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Since the mid-1970s there have been dozens of articles, and now books, on issues related to social networks and social support. It is now recognized widely that social relationships and aﬃliation have powerful eﬀects on physical and mental health for a number of reasons (House et al. 1988, Berkman and Glass 2000, Cohen et al. 2000).
When investigators write about the impact of social relationships on health, many terms are used loosely and interchangeably, including social networks, social support, social ties, and social integration. The aim of this research paper is to discuss: (a) theoretical orientations from diverse disciplines which are fundamental to advancing research in this area; (b) ﬁndings related to mortality; (c) a set of deﬁnitions of networks and aspects of networks and support; and (d) an overarching model which integrates multilevel phenomena.
1. Theoretical Orientations
There are several sets of theories that form the bedrock for the empirical investigation of social relationships and their inﬂuence on health. The earliest theories came from sociologists such as Emile Durkheim, as well as from psychoanalysts such as John Bowlby, who ﬁrst formulated attachment theory. A major wave of conceptual development also came from anthropologists including Bott and Mitchell, as well as quantitative sociologists such as Burt, Laumann, and Wellman who, along with others, have developed social network analysis. This eclectic mix of theoretical approaches coupled with the contributions of epidemiologists form the foundation of research on social ties and health.
Durkheim’s contribution to the study of the relationship between society and health is immeasurable. Perhaps most important is the contribution he has made to the understanding of how social integration and cohesion inﬂuence suicide (Durkheim 1897). Durkheim’s primary aim was to explain how individual pathology was a function of social dynamics. In light of recent attention to ‘upstream’ determinants of health, Durkheim’s work re-emerges with great relevance today.
Bowlby (1969), one of the most important psychiatrists of the twentieth century, proposed theories suggesting that the environment, especially in early childhood, played a critical role in the genesis of neurosis. Bowlby proposed that there is a universal human need to form close aﬀectional bonds. Attachment theory, proposed by Bowlby, contends that the attached ﬁgure creates a secure base from which an infant or toddler can explore and venture forth. The strength of Bowlby’s theory lies in its articulation of an individual’s need for secure attachment for its own sake, for the love and reliability it provides, and for its own ‘safe haven.’ Primary attachment promotes a sense of security and self-esteem that ultimately provides the basis on which the individual will form lasting, secure and loving relationships in adult life.
1.1 Social Network Theory: A New Way Of Looking At Social Structure And Community
During the mid-1950s, a number of British anthropologists found it increasingly diﬃcult to understand the behavior of either individuals or groups on the basis of traditional categories such as kin groups, tribes, or villages. Bott (1957) and Mitchell (1969) developed the concept of ‘social networks’ to analyze ties that cut across traditional kinship, residential, and class groups to explain behaviors they observed such as access to jobs, political activity, or marital roles. The development of social network models provided a way to view the structural properties of relationships among people.
Network analysis ‘focuses on the characteristic patterns of ties between actors in a social system rather than on characteristics of the individual actors themselves and use these descriptions to study how these social structures constrain network members’ behavior’ (Hall and Wellman 1985, p. 26). Network analysis focuses on the structure and composition of the network, and the contents or speciﬁc resources that ﬂow through those networks. The strength of social network theory rests on the testable assumption that the social structure of the network itself is largely responsible for determining individual behavior and attitudes, by shaping the ﬂow of resources which determine access to opportunities and constraints on behavior.
2. Health, Social Networks, And Integration
From the mid-1970s through the present, there has been a series of studies showing consistently that the lack of social ties or social networks predicted mortality from almost every cause of death. These studies have been done in the USA, Europe, and Asia and most often captured numbers of close friends and relatives, marital status, and aﬃliation or membership in religious and voluntary associations. These measures were conceptualized in any number of ways as assessments of social networks or ties, social connectedness, integration, activity, or embeddedness. Whatever they were named, they deﬁned embeddedness or integration uniformly as involvement with ties spanning the range from intimate to extended.
In the ﬁrst of these studies, from Alameda County (Berkman and Syme 1979), men and women who lacked ties to others (in this case, based on an index assessing contacts with friends and relatives, marital status, and church and group membership) were 1.9 to 3.1 times more likely to die in a 9-year follow-up period than those who had many more contacts.
