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The Prospective Association of Social Integration With Life Span and Exceptional Longevity in Women


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Objectives: Although stronger social relationships have been associated with reduced mortality risk in prior research, their associations with favorable health outcomes are understudied. We evaluated whether higher social integration levels were associated with longer lifespan and greater likelihood of achieving exceptional longevity. Method: Women from the Nurses' Health Study completed the Berkman-Syme Social Network Index in 1992 (N=72,322; average age=58.80 years), and were followed through 2014 with biennial questionnaires. Deaths were ascertained from participants' families, postal authorities, and death registries. Accelerated failure time models adjusting for relevant covariates estimated percent changes in lifespan associated with social integration levels; logistic regressions evaluated likelihood of surviving to age 85 or older among women who could reach that age during follow-up (N=16,818). Results: After controlling for baseline demographics and chronic diseases, socially integrated versus isolated women had 10% (95%Confidence Interval [CI]=8.80-11.42) longer lifespan and 41% (95%CI=1.28-1.54) higher odds of surviving to age 85 years. All findings remained statistically significant after further adjusting for health behaviors and depression. Discussion: Better social integration is related to longer lifespan and greater likelihood of achieving exceptional longevity among midlife women. Findings suggest social integration may be an important psychosocial asset to evaluate for promoting longer, healthier lives.
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Research Article
The Prospective Association of Social Integration With
Life Span and Exceptional Longevity inWomen
Claudia Trudel-Fitzgerald, PhD,1,2,*, EmilyS. Zevon, ScD,1 Ichiro Kawachi, MB ChB, PhD,1
ReginaldD. Tucker-Seeley, ScD,3 Francine Grodstein, ScD,4,5 and LauraD. Kubzansky, PhD1,2
1Department of Social and Behavioral Sciences and 2Lee Kum Sheung Center for Health and Happiness, Harvard T.H. Chan
School of Public Health, Boston, Massachusetts. 3Leonard Davis School of Gerontology, University of Southern California,
Los Angeles. 4Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. 5Channing
Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston,
*Address correspondence to: Claudia Trudel-Fitzgerald, PhD, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, 6th Floor,
Boston, MA 02115. E-mail:
Received: May 24, 2019; Editorial Decision Date: August 27, 2019
Decision Editor: Lynn Martire, PhD
Objectives: Although stronger social relationships have been associated with reduced mortality risk in prior research, their
associations with favorable health outcomes are understudied. We evaluated whether higher social integration levels were
associated with longer life span and greater likelihood of achieving exceptional longevity.
Method: Women from the Nurses’ Health Study completed the Berkman–Syme Social Network Index in 1992 (N=72,322;
average age=58.80years), and were followed through 2014 with biennial questionnaires. Deaths were ascertained from
participants’ families, postal authorities, and death registries. Accelerated failure time models adjusting for relevant
covariates estimated percent changes in life span associated with social integration levels; logistic regressions evaluated
likelihood of surviving to age 85years or older among women who could reach that age during follow-up (N=16,818).
Results: After controlling for baseline demographics and chronic diseases, socially integrated versus isolated women had
10% (95% condence interval [CI]=8.80–11.42) longer life span and 41% (95% CI=1.28–1.54) higher odds of surviving
to age 85years. All ndings remained statistically signicant after further adjusting for health behaviors and depression.
Discussion: Better social integration is related to longer life span and greater likelihood of achieving exceptional longevity
among midlife women. Findings suggest social integration may be an important psychosocial asset to evaluate for pro-
moting longer, healthier lives.
Keywords: Death, Health, Mortality, Relationships, Social isolation
As life span has increased in industrialized countries, excep-
tional longevity—typically dened as survival to 85years
(Newman & Murabito, 2013; Revelas etal., 2018)—has
become increasingly common. Empirical evidence obtained
across diverse organisms has consistently demonstrated
that improvements in life span often co-occur with delayed
morbidity (Longo et al., 2015), indicating that studying
factors associated with increased longevity may yield new
insights regarding how to promote both long and healthy
lives (also known as “healthspan”) (López-Otín, Blasco,
Partridge, Serrano, & Kroemer, 2013). Research on excep-
tional longevity has largely focused on identifying biomed-
ical factors (e.g., genetic variants) that are associated with
increased survival, but an emerging body of research has
Journals of Gerontology: Psychological Sciences
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suggested nongenetic factors matter as well. Accordingly,
research has begun to identify psychosocial assets, such as
optimism and other facets of psychological well-being, as
potential predictors of longer life (Kubzansky etal., 2018;
Lee etal., 2019; Steptoe, 2019).
Social relationships have also been identied as a key
predictor of human health (Berkman & Krishna, 2014;
Holt-Lunstad, Robles, & Sbarra, 2017). Research has
demonstrated benecial effects of social support and
networks on a wide range of health outcomes (Berkman
& Krishna, 2014; Holt-Lunstad et al., 2017; Trudel-
Fitzgerald, Chen, Singh, Okereke, & Kubzansky, 2016),
with cognitive, emotional, behavioral, and direct biolog-
ical pathways proposed to explain observed associations
(Berkman, Glass, Brissette, & Seeman, 2000; Cohen,
1988; Kroenke, 2018). The relationship between social
relationships and premature mortality has been assessed
extensively, with many studies demonstrating an associ-
ation between social isolation and increased risk of pre-
mature death (Berkman & Krishna, 2014; Holt-Lunstad
etal., 2017). This work has generally followed a tradi-
tional adverse-outcomes-oriented and risk-focused per-
spective. However, investigators have called for applying
a positive health framework to gain greater insight into
how to promote and preserve healthy functioning (Lloyd-
Jones, 2014; National Research Council Committee on
Future Directions for Behavioral and Social Sciences
Research at the National Institute of Health, 2001).
