By Sara Honn Qualls
Social relationships have as much impact on physical health as blood pressure, smoking, physical activity, and obesity, as demonstrated in 1988 by House, Landis, and Umberson. Their meta-analysis of 148 longitudinal studies found a 50 percent increase in survival of people with robust social relationships, regardless of age, gender, country of origin, or how such relationships were defined. Just as obesity has taken center stage in our cultural self-awareness, social relationships belong on the list of potent risk and protective factors for morbidity and mortality.
This article provides a brief overview of key findings on health and positive social relationships, paralleling Karen Rook’s article, which reviews the powerful negative effects on health of negative social interactions. Not surprisingly, positive and negative aspects of social relationships offer distinct impacts on health, and close relationships typically include both positive and negative characteristics, adding complexity to an already complicated picture.
Consider the following brief examples of older adults whose relationships show a link to health outcomes:
- Mrs. L lives in an assisted living facility and her son visits frequently, involving himself in the community by getting acquainted with his mother’s friends there, and doing projects such as building a raised-bed vegetable garden that all residents tend. The facility cook routinely incorporates the garden’s produce into the daily menus, and much of residents’ mealtime conversation focuses on “their” vegetables and herbs. Mrs. L experiences obvious bursts of energy and motivation to attend exercise classes after each of her son’s visits, increasing her strength and cardiovascular functioning.
- Mr. and Mrs. M have a kind, loving friendship within their marriage; this functions well as an invisible protective shield, buffering their physical health from impacts of day-to-day stresses that wear on other older adults’ health.
- Ms. C’s bitterness about her arthritis is exceeded only by her bitterness at the many people who have betrayed and disappointed her over her lifespan. She views both her physical and social health as poor, with little insight into how her negative approach to mental health undermines both.
- Mr. K’s recovery from a quadruple heart bypass was aided significantly by his wife’s deliberate adjustment of their diet and activity patterns to match his health provider’s recommendations. Without her involvement, he was unlikely to adhere to recommended lifestyle changes that were key to his recovery.
- Ms. B and Mrs. J maintain a regular schedule at the local elementary school, where they read to children. Afterward, they sit and swap funny stories together over a healthy lunch. The children keep them on the move physically, and the students’ improvement in reading ability bolsters the women’s sense of personal meaning. The volunteer role helps build psychological and social health.
Many health benefits of relationships are likely to be more subtle than those illustrated in these examples. An uplifting conversation that introduces hope and joy into the morning may influence physical activity, healthy food selection, or the choice to engage further in proactive social relationships later in the day or week. Open communication with a physician may encourage stronger engagement in answering health questions. A social service agency that provides volunteers to maintain landscaping or home maintenance enables many older adults to live in long-term neighborhood social networks. The range of examples is broad, and the individual variation almost infinite.
Researchers have generated a substantial body of knowledge about the positive benefits of relationships on health. This article explores the question of how the size and composition of a network might influence health, considers how different types of social engagement or support benefit health, demonstrates how physical environments can shape social experiences that might influence health, and explains how healthcare systems could use the power of social relationships to benefit health.
Is More Always Better?
The quantity and quality of social relationships have powerful effects on health across the lifespan. Although older adults experience some shrinkage in the size of their networks as they age, the size of their close network tends to remain relatively stable (Fung, Carstensen, and Lang, 2001). Social losses occur with increasing frequency in advanced old age (Rook, 2000), but most older adults adapt relatively well to those losses. Indeed, satisfaction with relationships increases with age (Carstensen, 1992), including higher levels of positive affect with friends and family, and a better balance of positive-to-negative affect when compared with younger adults (Charles and Piazza, 2007; Newsom et al., 2005). Carstensen’s socioemotional selectivity theory claims that older adults respond to their awareness of reduced years ahead by pruning social networks selectively, with the goal of maintaining only those relationships that support emotional well-being (Carstensen, Isaacowitz, and Charles, 1999). Of course, many older adults also experience involuntary network downsizing through death or illness (Rook, 2000).
The benefits of social network size on health are robust (Berkman and Syme, 1979). Older adults with larger networks show higher levels of health and well-being in many areas, including executive function and episodic memory (Seeman et al., 2011), cognitive decline (Barnes et al., 2004), and allostatic load (Seeman et al., 2002).