Another study in Tecumseh, Michigan (House et al. 1982) shows a similar strength of positive association for men, but not for women, between social connectedness/social participation and mortality risk over a 10–12 year period. An additional strength of this study was the ability to control for some bio- medical predictors assessed from physical examination (e.g., cholesterol, blood pressure, and respiratory function).
Similar results from several more studies have been reported, one from a study in the United States and three from Scandinavia. Using data from Evans County, Georgia, Schoenbach et al. (1986) found risks to be signiﬁcant in older white men and women even when controlling for biomedical and sociodemographic risk factors, although some racial and gender diﬀerences were observed. In Sweden, two studies (Welin et al. 1985, Orth-Gomer and Johnson 1987) report signiﬁcantly increased risks among socially isolated adults. Finally, in a study of 13,301 men and women in Eastern Finland, Kaplan et al. (1988) have shown that an index of social connections predicts mortality risk for men but not for women, independent of standard cardiovascular risk factors.
Studies of older men and women conﬁrm the continued importance of these relationships into late life (Seeman et al. 1993a). Furthermore, two studies of large cohorts of men and women in a large Health Maintenance Organization (HMO) (Vogt et al. 1992), and 32,000 male health professionals (Kawachi et al. 1996) suggest that social networks are, in general, more strongly related to mortality than to the incidence or onset of disease.
Two studies, in Danish men (Pennix et al. 1997), and Japanese men and women (Sugiswa et al. 1994), further indicate that aspects of social isolation or social support are related to mortality. Virtually all of these studies ﬁnd that people who are socially isolated or disconnected from others have between two and ﬁve times the risk of dying from all causes compared to those who maintain strong ties to friends, family, and community.
Social networks and support have been found to predict a very broad array of other health outcomes from survival post-myocardial infarction to disease progression, functioning and the onset and course of infectious diseases. The reader is referred to several lengthy reviews mentioned earlier for additional information.
3. A Conceptual Model Linking Social Networks To Health
Although the power of measures of networks or social integration to predict health outcomes is indisputable, the interpretation of what the measures actually assess has been open to much debate. Hall and Wellman (1985) have commented appropriately that much of the work in social epidemiology has used the term social networks metaphorically, since rarely have investigators conformed to more standard assessments used in network analysis, according to calls to develop a second generation of network measures (Berkman 1986, House et al. 1988).
A second wave of research developed in reaction to this early work, and as an outgrowth of work in health psychology, that turned the orientation of the ﬁeld in several ways (House and Kahn 1985, Sarason et al. 1990). These social scientists focused on the qualitative aspects of social relations (i.e., their provision of social support or, conversely, detrimental aspects of relation- ships) rather than on the elaboration of the structural aspects of social networks.
Most of these investigators follow an assumption that what is most important about networks is the support function they provide. While social support is among the primary pathways by which social networks may inﬂuence physical and mental health status, it is not the only critical pathway (Berkman and Glass 2000). Moreover, the exclusive study of more proximal pathways detracts from the need to focus on the social context and structural underpinnings that may have an important inﬂuence on the types and extent of social support provided.
In order to have a comprehensive framework in which to explain these phenomena, it is helpful to move ‘upstream’ and return to a more Durkheimian orientation to network structure and social context. It is critical to maintain a view of social networks as lodged within those larger social and cultural contexts which shape the structure of networks. In fact, some of the most interesting recent work in the ﬁeld relates social aﬃliation to social status, and social and economic inequality (Kawachi et al. 1997).
Conceptually, social networks are embedded in a macrosocial environment in which large-scale social forces may inﬂuence network structure, which in turn inﬂuences a cascading causal process beginning with the macrosocial to psychobiological processes to impact health. Serious consideration of the larger macrosocial context in which networks form and are sustained has been lacking in all but a small number of studies, and is almost completely absent in studies of social network inﬂuences on health.
