HEALTH, SOCIAL FACTORS

To understand the connection between social factors and health, it is necessary to examine the average level of health of aging people in one social group and then compare this to the average level of health of those in another social group. One's social situation can be examined in several ways including marital status, social class, religiousness, and relationships with others.

If the health of people in one group, such as married individuals, is better on average than the health of those in another, such as widowed persons, one can conclude there is a relationship between that particular marital status and health. Once a relationship is observed, it is important to examine the underlying mechanisms that explain it. First, it is necessary to determine whether health determines one's social position or whether the social position influences health outcomes. If people with certain health problems are not able to attain or remain in a certain social position, researchers say that the underlying mechanism was selection into the social status. In other words, if an existing physical or mental health problem makes it less likely that a person will marry, then that person's health causes his or her marital status. Alternately, if being in a particular social position or group has an effect on one's health, researchers say that something about the social environment associated with that position or group has an effect on health, and they then must investigate further to determine the underlying factors. Information collected at one point in time, however, does not untangle whether one's current social position or one's health status came first. To address this problem, some researchers design studies that follow the same individuals over time, noting the changes in health status and social position over the course of their lives.

Health outcomes are often measured in terms of how a person defines his or her own health, the number of health problems a person has, the amount of disability a person experiences, and the chances a person has of dying—commonly known as mortality. Various social factors may have an effect on health and health outcomes.

Social support

Social support includes resources, either practical or emotional, provided by others. A person's social network, which includes the number of relationships and the frequency of contact with others, provides information about how socially integrated an individual is, but does not give information about the quality of the relationships. More in-depth measures of social support include whether the type of support is emotional and provides a feeling of being cared for, or whether it is instrumental and provides practical help with tasks or financial aid. Further, the quality of the interaction indicates whether the social relationship is positive and helpful or negative and conflictual.

Social relationships have a powerful effect on physical and mental health, and on mortality. In one of the earliest studies to note this association, Berkman and Syme (1979) found that even after taking into consideration levels of self-reported health, a social network index comprised of social ties with a spouse, family, and friends; church membership, and other group membership predicted mortality within the next nine years. For people between sixty and sixty-nine years of age, the relative risk of dying over the next nine years for the most isolated men was 1.8 times the risk associated with the most connected men. For women in this age group, those with the least connections had three times the relative risk of those with the most connections. Later studies took into consideration baseline levels of health and found that social integration or isolation added to a prediction of later mortality.

Dean, Kolody, and Wood (1990) found that older individuals who reported higher levels of care and concern from spouses, friends, and children had lower levels of depression than those who experienced little social support. Interestingly, those who reported low levels of expressive support from adult children and spouses had higher levels of depression than those who did not have children or a spouse. This suggests that it is not only the presence of a social tie, but also the quality of the relationship that affects mental health.

Marriage

On average, the health of those who are married is better than the health of individuals who live alone. Further, married individuals live longer than those who are not married. For older adults, the problems associated with being alone are mainly seen in those who are widowed, rather than in those who are divorced or who never married. Goldman, Korenman, and Weinstein (1995) found that for individuals age seventy and older, after taking into consideration self-rated health, functional ability, and medical conditions, widowhood predicts later disability for both men and women, and mortality for men. It is unlikely that the poorer health status of the widowed is due to the crisis of bereavement, because only 7 percent of the widowed in the sample had lost their spouse within two years of the initial interview. Rather, factors associated with being widowed and not remarrying appear to cause poorer health. However, the relationship between widowhood and mortality is only seen for men, and the relationship with disability is much stronger for men than for women. This may be because women are likely to serve as care-givers who monitor their husbands' health behaviors—after their wife's death, men lose an important source of instrumental support.

Marriage does seem to offer a distinct health benefit that the widowed do not enjoy. The protective aspect of marriage could occur because marriage acts as a form of social control that encourages individuals to engage in better health practices and less risky behavior. It could also be due to the social support that a spouse offers. A spouse can serve as a confidant who offers emotional support and practical advice in the face of a problem or stressor. In this way, a spouse serves as a buffer that protects the person from becoming affected by the stress caused by serious life events. Furthermore, support from the spouse can be helpful not only during serious problems, but also during everyday hassles and challenges. Aside from offering emotional and practical support in the face of difficulties, a spouse can serve as someone who offers love, care, and respect, as well as someone who encourages a healthy self-esteem. In addition to these benefits of marriage, it is also possible that the healthiest individuals are better able to remarry after losing a spouse, thereby letting their health status select them into their social position.

Religion

Many studies have found religiosity to have a beneficial influence on the health of older adults. In reviewing the research on the association between religiosity and health, Jeffery Levin (1994) notes that there are several mechanisms through which religion may affect health. First, religious organizations promote behaviors that are congruent with good health outcomes, such as abstaining from smoking; drinking in moderation; and taking care of oneself through exercise and diet. In a study of older adults, Idler and Kasl (1997a) found that those who regularly attended religious services were more likely to engage in physical exercise, to drink only in moderation, and not to have smoked than were those who attended services less frequently or not at all.

Religious involvement may also lead to better health by providing individuals with social support and a feeling of social integration. Compared with individuals who never or rarely attend religious service, those who frequently attend also engage in more leisure activities, have contact with and feel closer to a greater number of friends and kin, and celebrate holidays that involve various social ties.

