Social Relations, Health Behaviors, and Health Outcomes: A Survey and Synthesis
Social Relations, Health Behaviors, and Health Outcomes: A Survey and Synthesis
Social Relations, Health Behaviors, and Health Outcomes: A Survey and Synthesis
Kenneth Tan
Purdue University, USA
Ed Diener
University of Illinois and the Gallup Organization, USA
Elizabeth Gonzalez
University of Illinois, USA
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Association of Applied Psychology. Published by Blackwell Publishing Ltd., 9600 Garsington
Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
SOCIAL RELATIONS AND HEALTH 29
INTRODUCTION
Since the seminal works by Cassel (1976) and Cobb (1976) on social relations
as a generalised protective factor in health, there has been a proliferation
of studies on this topic, culminating in the first meta-analyses done by
Schwarzer and Leppin (1989, 1991). A keyword search of “social relations”
or “social support” and “health” in PsycINFO and MEDLINE showed that
before the year 2000, there were 7,757 articles on this topic, but in the past
decade alone there have been 18,487 new articles. This sharp increase points
to a growing interest in this topic, for example research on social isolation,
loneliness, and health (Cacioppo et al., 2002; Cacioppo & Hawkley, 2003),
divorce and death (Sbarra & Nietert, 2009; Sbarra, Law, & Portley, 2011)
amongst many others. Thus, it is increasingly difficult to navigate this subject
due to its breadth and the voluminous numbers of articles. In view of this, we
seek to provide an updated overview to this topic by surveying and summa-
rising the literature.
In our review, we use the theoretical models linking social relations
and health proposed by Cohen and Wills (1985), Uchino (2006), Berkman
(1995), and Antoni et al. (2006) as summarised in Figure 1. We examine how
social relations are associated with different types of health behaviors (i.e.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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30 TAY ET AL.
healthy diet, physical activity, smoking, alcohol abuse, chronic illness self-
management, and suicide/self-injury) and the extent to which social relations
affect different physical health outcomes (i.e. mortality, cardiovascular
disease, and cancer). To balance breadth with depth, we focus on the use
of past systematic reviews, meta-analyses, and narrative reviews on these
different aspects of health. Because there are excellent reviews describing
the linkages between social relations and physiological processes (e.g. Cohen,
1988; Cohen & Herbert, 1996; Cohen & Wills, 1985; Miller, Chen, & Cole,
2009; Reblin & Uchino, 2008; Uchino, 2006, 2009), we omit these from our
review for space considerations. By evaluating the literature on health behav-
iors and health outcomes in a panoramic manner, we seek to contribute to the
literature by raising new questions that arise from a broad summary of social
relations and health.
The paper is structured as follows: (a) conceptual definition of social rela-
tions and the issues that could affect the association between social relations
and health behaviors; (b) conceptual questions underlying social relations and
health behaviors that serve to guide our current review and literature search;
(c) a summary and discussion of the results for different health behaviors and
outcomes.
Social Relations
Conceptual Definition. We focus on two aspects of social relations that
have been identified as important predictors of health and well-being (Cohen,
2004)—social support and social integration. Social support is defined as the
perception or experience that one is loved and cared for by others, esteemed
and valued, and part of a social network of mutual assistance and obligations
(Wills, 1991). Following this definition, social support may involve specific
instances of actual support whereby one person explicitly receives benefits
from another, or it may involve simply the perception that these benefits and
resources are available should they be needed. It is often delineated in terms
of three different types: instrumental, informational, and emotional. Respec-
tively, they involve the provision of tangible and material aid; the provision
of resources or strategies that may be needed to deal with a problem; and
providing warmth and nurturance to a person. Furthermore, there can also
be different sources of social support such as support from family, support
from friends, or support from colleagues.
Social integration is defined as the participation in a broad range of social
relationships (Brissette, Cohen, & Seeman, 2000). Social integration is often
measured by the number of social relationships, contact frequency as well as
the structure of interconnections amongst these relationships (Taylor, 2007).
For example, measures of social integration primarily focus on the social
networks of individuals, including their structure (e.g. size, range, density) and
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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SOCIAL RELATIONS AND HEALTH 31
characteristics of ties (e.g. frequency of contact) (Berkman, Glass, Brissette, &
Seeman, 2000). Other proxies of network structure include features such
as marital status, living arrangement, and the extent of organisational
involvement/activity (e.g. church, group activities) (House, Landis, & Umber-
son, 1988). Social integration may be measured using a single index (e.g.
marital status or activity engagement) or a combination of indices, which are
sometimes referred to as complex measures.
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32 TAY ET AL.
by others and experience high general social support also experience negative
social norms, resulting in non-congruence between social relations and health
behaviors.
At other times, measures of specific social relations focusing on support of
health behaviors are used; for example, whether one receives targeted support
for corresponding health behaviors such as smoking or exercise. Unlike
general measures of social relations, the effect of social relations on health
behaviors in this case is clearly defined. Therefore it is likely that specific
measures of social relations, rather than general measures, would be more
strongly related to health behaviors. On this basis, we attempt to differentiate
these two aspects where possible.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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SOCIAL RELATIONS AND HEALTH 33
Third, how do social relations affect the life course of disease formation
and progression (Cohen, 1988)? The extent to which social relations play
a protective role against disease incidence versus disease progression has
not been extensively reviewed. Current research will be used to examine the
prediction of disease incidence versus prognosis.