This shift in priorities grows out of an increasing un-
derstanding that insights derived from considering risk
factors associated with increased disease and mortality
may differ from those derived from examining positive
factors that may be associated with the attainment and
maintenance of good health. Moreover, the absence of
a harmful risk factor is not necessarily the opposite of
the presence of a positive or protective factor. For ex-
ample, not being socially isolated is different from being
social integrated. Depending on the measure used to as-
sess social isolation, it may not be possible to determine
whether an individual who does not meet criteria for so-
cial isolation is in fact truly socially integrated, without
additional information. Recent studies investigating
the potential role of positive factors with future risk of
chronic diseases and premature mortality have found
meaningful associations independent of not only conven-
tional risk factors (e.g., health status), but also psychoso-
cial risk factors (e.g., depressive symptoms), reinforcing
the idea that positive factors capture more than merely
the absence of negative factors (VanderWeele etal., in
press). Yet, to the best of our knowledge no studies have
explicitly examined the association of social relation-
ships with exceptional longevity.
Research suggests being social integrated (and other
psychosocial assets) is associated with health out-
comes above and beyond the effects of other risk factors
(Berkman & Krishna, 2014; Holt-Lunstad et al., 2017;
Steptoe, 2019). From a positive health framework, social
relationships are considered as a health asset or a life skill
(Steptoe & Wardle, 2017), not only reducing likelihood of
specic diseases, but also leading to positive health out-
comes, such as achieving or maintaining health or healthy
aging, more likely. Identifying diverse assets that promote
health across the life course, particularly health in aging,
will help inform efforts not only to reduce exposure to
health risks, but also to achieve optimal functioning,
informing a “primordial prevention” approach (Strasser,
1978). Although healthy aging is a multidimensional con-
struct that is often dened to incorporate physical, cogni-
tive, and emotional well-being, the achievement of long
life span is its most basic prerequisite (Anton etal., 2015;
Woods et al., 2016). By understanding assets that pro-
mote longevity, we can take a step outside the paradigm
of disease and death, and create new insights regarding
the means through which long and healthy lives can be
In this study, we assessed social integration, which re-
fers to the number, type, and frequency of social contacts,
and evaluated its association with increased longevity. We
focus on social integration because it has been associated
with health outcomes more consistently than other so-
cial relationship constructs such as emotional social sup-
port (Cohen & Janicki-Deverts, 2009; Holt-Lunstad etal.,
2017; Nausheen, Gidron, Peveler, & Moss-Morris, 2009).
We used data from the Nurses’ Health Study (NHS), a large
ongoing cohort of women, to evaluate if higher levels of
social integration are associated with longer life span, as
well as with greater likelihood of attaining exceptional lon-
gevity. All analyses controlled for potential confounders,
including demographics and initial health status, following
prior research in this domain.
We also considered the role of depression, because
prior research has suggested that greater social integration
is associated with less depression (Chang, Pan, Kawachi,
& Okereke, 2016) and also that depression is related to
a greater risk of premature mortality (Wei etal., 2019).
The direction of causality between social integration and
depression is uncertain (Berkman etal., 2000), but due to
data limitations, we considered depression as a potential
confounder in sensitivity analyses. As lifestyle factors are
posited to lie on the pathway linking social integration to
longevity, we included a separate set of models adjusting
for health-related behaviors to examine explicitly whether
adding these variables may partly or fully explain the as-
sociations of interest. Finally, in secondary analyses we in-
vestigated individual domains of social integration (e.g.,
religious participation; number of close friends/relatives)
to ascertain whether some components were differen-
tially salient for longevity. We hypothesized that greater
levels of social integration were associated with longer life
span, as well as with greater likelihood of attaining excep-
tional longevity, beyond statistical adjustment for potential
confounders and pathways.
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Study Population
Data are from the ongoing NHS cohort, which began in
1976 with 121,700 married female registered nurses aged
30–55 years old. Since 1976, NHS participants have re-
turned biennial questionnaires collecting data on health,
nutrition, and lifestyle, as well as a variety of social and
psychological factors, with follow-up rate approximately
85%–90% (Bao et al., 2016). The sample for our pri-
mary analysis included women who completed the 1992
measure of social integration—the Berkman–Syme Social
Network Index (SNI)—and have been followed through
2014. Participants were excluded from analyses if they
were missing data on social integration or demographic
covariates (excluding husband’s education for which we
created a missing indicator because 15.51% of data were
missing) or if they died within 2 years after baseline, to
reduce likelihood of reverse causation whereby imminent
death would inuence social relationships or the reporting
of them. These exclusions reduced the sample size from
103,601 to 72,322 women. This sample size is either com-
parable to or larger than most prior studies investigating
either social integration with various health-related out-
comes (Pinquart & Duberstein, 2010; Trudel-Fitzgerald
etal., 2016) or psychosocial factors with longevity (Costa,
Weiss, Duberstein, Friedman, & Siegler, 2014; Lee et al.,
2019). Further assessment of the statistical stability of
the results for this study was quantitatively evaluated by
considering the width of condence intervals (CIs). For
analyses assessing the likelihood of survival to the age of
85years, the sample was further restricted to participants
born before 1928, for whom it was possible to reach the
age of 85years during the study period (N=16,818). The
study protocol was approved by the institutional review
boards of the Brigham and Women’s Hospital.
