THE ROLE OF SOCIAL SUPPORT IN PHYSICAL HEALTH

HIGHLIGHTS

• Restricted social networks predict mortality twice that of those who enjoy greater social integration.

• Smaller, weaker, and more conflicted social ties are associated with poor health outcomes, reduced treatment adherence, and an increase in mortality by as much as 50%.

• Childhood abuse and trauma are associated with poorer quality of health in later years.

• Unhealthy or unhappy marriages are associated with increased morbidity and mortality.

• Acts of generosity raise levels of happiness and emotional well-being.

• Pet ownership can quell loneliness and isolation and protect against premature mortality.

• Supportive social ties are associated with better immune, endocrine, and cardiovascular functioning.

• Networks with less diversity, limited social capital, and lower educational and economic advantage have fewer perceived supports.

• Social norms about ideal body image are shared across most age groups and are largely responsible for chronic body dissatisfaction in women and eating disorders in teens

SOCIAL NETWORKS

Social interaction is essential to every aspect of human health. Research shows that having a strong network of support or strong community bonds fosters both emotional and physical health and is an important component of adult life. Social relationships are one of the most robust behavioral predictors of longevity. Numerous studies in the past few decades showcase the relationship between social networks, social support, and the quality of physical and psychological health.

The term social network refers to linkages between people and organizations and are conceptualized through structural and functional components. Structural components include network size and frequency of contact between members. The most salient social structure is social integration: being a part of different networks and participating socially. Functional components describe the relationship characteristics of a social network and, collectively, are referred to as “social support.” Functional social support is typically partitioned into 4 social support subtypes: emotional (expression of caring), instrumental (aid and service), informational (advice and information), and appraisal (information for self-evaluation).

MORTALITY

Social integration is an important social determinant of mortality. Social isolation alone is identified as an independent major risk factor for all-cause mortality, and especially for coronary vascular related deaths. Social isolation and loneliness, growing health crises in and of themselves, were elevated to center stage across communities and households during the COVID pandemic. For many, this was a first glimpse of the cost and burden of social deficits on morbidity. Umberson and Montez (2010) reported that after controlling for socioeconomic status, health behaviors, and existing morbidities, restricted social networks predict mortality twice that of those who enjoy greater social integration.

Structural and functional characteristics interact in ways that can either protect or can reduce health, wellbeing, and longevity. For example, small network size or lack of social ties predicts mortality of adults experiencing strokes and cancer but does so differently relative to age and type of cancer: correlations between social network and reduced mortality are strongest in younger patients, and associations of marital status with decreased mortality were stronger in studies with shorter time intervals and in early-stage cancer. Moreover, the size of the effect varies by cancer site: social support’s strongest impact on mortality and self-reported wellbeing is with nonsolid cancers such as leukemia and lymphomas: In breast cancer the effect of social networks on health status and mortality is largely a function of social network size and composition. Social network size is the largest social determinant of stages I/II breast cancer mortality. Regarding composition, a lack of spouse and/or lack of community ties is inversely associated with cancer survival in white, older women, whereas lack of relatives and friendships is more heavily associated with mortality in nonwhite minority women.

MORBIDITY

The incidence of chronic health conditions is reaching epidemic levels and costing untold dollars and pervasive human suffering. In one decade, the incidence of chronic illness in the United States increased by 15 million. At present, nearly half the population suffers from at least one chronic illness such as diabetes, hypertension, heart disease, and arthritis. The CDC identifies tobacco use, poor nutrition, lack of physical activity, and excessive alcohol use as the primary risk behaviors largely responsible for otherwise preventable chronic illnesses and has directed health initiatives accordingly. And yet citizens’ behaviors are not changing, and prevalence is not declining. Academic and clinical research exploring the biopsychosocial determinants of chronic disease and wellbeing has shed compelling light on the role of social networks in preventing or exacerbating chronic health conditions.

The irrefutable conclusion from hundreds of studies across the last 3 decades is that quantity and quality of social relationships can be benchmarked against other well-established lifestyle risk factors associated with disease prevalence, severity, and disease management or progression. Smaller, weaker, and more strained/conflicted social ties are positively correlated with poor health outcomes, reduced treatment adherence, and are associated with roughly $6.7 billion in additional Medicare health care costs annually and an increase in mortality by as much as 50%. Given the heavy toll this inflicts on individuals, families, and communities, global organizations like the WHO and now many European countries, have defined social relations as an equal player in the list of primary health behaviors and social determinants associated with chronic illness that need address.

The most salient social ties for health vary across the lifespan and often have long reaching health implications. Childhood abuse and trauma are associated with poorer quality of health in later years. Springer, et al (2007) analyzed population-based survey data from 2,800 middle-aged men and women, finding that childhood physical abuse is “significantly associated with a 15% increase in medical diagnoses, a 16% increase in medical symptoms, a 19% increase in depression, a 22% increase in anger, and a 21% increase in anxiety.” What is even more remarkable is that childhood abuse increased the likelihood of disease nearly 40 years post abuse. Both Springer’s project and Shaw and Krause (2002) found that heart trouble but not diabetes or cancer was significantly greater in survivors of childhood physical abuse, however, cancer patients and Type 2 diabetics without abuse histories fare better in disease management than do their abused cohorts.

Multiple interaction effects between structural and functional supports and between supports and demographic variables are a reminder of the nuanced complexities embedded in social networks. For example, while social support is significantly protective of health promoting health behaviors in both younger and older groups, only in older subjects does social support have a direct effect on subjective wellbeing, health quality, and status.

Moreover, as people age, there is a preferential selection for quality over quantity; and for good reason as significantly large and diverse social networks can become a health prohibitive for older populations who do better with smaller, meaningful, intimate connections.

