 0.006), vitality (P= 0.047) and social functioning (P= 0.017) subscales of the SF-36. CONCLUSION: These results suggest that the level of social support did not have an impact on measured outcomes such as anthropometric data and stress test results. However, there were clear effects when examining the Health Related Quality of Life Measure. The group lower in social support, despite apparent physical improvements on the stress test, actually had declines in the physical composite scale and several specific subscales. This finding warrants further study and replication within a larger sample as it suggests potentially negative outcomes in individuals that are not receiving high levels of support.

participating in cardiac rehabilitation. They completed all twelve weeks, completed all necessary paperwork and completed a treadmill stress test. This was a descriptive study design that used pre and post testing physiological measurements. The ENRICHD Social Support Instrument (ESSI) was given after the participant completed the consent form. The majority of these participants had high levels of social support (N= 49). Individuals were considered to have high social support if they had a minimum score of 28 out of 34 and were considered to have low social support if they scored at or below 27 out of 34. Pre test measurements included anthropometrics (body mass index (kg/m 2 ): high social support= 28 39.19± 7.63, low social support= 36.67± 3.76). RESULTS: The level of social support did not have an impact upon changes in weight, BMI, stress test time and maximum attained heart rate over the course of cardiac rehab enrollment. A generalized linear model showed that those with higher social support reported higher scores on the overall physical composite score (P= 0.000); as well as, the physical functioning (P= 0.006), vitality (P= 0.047) and social functioning (P= 0.017) subscales of the SF-36. CONCLUSION: These results suggest that the level of social support did not have an impact on measured outcomes such as anthropometric data and stress test results. However, there were clear effects when examining the Health Related Quality of Life Measure. The group lower in social support, despite apparent physical improvements on the stress test, actually had declines in the physical composite scale and several specific subscales. This finding warrants further study and replication within a larger sample as it suggests potentially negative outcomes in individuals that are not receiving high levels of support.
iv ACKNOWLEDGMENTS There are numerous people who significantly assisted me in producing a research study. A special thank you to all of the participants who allowed me to ask them many questions. Additionally, I would like to thank my major advisor, Dr.
Linda Lamont for her continued support and guidance throughout the entire process.
A special thank you goes to Dr. Peter Tilkemeier who volunteered his time and energy to allow me to complete my research study at The Miriam Hospital. Without his support this project would not have been possible. I would also like to thank all of the staff at The Miriam Hospital Center for Cardiac Fitness for their guidance and support.
I would also like to thank Dr. Bryan Blissmer for his assistance with the data analysis and statistics, and Dr. Susan Roush for her contributions to the research study.
Finally, I would like to thank my family and friends for encouraging me to always do my best and never give up.

INTRODUCTION
An estimated 82 million American adults have one or more types of cardiovascular disease. Of these Americans 400,000 are 60 years of age or older. 1 Roger, Go, Lloyd-Jones et al. 1 stated that cardiovascular disease (CVD) has accounted for more deaths than any other cause of death in the United States since the 1900's. According to the American Heart Association (AHA), CVD, also known as heart disease, describes several problems related to the buildup of plaque in the artery walls. 2 Heart muscle needs oxygen to survive. A heart attack occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely. This happens because the coronary arteries that supply the heart with blood can slowly become thicker and harder from a buildup of fat, cholesterol and other substances that together are called plaque. This slow process is known as atherosclerosis. When plaque breaks, a blood clot forms around the plaque that causes a block in the artery that can shut off blood flow to the heart muscle. When the heart muscle is starved for oxygen and nutrients, it is called ischemia. Damage or death of heart muscle occurs as a result of the ischemia, and this is called a heart attack or myocardial infarction. 2 CVD is more prevalent in our developed country compared to an underdeveloped country because our lifestyle is poor. According to Carlsson, Wändell, Gigante et al. 3  Research has shown that health behavior modification is a dynamic process requiring a tremendous amount of commitment from both the individual and their social support. 6 Therefore, it has been suggested that close relationships may protect against CVD by shielding stress. Furthermore, the cultivation of extended networks with people sharing similar experiences has been observed to be just as important in CVD protection. 7 Social support is the resources provided by others and the quality of them. 8,9,10 Evaluating the perceived level of social support of a patient with CVD may help to modify their risk factors by allowing them to more actively engage in life. 6 Perceived social support is the amount of support an individual believes is available to them. 11 Accordingly, this study was created to examine the effects of social support on 12-weeks of cardiac rehabilitation (CR). This study was designed to examine the individuals perceived level of social support using the ENRICHD Social Support Instrument (ESSI).