Social integration
Social integration, a construct that captures the number,
type, and frequency of social contacts, was assessed with the
Berkman–Syme SNI (Berkman & Krishna, 2014; Berkman
& Syme, 1979), administered via self-reported scale in 1992.
The SNI assesses quantity and type of social relationships
across four domains: marriage, contacts with close friends
and relatives, participation in religious activities, and par-
ticipation in group associations (Berkman & Syme, 1979).
The measure has shown good test–retest reliability and ac-
ceptable construct validity, and has predicted breast cancer
survival and mental functioning in NHS women (Trudel-
Fitzgerald etal., 2016). Following prior work using the SNI
in this cohort (Chang et al., 2017; Kroenke, Kubzansky,
Schernhammer, Holmes, & Kawachi, 2006; Trudel-
Fitzgerald etal., 2016), each of the four domains of social
integration was scored from 0 (least integrated) to 3 (most
integrated; Supplementary Table 1). These domain scores
were summed to create a continuous SNI score ranging from
0 (highly socially isolated) to 12 (highly socially integrated).
The continuous SNI score was considered missing if scores
for any of the four domains were unavailable. This score was
then divided into quartiles to allow for examination of po-
tential discontinuous or threshold effects. Thus, participants
were classied according to four levels of social integration:
highly socially isolated (reference group), moderately iso-
lated, moderately integrated, and highly socially integrated
(Chang etal., 2017; Kroenke etal., 2006; Trudel-Fitzgerald
etal., 2016). In the NHS, the SNI was administered every
4 years, covering a 16-year period from 1992 to 2008.
Scores are fairly stable across assessments, as supported by
a high intra-class correlation coefcient (ICC) value (ICC:
0.76, 95% CI: 0.76–0.77) and low within-subject variability
(0.18, 95% CI: 0.18–0.18) in the current analytic sample.
Therefore, we did not conduct additional analyses updating
the SNI score or considering trajectories of change in SNI
over time. Of note, to enter the cohort study when it was rst
initiated in 1976, women had to be married; consequently,
most participants were still married or in a domestic partner-
ship in 1992 when the SNI was rst queried.
Life span was operationalized as changes in predicted life
span. We also considered exceptional longevity, which was
dened as survival to the age of 85years or older. Deaths
are reported by participants’ families and by postal author-
ities. The names of nonrespondents are searched within the
National Death Index, which has compiled data from state
death registries since 1979 and correctly identies 98% of
known deaths among a sample of NHS participants for
whom death certicates were available (Rich-Edwards,
Corsano, & Stampfer, 1994). Date of death is ascertained
from death records. In this study, deaths were identied
through the end of 2014, the most recently available data.
All covariates were queried at baseline (in 1992), unless
otherwise noted. Demographic variables including age
(continuous), education level (registered nurse vs under-
graduate/graduate degree), and husband’s education level
(≤high school, above high school, missing level) were con-
sidered as potential confounders. Analyses also considered
self-reported prevalence or history of the following major
chronic diseases, individually (yes vs no): high cholesterol,
high blood pressure, diabetes, cancer, stroke, and myocar-
dial infarction (MI). Depressive symptoms were assessed
via the ve-item Mental Health Inventory (MHI-5), a
subscale of the 36-Item Short Form Survey from the RAND
Medical Outcomes Study (Ware & Sherbourne, 1992).
Scores ranged from 0 (most depressed) to 100 (least de-
pressed), and participants were classied as having clinical
depressive symptoms (yes vs no) if their score was less than
or equal to 60 (Rumpf, Meyer, Hapke, & John, 2001).
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Health behavior-related variables, such as smoking
status, physical activity, alcohol consumption, diet quality,
and body mass index (BMI) were considered as covariates
that might either confound or potentially mediate the associ-
ation between social integration and longevity. Self-reported
smoking status was dened as never, former, or current
smoker. Physical activity was modeled as a dichotomous
variable indicating whether the participant met recom-
mended levels of physical activity (i.e., reporting ≥150min
of moderate-to-vigorous physical activity per week; yes vs
no). Alcohol consumption and diet quality were assessed
via a food frequency questionnaire (Yuan etal., 2017) ad-
ministered in 1994. Alcohol was modeled as a dichotomous
variable indicating whether participants met recommenda-
tions for no more than one serving of an alcoholic drink
per day (yes vs no) (U.S. Department of Health and Human
Services & U.S. Department of Agriculture, 2010). Diet
quality was operationalized as a continuous variable using
the Alternative Health Eating Index (AHEI), which assigns a
dietary score ranging from 0 (lowest quality) to 100 (highest
quality) based on higher intake of vegetables, fruit, whole
grains, nuts and legumes, long-chain (n−3) fatty acids, poly-
unsaturated fats, and lower intake of sugar-sweetened bev-
erages and fruit juice, red/processed meat, saturated fats,
sodium (McCullough et al., 2002). BMI was calculated
using participants’ self-reported height and weight (kg/m2).
Self-reported weight has been shown to be highly correlated
(r= .97) with weight measured by study staff within this
cohort (Rimm etal., 1990).
Statistical Analysis
Statistical analyses were conducted using SAS, 9.4. We rst
computed the descriptive statistics for each covariate across
levels of social integration, adjusting for age. Aset of four
accelerated failure time (AFT) models were used in primary
analyses to estimate the proportion by which participants’
life spans differed in association with level of social inte-
gration (N=72,322). Compared to the Cox proportional
hazards models, the AFT models provide the advantage of
easily interpretable results (i.e., percent change in life span),
while still incorporating longitudinal data and controlling
for multiple covariates (Swindell, 2009; Wei, 1992). AFT
models were shown to be a useful statistical framework for
aging research (Swindell, 2009), and have been leveraged
in prior studies investigating the relationship of personality
(Costa et al., 2014), optimism (Lee et al.,2019), and in-
ammation markers (Wassel, Barrett-Connor, & Laughlin,
2010), respectively, with longevity.