With regard to the previous three conceptual questions, we examine
epidemiological evidence to determine whether an association exists. Where
available, we also evaluate reviews on interventions that promote social
relations (e.g. social support intervention) to see if there is a causal basis for
social relations on health behaviors and outcomes. This is because in most
conceptual models, social relations are antecedent to health outcomes and
behaviors (see Figure 1).
METHOD
A literature search was conducted using PsycINFO and MEDLINE with
keywords “social support” or “social integration” or “social networks” and
“review” with the keywords found in Table 1. The eligibility criterion was
whether the papers were meta-analyses, systematic reviews, or narrative
reviews of social relations and the specified health behaviors or outcomes.
References of the reviews were examined and subsequent hand searches were
conducted. We found 146 articles in total, of which 51 articles were relevant,
including those from subsequent hand searches. Apart from these papers, we
also included nine papers suggested by the reviewers and these are denoted by
asterisks in the result tables.
Using these articles, the second and fourth authors coded for (a) the type
of article (i.e. meta-analyses, systematic reviews, or narrative reviews); and
(b) the measures used in the reviews. We also present a summary of the main
TABLE 1
Keyword Search for Review Articles
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34 TAY ET AL.
RESULTS
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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SOCIAL RELATIONS AND HEALTH 35
relations appear to be more directly related to health behaviors such as
chronic illness self-management and suicide and self-injury. This may be
because of the uniqueness of such behaviors that are less sensitive to behav-
ioral norms but benefit directly from social relations. In the following,
we elaborate on these findings between social relations and specific health
behaviors.
Healthy Diet. By and large, the evidence suggests that the relationship
between general measures of social relations and healthy diet and exercise
is weak; however, specific measures exhibited a stronger relationship.
Regarding healthy diet, a review of both cross-sectional and prospective
studies showed that social support was related to a healthy dietary intake of
fruit and vegetables for adults (Shaikh, Yaroch, Nebeling, Yeh, & Resnicow,
2008). Specifically four out of four prospective studies, and three out of four
cross-sectional studies, showed that social support was significantly related to
fruit and vegetable intake. It is important to note that social support defined
in the study included support for healthy eating, such as receiving encour-
agement and being influenced to eat fruit and vegetables. A similar review on
children and adolescents (McClain, Chappuis, Nguyen-Rodriguez, Yaroch,
& Spruijt-Metz, 2009) using a general definition of social support, however,
did not find consistent evidence. Table 2 presents a summary of the evidence.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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TABLE 2
Social Support and Healthy Diet Reviews
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Social relation
Authors N Sample type measure(s) Type of review Findings
McClain et al. 77 Healthy children Familial social Meta-analytic Social support was not a consistent predictor of dietary
(2009) and adults support systematic review behaviors in children and adolescents. Only 1 out of
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
SOCIAL RELATIONS AND HEALTH 37
Schwarzer, 2011; Hong et al., 2005; Wing & Jeffery, 1999). There was less
consistent evidence for informational support. Therefore, there is reasonable
evidence that some social relations supportive of exercise are related to physi-
cal activity. Table 3 summarises the reviews regarding this topic.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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TABLE 3 38
Social Support and Physical Activity
Social relation
Authors N Sample type measure(s) Type of review Findings
Ayotte et al. – Long-term Positive Social Empirical 224 couples took part in a longitudinal study. Social support was directly positively
(2010) * married Influence Scale study related to self-efficacy (b = .40) and self-regulatory behavior (b = .17) with
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couples regards to engaging in physical activity. Social support was indirectly positively
between related to engaging in physical activity (b = .34). The relationship between social
50–75 support and physical activity was through self-efficacy and self-regulatory
behavior. Other covariates included chronic health conditions, outcome
expectancies and perceived barriers of physical activity.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
suggesting mismatched support and pressure from the social network.
Hong et al. – Patients with Exercise support Empirical 109 couples participated in a study to examine the moderating effect of partners’
(2005) * heart provided and study similarity in exercise behavior on social support provision and receipt.
disease and received Individuals whose partners were similar in exercise behavior reported significant
their Exercise similarity positive influences of dyadic receipt and provision of exercise support in their
partners relationship. Individuals whose partners were not similar in exercise behavior
reported no significant influence of receipt and provision of exercise support in
their relationship. Effective dyadic exchanges of provision and receipt of exercise
support only existed when partners were similar in exercise behavior.
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TABLE 3
Continued
Social relation
Authors N Sample type measure(s) Type of review Findings
Sherwood & 9 Healthy Family social support Narrative Review of research findings on the determinants of exercise behavior. 9 studies
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Jeffery (2000) adults Friend social support review examined social support for exercise and found it to be a correlate of physical
activity. Presence of social support was correlated with higher adherence of
fitness program, regular participation in physical activity, and more positive
attitudes toward exercise. Social support had greater influence in the motivation
of exercise adoption in women than in men.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
SOCIAL RELATIONS AND HEALTH 41
abstinence. Importantly, the authors found that individuals with initial nega-
tive social networks supportive of drinking benefited most from AA involve-
ment because individuals replaced substance-using friends with individuals
who abstain. Therefore, this suggests that measures of social support that
take into account influences on target health behaviors are more directly
related than general measures of social support. Table 4 summarises the
reviews on this topic.