I. Cardiovascular Disease
According to the AHA 2 , CVD, also known as coronary artery disease (CAD) or heart disease, describes the narrowing and hardening of arteries through plaque buildup. This process is called atherosclerosis and it can lead to angina, or chest pain, the most common symptom of CAD. 12 Angina or chest pain occurs because of the reduced blood flow to the heart. 12,13 Gradually, heart disease weakens the heart muscle and decreases the blood flow transporting oxygen to the heart muscle. Possible outcomes may be a myocardial infarction (MI). An MI occurs when part of the heart muscle or myocardium dies or sustains damage due to a lack of oxygen.
CVD is the leading cause of death in the United States of America. 1 It affects over 100 million people and contributes to 7.2 million deaths each year. 14,15,16,17 Most of the individuals suffering from CVD are sixty years or older. 5  CVD is often thought of as a disease affecting men more than women. Yet, statistics have shown that CVD, heart attack and stroke are the leading cause of death among women in. It has been said that it converts to nearly 1 death per minute. It has also been found that women who are forty years and older are less likely than men of the same age to survive a year after the heart attack. 18 Typically women, do not develop heart disease or experience any symptoms until they are older than forty-nine years of age. Once a women reaches the age of sixty-five their risk for CVD surpasses men of the same age. Also, women over the age of sixty-five have a thirty-three percent chance of developing heart disease. 19 Men may develop their first heart disease symptoms between the ages of thirty-five and forty. Also, men are six and a half times more likely than women between the ages of thirty-nine to forty-nine to have a heart attack. 19 Symptoms of a heart attack differ greatly between men and women. The symptoms that men incur are much more definitive. Women often experience more subtle symptoms than men, which sometimes can lead to a misdiagnosis. Because women experience more subtle symptoms, they often do not undergo the same diagnostic testing that do men. 20 Roughly 700,000 CVD patients undergo CABG or angioplasty per year. Of these, only thirty-one percent of all PTCA, with and without stents, were performed on women in 2005. Of Medicare patients, men were two to three times more likely than women to receive an implantable defibrillator for prevention of sudden cardiac death. 20 When an individual is diagnosed with heart disease, they have the option to participate in a CR program, typically within two to six weeks following acute coronary artery disease symptoms and four to eight weeks after coronary artery bypass graft surgery. The CR program typically lasts about three months. 19,21

A. Background
In 2010, heart disease was projected to cost a total of 109 billion dollars, including health care services, medications, and loss of productivity. 2  peripheral artery disease . 24 The most common conditions seen in CR facilities are stent implantations, MI and coronary artery bypass grafts. 22 CR is a fairly new form of care within the medical field, and over the past twenty years substantial progresses has been made. 24,25 CR is a safe and effective way to treat patients who have experienced cardiac events. 12,22,25 The overall goal of CR is for the patient to return to a productive and enjoyable life implementing the learned lifestyle changes. The goal is not to cure, but to improve function based on physical symptoms, decrease the severity of the disease, and to limit CVD progression. These goals are met using physical training to improve aerobic capacity, psychological counseling to improve stress management, nutritional counseling to improve diet, education, and the ability to return to work. 9 These programs employ a team of exercise physiologists, nurses, cardiologists, dieticians, and behavioral medicine specialists to meet these goals.
CR is split into a four-phase program. Phase I is an inpatient program.