The effect of marital social support on mortality and wellbeing has been one of the most heavily researched social support typologies and has consistently demonstrated it to be a strong predictor of mortality, ahead of other family members and friends. In marriages that are unhealthy or unhappy marital status is no longer protective of health, rather it is associated with increased morbidity and mortality, presumably through heightened stress levels that, in turn, create risk of CVD and depression. And the burden of caring for one’s ill or impaired spouse, significant other, or other family member can exact a hefty toll, including higher mortality risk for the caretaker. Schulz and Sherwood (2008 and 2011) have twice demonstrated that caring for a sick loved one elevates physical and psychological morbidity including impaired immune function and poorer health behavior for the provider and may actually be detrimental to the health status of the sick recipient, particularly if the relationship between caregiver and recipient is stressed. Very recent research suggests that it is having a happy spouse that correlates most positively with self-rated health and may protect against premature mortality. The effect size of spousal happiness or partner life satisfaction is comparable to other known predictors of mortality and morbidity such as income and education. And providing social support to one’s spouse and other social ties may be uniquely associated with better health outcomes in the provider/giver than in the receiver.

This is consistent with another but related set of research data examining the role of giving versus receiving support. It has long been acknowledged that acts of generosity raise levels of happiness and emotional well-being, giving charitable people a pleasant feeling known, in behavioral economics, as a “warm glow.” The last several years has seen a burst of new research quantifying and validating the moto that to be happy, one need only make another happy. Giving support (emotional or instrumental) to others appears to protect the giver from health hazards more so than if he or she is the one receiving support. And deriving benefits from giving in a relationship need not be a relationship between 2 humans. A growing body of evidence is suggesting that pet ownership can quell loneliness and isolation, protect against premature mortality, provide meaning and purpose in caring for another creature, and helps keep especially older persons and persons with chronic pain conditions more physically and socially active. And much like how relationships function between persons as they age, the health benefits provided by the relationship between person and pet are greatest in pet owners who own 1 to 3 pets versus those who own more.

MECHANISMS

The pathways underlying the relationship between social ties and physical health are three-fold: behavioral, psychosocial, and physiological. Findings from studies that analyze physiological markers under various social situations suggest that social support is likely a moderator of stress and cardiovascular reactivity. Supportive social ties are associated with better immune, endocrine, and cardiovascular functioning, presumably by reducing allostatic load, the cumulative “price” the body pays when subjected to repeated or chronic stress. Such physiological processes may interact with behavioral and social mechanisms as it is well documented that persons of all ages are at risk of engaging in hazardous health behaviors in efforts to reduce the unpleasant physical and emotional sensations experienced when inundated by environmental and internal stressors.

Health behaviors are dynamic, vary over the lifespan, and are best understood by examining individual actions in sociological context.

Behavioral explanations typically focus on health behaviors, actions individuals take that affect their health. These include actions that are protective of health such as eating well and being physically active. Likewise, health behaviors can also include actions that increase risk of disease as is seen with tobacco and excessive alcohol use. Health behaviors are dynamic, vary over the lifespan, and are best understood by examining individual actions in the sociological context of constraints, social norms, and identities that arise from membership in social networks. For example, medical treatment adherence and health status correlate positively with disease management. What drives compliance in conditions such as hypertension and diabetes is multidimensional, but most notable is the patient’s perceived necessity and perceived harmfulness of prescribed medication. These perceptions are shaped by the information and values shared within the patients’ social networks. Perhaps not surprising is the finding that networks with less diversity, limited social capital, and lower educational and economic advantage are associated with fewer perceived functional supports. Lacking is the collective trust in healthcare providers and the shared values and beliefs regarding healthy living, personal agency, and perceived efficacy that help “spread” medical compliant behavior. Positive family and community social support during initial disease onset and assistance accessing health resources elevate the odds of medication compliance.

The effect of social ties on risky health behaviors runs along dimensions of age, geography, type and strength of social ties with smoking. The likelihood of initiation varies with age (younger more apt to take up smoking than older individuals who have never smoked), the prevalence of smoking is higher in the southern versus western sections of the US, and adolescents’ smoking behaviors are more influenced by similar behavior of their peers than is the case for adults.

Obesity, like other conditions driven by health behaviors, has historically been conceptualized as a preventable condition caused by individual behavior and the emotional and cognitive components of behavior. Interventions directed at the individual level have not been effective in curtailing the obesity epidemic and recent compelling evidence suggests that obesity is best appreciated in the context of social networks. Obesity risk behaviors such as physical inactivity, unhealthy eating, and sleep deprivation are examples of health behaviors influenced by social networks’ norms and social support. Adolescent physical activity and healthy diet are positively correlated with perceived social support from friends. And though social ties are not statistically correlated with obesity in younger populations as it is with older subjects, the levels of physical activity and healthy food consumption of adolescents mirrors those of their close friends.

Perceived social norms about ideal body image are shared across most age groups and are largely responsible for chronic body dissatisfaction in women of all ages and eating disorders in children and teens. However, friendship norms about dieting influence and unhealthy weight control have their strongest effect with young to middle aged adults. A 32-year longitudinal study of body weight in men and women revealed that the odds of becoming obese increase by 57% if he/she had friends that also became or were obese. Moreover, only social distance, not geographical distance, between friends has an influence on the “spread” of obesity.

CONCLUSION

What can be gleaned from the majority of research is that social networks and social support unequivocally affect physical health and wellbeing, they do so as strongly as any other well established health determinant, and they do so not through any one pathway but through a complex and dynamic interplay of biopsychosocial correlates. Improving rates of mortality and lessening the prevalence and burden of morbidities may have more success if interventions exploit the social network phenomena by reconceptualizing health and wellbeing in their social context and creating macro and micro interventions that facilitate and improve the utility and quality of social networks.

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