Social activities and close family relationships do explain some of the relationship between religion and health, but it seems that attendance at religious services also provides something more. Other possible factors linking religion and health involve the psychodynamics of belief systems, religious rites, and faith. Religious rites have a calming effect on members, and religious faith may increase the expectation of positive health outcomes. These factors may serve as a placebo and result in better health outcomes.

Much of the research that finds an association between religion and health cannot determine whether religion causes better health. It is possible that healthy individuals are better able to get to services, while those with worse health and disability are not able to participate. If this is the case, then it is health status that selects individuals into the position of religious participation. Idler and Kasl (1997b) examined data that tracked a group of older adults over twelve years and noted frequency of attendance at religious service and levels of functional ability at different time periods. They found that initial levels of religious participation protected against disability in later years; however, initial levels of disability did not affect attendance three years later. This suggests that religious involvement affects health to a greater extent than health affects religious involvement.

Socioeconomic status

Individuals with lower socioeconomic status (SES)—those who have less education and income—have an earlier onset of illness, more illness overall, and earlier deaths than those with higher SES. Social stratification early in the life course affects the trajectory an individual is likely to follow. Being born with economic advantages is likely to lead to educational success, which is linked to occupational advantage and later financial security. Data from the National Longitudinal Survey of Labor Market Experience: Mature Men, 1966–1990 was used to examine the impact of educational and occupational experiences on premature death. Length of education, type of first job, type of job in middle age, and family wealth in middle age each were found to contribute independently to the risk of a premature death. Data from other countries replicate this importance of social class over the life course for timing of death. When individuals were categorized according to the number of points in their life when they were living with a father who held a manual labor job or they themselves held a manual job, those who never engaged in manual labor had better health than those who did so at all points. While social status in childhood influences later social status through educational advancement, social position at each stage of life has also been found to exert an independent influence on later health.

A large dataset of noninstitutionalized adults in the United States found that in the six years before death, the health status of older respondents varied based on their level of education. In the years before death, those with less education were likely to be more limited in activity, to have multiple chronic health conditions, and to have spent more days in bed and in the hospital. This suggests that those with higher socioeconomic status are likely to live more of their life in good health than those with lower SES.

What is it about lower levels of education and income that leads to declines in health? House, et al. (1994) found that people with lower socioeconomic status are more likely to be exposed to risk factors. Compared with those with more money and education, those with less are at a disadvantage, in terms of drinking, marital status, informal social integration, and chronic financial stress, across all age groups. For other risk factors, including smoking, being overweight, formal social integration, perceived social support, and self-esteem and self-mastery, the disadvantage of those with lower SES increases through middle age and then diminishes later in life. This suggests that early disadvantage based on these risk factors may cause less healthy individuals with lower socioeconomic status to die at earlier ages.

Overall, the health status of older adults is positively related to their social status. Being married, having high levels of social support, attending religious services, and having a high socioeconomic status offers health benefits that the widowed, elderly persons with little social support, those who do not attend religious services, and those of low socioeconomic status do not enjoy. The social position that each older individual occupies, which exerts such strong influence on health, is the result of lifelong processes, and may itself be influenced by earlier health status.

Ellen L. Idler Julie McLaughlin

See also Divorce: Trends and Consequences; Education; Inequality; Marital Relationships; Marriage and Remarriage; Religion; Social Support.

BIBLIOGRAPHY

Berkman, L. F., and Syme, S. L. "Social Networks, Host Resistance, and Mortality: A Nine-Year Follow-up Study of Alameda County Residents." American Journal of Epidemiology 109, no. 2 (1979): 186–204.

Blane, D. "The Life Course, the Social Gradients and Health." In Social Determinants of Health. Edited by M. Marmot and R. G. Wilkinson. Oxford, U.K.: Oxford University Press, 1999. Pages 64–80.

Dean, A.; Kology, B.; and Wood, P. "Effects of Social Support from Various Sources on Depression in Elderly Persons." Journal of Health and Social Behavior 31 (1990): 148–161.

Goldman, N.; Korenman, S.; and Weinstein, R. "Marital Status and Health Among the Elderly." Social Science and Medicine 40, no. 12 (1995): 1717–1730.

House, J. S.; Lepkowski, J. M.; Kinney, A. M.; Mero, R. P.; Kessler, R. C.; and Herzog, A. R. "The Social Stratification of Aging and Health." Journal of Health and Social Behavior 35 (1994): 213–234.

Idler, E. L., and Kasl, S. V. "Religion Among Disabled and Nondisabled Persons I: Cross-Sectional Patterns in Health Practices, Social Activities, and Well-Being." Journal of Gerontology: Social Sciences 52B, no. 6 (1997): S294–S305.

Idler, E. L., and Kasl, S. V. "Religion Among Disabled and Nondisabled Persons II: Attendance at Religious Services as a Predictor of the Course of Disability." Journal of Gerontology: Social Sciences 52B, no. 6 (1997): S306–S316.

Levin, J. S. "Religion and Health: Is There an Association, Is it Valid, and Is it Causal?" Social Science and Medicine 38, no. 11 (1994): 1475–1482.

Liao, Y.; McGee D. L.; Kaufman J. S.; Cao, G.; and Cooper R. S. "Socioeconomic Status and Morbidity in the Last Years of Life." American Journal of Public Health 89, no. 4 (1999): 569–572.

Stansfeld, S. A. "Social Support and Social Cohesion." In Social Determinants of Health. Edited by M. Marmot and R. G. Wilkinson. Oxford, U.K.: Oxford University Press, 1999. Pages 155–178.