Networks may operate at the behavioral level through at least four primary pathways: (a) provision of social support, (b) social inﬂuence, (c) social engagement and attachment, and (d) access to resources and material goods. These psychosocial and behavioral processes may inﬂuence even more proximate pathways to health status, including: (a) direct physiological responses, (b) psychological states including self-esteem, self-eﬃcacy, depression, (c) health-damaging behaviors such as tobacco consumption or high-risk sexual activity, and health promoting behavior such as appropriate health service utilization or exercise, and (d) exposure to infectious disease agents such as HIV, other sexually transmitted diseases (STDs), or tuberculosis. The four primary psychosocial or behavioral pathways by which networks may inﬂuence health will be reviewed brieﬂy. The reader is referred to Berkman and Glass (2000) for a lengthier review.
3.1 The Assessment Of Social Networks
Social networks might be deﬁned as the web of social relationships that surround an individual and the characteristics of those ties. Burt (1982) has deﬁned network models as describing ‘the structure of one or more networks of relations within a system of actors.’ Network characteristics cover:
(a) range or size (number of network members),
(b) density (the extent to which the members are connected to each other),
(c) boundedness (the degree to which they are deﬁned on the basis of traditional structures such as kin, work, neighborhood), and
(d) homogeneity (the extent to which individuals are similar to each other in a network).
Related to network structure, characteristics of individual ties include:
(a) frequency of contact,
(b) multiplexity (the number of types of trans- actions or support ﬂowing through ties),
(c) duration (the length of time an individual knows another), and
(d) reciprocity (the extent to which exchanges are reciprocal).
3.2 Downstream Social And Behavioral Pathways
3.2.1 Social Support. Moving downstream, discussion follows of the mediating pathways by which networks might inﬂuence health status. Most obviously the structure of network ties inﬂuences health via the provision of many kinds of support. This framework acknowledges immediately that not all ties are supportive, and that there is variation in the type, frequency, intensity, and extent of support provided. For example, some ties provide several types of support while other ties are specialized and provide only one type. Social support typically is divided into subtypes which include emotional, instrumental, appraisal, and informational support (House 1981). Emotional support is related to the amount of ‘love and caring, sympathy and understanding and/or esteem or value available from others.’ Emotional support is most often provided by a conﬁdant or intimate other, although less intimate ties can provide such support under circumscribed conditions.
Instrumental support refers to help, aid, or assistance with tangible needs such as getting groceries, getting to appointments, phoning, cooking, cleaning, or paying bills. House identiﬁes instrumental support as aid in kind, money, or labor. Appraisal support often deﬁned as the third type of support, relates to help in decision-making, giving appropriate feedback, or help deciding which course of action to take. Informational support is related to the provision of advice or information in the service of particular needs. Emotional, appraisal, and informational support are often diﬃcult to disaggregate and have various other deﬁnitions (e.g., self-esteem support).
Perhaps even deeper than support are the ways in which social relationships provide a basis for intimacy and attachment. Intimacy and attachment have meaning not only for relationships that we think of traditionally as intimate (e.g., between partners, parents, and children) but for more extended ties. For instance, when relationships are solid at a community level, individuals feel strong bonds and attachment to places (e.g., neighborhood) and organizations (e.g., voluntary and religious).
3.2.2 Social Inﬂuence. Networks may inﬂuence health via several other pathways. One pathway that is often ignored is based on social inﬂuence. Shared norms around health behaviors (e.g., alcohol and cigarette consumption, healthcare utilization) might be powerful sources of social inﬂuence with direct consequences for the behaviors of network members, quite apart from the provision of social support taking place within the network concurrently. For instance, cigarette smoking by peers is among the best predictors of smoking for adolescents (Landrine et al. 1994). The social inﬂuence which extends from the network’s values and norms constitutes an important and under-appreciated pathway through which networks impact health.
3.2.3 Social Engagement. A third and more diﬃcult to deﬁne pathway by which networks may inﬂuence health status is by promoting social participation and social engagement. Participation and engagement result from the enactment of potential ties in real life activity. Getting together with friends, attending social functions, participating in occupational or social roles, group recreation, and church attendance are all instances of social engagement. Thus, through opportunities for engagement, social networks deﬁne and reinforce meaningful social roles including parental, familial, occupational, and community roles, which in turn provide a sense of value, belonging, and attachment. Several recent studies suggest that social engagement is critical in maintaining cognitive ability (Bassuk et al. 1999) and reducing mortality (Glass et al. 1999).