B. Benefits of CR
Exercise is essential for improving a cardiac patient's physical fitness.
Improving a patient's fitness has been shown to enhance a patient's quality of life 17,26,27 and allow older adults to live independently. An improved exercise capacity is associated with decreased heart rate, systolic blood pressure and myocardial oxygen demand. Other physical benefits observed through CR are increased muscle functioning, decreases in overall body weight, and a reduction in body fat. 28 Along with an improved health status, increases in muscular strength with resistance training can make everyday tasks, such as carrying the groceries easier, and may allow the elderly to live independently and enjoy an improved quality of life. 27 The most significant improvements have been recorded among deconditioned individuals, 28 after a three-month-period of supervised exercise.
The most noticeable changes are reported in peak oxygen uptake. 27 Also noteworthy is the decrease in the number of female patients that experience social isolation and anxiety. 28 Attendance in CR is associated with an overall decreased mortality; however, the patient must make a commitment to CR and their own health to gain the benefits. 29 Other medical benefits achieved through exercise training include reductions in myocardial ischemia and oxygen demand during physical activities. Nutritional counseling can assist in the prevention and management of obesity, hypertension, dyslipidemia and diabetes. 27 Finally, it has been shown that "maximum exercise capacity, emotional, physical, and social quality of life; smoking abstinence; and blood cholesterol improved during 12- week a cardiac rehabilitation program 30 " (p. 87).

C. Factors Influencing CR Attendance
For an individual to begin CR and be rewarded with the benefits of participating, a physician or cardiologist must refer them. 30,31,32 Currently women are less likely to receive referrals to CR than men. 30,32 Cardiologist and physician opinions have the ability to affect the patient's enrollment in CR; if the their opinion is negative then a patient is less likely to attend a program. 33,34 Patients are often referred to CR but opt not to attend because of various reasons. According to Evenson and Fleury,35 the most common reason patients elect not to attend the program is because of their financial situation.
Other reasons identified were work or time conflicts, lack of physician support or referrals, and lack of motivation or commitment.
Johnson, Weinert and Richardson 34 found that older adult patients who lived in an urban area and had a higher level of social support were more likely to enroll in CR than those with lower levels of social support. However, it seemed that patients who needed to attend CR the most were often the ones that chose not to participate. These are often individuals who use more health services, have a more complicated illness, and have financial constraints. 34 Patients who enroll and then drop-out of the program are often younger females who believe that their illness is less severe, but suffer from depression, experience angina, or have had a less invasive cardiac procedure. It is essential to identify these patients because they are in need of support and are at risk of dropping out of CR. It is especially important to enlist the support of those around the patient in order for them to embrace these new challenges. 36