In this study, a “basic” adjusted model included poten-
tial demographic confounders (i.e., age, husband’s edu-
cation, and participant’s education). Asecond model, the
core model, further adjusted for baseline health status vari-
ables (i.e., prevalent or history of high cholesterol, high
blood pressure, MI, stroke, diabetes, and cancer). Athird
model included both demographic confounders and health
behavior-related factors (i.e., smoking status, physical ac-
tivity, alcohol consumption, diet quality, and BMI) to assess
whether behaviors accounted for any of the observed asso-
ciation between social integration and longevity. Afourth
model adjusted for all covariates simultaneously. Sample
size for the third and fourth models was slightly reduced
as they were evaluated among women who had data on all
health-behavior related variables (n=66,684; 92.20% of
the main analytic sample). We applied the transformation
100(eβ − 1) to the regression coefcient for our primary
exposure, social integration, to interpret the ndings as the
percent change in the expected survival time comparing
each social integration level to the reference (highly socially
isolated). Apositive coefcient suggests that greater levels
of social integration are associated with greater longevity.
We conducted three additional analyses. A rst sensi-
tivity analysis considered the role of depression in a subset
of women who had data on depression (n=72,123; 99.72%
of the main analytic sample) by evaluating changes in the
effect estimates for social integration when including de-
pressive symptoms in the core model controlling for dem-
ographic and health status covariates. Asecond sensitivity
analysis evaluated the main models without excluding
women who died within 2years of baseline (n =72,776).
Finally, in secondary analyses, we examined whether any
of the four domains of social integration (i.e., marriage,
close friends/relatives, group associations, and religious ac-
tivities) were differentially predictive of longevity. In this
analysis, we evaluated separate models, considering each
domain as an independent predictor in the core AFT model
described earlier.
We also conducted analyses using logistic regression
models to assess the likelihood of survival to the age of
85years or older, representing exceptional longevity, using
the same modeling strategy described for AFT analyses
(N=16,818 for Models 1 and 2; n=15,598 for Models 3
and 4 [92.75% of the main analytic sample]). No standard
denition for exceptional longevity has been established;
however, the cut point of 85 years is commonly used
(Newman & Murabito, 2013; Revelas etal., 2018) because
it is well beyond the average life expectancy of individuals
born in the early 20th century, without being extremely
rare. Secondary analyses with the logistic regression models
explored the roles of individual domains of social integra-
tion whereas sensitivity analyses assessed depressive symp-
toms (n=16,757; 99.64% of the main analytic sample) as
a potential confounder and the main models without ex-
cluding deaths 2 years after study onset (n = 17,016; as
described earlier).
Table 1 shows the age-adjusted distributions of covariates
in 1992 by level of social integration for the primary an-
alytic sample (i.e., the sample for AFT analyses). Over an
average of 18.73 (SD = 4.15) years of follow-up, about
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a third of this sample (n=25,723) died within the study
period. Participants classied as “highly socially inte-
grated” (highest level of social integration) had continuous
SNI scores that ranged from 10 to 12, and the mean SNI
score in the overall sample was 7.76. At the study baseline
in 1992, 81.55% of participants were married, 46.10% re-
ported having six or more close friends/relatives, 53.56%
reported attending religious activities once a week or more,
and 11.07% reported participating in group associations for
6 or more hours per week. The mean age was 58.80years.
Women categorized as highly socially integrated reported
husbands having higher levels of education, were less likely
to be depressed, and had healthier lifestyle (e.g., were less
likely to be current or former smoker whereas more likely
to be physically active).
AFT analyses demonstrated a graded association be-
tween higher levels of social integration and longer life span
(p value for trend ≤.0001 in all models; Table 2). In models
adjusted for demographic variables and health status (core
model), compared to women with the lowest levels of social
integration, women who were moderately integrated and
highly socially integrated had 7.06% (95% CI: 5.87–8.27)
and 10.10% (95% CI: 8.80–11.42) longer life span, re-
spectively. These associations declined to 3.74% (95% CI:
2.60–4.89) and 4.88% (95% CI: 3.66–6.11) when health
behaviors were further added to the model, but remained
statistically signicant. In a fully adjusted model assessing
SNI score as a continuous variable, each one-unit increase
in social integration was modestly but signicantly as-
sociated with a 0.69% (95% CI: 0.53–0.86) increase in
In AFT models assessing the domains of social inte-
gration separately, all four domains were associated with
increased longevity in core models controlling for demo-
graphic and health status variables (Supplementary Table
2). Participants with the highest versus lowest level of par-
ticipation in group associations and religious activities had
a life span 3.81% longer (95% CI: 2.49–5.14) and 6.39%
longer (95% CI: 5.36–7.42), respectively. Moreover, having
six or more close friends versus none was related to a 7.39%
(95% CI: 1.23–13.93) increase in life span, whereas being
married/partnered was associated with a 6.09% increase in
life span compared to being widowed/separated/divorced
(95% CI: 5.05–7.13). In a sensitivity analysis assessing de-
pressive symptoms as a potential confounder, ndings were
materially unchanged; for example, the effect estimate
comparing the most to the least socially integrated partici-
pants declined slightly to 9.24% and remained statistically
signicant (95% CI: 7.94–10.55). Similarly, results were
robust when including women who died within the rst
2years after study onset: in the core model, compared to
women with the lowest levels of social integration, women
Table 1. Age-Adjusted Covariates by Quartiles of Social Integration in 1992 (N=72,322)
socially isolated
socially integrated
Agea58.48 (7.12) 58.63 (7.21) 58.69 (7.10) 59.32 (7.09)
Registered nurse education level, % 69 69 72 69
Husband’s education
-Less or equal to high school degree, % 31 36 38 35
-More than high school degree, % 38 49 51 56
-Missing, % 32 17 11 9
Clinical depressive symptoms, % 23 17 15 9
High cholesterol, % 45 45 47 46
High blood pressure, % 36 35 34 32
Diabetes, % 6 6 5 5
Cardiovascular disease, % 3 3 2 2
Cancer, % 10 10 10 10
Smoking status
-Never smoker, % 33 39 46 54
-Former smoker, % 44 44 42 39
-Current smoker, % 24 17 12 8
≥150min of moderate-to-vigorous physical activity/week, % 50 55 55 62
Low-to-moderate alcohol consumption, % 88 89 91 92
Body mass index 26.01 (5.70) 26.01 (5.32) 25.92 (5.13) 25.93 (5.08)
Alternative Healthy Eating Index scoreb48.26 (10.28) 48.54 (9.91) 48.27 (9.83) 49.08 (9.55)
Note: Values are means (SD) or percentages and are standardized to the age distribution of the study population. Values of polytomous variables may not sum to
100% due to rounding.