In addition, network participation provides opportunities for companionship and sociability. Rook (1990) argues that these behaviors and attitudes are not the result of the provision of support per se, but are the consequence of participation in a meaningful social context in and of itself. One reason measures of social integration or ‘connectedness’ may be such powerful predictors of mortality over long periods of follow-up is that these ties give meaning to individuals’ lives by virtue of enabling them to participate in it fully, to be obligated (in fact, often to be providers of support), and to feel attached to their community.
3.2.4 Person-To-Person Contact. Another behavioral pathway by which networks inﬂuence disease is by restricting or promoting exposure to infectious disease agents. In this regard, the methodological links between epidemiology and networks are striking. What is perhaps most remarkable is that the same network characteristics that can be health-promoting can at the same time be health-damaging if they serve as vectors for the spread of infectious disease.
The contribution of social network analysis to the modeling of disease transmission is the understanding that in many, if not most, cases, disease transmission is not spread randomly throughout a population. Social network analysis is well suited to the development of models in which exposure between individuals is not random but rather is based on geographic location, sociodemographic characteristics (age, race, gender), or other important characteristics of the individual such as socioeconomic position, occupation, or sexual orientation (Laumann et al. 1989). Furthermore, because social network analysis focuses on characteristics of the network rather than on characteristics of the individual, it is suited ideally to the study of diﬀusion of transmissible diseases through populations via bridging ties between networks, or uncovering characteristics of ego-centered networks that promote the spread of disease.
3.2.5 Access To Material Resources. Surprisingly little research has sought to examine diﬀerential access to material goods, resources, and services as a mechanism through which social networks might operate. This is unfortunate given the work of sociologists showing that social networks operate by regulating an individual’s access to life-opportunities by virtue of the extent to which networks overlap each other. In this way networks operate to provide access or to restrict opportunities in much the same way that social status works. Perhaps the most important among the studies exploring this tie is Granovetter’s classic study of the power of ‘weak ties’ that, on the one hand lack intimacy, but on the other facilitate the diﬀusion of inﬂuence and information, and provide opportunities for mobility (Granovetter 1973).
There are ﬁve mechanisms by which the structure of social networks might inﬂuence disease patterns. While social support is the mechanism most commonly invoked, social networks also inﬂuence health through additional behavioral mechanisms including (a) forces of social inﬂuence, (b) levels of social engagement and participation, (c) the regulation of contact with infectious disease, and (d) access to material goods and resources. To date, the evidence linking aspects of social relationships to health outcomes is strongest for general measures of social integration, social support, and social engagement. However, it should be noted that these mechanisms are not mutually exclusive. In fact, it is most likely that in many cases they operate simultaneously.
The aim in this review was to integrate some classical theoretical work in sociology, anthropology, and psychiatry with the current empirical research underway on social networks, social integration, and social support. Rather than review the vast amount of work on health outcomes which is the subject of several excellent recent papers, a conceptual framework that guides work in the future has been developed.
With the development of this framework, two issues of profound importance stand out. The ﬁrst is the ‘upstream’ question of identifying those conditions that inﬂuence the development and structure of social networks. Such questions have been the substantive focus of much of social network research, especially in relationship to urbanization, social stratiﬁcation, and culture change. Yet little of this work becomes integrated with health issues in a way that might guide us in the development of policies or intervention to improve the health of the public. Of particular interest would be more cross-cultural work comparing countries with diﬀerent values regarding social relationships, community, or sense of obligation. The same might be true to speciﬁc areas within countries, or speciﬁc cultural or ethnic groups with clearly deﬁned values.
The second major issue relates to the ‘downstream’ question. Many investigators have assumed that networks inﬂuence health via social support functions. The framework in this research paper makes clear that this is but one pathway linking networks to health outcomes. Furthermore, the work on conﬂicts and stress points out that not only are not all relationships positive in valence, but that some of the most powerful impacts on health that social relationships may have are through acts of abuse, violence, and trauma (Rook 1992). Fully elucidating these downstream experiences, and how they are linked to health via which biological mechanisms, remains a major challenge in the ﬁeld.
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