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TABLE 4
Social Support and Smoking and Alcohol Abuse
Social relation
Authors N Sample type measure(s) Type of review Findings
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Beattie (2001) 297 Healthy Functional support Meta-analysis High level of functional support predicted more positive drinking outcomes
adults Marital status (weighted mean r = 0.220), and the relationship was accentuated with the
involvement of significant others in treatments (r = 0.416). However, structural
support (i.e. marital status) was weakly associated with positive drinking outcomes
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Groh et al. 24 Alcoholic Social integration Narrative AA membership and participation, through which participants gained and
(2008) adults Instrumental social systematic strengthened friendship networks, improved friendship quality and friend
support review resources, and improved partner relationship quality, positively impacted
abstinence and recovery from alcohol abuse, especially for individuals with
harmful social networks supportive of drinking. One study found that the odds of
abstinence were 1.6 times higher for those receiving support from others in AA.
However, its influence on expanding and improving networks consisting of family
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TABLE 4
Continued
Social relation
Authors N Sample type measure(s) Type of review Findings
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May & West 10 Smokers Friend social Narrative Two types of “buddy” support intervention aiming at smoking cessation were
(2000) support systematic identified: one sought to improve the quality of existing support and another to
Group treatments review initiate new ties. Out of 10 studies that examined the effectiveness of “buddy”
support intervention on smoking cessation reviewed, only 2 showed that such
intervention was effective and significant in increasing the smoking abstinence rate.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
SOCIAL RELATIONS AND HEALTH 45
Among chronic illness self-management behaviors, medical adherence
is particularly important. It has been estimated that non-adherence rates are
very high and a recent meta-analysis of 569 studies across 50 years suggests
non-adherence rates of about 25 per cent (DiMatteo, 2004b). Overall, social
relations are associated with medical adherence and interventions that boost
social relations were found to be effective half the time.
A comprehensive meta-analysis of 122 studies of the association between
social relations and medical adherence showed a significant effect (DiMatteo,
2004a). The results suggest that social integration (family cohesiveness,
marital status, living arrangement) and social (practical, emotional, global)
support were related to medical treatment adherence. Among social support
types, practical support was most related to medical adherence; patients with
low support were 1.9 times more likely not to adhere to treatments. Overall,
social support was more related to medical adherence than social integration.
This was consistent with findings from Sherbourne et al. (1992) who found
that social support was a better predictor of medical adherence than social
integration.
Meta-analysis of intervention studies using randomised controlled trials
found limited evidence for the effectiveness of interventions of social relations
combined with informational, behavioral interventions: Eight out of 15 inter-
ventions had moderate to large effect sizes on adherence (Kripalani, Yao, &
Haynes, 2007); 18 out of 32 studies found that couple interventions had more
positive impact on psychological functioning compared to usual care or
patient-only care whereas the remaning studies showed mixed or null results
(Martire, Schulz, Helgeson, Small, & Saghafi, 2010). Therefore, medical
adherence and social relations are associated, and social support interven-
tions were found to be effective half the time. Table 5 presents a summary of
these studies.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
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TABLE 5
Social Support and Chronic Illness Self-Management
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Social relation
Authors N Sample type measure(s) Type of Review Findings
DiMatteo 122 Chronically Practical support Meta-analysis The risk of nonadherence to medical regimen in individuals who did not
(2004a) ill adults Emotional support receive practical support (ES .31), emotional support (ES .00–.37), and
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Social support social support (ES .20 and .21) in general were 3.6 times, 1.35 times,
Social integration and 1.53 times higher than individuals who did, respectively. Both
low levels of family cohesiveness and high levels of family conflict
contributed to 1.74 and 1.53 times higher risk of nonadherence.
Unmarried individuals were 1.13 times more likely to not adhere to
medical regimen, and increased the risk of nonadherence in children by
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
effect was seen only in men but not in women.
Kripalani 37 Chronically Social support Meta-analytic 6 out of 12 studies on informational interventions reported a significant
et al. ill adults systematic increase of at least one measure of adherence, but the effect size for
(2007) review most studies remained moderate. 8 out of the same 12 studies showed
that informational interventions did not improve clinical outcomes.
Behavioral interventions, most commonly dosage simplification,
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TABLE 5
Continued
Social relation
Authors N Sample type measure(s) Type of Review Findings
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Martire 33 Chronically Group social support Meta-analytic 18 out of 32 studies found that couple intervention had more impact
et al. ill adults Partner social support review on psychological functioning as opposed to usual care or patient
(2010) * psychosocial intervention. 7 studies found no differences whereas the
rest of the studies showed mixed effects. Couple interventions had
significant effects on depressive symptoms (d = .18), marital functioning
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SOCIAL RELATIONS AND HEALTH 49
USA adolescents also showed a strong inverse association between social
support and suicidal acts, controlling for self-reported misconduct and
history of suicide ideation and attempts (Winfree & Jiang, 2010). In this case
parental expressive social support was more inversely related to suicide than
tangible support. Data from the Center for Disease and Control and Preven-
tion (CDC) in 2005 show that social integration—specifically participation
in group sport activities—was associated with lower suicide risk, including
suicidal thoughts and attempts (Taliaferro et al., 2008). A fine-grained analy-
sis indicated that interpersonal conflict and belongingness were signifi-
cant predictors of a history of suicidal ideation, and that belongingness,
perceived social support, and living alone were significant predictors of
suicide attempts, controlling for depression as well as substance use (You,
Van Orden, & Conner, 2011). This suggests that both social integration and
social support play a role in reducing suicide.