aValue is not age adjusted.
bHigher score indicates healthier diet.
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who were moderately integrated and highly socially inte-
grated had 8.12% (95% CI: 6.77–9.49) and 11.63% (95%
CI: 10.15–13.13) longer life span, respectively.
Of the women included in analyses of exceptional lon-
gevity, 9,070 (53.93%) survived to the age of 85 years or
older. Similar to ndings in AFT analyses, there was a graded
association between higher levels of social integration and
greater likelihood of exceptional longevity (p value for trend
≤.001 in all models; Table 3). For example, in the core model,
compared to highly socially isolated women, the likelihood
of achieving exceptional longevity for participants who were
moderately integrated and highly socially integrated was
higher with odds ratios (ORs) of 1.28 (95% CI: 1.17–1.40)
and 1.41 (95% CI: 1.28–1.54), respectively. These associ-
ations declined slightly, but remained statistically signicant,
when health behaviors were further included in the models.
In a fully adjusted model assessing SNI score as a continuous
variable, the OR for exceptional longevity was barely but
signicantly associated with a one-unit increase in social in-
tegration was 1.02 (95% CI: 1.01–1.04).
Component-specic analyses of the SNI demonstrated
that greater participation in group associations, greater
religious activities attendance, and currently being mar-
ried/partnered were associated with greater likelihood of
exceptional longevity, although there was no statistically
signicant association for number of close friends/relatives
(Supplementary Table 3). In additional sensitivity ana-
lyses, effect estimates were materially unchanged (OR for
highly socially integrated vs highly socially isolated in core
model=1.42, 95% CI: 1.30–1.56) when depressive symp-
toms were included in the model as a potential confounder
or when women who died within the rst 2years of fol-
low-up were not excluded (core model: ORmoderately integrated vs
highly isolated= 1.29, 95% CI: 1.18–1.41; ORhighly integrated vs highly
isolated=1.43, 95% CI: 1.30–1.57).
To the best of our knowledge, this is the largest study to
assess the association between social integration and life
span, and the rst to consider the association between so-
cial integration and the achievement of exceptional lon-
gevity. Consistent with our hypothesis, higher levels of
Table 3. Odds Ratios for the Association of Social Integration With Survival Past Age of 85 (N=16,818)
Social integration score quartiles
socially isolated
socially integrated
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Model 1: demographics 1.00 Referent 1.21 1.10–1.33 1.32 1.21–1.44 1.47 1.34–1.61
Model 2: demographics and health conditions 1.00 Referent 1.19 1.08–1.31 1.28 1.17–1.40 1.41 1.28–1.54
Model 3: demographics and health behaviorsa1.00 Referent 1.11 1.00–1.23 1.14 1.04–1.26 1.20 1.08–1.32
Model 4: all variablesa1.00 Referent 1.09 0.98–1.21 1.11 1.01–1.22 1.15 1.04–1.27
Note: Model 1: age, education, and husband’s education. Model 2: age, education, husband’s education, as well as prevalent/history of high cholesterol, high blood
pressure, diabetes, cancer, stroke, and myocardial infarction. Model 3: age, education, husband’s education, smoking status, physical activity, alcohol, body mass
index, and the Alternative Health Eating Index (AHEI) diet index. Model 4: age, education, husband’s education, as well as prevalent/history of high cholesterol,
high blood pressure, diabetes, cancer, stroke, and myocardial infarction, smoking status, physical activity, alcohol, body mass index, and the AHEI. CI=condence
interval; OR=odds ratio.
aSample size for these models was 15,598 because of missing data for health behaviors.