A. Background
Numerous studies have indicated that there are significant social support effects on health and well being. 4 An individual's social support can assist with everyday challenges and improve physical and psychological health. A few of the potential improved health outcomes are: psychological adjustment, improved efficacy, better coping, resistance and recovery to disease and reduced mortality. 11 There is an increasing amount of evidence suggesting that there is a relationship between social support and CVD. 15,37 Social support can safeguard against the effects of a stressful event by permitting the individual to perceive the event as less stressful. There is a great deal of evidence that social support diminishes the stress experienced by CVD patients during their immediate recovery and it positively affects the patient's long term adjustment, well-being, and health outcomes. A sufficient amount of social support positively influences self-esteem, perceptions of health, mood, and adjustment to CVD. 9 Typically, three categories are described: social networks, social relationships and social support. Social networks are individuals' everyday contacts including a person's family, friends, co-workers, health professionals, and community resources. Social relationships are the quantity, existence and type of relationships. They provide sources of positive evaluation, and for a sense of control over their environment. These may also provide a sense of worth and lovability and importance. Social support is the resources provided by others and the quality of them. It can also be considered the quantitative description of an individual's social network and how much help they receive. 8,9,10 According to Sorenson and Wang, 38 social support is defined as "interpersonal assistance intended to enhance the well-being or protection from adverse life events, (p. 306)" and Moser 39 defined social support as "the comfort, assistance, and/or information one receives through formal or informal contacts with individuals or groups" (p. 27). However, social support has many definitions according to different people. Albrecht and Adelman 40 defined social support as "verbal and nonverbal communication between recipients and providers that reduces uncertainty about the situation, the self, the other, or the relationship, and functions to enhance a perception of personal control in one's life experience" (p. 19). The National Cancer Institute 41 states that social support is "a network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help." The use of many definitions tends to complicate things because each definition has many advantages and disadvantages.
When defining social support it is also important to think about actual versus perceived support. Actual support is the amount of support an individual actually receives (said and done for them).
Perceived support is the amount of support an individual believes is available to them and is available when needed. Perceived support is more commonly used than actual support and it has been found that an individuals' perception of social support is determined by their social environment and personality factors. 7 For this reason sometimes perceived support is more important than actual because it predicts positive mental health. 11 The two broad domains of social support are structural and functional. Structural support refers to the size, type, density, and frequency of contact with the network of people surrounding an Functional support is the support provided by the social structure. There are five types of functional support and they are instrumental, financial, informational, appraisal, and emotional support.
Instrumental support is receiving help to complete tangible tasks.
Financial support is receiving economic support. Informational support or feedback is provided in the form of necessary information.
Appraisal support is help for evaluating a situation or information for self-evaluation whereas social companionship involves spending time doing various activities or just being with others. 42,43 Additionally, information is needed when confronting a difficult situation, more specifically being diagnosed with a health problem or illness. These are difficult times and support can be an important factor in these situations. 11 Emotional support provides the feeling of being loved 6 and meets the individual's emotional needs. 11 Frequently, individual's relate this type of support to the term social support because it can increase an individual's mood. 11 Another commonly used label is tangible support, which describes the types of support that are quantified as instrumental or financial, 7 which is any material assistance provided by others. This assistance includes, but is not limited to driving the individual in need to an appointment, cooking and or possibly cleaning. 11 There is a direct relationship between social support and a pessimistic health outcome in patients that have chronic health conditions. "In the Alameda County study, a nine year community based prospective study, social support was found to be a determinant of mortality 6 " (p. 23). The population of individuals with low social support observed in this study were found to have two to three times higher mortality rates when compared to those who have social support.
Another study, the Tecumseh Community Health Study researched the connection between social relationships and mortality persisting after adjustments were made for age and other health factors. This study was geared towards all cause mortality. The most common cause of death was ischemic heart disease; this study found a relationship between ischemic heart disease and poor social support. 6,44 Evaluating social support is crucial to successfully modifying the health behaviors of patients that have CVD. Social support helps these individuals with physical activity, nutritional, and smoking cessation programs which all contribute to whether individuals with CVD will be successful. In another example of the effect of social support, those individuals who had positive support lost more weight than those who did not. 6,45,46 Furthermore, studies have shown that low perceived social support is a predictor of the progression of CVD. 7 Additionally, high levels of social support have been shown to protect CVD patients from the negative consequences of depression. 15 Other studies have indicated a decrease in mortality, 38,47,48,49,50 morbidity 47,48 and a reduced risk of further progression of CVD. 48

B. Social Support Outside of CR for Individuals enrolled in CR
Social support applies to a large network of individuals who assist the patient in their path to success in a time of need. It has been found that support networks vary between men and women. Men have a limited network structure that typically includes their wife, where as women have a larger, more multifaceted network that includes a variety of individuals who have specific roles. It was also recognized that women were more likely to have a confidant relationship and men were more likely to mention their wives as confidants but women typically did not mention their husband. 51 Women reported more support from their children and friends than males, and they are more likely to provide assistance to their friends. 4,16,32,38,51 Unfortunately, spouses can affect how their partner changes their health behavior by either controlling or supporting them. 34,52 This can be beneficial or harmful when participating in CR. McLean and Timmins 53 determined that spouses/ partners often felt isolated from the information process. If the spouse was included in the informationgiving process then this could significantly increase the level of support between the two individuals. 51

C. Why Are There So Many Surveys and Questionnaires?
There are a variety of social support instruments currently being used because the methods used to assess social support are varied due to a lack of clear conceptualization relating to social support and health outcomes. 42,54,55 Instruments are single or multiple items 42,55 and ask about different types of categories of social support (i.e. emotional, tangible, informational and instrumental support). 54,56 The instruments can also ask about different types of social support (i.e. support from spouse versus friends, family, co-workers) 57 The lack of "gold standard" measures makes it difficult to draw conclusions across different studies. Furthermore, some of the instruments have reliability and validity data while others do not.

