Social Connectedness and Health

The association between social connectedness and health has received much attention in recent years. Concepts of social connectedness relate to social integration at the broadest level, social networks, social support, and loneliness. Social connectedness may be conceptualized as a societal characteristic related to civic trust and social capital. This area-level experience is discussed in a later section. This section reviews the evidence that the structure of social ties is related to health outcomes and discusses pathways that may link such social experiences to health. People form ties to others the moment they are born. The survival of newborns depends upon their attachment to and nurturance by others over an extended period of time (Baumeister and Leary, 1995). The need to belong does not stop in infancy, but rather, affiliation and nurturing social relationships are essential for physical and psychological well-being throughout life.

Over the past 20 years, 13 large prospective cohort studies in the United States, Scandinavia, and Japan have shown that people who are isolated or disconnected from others are at increased risk of dying prematurely from various causes, including heart disease, cerebrovascular disease, cancer, and respiratory and gastrointestinal conditions (Berkman and Syme, 1979; Blazer, 1982; House et al., 1982, 1988; Welin et al., 1985; Schoenbach et al., 1986; Orth-Gomer and Johnson, 1987; Cohen, 1988; Kaplan et al., 1988; Seeman et al., 1988, 1993; Sugisawa et al., 1994; Seeman, 1996; Pennix et al., 1997). Studies of large cohorts of people enrolled in health maintenance organizations or occupational cohorts also report that social integration is critical to survival, although it may not be as critical an influence on the onset of disease (Vogt et al., 1992; Kawachi et al., 1996).

Powerful epidemiological evidence supports the notion that social support, especially intimate ties and the emotional support provided by them, is associated with increased survival and a better prognosis among people with serious cardiovascular disease (Orth-Gomer et al., 1988; Berkman et al., 1992; Case et al., 1992; Williams et al., 1992) and strokes (Friedland and McColl, 1987; Colantonio et al., 1992, 1993; Glass et al., 1993; Morris et al., 1993). The lack of social support, expressed in terms of conflict or loss of intimate ties, is also associated with health outcomes and risk factors such as neuroendocrine changes in women (Kiecolt-Glaser et al., 1997), high blood pressure (Ewart et al., 1991), elevated plasma catecholamine concentrations (Malarkey et al., 1994), and autonomic activation (Levenson et al., 1993). Caregivers of relatives with progressive dementia are characterized by impaired wound healing (Kiecolt-Glaser et al., 1995, 1998). Social conflicts have been shown to increase susceptibility to infection (Cohen et al., 1998).

Several studies have recently shown that older men and women with high levels of social engagement and networks have slower rates of cognitive decline (Bassuk et al., 1999; Fratiglioni et al., 2000) and better survival independent of physical activity (Glass et al., 2000). The pathways by which social networks might influence health are multiple and include pathways related to health behaviors, health care, access to material resources such as jobs, and direct physiological responses leading to disease development and prognosis. For instance, evidence suggests that, in general, social network size or connectedness is inversely related to risk-related behaviors. People who are socially isolated are more likely to engage in such behaviors as tobacco and alcohol consumption, to be physically inactive, and to be overweight (Berkman and Glass, 2000). Behavioral pathways such as these do not appear to account for a large part of the association between social isolation and poor health, but they are important to consider. It is important to note that networks themselves have generally been shown to exert powerful influences on the behavior of both adolescents and adults, so that networks can either promote health or increase risk depending on the norms of the networks themselves.

Experimental work with animals and humans indicates that social isolation can have a direct effect on physiologic function and subsequent diseases. Animals that are isolated in adulthood, that experience maternal separation, or that are not nurtured in infancy develop more atherosclerosis; have poor, inefficient, or exaggerated neuroendocrine responses; and may have higher levels of immunosuppression (Nerem, 1980; Shively et al., 1989; Suomi, 1991; Meaney et al., 1996). Among humans and primates, those who lack affiliation and strong social networks have been shown to be more likely to develop colds, have stronger stress responses in terms of neuroendocrine reactions and higher levels of cardiovascular reactivity, and have altered immune responses (Glaser et al., 1992, 1999; Kirschbaum et al., 1995; Cohen et al., 1997; Sapolsky et al., 1997; Roy et al., 1998; Cacioppo et al., 2000). There is limited research on whether access to material goods and resources is a mechanism through which social networks might influence health, and this is an important area for investigation. We do know, however, that networks have the capacity to provide informational and instrumental support effectively. Although much of the research in this area examines the effects of close relationships and social support, there is also evidence that weak social ties may also have indirect positive effects on health and well-being. For instance, a classic investigation of how people find jobs suggests that weak ties to others may be more helpful in enabling people to find jobs, providing access to one of the most critical life opportunities. Whereas one's close friends and relatives (who are likely to belong to the same social circles) may often provide redundant information, weak social ties (e.g., a friend of a friend) may allow individuals to tap into new sets of information (Granovetter, 1995). Instrumental and informational support, two critical components of the support paradigm, relate to help with practical matters such as grocery shopping; rides to the doctor; and information about health care, behavior, and risk. Finally, many of the observational data linking social connectedness to health outcomes do not permit us to rule out issues of reverse causation or the possibility that some unobserved condition explains these associations. More experimental work is needed to answer these questions completely. Much of the experimental work cited here supports the concept that social isolation increases the risk for poor health. However, a recent clinical trial, Enhancing Recovery in Coronary Heart Disease, aimed at improving social support to reduce mortality and reinfarction among subjects after myocar-dial infarction, found no effect (NIH, 2001). Developing both clinical and population-based experimental studies is the next step in this work.

A large body of evidence accumulated over the last two decades consistently points to the importance of social connectedness, and incorporation of this evidence would involve the inclusion of nurturing community and social networks. As we think of broad social determinants of health that could be influenced to improve health, social connections may be one example that has the support of a number of sectors. Because social relationships influence health through such a myriad of pathways, broad health improvements may be facilitated by considering and enacting policies that support social connections.

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