The Art of Health Promotion: linking research to practice

Social Connection by Sara S. Johnson, Ph.D.

Legend has it that one of the 4 key questions posed to the sick by Native American shamans was, “When did you stop being enchanted by the stories of others?”. ¹ Centuries later, there appears to be a growing consensus that loneliness is an invisible epidemic that represents a significant public health issue. ^2,3 In fact, the World Health Organization now recognizes having a social support network as a determinant of health. ⁴

The increased attention on this topic is supported by burgeoning research from multiple disciplines. Consider, for example, the Harvard Study of Adult Development which Dr. Robert Waldinger so eloquently summarized in a recent TEDx talk ⁵ (now viewed more than 20,000,000 times!). In that video, he describes the 75-year-long longitudinal study of 724 male Harvard sophomores recruited in 1938. A year into the study, the investigators recruited another sample of socioeconomically disadvantaged men from Boston’s poorest neighborhoods. Comprehensive data gathered regularly from medical record review and examinations, blood tests, self-report questionnaires, and interviews (of participants, spouses, and children) revealed that the best predictor of becoming a happy, healthy octogenarian was not genetic make-up, biomarkers like cholesterol levels, lifestyle choices, or socioeconomic status. The best predictor was high-quality social connections: The individuals who were more connected to family, friends, and community were happier, healthier, had less decline in cognitive function, and lived longer than those who were less well connected. Waldinger noted that the quality of the social connections was critical: Simply having more friends or being married was not protective. Rather, individuals had to know that they could count on their connections.

Reviews and longitudinal population-based studies from multiple countries underscore Waldinger’s conclusion regarding the link between social connection and longevity. One such meta-analysis of 148 studies that included more than 300,000 participants reported that there is a 50% increased likelihood of survival for participants with stronger social relationships, even after controlling for gender, health status, age, cause of death, and length of follow-up period. The increased risk of premature death associated with lack of social connection was on par with other well-established risk factors for death, including obesity. ⁶ The results from the 8-year English Longitudinal Study on Aging, which included a representative sample of adults aged 50 years and older (n = 7731), were quite similar: Social isolation was independently associated with all-cause mortality. Participants with high social isolation were 28% more likely to die even after controlling for age, sex, demographic variables, baseline health status, health behaviors, and cognitive function. ⁷ A 10-year survival study in older (age 70+) Australians (n = 1477) also found a significant protective effect against mortality for total social network score (summing friends, children, relatives, and confidantes) after controlling for a number of covariates (ie, age, sex, place of residence [community vs residential care], number of comorbid conditions, self-rated health, cognitive function, and smoking status). Interestingly, the protective effect was greatest from a larger, strong friend network (defined by the number of friends and frequency of personal/phone contacts). There was a smaller protective effect from having confidantes, but no protective effect from children or other relatives. ⁸

Anthropological research from folks like Dan Buettner also supports the importance of social connection for a long, well-lived life. In his book, Blue Zones, ⁹ he identifies “a right tribe” as a key factor in longevity, providing examples of regions where cultural and societal norms foster connectivity, such as a Moai in Okinawa. Similarly, a narrative inquiry of 102 interviews with a diverse group of adults aged 18 to 86 years conducted by the Stanford WELL for Life Measures Work Group indicated that social connectedness was the single most influential domain of well-being. In fact, 97% of participants mentioned social connections in their stories of times in their lives when they experienced a particularly high level of well-being or a particularly low level of well-being. ¹⁰

These compelling and consistent findings raise a number of questions about the mechanisms for social connection to impact longevity. There are many potential pathways. A number of studies have demonstrated a link between lack of connection or poor quality social relationships and increased risk for chronic disease, including diabetes, ¹¹ and an approximately 30% higher risk for coronary heart disease and stroke. ¹² Looking back further into potential pathways, some have suggested that loneliness may trigger a cortisol response and impaired immune function. ¹³ Others have hypothesized that the contribution of loneliness to adverse health outcomes may be due in part to promotion of inflammation. ¹⁴ Yang et al., ¹⁵ for example, analyzed population-level data from 4 nationally representative longitudinal studies of Americans (adolescence through late adulthood) to examine linkages between social relationships and objectively measured markers of physiological health (C-reactive protein, blood pressure, body mass index, and waist circumference). This research examined social relationships in 2 ways—as characterized by social integration and social support. Overall, social integration was related to improved physiological functioning and reduced risk of physical disorders at all life stages—even after adjusting for covariates. The effects of isolation, however, varied by age. For example, the increased inflammation from social isolation was comparable to that of being physically inactive for young adults. In older adults, isolation created a higher risk for hypertension than even co-occurring diabetes. Perceived support/relationship quality was also predictive of physiological function and risk of clinical risk factors, though the associations were smaller. Additional research is certainly needed, as a recent article ¹⁶ reveals the complex interplay of a number of interpersonal processes (eg, social support in the face of stressful positive life events) and intrapersonal mediators (eg, biological and psychosocial pathways). What is clear is that both social connection and social disconnection influence biological responses and behaviors that have an impact on health.

These data on the potential impact of lack of social connection are troubling, particularly considering that, although estimates of prevalence vary, one recent survey indicated that more than 70% of Americans reported experiencing loneliness—with more than 30% indicating that they experience loneliness at least once a week. ¹⁷ Even more concerning than the prevalence is how largely unaware Americans seem to be about the importance of social connection. Take, for example, recent data from the 2018 National Sleep Foundation’s Sleep in America Poll ¹⁸ —an annual poll of a random sample of over 1000 Americans. This year, respondents were asked to prioritize 1 of 5 topics by selecting which was most important to them personally among the following options: physical fitness and nutrition, work or occupation, social life, sleep, or hobbies and personal interests. Guess what was dead last? You guessed it: Only 9% of people named their social life.