There is also a bidirectional relation between social relations and self-
injury. For example, a review of self-injury strongly suggests that such behav-
iors are used to elicit social support (Nock, 2010). This implies that a lack of
social relations may be the key issue underlying self-destructive behaviors.
More evidence for the causal nature of social support on suicide comes from
a 4-year prospective study among 1,253 college students demonstrating that
low perceived social support consistently predicted suicidal ideation, control-
ling for depression, domestic violence, substance abuse, and affective dys-
regulation (Wilcox et al., 2010). Stronger evidence comes from one of the first
randomised control trials demonstrating that social network intervention for
suicide was effective for girls in reducing suicidal ideation, but not for boys
(King et al., 2009). Overall, this demonstrates that the lack of social relations
is predictive and possibly causal in relation to suicidal ideation and suicide.
These results are summarised in Table 6.
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TABLE 6
Social Support and Suicide / Self-Injury
Social relation
Authors N Sample type measure(s) Type of review Findings
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Blackmore – Healthy adults Social integration Empirical study A large Canadian national epidemiological survey of 36,984 respondents
et al. (2008) Instrumental social reported that being separated or divorced and social isolation were strong
support correlated with suicidal acts and attempts. Frequent and regular religious
Informational participation posited increased instrumental support and broader social
social support network were protections against suicidal acts or attempts. Other covariates
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Wilcox et al. – College Social support Longitudinal A 4-year study in one large mid-Atlantic university conducted from 2004 to
(2010) students appraisal scale study 2008 with 1,253 first-year college students revealed that low perceived social
support posited relative risk ratio of 3.7 for one-time suicide ideators (95%
CI (2.0–6.6) and relative risk ratio of 5.1 for persistent suicide ideators
(95% CI (2.0–13.1). Other covariates in this study were own depression,
family history of depression, victimisation and exposure to domestic
violence, substance abuse and affective dysregulation.
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SOCIAL RELATIONS AND HEALTH 53
others (i.e. instrumental support to friends and emotional support to spouse)
rather than receiving social support was related to decreased mortality even
after controlling for various demographic, personality, health, and mental
health status (Brown, Nesse, Vinokur, & Smith, 2003). Furthermore, a meta-
analysis carried out by Pinquart and Duberstein (2010b) found that higher
levels of perceived social support, larger social network, and being married
were associated with a decrease in relative risk for mortality for cancer
patients.
These data strongly suggest that social relations are associated with mor-
tality. But does having fewer social relations cause mortality? Experimental
data from animal models strongly demonstrate that social isolation is related
to increased risk for morbidity and mortality (House et al., 1988). However,
social relations interventions on mortality have been less clear. One of the
primary issues is that social relations interventions occur in the context of
chronic illnesses to buffer disease-specific mortality rather than all-cause
mortality. A review of social relations intervention studies with various
health outcomes did not show consistent effects of social support on mortal-
ity (Hogan, Linden, & Bahman, 2002). However, the authors suggested that
this was because the intervention types differed greatly, along with the
subpopulations, and a range of health outcomes were examined. Another
meta-analytic review of 70 randomised studies comparing family member
interventions with usual medical care on a range of health outcomes found
that there were positive effects on mortality when mixed family members (i.e.
support from different family members including spouses) were engaged
(Martire, Lustig, Schulz, Miller, & Helgeson, 2004). This is consistent with
past research showing the importance of family support over other forms of
support in relation to physiological functioning (Uchino et al., 1996). These
findings are summarised in Table 7.
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TABLE 7
Social Support and Mortality
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Social relation
Authors N Sample type measure(s) Type of review Findings
Brown – Older Giving and receiving Empirical The Changing Lives of Older Couples (CLOC) study revealed that provision of
et al. married instrumental support study support to others (instrumental support to neighbors, friends and relatives;
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Holt-Lunstad 148 Healthy Social integration Meta-analysis Social relationships were effective in reducing mortality. A 50 per cent increase in
et al. adults Social support survival was seen in participants with stronger social relationships (OR 1.50; 95%
(2010) CI 1.42–1.59). This overall effect size includes significant findings for structural
measures of social support (OR 1.57), functional aspects of social relationships (OR
1.46), and combined assessments of social relationships (OR 1.44). The effect was
consistent across age, sex, initial health status, cause of death, and follow-up period.
Complex measures of social integration (i.e. a single measure that assessed multiple
components of social integration such as marital status, network size and network
participation) was the strongest predictor of survival rate increment (OR 1.91; 95%
CI 1.63–2.23); while the binary indicators of residential status (i.e. living alone vs.
with others) was the weakest predictor (OR 1.16; 95% CI 0.99–1.44).
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was found in six out of nine studies (Kuper, Marmot, & Hemingway, 2002).
One of the strengths of these types of studies is that because social support is
assessed before clinical signs of the disease are present we can be more certain
about the directionality of influence from low social support to CHD rather
than the converse (Orth-Gomer, 1994).
