Thomas A. Glass

From social integration to health: Durkheim in the new millennium☆

It is widely recognized that social relationships and affiliation have powerful effects on physical and mental health. When investigators write about the impact of social relationships on health, many terms are used loosely and interchangeably including social networks, social ties and social integration. The aim of this paper is to clarify these terms using a single framework. We discuss: (1) theoretical orientations from diverse disciplines which we believe are fundamental to advancing research in this area; (2) a set of definitions accompanied by major assessment tools; and (3) an overarching model which integrates multilevel phenomena. Theoretical orientations that we draw upon were developed by Durkheim whose work on social integration and suicide are seminal and John Bowlby, a psychiatrist who developed attachment theory in relation to child development and contemporary social network theorists. We present a conceptual model of how social networks impact health. We envision a cascading causal process beginning with the macro-social to psychobiological processes that are dynamically linked together to form the processes by which social integration effects health. We start by embedding social networks in a larger social and cultural context in which upstream forces are seen to condition network structure. Serious consideration of the larger macro-social 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. We then move downstream to understand the influences network structure and function have on social and interpersonal behavior. We argue that networks operate at the behavioral level through four primary pathways: (1) provision of social support; (2) social influence; (3) on social engagement and attachment; and (4) access to resources and material goods.

Social Disengagement and Incident Cognitive Decline in Community-Dwelling Elderly Persons

Social engagement, which is defined as the maintenance of many social connections and a high level of participation in social activities, has been thought to prevent cognitive decline in elderly persons. Associations between a socially engaged lifestyle and higher scores on memory and intelligence tests have been observed among community-dwelling older persons (1-5). Short-term interventions to foster social and intellectual engagement have enhanced cognition among nursing home residents (6) and patients with dementia (7). In animal studies (8), mature rodents exposed to complex social and inanimate environments showed better maze-learning ability than those in sparser surroundings. Social engagement challenges persons to communicate effectively and participate in complex interpersonal exchanges. Besides providing a dynamic environment that requires the mobilization of cognitive faculties, social engagement may also indicate a commitment to community and family and engender a health-promoting sense of purpose and fulfillment. Another putative benefit of social engagement is greater availability of emotional support from relatives and friends. Lack of such support can predict adverse health outcomes (9), but its influence on cognitive decline has not been examined. Although published findings on cognitive function are suggestive, interpretation of available epidemiologic data is hampered by methodologic and conceptual shortcomings. Most studies are not longitudinal assessments of representative population-based cohorts but cross-sectional observations of volunteers or other special samples. Adjustment for potential confounders, such as education or health status, is often lacking. Finally, although the concept of social engagement is intuitively accessible, it has been difficult to measure this construct. Early studies viewed previous favorable socioeconomic or occupational status as synonymous with social engagement in old age (1); this precluded examination of more salient or malleable postretirement behaviors. Recent investigations (10-12), however, have used narrowly defined indicators (for example, marital status or specific recreational activities) to make inferences about the effect of late-life social environments on cognition. Other investigations (5) have used composite activity scales as proxies for social engagement but have not distinguished between activities that demand a high level of externally directed attention and those that do not. Social and solitary pursuits are also rarely disaggregated, although each may affect cognitive function differently. We determined whether a global measure of social disengagement was associated with incident cognitive impairment in a large cohort of community-dwelling elderly persons followed for 12 years. We acknowledge the potential salutary influence of solitary mental pursuits, but we focused on whether interpersonal connections and activities can prevent cognitive decline. Convincing demonstration of such an association could motivate elderly persons, their families, and their care providers to maintain active relationships. It would also justify continued funding for community-based and institutionally based social programs for elderly persons and the adoption of social policies in which activities of older persons are valued. Methods Participants The study sample was drawn from the New Haven, Connecticut, site of the Established Populations for Epidemiologic Studies of the Elderly (EPESE) project, described in detail elsewhere (13). The New Haven cohort is a multistage probability sample of 2812 noninstitutionalized persons 65 years of age or older who were living in New Haven, Connecticut, in 1982. Samples were drawn from three housing strata: public (income-restricted) housing for elderly persons, private housing for elderly persons, and community housing. Women were randomly subsampled to achieve equal representation of both sexes. The baseline response rate was 82%. Trained lay examiners interviewed members of the cohort at home in 1982, 1985,1988, and 1994 and by telephone in intervening years. Our study was approved by the institutional review board of Yale University. Measurements Cognitive Function Cognitive performance was measured during in-home interviews with the 10-item Short Portable Mental Status Questionnaire (SPMSQ) (14). (The original item What is the name of this place? was changed to What is your address? because this seemed more appropriate for community-dwelling persons.) Correct answers received 1 point each. If respondents declined to answer 4 or more items or if answers to 4 or more items were missing, the questionnaire was not scored. Otherwise, a participants decision not to answer a question was scored as an incorrect answer and scores on missing items were imputed by assigning the mean score of the nonmissing items. As has been done previously (15-17), scores were divided into three categories: high (a score of 9 or 10), medium (a score of 7 or 8), and low (a score of 0 to 6). The validity of the questionnaire as a cognitive impairment measure has been assessed in a subsample of respondents at another EPESE site. Participants received detailed medical examinations to determine the presence and severity of cognitive impairment. When medium scores on the SPMSQ and the category of mild impairment were excluded, the questionnaires sensitivity and specificity in identifying moderate or severe impairment were 85% and 96%, respectively (18). Social Disengagement A comprehensive assessment of social connections and activities was completed during in-home interviews. We examined six indicators of social engagement: presence of a spouse, monthly visual contact with at least three relatives or close friends, yearly nonvisual contact (telephone calls or letters) with at least 10 relatives or close friends, frequent attendance (at least once per month) at religious services, membership in other groups, and regular participation in recreational social activities. The Appendix provides exact questions and coding rules for these indicators. A composite social disengagement index was constructed from the six indicators. Five to six social ties received a score of 1, three to four social ties received a score of 2, one to two social ties received a score of 3, and no social ties received a score of 4. Tie refers to any type of social contact. If scores for more than two indicators were missing, the index was not scored. Emotional Support Perceived availability of emotional support from a social network was assessed with the question, Can you count on anyone to provide you with emotional supportthat is, talking over problems or helping make a difficult decision? The adequacy of this support was assessed by the question, Could you have used more emotional support than you received? Covariates We selected the following self-reported variables as potential confounders because they had cross-sectional associations with disengagement or impaired cognition among the cohort or because they are established risk factors for Alzheimer disease or vascular dementia (both of which are prevalent causes of progressive cognitive decline in elderly persons) (19, 20). Sociodemographic factors were age, sex, ethnicity (white or nonwhite), education ( 12 years or<12 years), annual income (<