Health benefits vary across type of relationship because not all relationships are equal. Marriage and intimate partnerships generally offer protective functions to health (Burleson et al., 2013). Marital partners can offer the widest range of support functions because of the high rate of integration in each others’ lives, including companionship, emotional support, and instrumental assistance (see Rook’s article for a description of the darker impact of marital relationships on health). Adult children are important sources of emotional and instrumeninstrumental support, and sibling relationships increase in value and importance in later life (Blieszner, 2009). Friendships are important sources of well-being, too, including positive effects on physical health as discussed by Blieszner. Relationships formed within the context of volunteering also have positive effects on health (Konrath and Brown, 2013).
We live within overlapping social networks, with some relationships nested in other networks, such that the effects of relationships on health can be multifaceted and overlapping. Among women diagnosed with breast cancer, midlife and older women with high social support showed a benefit of marriage in reduced
mortality from breast cancer compared to those with lower social support (Kroenke et al., 2012).
So marriage may not have a simple, nor singular, effect on health. A good marriage, embedded within a socially supportive broader family or community network, may have a different impact on health than a good marriage in a socially isolated world, or a difficult marriage within a non-supportive social network. The broader social context in which particular relationships are embedded can alter the impact of those relationships on health.
By What Mechanisms Do Relationships Impact Health?
The bio-psychosocial model (Engel, 1977) offers a framework for conceptualizing health as being made up of biological, psychological, and social components. Each component represents a domain of health within which the mechanisms of relationship health effects have been investigated.
Relationships impact physical health through multiple biological mechanisms. Early studies focused on effects of social support on cardiovascular health indicators including blood pressure, heart rate, and cholesterol levels (Ryff, Singer, and Love, 2004). Recent attention has been focused more on the hypothalamic pituitary adrenal axis that produces cortisol in response to stressful events (Friedman et al., 2012).
A recent review (Eisenberger and Cole, 2012) of the physiological mechanisms by which social relationships may impact health suggests a twopronged impact: threats to social connection may prompt activation of a physiological alarm system, and supportive social relationships may buffer that same type of physiological alarm to any type of threat. So there is a reciprocal relationship between social relationships and biological threats. Not surprisingly, lifetime accumulated benefits of social integration and emotional support are evident in comprehensive measures of biological risk for older adults (Seeman et al., 2002).
Of the many possible mechanisms, two are described here. A positive conversation may positively influence health through its impact on positive affect and reductions in physiological arousal, as was shown in long-term married couples (Levenson, Carstensen, and Gottman, 1994).
A second psychological mechanism relates to perceptions and appraisals of social relationships. Judgments about whether an interaction or a relationship is positive or negative are referred to as appraisals. The appraisal of one’s network as adequate, supportive, positive, and helpful may also influence health separately from the actual number of persons in the network. Those who view friends and families as supportive report a greater sense of meaning in life and a stronger sense of purpose (Krause, 2007), and perceptions of social support are more powerful predictors of well-being than the actual amount of support (Barrera, 1986). Appraisals of positive and negative social exchanges in older adults influence well-being (Newsom et al., 2005) in ways that are similar to findings in young and midlife adults (Croezen et al., 2012). In short, what we tell ourselves about our relationships is as important as the number of people in our networks.
A category system for examining social benefits to health distinguishes between social support (aid or care), companionship, and control or regulation (Rook, August, and Sorkin, 2011). All three types of social benefits impact health and can be provided by a range of social partners.
Social support, which includes practical assistance (often referred to as instrumental support) and emotional support, helps individuals cope with life stressors. Instrumental support is of particular importance to a person’s experience of health problems that result in functional disability. Reduced mobility, vision, hearing, or strength can all limit a person’s ability to accomplish the instrumental activities of daily living that support independence. Often, instrumental support services are accompanied by emotional support or other types of social engagement that fulfill more than one social need.
Companionship refers to the pleasant benefits of shared activities, camaraderie, and enjoyable interaction. The benefits of companionship are expected to be found in the moodenhancing effects of good interactions—effects that may alleviate or buffer stress, enhance positive affect, support resilience, and support a person’s sense of self-worth (Rook et al., 2011). Friends often are sought out for companionship benefits rather than to gain social support per se. Family relationships may provide companionship, but often bring a mix of role obligations as well as chosen companionship opportunities.