Table 2. Percent Change in Life Span Associated With Social Integration From 1992 to 2014 (N=72,322)
Social integration score quartiles
socially isolated
socially integrated
% 95% CI % 95% CI % 95% CI % 95% CI
Model 1: demographics 0.00 Referent 5.52 4.28–6.78 7.87 6.65–9.10 11.04 9.71–12.38
Model 2: demographics and health conditions 0.00 Referent 4.97 3.75–6.22 7.06 5.87–8.27 10.10 8.80–11.42
Model 3: demographics and health behaviorsa0.00 Referent 2.70 1.53–3.87 3.74 2.60–4.89 4.88 3.66–6.11
Model 4: all variablesa0.00 Referent 2.37 1.22–3.54 3.22 2.10–4.36 4.33 3.13–5.56
Note: Model 1: age, education, and husband’s education. Model 2: age, education, husband’s education, as well as prevalent/history of high cholesterol, high blood
pressure, diabetes, cancer, stroke, and myocardial infarction. Model 3: age, education, husband’s education, smoking status, physical activity, alcohol, body mass
index, and the Alternative Health Eating Index (AHEI) diet index. Model 4: age, education, husband’s education, as well as prevalent/history of high cholesterol,
high blood pressure, diabetes, cancer, stroke, and myocardial infarction, smoking status, physical activity, alcohol, body mass index, and the AHEI. CI=condence
aSample size for these models was 66,684 because of missing data for health behaviors.
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social integration were associated with increased life span
and greater likelihood of exceptional longevity. This as-
sociation persisted in models adjusting for chronic health
conditions; while estimates were slightly attenuated when
controlling for health behaviors, they remained statisti-
cally signicant. Such attenuation is congruent with our
hypothesis that health-related behaviors serve in part as
pathways by which social relationships affect physical
health, although further work is needed with more clear
temporality between the measures of social integration and
health-related behaviors and to rule out the possibility of
confounding. Similarly, due to data availability, we could
not denitively assess whether depression preceded or was
consequent to social integration levels; however, in sensi-
tivity analyses controlling for depressive symptoms, effect
estimates barely changed and remained statistically sig-
nicant. Moreover, in all analyses, CIs were fairly narrow
around the effect estimates, indicating the estimates are
stable. The magnitude of associations was also comparable
to those observed in prior research targeting psychosocial
determinants of longevity using analogous analyses (Costa
etal., 2014; Lee etal., 2019).
In analyses where SNI domains were assessed separately,
religious activities attendance, participation in group asso-
ciations, and being married/partnered were each associated
with increased life span and likelihood of exceptional lon-
gevity, whereas number of close friends and relatives was
less clearly related to these outcomes. This is consistent
with previous research in the same cohort that demon-
strated lower risk of coronary heart disease in relation to
greater social integration using the composite measure,
as well as all individual components of social integration
except the close friend/relatives subdomain (Chang etal.,
2017). However, other research using a breast cancer pa-
tient population from this cohort demonstrated that the
composite measure and the number of close friends/rela-
tives, but not other individual domains of social integra-
tion, were associated with greater likelihood of breast
cancer survival (Kroenke et al., 2006). These differences
point to the potential specicity of associations between
health and social relationships—what is benecial in one
set of circumstances (i.e., a healthy population) may be less
effective in another (i.e., a patient population)—and lends
support to the idea that associations of health to social in-
tegration may be context dependent, rather than universal.
At a minimum, ndings in healthy versus patient popula-
tions may not be interchangeable.
A variety of mechanisms might explain the association
between greater social integration and improved health
outcomes. More favorable social relationships, captured for
instance by social support and social integration, are asso-
ciated with healthier levels of behavioral factors, including
physical activity (Kroenke et al., 2017; Tay, Tan, Diener,
& Gonzalez, 2013), successful management of chronic
illnesses (Gallant, 2003; Tay et al., 2013), and smoking
abstinence/cessation (Kroenke etal., 2017; Wagner, Burg,
& Sirois, 2004). Positive social relationships may increase
likelihood of experiencing psychological well-being (e.g.,
optimism, positive affect) (Kubzansky etal., 2018; Steptoe,
2019), which have been associated with future engage-
ment in health-related behaviors (Kubzansky etal., 2018;
Steptoe, 2019).
Social relationships may also improve health independ-
ently of health behaviors by enhancing positive affect and
feelings of belonging and self-worth, which may have di-
rect benecial effects on physiology through neuroendo-
crine and immune pathways (Berkman etal., 2000; Cohen,
1988; Kroenke, 2018). Or they may buffer potentially toxic
effects of adverse experiences and psychosocial distress
(Berkman & Krishna, 2014; Kubzansky et al., 2018). In
both cross-sectional and longitudinal observational studies,
greater social integration and other positive characteristics
of social relationships have been linked to improved bio-
markers of metabolic function (e.g., cholesterol and blood
pressure) (Yang et al., 2016; Yang, Li, & Ji, 2013) and to
reduced systemic inammation (Penwell & Larkin, 2010;
Yang et al., 2016). It is also possible that shared genetics
(e.g., among biological relatives) affect both social integra-
tion and longevity. Furthermore, prior ndings also showed
that social relationships, including the size of one’s social
network, are positively associated with cognitive abilities
and slower cognitive decline in midlife and older adults
(Kelly etal., 2017). Results from this study suggest health
behaviors may mediate partly but not fully the social in-
tegration–longevity relationship. Thus, further research
should evaluate whether biological processes and cognitive
function might also be atplay.
Several limitations of this study should be noted. Findings
in these primarily white women may not be generalizable to
minorities or to men, as both social integration and mor-
tality rates are different in different racial/ethnic groups
and in different sexes; yet, the homogeneity of this cohort
enhances the study’s internal validity. As with all observa-
tional research, potential for unmeasured confounding re-
mains possible. Nonetheless, our analyses controlled for a
wide range of demographic and health status variables that
may serve as confounders, including health behaviors and
depressive symptoms. Because all women were married at
cohort baseline (1976), most (but not all) participants were
still married/partnered in 1992, hence reducing variability
in the exposure at the current study baseline. However, het-
erogeneity increased over follow-up, as a higher proportion
of women experienced separation/divorce or widowhood.