Driving Cessation and Increased Depressive Symptoms: Prospective Evidence from the New Haven EPESE

10 000,

The built environment and obesity: A systematic review of the epidemiologic evidence

10 000, or not given), and housing. Health status indicators were the presence of physical disability, which was defined as requiring assistance from another person or special equipment with at least one activity of daily living (walking across a room, dressing, eating, transferring from bed to chair, bathing, or using the toilet) (21) or limitations in gross mobility (climbing one flight of stairs or walking half a mile) (22); high-risk cardiovascular profile (compared with low risk, where high risk was defined as a measured sitting blood pressure>160/95 mm Hg or a history of physician-diagnosed stroke, diabetes, or myocardial infarction); visual impairment (difficulty in reading ordinary newspaper print); auditory impairment (difficulty in hearing what a person says without seeing his face if that person talks in a normal voice in a quiet room); and symptoms of depression (a score 16 on the Center for Epidemiologic Studies Depression Scale [23]). Health-related behaviors were current smoking status, alcohol consumption, and level of physical activity (described in the Appendix). Statistical Analysis Cognitive decline was defined as a transition to a lower SPMSQ category (transition from high to medium or low or transition from medium to low) during a given interval. Respondents with low SPMSQ scores at the beginning of an interval were excluded from consideration during that interval. Incidence of cognitive decline by initial level of social disengagement was estimated over intervals of three lengths:3-year intervals (1982 to 1985 and 1985 to 1988), 6-year intervals (1982 to1988 and 1988 to 1994), and a 12-year interval (1982 to 1994). Approximately20% of respondents with low SPMSQ scores in 1982 scored higher in 1985 or 1988and were therefore included in the 1985 to 1988 or 1988 to 1994 analyses. Polytomous logistic regression was used to estimate the relative risk for cognitive decline or death by level of disengagement, controlling for potential confounders. The three outcomesmaintenance of cognitive function, cognitive decline, and deathwere treated as unordered categorical variables. To examine the validity of the assumption of a linear dose-response relation between social disengagement and cognitive decline or death, disengagement was initially coded as a set of indicator variables, each corresponding to 1 point on the composite disengagement index. Inspection of the resulting coefficients suggested that modeling disengagement as an ordered categorical covariate was justified; the addition of quadratic or cubic terms did not substantially improve model fit.

A Social Model for Health Promotion for an Aging Population: Initial Evidence on the Experience Corps Model

OBJECTIVES: The purpose of this study was to determine the association between driving cessation and depressive symptoms among older drivers. Previous efforts in this area have focused on the factors associated with cessation, not the consequences of having stopped.