If a lack of social relations potentially leads to incidence of CHD, what is
the effect size? In the review by Hemingway and Marmot (1999), the relative
risks, where calculated in studies, ranged from 1.14 to 2.13 in the eight studies
examined. Similarly, a more recent review showed that fewer social relations
conferred a relative risk of 1.5 to 2.0 in healthy populations for CHD inci-
dence and deaths (Lett et al., 2005). A recent systematic review further exam-
ined the impact of social integration and social support (Barth, Schneider, &
Kanel, 2010). Three studies assessed social support and myocardial infarction
(MI). The hazard ratios—an estimate of relative risk—ranged from 1.00 to
4.25. One study found a significant effect whereas another found a significant
effect only for men. Also, one study reported an effect size of 0.20 from a
time-dependent Cox regression analysis that was not significant. On the other
hand, social integration and prevalence of MI were examined in two studies
but were not significantly related to CHD. Overall, this shows that having
fewer social relations—particularly social support—confers a substantial risk
to CHD incidence.
Longitudinal studies show that having fewer social relations is also related
to poorer CHD prognosis. Prognostic cohort studies showed that social
support was related to the prognosis of patients in that it was related to
mortality in nine out of ten studies (Hemingway & Marmot, 1999). Another
systematic review found that 14 out of 21 prognostic studies showed substan-
tial linkages (Kuper et al., 2002). Further, a systematic review found that 18
out of 19 prognostic studies had at least one measure of social relations—
both social support and social integration—that was predictive of CHD
outcomes such as cardiac mortality and mortality in CHD patients (Lett
et al., 2005).
The effect size between social relations and CHD prognosis appears to
be similar or larger than CHD incidence. Based on a review of several large
primary studies, it was suggested that having fewer social relations has an
even greater association with CHD prognosis than incidence (Greenwood
et al., 1996). Although Lett et al. (2005) showed that low social relations
predicted CHD events (e.g. mortality or cardiac mortality) with a relative risk
of around 1.5 to 2.0—similar to that of CHD incidence—Hemingway and
Marmot (1999) found that across the 10 studies, the relative risk calculations
ranged from 1.46 to 5.60.
There were differential predictions between social integration and social
support on CHD prognosis, with social support being more important. One
systematic review consistently showed that low social support was negatively
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SOCIAL RELATIONS AND HEALTH 57
linked to cardiac and all-cause mortality (pooled relative risk [1.59–1.71]),
but low social integration did not increase mortality in patients with CHD
(Barth et al., 2010). A literature review of prospective studies investigating
the empirical evidence between social ties, social support, and social conflict
on health outcomes (e.g. MI, CVD mortality, or carotid atherosclerosis)
found similar trends. Low social support—specifically emotional social
support—was related to about a three-fold risk of MI and CHD mortality,
and fatal and non-fatal CVD. On the other hand, low social integration was
found to produce about twice the risk of fatal CHD and CVD mortality
(Everson-Rose & Lewis, 2005).
Disease severity appears to be an important moderator of the relationship
between social relations and CHD prognosis. Social relations were less effec-
tive for patient samples that had more severe CVD. One review showed that
for patients who experienced heart failure (HF), the relationship between
social relations and prognostic measures was mixed (Luttik, Jaarsma, Moser,
Sanderman, & van Veldhuisen, 2005). Out of 17 studies, only four found a
relationship between social relations and rehospitalisations and mortality. In
another review, examining studies that focused on patients with congestive
heart failure (MacMahon & Lip, 2002), there was mixed evidence for social
support. Importantly, the authors ensured that major surgery was not con-
founded with social support.
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58 TAY ET AL.
compared to usual care (Linden, Phillips, & Leclerc, 2007). This effect was
found for men (odds ratio = 0.73) but not women. Third, interventions that
started at least 2 months after a cardiac event were more protective against
mortality (odds ratio = 0.28) compared to treatments that started immedi-
ately after the event (odds ratio = 0.87). It was speculated that early recruit-
ment targets patients with much better psychosocial resources, and they often
recover with or without interventions regardless whether they were in the
treatment or in the control group.
Finally, a meta-analysis by Uchino et al. (1996) found that family ties and
social support were more important to cardiovascular functioning than other
types of social relations. This trend is borne out in intervention studies as
well. A meta-analysis of 70 randomised controlled studies focusing on the
effects of psychosocial interventions when a family was included compared to
usual patient care showed that spousal engagement lowered depressive symp-
tomology (d = .33), and mixed family member engagement (e.g. spouses and
adult children) reduced the risk of mortality (d = .14), specifically in cardiac
patients (Martire et al., 2004). On the other hand, systematic review of peer-
support interventions for heart disease patients based on six randomised
controlled trial studies found more limited support (Parry & Watt-Watson,
2010). There were, however, some positive effects on self-efficacy, activity
levels, reduced pain, and fewer emergency room visits. In another review of
38 articles, no positive health benefits were found for online peer-to-peer
interventions (Eysenbach, Powell, Englesakis, Rizo, & Stern, 2004). There
was mixed evidence from a review of 55 articles using randomised controlled
trials of nursing interventions in patients with coronary artery disease or
heart failure (Allen & Dennison, 2010). Therefore, this suggests that family-
based interventions may be more useful compared to interventions using
other sources.
In sum, many factors need to be considered when evaluating the effective-
ness of social relations interventions on CVD. Currently, it appears that
family-based interventions are more useful compared to usual patient care.