The Social Support Questionnaire (SSQ)
The SSQ is another measurement tool of social support obtains a score for satisfaction with social support based on the availability and perceived number of social supports. It is a 27item questionnaire designed to measure perceptions of social support and satisfactions with received social support. Each item has a two-part answer. The first part asks to list all of the people that fit the description of the item and part two asks to indicate how satisfied they are with these people. Hence, each administration of this tool results in two scores: a number score (how many people) and a satisfaction score. 58 The Additionally, test-retest reliability correlation was 0.83 for satisfaction scores and 0.90 for overall number scores. 58 The concurrent validity of the SSQ was shown through a negative correlation between the number scores, satisfaction scores and depression, anxiety and hostility scores (-0.22 to -0.43). Correlation between overall number scores and satisfaction scores were of 0.34. 58

Sorenson & Wang 38
Sorenson and Wang measured social support by having the patient's answer one question. The question was, "whom would you rely on in time of trouble?" In order to reduce measurement burden this question was asked. It also yielded interval-level data about the size of the patients' social support group. It is easier for older adults to list individuals who assist them with their tasks rather than attempting to determine the appropriate answer in a survey. The limitation to this measure of social support is that social support is a multi-dimensional concept. The reliability of this instrument could not be analyzed because it is a single item measure. Additionally, single item measures have threats to internal and external validity. 38

Boutin-Foster, 2005 6
Boutin-Foster developed a two-question questionnaire administered to patients in the hospital with CVD to "identify the categories of instrumental social support that patients with coronary artery disease perceived as being most helpful when attempting to make changes in their lifestyles 6 " (p. 24). The first question asked was, "people who are diagnosed with CAD often have to make changes in their health behaviors. What are some of the changes that you have had to make in an effort to stay healthy?" The second question was, "what are some things that your family members, close friends, coworkers, and health care providers have actually done that you found most helpful in making these changes? 6 " Patients were asked these two questions, because it is important to determine the type of instrumental social support that an individual with CAD may have. This is because individuals with a significant amount of instrumental support are perceived to have better success with health behavior modifications. If determined that an individual has instrumental support, it indicates that their support is able to provide and promote better health outcomes. The first question addresses behaviors that were specific to CVD, and the second question gave the patient an opportunity to describe their experiences in detail. These questions were also chosen because they did not limit the social network members to family members, but expanded to other types of social network. The questions were chosen based on other theories from studies that had been successful. The questions were specifically chosen to eliminate some of their perceived limitations and restrictions to a specific gender, race, ethnicity, and social support. The reliability of this measure is not known and the questionnaire is being further developed and validated. 6

Perceived Social Support Scale (PSSS)
The PSSS was developed to measure the extent to which an individual perceives information, feedback and support from friends and family. The PSSS is a 20 item scale to which the individual answers "Yes, No or Don't Know." The items are score 0 for "No," 1 for "Yes" and an answer of "Don't Know" is not scored. Scores range from 0 to 20 with higher scores indicating maximum perceived social support provided from friends and family. This survey has an internal consistency of 0.90 for the friends subscale and 0.88 for the family subscale . 59 Procidano and Heller 59 claimed the PSS survey has construct validity although they do not provide objective data to support this claim.

