It has also been suggested (Cassel, 1976) that stress

enhances susceptibility to disease. Although little study

has been made of how social support protects people from

distress, and hence, influences health outcomes, both Cobb

(1976) and Wortman (1984) have speculated that more than one

mechanism may be involved. As Cobb has pointed out, two

major classes of theoretical views have been considered. The

first suggests a direct effect through neuroendocrine

pathways; the second suggests an indirect effect. Among the

indirect effects that has been suggested by Wortman is that

social support might influence the occurrence of the stress-

ful event being studied. Wortman also noted that once a

stressful event such as the diagnosis of cancer has occurred,

social support may influence the way the event is initially

appraised, and hence, influence subsequent outcomes. Both

Wortman and Cobb have suggested that social support may alter

coping and adaptation or that it may facilitate effective

coping by enhancing motivation to engage in adaptive or com-

pliant behaviors. Wortman has noted that an indirect effect

on coping might result from the enhancement of self-esteem,

and she has suggested that social support may also protect

people from the deleterious effects of stress by altering

their mood. Finally, Wortman has recognized that the rela-

tionship between social support and health outcomes is fur-

ther complicated by the fact that prognosis, coping, or pre-

vious adjustment influences the amount of support available.