Social control, or regulation, uses some form of constraint on risky behavior, and this assists with stabilizing health behaviors (Rook et al., 2011). A spouse’s encouragement of their partner’s choosing healthy foods from a restaurant menu or engaging in exercise are two examples of social control. But social control can lead to feeling nagged, coerced, or bossed around in ways that undermine a strong sense of efficacy or positive well-being. High levels of social skill are required to generate positive benefits from social control interactions. Although we may not seek social control in relationships, we may still benefit from it if our network pushes us toward health-promoting behaviors. On the other hand, the potential for negative effects of social control interactions (e.g., loss of self-efficacy, increased distress, and lack of self-control) are high. Social control is most likely to lead to positive health outcomes when it does not generate negative affects.
As the findings reviewed above illustrate, the bio-psychosocial model of health can organize the search for mechanisms by which social relationships affect health. External factors can also influence health, including physical environments, and the ways in which the healthcare system operates.
Physical Environments Set the Stage
Physical environments such as urban, architectural, or interior design shape social relationships in ways that can impact health. A large lobby in a senior housing complex may invite or impede social interaction, depending upon the layout of the space, lighting, and furniture selection.
The power of encouraging social interaction through thoughtful design is evident when walking through dining spaces in some assisted living facilities. Spaces designed to encourage interaction can help residents feel at home more quickly, leading to lower rates of anxiety, higher life satisfaction, and more engagement in cognitive and physical stimulation. Memory boxes used as a design element outside
apartments of people with dementia can also influence social interaction. Although designed primarily to support recognizing and identifying a room, the boxes may also serve social functions, such as helping other residents and staff know something about each person’s life. Does that support for knowing one another and knowing oneself translate into improved engagement, activity, or relationship development in ways that influence health? Designers of environments for older adults are increasingly paying attention to the direct and indirect impacts of environments on relationships and on health, and the connections between them (Brawley, 2006).
Relationships within Healthcare Delivery Systems
The power of the link between social relationships and health is hard to overstate, and yet it is almost ignored in healthcare service delivery systems. The patient-centered medical home emphasizes the value and importance of collaboration within that primary care relationship (Rittenhouse and Shortell, 2009). The medical home concept is relational at its core, with an emphasis on stabilizing the relationship between health providers and patients, while engaging patients and providers in addressing patients’ health goals in a bilateral planning process. Ironically, primary care still does not systematically view patients within the context of personal relationships at work, home, and in community, even though those relationships almost certainly impact the patient’s health. The potency of social relationships for health and well-being warrants understanding and application by those tasked with improving public or personal health.
The intertwining of relationships and health may be more visible outside the healthcare service delivery system. To sustain a new exercise routine, most people recognize they need either a trainer for accountability or an exercise buddy to join them. Smoking cessation program staff know people who live with others who smoke are going to struggle to maintain abstinence. Yet health intervention programs all too often limit their focus on changing the behavior of the patient, without engaging that person’s social network.
The healthcare system should take advantage of the social embeddedness of human lives to influence health behavior and lifestyle changes that are central to preventing and managing chronic disease. Engaging key family members in healthcare visits could be encouraged and welcomed. Chronic disease treatment plans could include social influences as useful strategies to encourage and empower older persons to achieve their healthcare goals. Patient portals to electronic health record systems could offer the option of including social network members in communications about health.
The social portion of the bio-psychosocial model may be the next frontier for targeted interventions to improve health across the lifespan, with direct impact on the experience of aging. As a colleague once quipped to me, “We are surrounded by insurmountable opportunity.” Where do we begin to engage social relationships in building a healthier aging population? From personal trainers to public policy makers, the power to influence health through relationships begs to be explored. Scientists must continue to explore the linkage, from the molecular level effects of social interactions to evaluation of interventions designed to soften the negative effects of toxic relationships in persons with chronic illness. Perhaps we need to create a health-focused “decade of relationships”!
Sara Honn Qualls, Ph.D., is a professor of psychology at the University of Colorado Colorado Springs. She also serves as the Kraemer Family Professor of Aging Studies at the University and is director of the University’s Gerontology Center.
Editor’s Note: This article is taken from the Spring 2014 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Relationships, Health, and Well-Being in Later Life.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.
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