ENRICHD Social Support Instrument (ESSI)
The Enhancing Recovery in Coronary Heart Disease (ENRICHD) study was a large, randomized, multicenter trial, that assessed whether morbidity or mortality would be reduced by a psychosocial intervention in people hospitalized for an acute myocardial infarction associated with depression and low social support. The ESSI is a seven-item, selfreported measure used in the ENRICHD trial. The ESSI identified items regarding structural, instrumental and emotional support, which have all been found to be predictive of mortality in CVD patients. The categories were modified from the Medical Outcomes Survey. 60 Individual items are then summed for a total score, with higher scores indicating greater social support. 48 The internal consistency of the ESSI using Cronbach's alpha was found to be 0.88. The inter-item correlations was significant with a P < 0.001. Concurrent and predictive validity was assessed using the correlation between ESSI total score and the SF-36 social functioning subscale was significant (P = 0.002 and r = 0.19). 48

E. ENRICHD Social Support Instrument (ESSI)
Psychosocial dysfunction is common in patients undergoing CR, and dysfunction presents itself in the form of depression, anger, anxiety disorders, and social isolation. Studies have shown associations between psychosocial disorders and the risk of initial or recurrent cardiovascular events. The ENRICHD study, assessed whether morbidity or mortality would be reduced by a psychosocial intervention in people hospitalized for an acute myocardial infarction associated with depression and low social support. Treatment for depression was provided, when indicated, through cognitive behavioral therapy and selective serotonin reuptake inhibitors.
ENRICHD study did not improve reoccurrence of an additional cardiac event, but depression and social isolation improved in the intervention and control groups. Even if psychosocial interventions ultimately are not shown to alter the prognosis of the coronary heart disease patient, they remain an integral part of cardiac rehabilitation to improve the psychological well-being and quality of life of cardiac patients. 27,47 The ESSI was "originally developed to assess social support among post-myocardial infarction patients, including the availability of instrumental aid and emotional support. The ESSI was chosen because of its high test-retest reliability, good convergence with standard emotional support measures, and its link to cardiac outcomes. The ESSI is also recommended for use when a short screening instrument is desired, as in the case of this study 48 " (pg. 92-93). The ESSI was also developed to accommodate a demographically, medically, and psychiatrically diverse population. 47