Although psychosocial interventions are useful in addressing causality,
animal studies can directly address this issue because of direct assignment to
support or non-supportive conditions. In a review of psychological factors
linked to CVD, it was shown that a lack of social relations (i.e. social isolation)
in swine and monkeys leads to atherosclerosis (Rozanski, Blumenthal, &
Kaplan, 1999). A summary of these studies linking social relations and car-
diovascular outcomes can be found in Table 8.
Cancer. There are clear pathways by which social relations and stress are
related to cancer (Uchino et al., 1996). Specifically, stressors release stress
hormones which then modulate the tumor microenvironment; stress hor-
mones can also activate oncogenic viruses and lower immune functioning
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Association of Applied Psychology.
TABLE 8
Social Support and Cardiovascular Disease
Social relation
Authors N Sample type measure(s) Type of review Findings
Allen & 55 Patients with Informational Meta-analytic Nursing interventions incorporating education plus behavioral counseling and support
Dennison heart disease social support systematic were the most commonly employed interventions in patients with coronary artery
(2010) Emotional social review diseases (CAD) or heart failure (HF), in addition to educational and informational
support interventions. 57 per cent of these interventions showed significant positive outcomes
Instrumental social in at least one of the following domains of CAD or HF patients: blood pressure,
support lipids, dietary intake, cigarette smoking, weight loss, healthcare utilisation, mortality,
quality of life, and psychosocial outcomes.
Eysenbach 38 Healthy adults Social support Narrative A review of 38 articles on online peer-to-peer interventions and complex interventions,
et al. (2004) Social integration systematic which combined educational or cognitive behavioral therapy with peer-to-peer
review interventions, did not find such interventions effective in inducing positive health
outcomes including reducing depression, weight loss, or smoking cessation.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
59
60
TABLE 8
Continued
Social relation
Authors N Sample type measure(s) Type of review Findings
TAY ET AL.
Greenwood 4 Healthy adults Social integration Narrative Social support was a stronger predictor for new incidence of coronary heart disease
et al. (1996) Patients with Emotional social systematic (CHD) than stress. Family problems, signifying damage to perceived familial
heart disease support review support, predicted higher risk of angina pectoris in Israeli men. Associations were
found between social resources and severity of CHD. Low emotional support and
poor social integration also predicted higher incidence of major coronary events.
Quality of social support, especially emotional support, had a greater influence on
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Lett et al. – Patients with Perceived social Empirical study Increased perceived social support predicted improved health outcomes, measured
(2007) heart disease support in terms of all-cause mortality and nonfatal reinfarction rates, for AMI patients
Social integration without elevated depression, but not for patients with severe depression. Perceived
tangible support and network support showed no association with improved clinical
outcomes of AMI patients.
Linden et al. 23 Patients with Social integration Meta-analysis Psychosocial treatments were correlated with reductions in psychological distress, heart
(1996) heart disease Social support rates, cholesterol levels, and systolic blood pressure in patients with coronary artery
disease (CAD). Patients who were treated psychosocially showed a 46 per cent
reduction in recurrence of CAD for two years or less, and a 39 per cent reduction for
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
61
62
TABLE 8
Continued
Social relation
TAY ET AL.
MacMahon & Lip 4 Patients with Emotional social Narrative Social support was found to have mixed effects on patients with congestive heart
(2002) heart disease support systematic failure (CHF). Lack of emotional social support predicted high risk of fatal or
review nonfatal cardiovascular events in 292 patients in a one-year longitudinal study, with
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Rozanski et al. 15 Healthy adults Social isolation Narrative Social isolation or low social support predicted 2- to 3-fold increase in CAD incidence
(1999) Patients with Social support systematic in an initially healthy population, and an approximate 2-fold increase in subsequent
heart disease Social integration review cardiac events in patients with existing CAD. Higher acculturation levels (viewed
as social disruption) in Japanese-Americans and Italian-Americans was associated
with higher incidence of CAD. Animal studies confirmed that social disruption
and isolation promoted the development of atherogenesis. Pathophysiological
mechanisms explaining such relationship included elevated resting heart rates and
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
63
64 TAY ET AL.
that then lead to tumor development and progression (Antoni et al., 2006).
However, unlike CVD, there has been less research examining the associa-
tion between social relations and cancer. In general, there is limited evidence
pointing to a relationship between the two. In an early review, it was shown
that out of five prospective randomised studies, three showed positive effects
of social relations on cancer morbidity (Spiegel, Sephton, Terr, & Stites,
1998). A more recent systematic review of only longitudinal studies found
limited evidence for social relations (Garssen, 2004). Although social rela-
tions were related to lowered risk in the studies examined, seven studies
showed that social relations were significantly related to cancer initiation and
progression, whereas seven others did not. Therefore, there is weak evidence
that social relations are related to cancer incidence and prognosis.
However, the role of social relationships may be primarily moderated
by the severity of cancer. A consistent trend in the literature is that social
relations may be particularly protective for cancers with higher survival
rates. For instance, according to the National Cancer Institute, the 5-year
survival rates for breast cancer were 91.4 per cent whereas lung cancer was
16.7 per cent. A review of 31 prognostic studies showed that the relationship
between a lack of social relations and cancer progression was the strongest in
breast cancer but weaker in other types of cancers (e.g. lung cancer) (Naush-
een, Gidron, Peveler, & Moss-Morris, 2009). Another review also found that
variables such as social support and marriage with significant psychosocial
components were helpful for the survival of breast cancer patients but not for
other forms of cancer or mixed cancers (Falagas et al., 2007). An analysis of
cancer studies in which a majority of the studies were of breast cancer patients
(20 out of 33 studies) showed that there was a positive association between
social relations and prognosis in regard to cancer relapse and survival (De
Boer, Ryckman, Pruyn, & Van den Borne, 1999).