Some public health organizations, researchers, and payers, however, are taking up the charge to address lack of social connection. Dr Paul Tang, for example, is combating isolation via an innovative program entitled “linkAges.” ¹⁹ linkAges is a social network merged with cross-generational service exchange platform. Members post requests for assistance (eg, help with a task, a ride to an appointment), and other members respond. In turn, they earn hours for a return favor in the future. ²⁰ Although currently only available in the San Francisco and Santa Cruz, California areas, there are plans to expand the program through partnerships with health systems and other organizations. ²¹ CareMore Health responded to an increased prevalence of loneliness among senior members by hiring a Chief Togetherness Officer. ²²

Other public health interventions are being deployed more broadly in the United Kingdom, where a Minister for Loneliness was recently appointed. The National Health Service and local governments are deploying programs in several cities and towns, including training fire brigades to inspect homes for signs that the residents may be socially isolated. “The Silver Line,” ²³ a 24-hour call center that connects older adults to other people, now fields some 10,000 calls a week. Seniors can call to chat or be linked up to Silver Line Friend who calls them weekly or writes them letters. There are also organizations mobilizing interventions, such as Campaigns to End Loneliness, Open Age, Men’s Shed, and Age UK. ¹³

Interventions targeting individuals are also being developed and refined, including those addressing social skills, opportunities for social interactions, social support, and maladaptive social cognition ²⁴ (ie, how individuals perceive and react to social cues). Masi and colleagues ²⁴ conducted a meta-analysis of 50 studies of interventions targeting loneliness, including 20 randomized trials. The results indicated that, based on the more rigorous randomized trials, interventions targeting maladaptive social cognition were more effective. The authors explained that such findings are consistent with a regulatory loop model of loneliness: “…lonely individuals have increased sensitivity to and surveillance for social threats, preferentially attend to negative social information, remember more of the negative aspects of social events, hold more negative social expectations, and are more likely to behave in ways that confirm their negative expectations.” Though promising, the mean effect size of the interventions targeting maladaptive social cognition was relatively low, suggesting that there is more work to be done. ²⁴ One of the study’s authors, John Cacioppo, and his colleague Stephanie Cacioppo, have developed social fitness exercises for the Army’s Comprehensive Soldier Fitness Program that target social cognition to reduce loneliness and develop social resilience. ²⁵ In a recent Harvard Business Review article, ²⁵ the Cacioppos recommended applying these lessons to the workplace.

The criticality of making strengthening social connections a strategic priority for organizations is indeed a rallying cry coming from multiple sources. ^2,26 In addition to the undeniable health consequences, loneliness among one team member can affect the performance of a whole team, ²⁷ as it affects an individual’s execution, ability to communicate effectively with others, and overall contribution to the group. Moreover, there are definite advantages to employers to promoting social connection, such as—in addition to those you will read more about later in this issue—increased loyalty ²⁸ and increased satisfaction. ²⁹ In fact, Gallup reports that that there are numerous benefits of having a best friend at work, including increased likelihood of being satisfied with pay and benefits, increased likelihood of recommending a company as a great place to work, and increased probability of feeling that one is working to his or her full potential. ³⁰ Furthermore, according to a recent Harvard Business Review article, ²⁶ community is 1 of 3 key elements of the psychological contract between employers and employees, sharing equal footing with career (autonomy, ability to use your strengths) and cause (purpose, feeling that work makes a positive impact). Jane Dutton has argued that building and nurturing high-quality social relationships characterized by mutual positive regard, trust, and active engagement among both participants can transform workplaces. ³¹ The potential for this type of transformation was illustrated at Campbell soup when Doug Conant assumed the helm. One of his first moves as a newly appointed CEO in 2001 was to explicitly create a more civil culture built on mutual respect. His “Campbell Promise” began with “Campbell valuing people.” ³²

So what can employers do? In this issue of The Art of Health Promotion, you’ll find a number of tips and suggestions from Dr. Julianne Holt-Lunstad, Dr. Mandy O’Neill, and Marissa King. Other recommendations abound. Former Surgeon General Vivek Murthy, for example, shared a story ² about a practice he employed at his office entitled the “Inside Scoop” to create opportunities for team members to learn about their colleague’s personal lives: His team members were asked to use photos to share something about themselves for 5 minutes at a weekly staff meeting. Similarly, in “The Power of Moments” ³³ Chip and Dan Heath encourage readers to leverage often overlooked opportunities to build relationships in organizations, citing an example from John Deere. This large global organization has created a “First Day Experience” that sets the stage for social connection by including a welcome e-mail in advance from colleague who later meets a new team member on his or her first day, a banner on the cubicle to welcome the new team member and alert other team members to stop by and introduce themselves, welcome video from the CEO, lunch with a small team of colleagues, and a plan for a later lunch date with the department lead. Ron Friedman, author of “The Best Place to Work,” ²⁷ recommends other ways to maximize the potential for onboarding to create connection. He suggests having new team members introduce themselves not based solely on their experience or capabilities but also with regard to their personal interests or passions so others can identify common ground. Other organizations use onboarding partners, which can lead to developmental networks to whom individuals can turn for task advice or emotional support. At NextJump, a comentoring program entitled “Talking Partners” fosters an environment of ongoing support for enhanced decision-making. ³⁴

There are a number of other strategies employers can take to promote connections among employees, including:

Promoting superordinate goals (such as sports teams or bands) ²⁷

In light of the data reviewed above, shifting demographic trends (eg, more individuals living alone), and societal shifts in the way we work (eg, more remote work), the time is right to carefully consider how we prioritize and implement strategies to promote high-quality social connections. In this issue of The Art of Health Promotion, we are fortunate to hear the perspectives of 3 of the nation’s brightest thought leaders on this important topic.