Finally, although the widely studied SNI is considered a
complex measure of social integration (i.e., assessing mul-
tiple dimensions), it does not capture the quality of these
relationships, which also likely affect health-related out-
comes (Kroenke, 2018). According to the socioemotional
selectivity theory (Löckenhoff & Carstensen, 2004), indi-
viduals would progressively prioritize existing emotionally
7 Journals of Gerontology: PSYCHOLOGICAL SCIENCES, 2019, Vol. XX, No. XX
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rewarding relationships over the expansion of their social
network toward the end of life. As a result, it is possible that
the association between larger social networks and longevity
captures the fact that younger individuals who are likely to
live longer, and that such bias would not be fully accounted
by statistical control for chronological age. However, in
the current sample, the SNI score was highly stable over
16years and comparable across age groups, reducing con-
cerns that these women experienced substantial changes in
the size of their social network over time. These limitations
are offset by several strengths, including the use of a large
and well-characterized cohort, as well as a follow-up over
two decades that enabled the assessment of exceptional lon-
gevity (i.e., attaining 85years). Another strength of the study
is its prospective research design, which combined with the
2-year lag introduced in our statistical analyses and control
for major health conditions at baseline, reduced concerns
about the potential for reverse causation.
As longer life spans become more achievable through
improved disease prevention and medical technology, it
is increasingly important to work toward a better under-
standing of psychosocial assets that can help promote longer
and healthier lives. Agreater appreciation of these assets
may be able to inform our thinking about the resources or
reserves that are necessary to help people successfully age
with better health. Social integration, as demonstrated in
these analyses, is one such health asset that may have a sub-
stantial association with longevity. Furthermore, although
many efforts at intervention have fallen short, there is also
evidence that social integration has the potential to be
modiable (Cohen & Janicki-Deverts, 2009; Holt-Lunstad
et al., 2017; Kroenke, 2018). If we can develop effective
ways to intervene on one’s social environment, we may be
able to develop low-cost and targeted interventions to help
individuals achieve longer and healthierlives.
Ethical Approval
The authors assume full responsibility for analyses and
interpretation of these data. All procedures performed in
studies involving human participants were in accordance
with the ethical standards of the institutional review boards
of the institutional and/or national research committee
(Brigham and Women’s Hospital; IRB protocol number:
1999P011114) and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual partici-
pants included in the study.
Supplementary Material
Supplementary data are available at The Journals of
Gerontology, Series B: Psychological Sciences and Social
Sciences online.
This work was supported by the National Institutes of
Health (grant number UM1 CA186107) for the Nurses’
Health Study and by a National Cancer Institute K01
Career Development Grant (grant number K01 CA169041)
to Dr. R.Tucker-Seeley.
We would like to thank the participants and the staff of
the Nurses’ Health Study for their valuable contributions.
Further information including the procedures to obtain and
access data from the Nurses’ Health Studies is described
at (contact
email:; study mater-
ials are available at:
participants/questionnaires. Analytic methods will be pro-
vided upon request to the rst author. This study was not
Conflict of Interest
None reported.
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Journals of Gerontology: PSYCHOLOGICAL SCIENCES, 2019, Vol. XX, No. XX 10
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... Lifespan was operationalized as changes in predicted lifespan, following previous studies investigating the association of psychosocial factors with longevity (28)(29)(30). Information on vital status was obtained from the National Death Index (31) and MIDUSIII survey fielding (26) through June 2018, the most recently available data. ...
Objectives Some stress-related coping strategies contribute to survival among medical populations, but it is unclear if they relate to longevity in the general population. While coping strategies are characterized as being adaptive or maladaptive, whether capacity to tailor their implementation to different contexts (i.e., flexibility of use) may influence lifespan is unknown. Method In 2004–2006, participants from the Midlife Development in the United States study completed a validated coping inventory including 6 strategies and provided information on sociodemographics, health status, and biobehavioral factors (N = 4398). Deaths were ascertained from death registries with follow-up until 2018. Accelerated failure time models estimated percent changes and 95% confidence intervals (CI) in predicted lifespan associated with use of individual coping strategies. As a proxy for flexibility, participants were also classified as having lower, moderate, or greater variability in strategies used, using a standard deviation-based algorithm. Results After controlling for sociodemographics and health status, maladaptive strategies (e.g., per 1-SD increase in Denial = −5.50, 95%CI = -10.50, −0.21) but not adaptive strategies (e.g., Planning) were related to shorter lifespan. Greater versus moderate variability levels were related to a 15% shorter lifespan. Estimates were somewhat attenuated when further controlling for lifestyle factors. Conclusion Although most associations were of modest magnitude, use of some maladaptive coping strategies appeared related to shorter lifespan. Compared to moderate levels, greater coping variability levels were also clearly detrimental for lifespan. Although adaptive strategies were unrelated to longevity, future work should examine other favorable strategies (e.g., acceptance) and more direct measures of flexibility (e.g., experience sampling methods).
... The variables comprised: (1) voting in the last elections (yes vs. no/not registered voter), (2) religious service attendance (at least once a week, less than once a week, never), (3) spiritual practices (at least once a week, less than once a week, never), (4) volunteering (at least once a week, less than once a week, never), and (5) community work (at least once a week, less than once a week, never). In prior studies, these factors were found to play a predictive role for health and well-being [40][41][42][43][44]77]. Next, since the impact of work on health has long been recognized in theory [45] and empirical research [46][47][48][49][50]78], we controlled for work characteristics. ...