There also appear to be preliminary differences between forms of social
relations in predicting cancer outcomes. A review of 31 prospective studies
showed that social integration was more strongly related to disease progres-
sion than social support (Nausheen et al., 2009). In part this may be because
a larger network provides a variety of contacts and awareness of cancer-
related issues that may encourage medical checkups and general health
behaviors—these behaviors may lead to shorter delays in diagnosing and
treating cancer, which improves cancer prognosis (see Richards, Westcombe,
Love, Littlejohns, & Ramirez, 1999).
A meta-analysis of 45 studies reporting 62 treatment–control comparisons
showed that there were beneficial effects of psychosocial treatment on cancer-
related symptoms (d = .26) (Meyer & Mark, 1995). Interestingly, there was
little difference between behavioral interventions, nonbehavioral counseling
and therapy, informational and educational methods, or social support
organised and provided by other patients. Although this provides some
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Association of Applied Psychology.
SOCIAL RELATIONS AND HEALTH 65
evidence that social relations may be positively related to cancer outcomes,
evidence from longitudinal studies appears to be mixed and more research is
required to determine why effects are found and why they are not. Table 9
summarises the papers on this issue.
DISCUSSION
More than two decades ago, Cohen (1988) proposed an agenda for examining
social relations with different health indicators. In this review we sought to
appraise current evidence on this topic. We found that social relations had
differential effects on various health behaviors and outcomes. When social
relations are measured with respect to specific health behaviors—which
broadly include aspects such as social influence, encouragement, and com-
panionship in engaging target behavior—they are more predictive of health
behaviors compared to general measures of support. However, social rela-
tions measured in a general manner are associated with health behaviors such
as chronic illness self-management, suicide, and self-injury. We posited that it
is because social norms may be accounted for by specific measures of social
relations but not in general measures.
There is now a growing recognition that network behavioral norms and
support can potentially exert opposing or consistent effects in influencing
health behaviors (Burg & Seeman, 1994). Not all relationships produce
health and wellness. For instance, adolescent substance abuse has been found
to be associated with family history of abuse (Wills & Yaeger, 2003). It has
been noted that because these negative ties are not accounted for, the positive
effect of social relations may actually be larger (Uchino, 2006). Indeed, we
found that evidence for general support was mixed, but support for specific
behaviors was more likely to predict behavioral outcomes. Aside from using
more specific measures of support, we encourage future research to incorpo-
rate network behavioral norms when studying social support and health
behaviors.
There is evidence that there is a causal effect of social support on mortality
and CVD, but evidence is mixed on cancer outcomes. One potential variable
that could explain this differential is disease severity and cancer type. We
suggest that the prognosis of diseases such as survival rates should be
included as potential moderators of social support effectiveness. One clear
implication is that social relations can change disease outcomes when they
are more malleable. We also speculate that diseases that have higher survival
rates have more routine medical screenings (e.g. breast cancer screening).
Social relations may also serve an additional role of either increasing aware-
ness or obligating individuals to go for routine medical screenings (e.g. breast
cancer screening); consider the case where a mother may feel greater respon-
sibility for taking care of her health than a single woman or when men take
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Association of Applied Psychology.
66
TABLE 9
Social Support and Cancer
TAY ET AL.
Social relation
Authors N Sample type measure(s) Type of review Findings
Antoni et al. – Cancer patients Social support Narrative Social support predicted longer survival in cancer patients. Low social support was
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Garssen (2004) 6 Cancer patients Social integration Narrative 6 longitudinal, prospective studies found a relationship between social support and
Social isolation systematic cancer progression. Experience of support, presence of confidants, presence of a
Perceived social review sufficient network of friends and relatives, and involvement in organisations
support predicted longer disease-free intervals and longer survival in cancer patients.
Canadian breast cancer patients with at least one type of confidant had a higher
survival rate (74%) than patients who did not have any confidants (56%) at a 7-year
period. Longer disease-free intervals were observed in recurrent cancer patients with
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
67
68
TABLE 9
Continued
Social relation
TAY ET AL.
Pinquart & 87 Cancer patients Social integration Meta-analysis (repeated in mortality summary)
Duberstein Perceived social
(2010a) * support
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
SOCIAL RELATIONS AND HEALTH 69
better care of their health when they are married by being more likely to
engage in preventive and follow-up health care.