IV. Quality of Life
Another

V. Conclusion
CVD is the leading cause of death in the United States. 1 Risk factors for heart disease include high cholesterol, metabolic syndrome, physical inactivity, diabetes, high blood pressure, being overweight and obese, and tobacco use. 2,12,13 When an individual is diagnosed with heart disease, they may be offered the option to participate in a CR program. 21 Currently, the following medical conditions are thought to benefit from cardiac rehab: stable angina, MI, PTCA, CABG, chronic stable heart failure, cardiac transplantation, and peripheral artery disease. 24 CR is a medically supervised program to help patients recover from a cardiac event. It often employs a team of exercise physiologists, nurses, cardiologists, dieticians, and behavioral medicine specialists to recover from cardiac events and to reduce the risk of CVD from occurring and improve the functional capacity and quality of life of the individual. 31 The goals of CR are to educate, improve the aerobic endurance and muscular strength, modify risk factors, lower cholesterol, lose weight, control blood pressure, improve glucose levels, and smoking cessation, as well as, regaining the ability to return to recreational and vocational activities. 9,22,23,24 These goals are achieved by attending CR which includes physical activity, education, nutritional counseling, as well as, behavioral medicine counseling . 31 CR has a significant number of benefits; it can enhance a patient's quality of life, allow older individuals to live independently again, decrease heart rate, systolic blood pressure, oxygen demand, weight or fat reduction, increase muscle functioning and improve tasks associated with activities of daily living, including but not limited to carrying groceries, bathing or cooking. Nutritional counseling is also available during CR. Speaking with a nutritionist can help prevent and manage obesity, hypertension, dyslipidemia and even diabetes. 17,26,27,28  If the patient encounters a difficult task or challenge they will be able to share their experiences and obtain the necessary support to succeed in cardiac rehabilitation.
Social support is a complex construct that is difficult to define in a clear manner. Often times the source of social support is from an individual's immediate support system consisting of, but not limited to, their spouse, family, friends, and co-workers. Support has been found to have a positive effect on restoring health, especially after a cardiac event. Social support often serves as a safeguard between psychological distress and health outcomes; therefore, significantly enhancing recovery, reducing morbidity and mortality. Social support is a construct applied by a large network of individuals assisting the patient.
However, social support varies significantly between men and women. Men have a smaller, more limited network typically consisting of only their spouse, while women have a larger, more multifaceted network with a larger variety of individuals who have specific roles. Women often reported that they received more support from their children and friends than men. Women also have more depressive and anxiety symptoms, as well as less social support, and less selfefficacy. 16 An extensive variety of social support instruments are used to analyze an individual's perceived level of social support. There are a large number of instruments because there is an overall lack of clear conceptualization related to social support and health outcomes. This is most likely because there is no "gold" standard instrument. Therefore, the different instruments may have a single item or multiple items, ask questions from different categories relating to social support, and about different types of social support. This often makes it very difficult to draw conclusions across studies . 42,54,55,56,57 Taking into account the complexity and multifaceted structure of CR programming, it is extremely difficult to create a standard to apply to every patient. Therefore, it is crucial to stay involved with the patient throughout the program. It is essential to oversee the support a patient receives in order for them to succeed. However, there were participants who did not participate in an exercise stress test before beginning the program. If a patient did not complete an exercise stress test then their exercise prescription was solely based on their rating of perceived exertion during each exercise session, the participants were monitored for blood pressure, heart rate measurements, and rating of perceived exertion. 31 Study Design: This research project was a descriptive pre and post study design that had no control group. Once the participants were identified as possible subjects they were spoken to about being recruited for the study. Once recruited the participants signed the consent form and completed the ENRICHED Social Support Instrument (ESSI). All measures tested at baseline were repeated post-CR. Pre-, during and post measures were as follows:  The stress test measurements used in this study were treadmill time and maximal attained heart rate. Total time on treadmill is recorded as the amount of time (seconds) that a patient is on the treadmill for the exercise test. The treadmill test protocol was varied and was assigned by the Registered Nurse supervising the test.
The maximum heart was obtained while completing the stress test on the Quinton Stress Test treadmill while simultaneously being monitored with a 12-lead EKG. The resting blood pressure was obtained before the patient began exercising. The blood pressure was taken after sitting for approximately five minutes in either their left or right arm using a Welch Allyn cuff and a Littman Stethoscope.
The questionnaires used in this study were the ENRICHD Social Support Instrument (ESSI) and the 36-item Short Form Health Survey (SF-36). The ESSI was given to the patient once during their twelve weeks of CR, usually during the first two weeks, but after they had completed their consent form. The SF-36 is a generic measure of health status. The thirty six items cover eight categories including: social functioning, physical functioning, role-emotional, role-physical, mental health, bodily pain, vitality, and general health.
Statistical Analysis: I used Statistical Package for the Social Sciences (SPSS) version 21.0 to analyze our data. The majority of participants had very high levels of social support as seen in Figure 1 (Mean= 31.36±3.43; Median= 33.00; . ESSI scores range from 8-34 with higher scores representing a higher level of perceived social support. Out of the fifty-five participants, twenty-two scored a perfect score of 34; and eleven others scored a near perfect score of 32 or 33. These participants accounted for a total 60% of the entire sample; therefore, making a median split not feasible. Participants also did not score below 19. According the ENRICHD study protocol participants are considered to have "low perceived social support if they score a 2 or less on at least two items, excluding item #4 (help with chores); or a score of 3 or less on two items, excluding items #4 and 7 (before help with chores and marital status) and a total score of 18 or less on items 1, 2, 3, 5, and 6. 47 " Due results of the total sample, which included many individuals with highperceived social support, I did not have any participants fall into the ENRICHD study protocol for individuals with low social support. In order to create two groups for the study I had to create a criterion in order to make a low social support group.