Social Engagement and Depressive Symptoms in Late Life Longitudinal Findings

We completed a systematic search of the epidemiologic literature on built environment and obesity and identified 63 relevant papers, which were then evaluated for the quality of between-study evidence. We were able to classify studies into one of two primary approaches for defining place and corresponding geographic areas of influence: those based on contextual effects derived from shared pre-determined administrative units and those based on individually unique geographic buffers. The 22 contextual papers evaluated 80 relations, 38 of which did not achieve statistical significance. The 15 buffer papers evaluated 40 relations, 24 of which did not achieve statistical significance. There was very little between-study similarity in methods in both types of approaches, which prevented estimation of pooled effects. The great heterogeneity across studies limits what can be learned from this body of evidence.

Neighborhood Characteristics and Availability of Healthy Foods in Baltimore

This report evaluates whether a program for older volunteers, designed for both benerativity and health promotion, leads to short-term improvements inmultiple behavioral risk factors and positive effects on intermediary risk factors for disability and other morbidities. The Experience Corps® places older volunteers in public elementary schools in roles designed to meet schools’ needs and increase the social, physical, and cognitive activity of the volunteers. This article reports on a pilot randomized trial in Baltimore, Maryland. The 128 volunteers were 60–86 years old; 95% were African American. At follow-up of 4–8 months, physical activity, strength, people one could turn to for help, and cognitive activity increased significantly, and walking speed decreased significantly less, in participants compared to controls. In this pilot trial, physical, cognitive, and social activity increased, suggesting the potential for the Experience Corps to improve health for an aging population and simultaneously improve educational outcomes for children.

New England medical center posterior circulation registry

Objectives: The purpose is to investigate whether social engagement protects against depressive symptoms in older adults. Method: Three waves of data from a representative cohort study of community-dwelling adults aged 65 years and above from the New Haven Established Populations for the Epidemiologic Study of the Elderly are examined using random effects models. Results: Social engagement (an index combining social and productive activity) is associated with lower CES-D scores after adjustment for age, sex, time, education, marital status, health and functional status, and fitness activities. This association is generally constant with time, suggesting a cross-sectional association. In addition, social engagement is associated with change in depressive symptoms, but only among those with CES-D scores below 16 at baseline. Discussion: Social engagement is independently associated with depressive symptoms cross-sectionally. A longitudinal association is seen only among those not depressed at baseline.

Impact of social support on outcome in first stroke.

BACKGROUND Differential access to healthy foods may contribute to racial and economic health disparities. The availability of healthy foods has rarely been directly measured in a systematic fashion. This study examines the associations among the availability of healthy foods and racial and income neighborhood composition. METHODS A cross-sectional study was conducted in 2006 to determine differences in the availability of healthy foods across 159 contiguous neighborhoods (census tracts) in Baltimore City and Baltimore County and in the 226 food stores within them. A healthy food availability index (HFAI) was determined for each store, using a validated instrument ranging from 0 points to 27 points. Neighborhood healthy food availability was summarized by the mean HFAI for the stores within the neighborhood. Descriptive analyses and multilevel models were used to examine associations of store type and neighborhood characteristics with healthy food availability. RESULTS Forty-three percent of predominantly black neighborhoods and 46% of lower-income neighborhoods were in the lowest tertile of healthy food availability versus 4% and 13%, respectively, in predominantly white and higher-income neighborhoods (p<0.001). Mean differences in HFAI comparing predominantly black neighborhoods to white ones, and lower-income neighborhoods to higher-income neighborhoods, were -7.6 and -8.1, respectively. Supermarkets in predominantly black and lower-income neighborhoods had lower HFAI scores than supermarkets in predominantly white and higher-income neighborhoods (mean differences -3.7 and -4.9, respectively). Regression analyses showed that both store type and neighborhood characteristics were independently associated with the HFAI score. CONCLUSIONS Predominantly black and lower-income neighborhoods have a lower availability of healthy foods than white and higher-income neighborhoods due to the differential placement of types of stores as well as differential offerings of healthy foods within similar stores. These differences may contribute to racial and economic health disparities.

Disability as a Function of Social Networks and Support in Elderly African Americans and Whites The Duke EPESE 1986–1992

Among 407 New England Medical Center Posterior Circulation registry patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs then strokes, and 16% had only TIAs. Embolism was the commonest stroke mechanism (40% of patients including 24% cardiac origin, 14% intraarterial, 2% cardiac and arterial sources). In 32% large artery occlusive lesions caused hemodynamic brain ischemia. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes); the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Severe occlusive lesions (>50% stenosis) involved more than one large artery in 148 patients; 134 had one artery site involved unilaterally or bilaterally. The commonest occlusive sites were: extracranial vertebral artery (52 patients, 15 bilateral) intracranial vertebral artery (40 patients, 12 bilateral), basilar artery (46 patients). Intraarterial embolism was the commonest mechanism of brain infarction in patients with vertebral artery occlusive disease. Thirty‐day mortality was 3.6%. Embolic mechanism, distal territory location, and basilar artery occlusive disease carried the poorest prognosis. The best outcome was in patients who had multiple arterial occlusive sites; they had position‐sensitive TIAs during months to years. Ann Neurol 2004;56:389–398