For disease trajectories that are less modifiable via medical treatment, it is
not surprising that social support exerts smaller effects. Apart from the
inherent immutability, it is also possible that steeper downward trajectories
of diseases offer less time for social relations to be fully activated. This further
compounds the limitation of social relations on severe diseases. While social
relations are often seen as protective factors against diseases, severe diseases
in particular may elicit more support. In one study on social support and
diabetes, patients received more support from their partners on days when
their physical symptoms were more severe. These symptoms served as a
signal to their partners who in turn offered greater emotional support (Iida,
Seidman, Shrout, Fujita, & Bolger, 2008). Also, a longitudinal study in a
group of patients who had undergone radical prostatectomy showed that
disease severity positively predicted support provision. Furthermore, positive
affect due to lower disease severity and recovery predicted less support pro-
vision as well as more reciprocal support provision from patients (Knoll,
Burkert, Luszczynska, Roigas, & Gralla, 2011a; Knoll, Burkert, Roigas, &
Gralla, 2011b). Therefore, the relation between social support and disease
severity is complex, and it is likely that the severity of the disease impacts both
the effectiveness of social support and the amount of support received.
We found that differences emerged between social support and social
integration in predicting health outcomes. Both social integration and
social support were associated with mortality, but complex measures of
social integration (e.g. marital status + network size + network participation)
were more predictive. Also, there is evidence that low social integration was
associated with cancer outcomes whereas social support was more associated
with CHD incidence and prognosis. It is difficult to ascertain the conceptual
basis for these differences, and the reason may lie in the measurement of these
constructs. There are large variations in how social support and social inte-
gration are measured. Social support can be measured as: (a) a general sense
of support; (b) a summation of different aspects of social support such as
emotional support, tangible support, and informational support; (c) different
sources of support such as family, friends, or colleagues. Along the same
lines, social integration measures may include a range of indices that are not
uniform across the literature. Overall, because social relations measured
in various ways are positively associated with health, it suggests a robust
association.
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Association of Applied Psychology.
70 TAY ET AL.
because it does not always delineate how specific types of social support relate
to health outcomes. In part, the exponential growth of social support and
health has limited our focus to review articles and more general aspects of
support and health. Nevertheless, our review reveals potential moderators
(e.g. social norms and disease severity) that need to be considered, and the
areas that need more primary research and focused quantitative reviews to
understand distinctions between types of support and health behaviors as
shown in Figure 1.
To date, most research on health outcomes has been limited to social
integration and social support. However, there are other aspects of social
relations such as received support and support provision to others. Received
or enacted support is defined as whether support has been provided recently;
support provision is the giving of help to others. Both facets are conceptually
distinct from social integration and social support (Barrera, 1986; Haber,
Cohen, Lucas, & Baltes, 2007). Importantly, the behavioral dynamic of
receiving and giving support and its impact on health requires further exami-
nation. Received social support is often triggered in times of stress and
may not be always helpful (Bolger & Amarel, 2007; Bolger, Zuckerman, &
Kessler, 2000). This is because received support incurs an emotional cost and
could potentially lower self-esteem and sense of self-efficacy when it is not
sought. On the other hand, there is some empirical evidence which suggests
that provision of social support may be more helpful than support receipt for
mortality outcomes (Brown et al., 2003). Yet, long-term provision of support
can be stressful and result in worse health outcomes. Therefore, it is impor-
tant for more research to determine when and how receiving and supplying
support can be beneficial to health.
Because social relations entail both rewards and costs (e.g. Rook, 1984),
the linkage between social relations and physical health is not necessarily
positive. Social relations can be a source of stress as individuals may provide
unwanted or ineffective help or negative interactions (Rook & Pietromonaco,
1987). For example, there is new evidence showing that negative and com-
petitive social interactions reduce physiological functioning (Chiang, Eisen-
berger, Seeman, & Taylor, 2012). Also, negative interactions may lead to
lower mortality in the long run because social control from significant others
(e.g. demanding medical adherence) could increase longevity but would be
perceived in a negative light (Birditt & Antonucci, 2008). Interestingly, nega-
tive and positive aspects of social relations appear to be independent (Reven-
son et al., 1991). Therefore, our conceptual model presented in Figure 1 can
include both positive and negative effects of social relations.
Related to social interactions, there needs to be more focused research into
the interaction patterns of individuals. According to Relational Regulation
Theory (Lakey & Orehek, 2011), it has been proposed that the main effect of
social support on mental health is based on commonplace interactions and
© 2012 The Authors. Applied Psychology: Health and Well-Being © 2012 The International
Association of Applied Psychology.
SOCIAL RELATIONS AND HEALTH 71
shared activities. More recent research has moved in this direction with
regard to physical health. Because it has been found that family support was
particularly important to physical health, Rosland, Heisler, and Piette (2011)
explored specific family behaviors in relation to several health outcomes. In
their review of 22 studies, half of which were longitudinal, they found that
family cohesion (e.g. marital cohesion/intimacy, family cohesion amount)
and family function (e.g. intimacy, accommodation, respect) was related
to lower risk of coronary heart disease. Apart from the use of self-reported
behaviors, studies can also examine specific dyadic transactions of commu-
nication behaviors (e.g. Cutrona & Suhr, 1994).
In virtually all the social relations studies related to physical health, social
support was measured using self-reports. Yet this neglects the interdependent
nature of social support. A reliance on self-reports may omit key support
transactions. A daily diary study of partners revealed that recipients who
were unaware of support provision (reported by their partner) were better
adjusted during major stressors (Bolger et al., 2000). Further, self-reports
may not account for all the situational factors to accurately assess the avail-
ability of support. In a study examining ratings of adolescents and adult
informants, only informant social support ratings were significant predictors
of postpartum depression scores both concurrently and after 6 weeks, even
when statistically controlling for self-ratings (Cutrona, 1989).
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