Therefore, to examine the differences I created two groups depending on the total score of the ESSI. Individuals were considered to have higher social support if they had chosen "most of the time" on items 1-6 and that they were married or living with a partner; therefore, giving them a minimum score of 28 out of 34 (Mean= 32.33±1.96; . Individuals were considered to have lower social support if they scored at or below 27 (Mean= 23.50±1.96; . I chose to create these groups because individuals who chose "most of the time" or a 4 out of 5 on items 1-6 of the ESSI are considered to have high perceived social support regardless of their total score. For the purposes of this study, individuasl who report social support "most of the time" through out their life were considered to be in the high perceived social support group. According to Greco,Steca,Pozzi,et al. 64 "perceived social support from relatives and friends promotes more efficacious coping with illness and easier recovery from sugery" (p. 222).
Therefore, individuals do not have to have perfectly perceived social support to cope better with their illness, they just need to perceive it better. Additionally, Greco,Steca,Pozzi,et al. 64 "found that different indicators of illness severity, such as number of diseased vessels, congestive heart failure, and ejection fraction, were predictors of perceived social support" (p. 222).
With the data I ran a series of repeated measures multivariate analysis of covariance (MANCOVA) tests using two time points (pre and post) to test for within subjects effects and social support groups for been subjects effects while controlling for gender. Significance was based on an alpha of 0.05 and a 95% confidence interval. All data are reported as mean ± the standard deviation.
The Institutional Review Board at The Miriam Hospital approved this study on July 2, 2013(IRB Committee # 2077 and The University of Rhode Island on September 13, 2013 (IRB Project # 466583-1,2,3,4) with an IRB Authorization Agreement signed between the two agencies on September 3 and 5, 2013.  Table 2.
A repeated measures multivariate analysis of covariance using two time points  Table 3).
The SF-36 composite score data is illustrated in Figure 2.  Figure 3). (See Table 4 ).     63 Additionally, a question remains whether using a survey with a more expanded set of questions would provide a more detailed analysis of participants' actual social support.
One of the primary limitations of this study was that the majority of the participants had high levels of perceived social support as measured on the ESSI.
Therefore, I artificially divided the subjects into high and lower social support groups, but the low group was not a clinically low perceived social support group.
The artificial creation of two groups using the ESSI would not affect its high test-rest raises questions about the validity of the ESSI, as used in this study. This tool was validated as a measure of social support, able to differentiate between those with high and low support. There is no empirical validity evidence supporting the creation of the two artificial groups used in this study. This lack of validity evidence may explain this study's non-significant findings: the two artificial groups were not different on social support. Consequently, caution in interpretation of the results is needed. Fortunately, the groups were created after considering the participants' responses on the utilized Likert scale. This procedure provides preliminary evidence of the content validity supporting the creation of the high and lower groups used in this study.
An additional limitation may include the honesty of participants' answer being confounded by the knowledge of being in a research study. The participants could have perceived themselves as having a sufficient or high level of social support. Other limitations include the small sample size, the high social support group had eight times more participants than the lower perceived social support group (49 to 6) and women were fewer in number thus limiting the generalizability of this data. Given the prevalence of CVD among older women, 19 it would be important to increase their participation in order to more widely apply these results. Also, the enrolled participants were from the same CR clinic, therefore, the same geographic location, which could potentially limit the generalizability of the results to individuals with CVD and participating in CR in other locations that have a more diverse population and or different environmental stresses.
In conclusion, CR participants with high perceived social support improved their physical health, physical functioning, vitality and social functioning over 12weeks of CR when compared with a lower perceived social support group.
Interestingly, those participants with lower social support decreased their physical composite score and physical functioning subscale despite improvements in their physical functioning measures. This finding is interesting considering the majority of these participants had high levels of perceived social support. Finally, assessments of social support can be effective and should be considered in CR programming. It may provide more detailed clinical information for the health care provider.

STATEMENT OF THE PROBLEM
The prevalence of CVD is rapidly increasing; therefore, increasing the number of individuals who attend CR. It is crucial to ensure that each individual achieves his or her individual goals while participating in the program. Success in the program fosters and creates close relationships and further assists the individuals who have CVD. It has been researched that individuals with close relationships may assist against further CVD complications; therefore, a research study to evaluate an individual's perceived level of social support may help to decrease their risk of CVD.
Accordingly, this study was created to examine this relationship.
Primary Aim: To determine the effects of social support on an individual's result of 12-weeks of CR.
Hypothesis: Patients with higher levels of social support will decrease their body mass index, increase their stress test duration, show greater changes in their maximum attained heart rate and overall improvements in health through their SF-36 scores.
SHORT  ADULT CONSENT FORM