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Purpose Excellent character, reflected in adherence to high standards of moral behavior, has been argued to contribute to well-being. The study goes beyond this claim and provides insights into the role of strengths of moral character (SMC) for physical and mental health. Methods This study used longitudinal observational data merged with medical insurance claims data collected from 1209 working adults of a large services organization in the US. Self-reported physical and mental health as well as diagnostic information on depression, anxiety, and cardiovascular disease were used as outcomes. The prospective associations between SMC (7 indicators and a composite measure) and physical and mental health outcomes were examined using lagged linear and logistic regression models. A series of sensitivity analyses provided evidence for the robustness of results. Results The results suggest that persons who live their life according to high moral standards have substantially lower odds of depression (by 21-51%). The results were also indicative of positive associations between SMC and self-reports of mental health (β = 0.048-0.118) and physical health (β = 0.048-0.096). Weaker indications were found for a protective role of SMC in mitigating anxiety (OR = 0.797 for the indicator of delayed gratification) and cardiovascular disease (OR = 0.389 for the indicator of use of SMC for helping others). Conclusions SMC may be considered relevant for population mental health and physical health. Public health policies promoting SMC are likely to receive positive reception from the general public because character is both malleable and aligned with the nearly universal human desire to become a better person.
... A number of rigorous longitudinal studies have identified positive temporal associations between advantageous, individual and relational social stimuli and health. For example, better social integration and cohesion have been shown to contribute to longevity and healthy life expectancy, reduced risk of all-cause mortality and mortality from cardiovascular disease, lower risks of hypertension, pulmonary disease, and abdominal obesity, better general metabolic health, and improved measures of physical and mental health [1][2][3][4]. Social engagement has been found to be associated with lower levels of inflammation [5,6]. Membership in social groups, close relationships, and friendship have been evidenced to protect against depression, alleviate depression symptoms and prevent depression relapse [7] as well as positively contribute to sense of purpose in life [8]. ...
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Objectives: Evidence on social stimuli associated with mental health is based mostly on self-reported health measures. We aimed to examine prospective associations between social connectedness and clinical diagnosis of depression and of anxiety. Methods: Longitudinal observational data merged with health insurance data comprising medical information on diagnosis of depression and anxiety were used. 1,209 randomly sampled employees of a US employer provided data for the analysis. Robust Poisson regression models were used. Multiple imputation was conducted to handle missing data on covariates. Results: Better social connectedness was associated with lower risks of subsequently diagnosed depression and anxiety, over a one-year follow-up period. Reports of feeling lonely were associated with increased risks of depression and anxiety. Association between community-related social connectedness and subsequent diagnosis of depression, but not of anxiety, was found. The associations were independent of demographics, socioeconomic status, lifestyle, and work characteristics. They were also robust to unmeasured confounding, missing data patterns, and prior health conditions. Conclusion: Social connectedness may be an important factor for reducing risks of depression and anxiety. Loneliness should be perceived as a risk factor for depression and anxiety.
... On the other hand, in non-Western countries that focus on more harmonious interdependence with others like Japan (Boylan et al., 2017;Carver et al., 2010;Uchida & Kitayama, 2009), the most optimistic individuals, who deviate from the population average, can be considered as "outliers". As a result, they may be less socially integrated, which can lead to experiencing more stressors, worse health outcomes, and shorter lifespan (Leigh-Hunt et al., 2017;Trudel-Fitzgerald et al., 2020). ...
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Optimism has been linked to better physical health across various outcomes, including greater longevity. However, most evidence is from Western populations, leaving it unclear whether these relationships may generalize to other cultural backgrounds. Using secondary data analysis, we evaluated the associations of optimism among older Japanese adults. Data were from a nationwide cohort study of Japanese older adults aged ≥ 65 years (Japan Gerontological Evaluation Study; n = 10,472). In 2010, optimism and relevant covariates (i.e., sociodemographic factors, physical health conditions, depressive symptoms, and health behaviors) were self-reported. Optimism was measured using the Japanese version of the Life Orientation Test-Revised (LOT-R). Lifespan was determined using mortality information from the public long-term care insurance database through 2017 (7-year follow-up). Accelerated failure time models examined optimism (quintiles or standardized continuous scores) in relation to percent differences in lifespan. Potential effect modification by gender, income, and education was also investigated. Overall, 733 individuals (7%) died during the follow-up period. Neither continuous nor categorical levels of optimism were associated with lifespan after progressive adjustment for covariates (e.g., in fully-adjusted models: percent differences in lifespan per 1-SD increase in continuous optimism scores = − 1.2%, 95%CI − 3.4, 1.1 higher versus lower optimism quintiles = − 4.1%, 95%CI − 11.2, 3.6). The association between optimism and lifespan was null across all sociodemographic strata as well. Contrary to the existing evidence from Western populations, optimism was unrelated to longevity among Japanese older adults. The association between optimism, as evaluated by the LOT-R, and longevity may differ across cultural contexts.
... Theoretical arguments from positive health and positive psychology (Kubzansky et al., 2018;Seligman, 2008;Seligman et al., 2005;Van-derWeele et al., 2020), as well as empirical evidence on various determinants of positive health impacts (Chen et al., 2019;Kim et al., 2017;Trudel-Fitzgerald et al., 2019;Węziak-Białowolska et al., 2018), suggest that properly executed precautionary financial behaviors, leading to increased financial security and financial capability, may promote well-being and translate into better health outcomes. For example, economic resources may affect health conditions indirectly by granting a healthier life-style (Molarius et al., 2007), which has been shown for savings limiting smoking and promoting sport activities (Białowolski et al., 2019). ...
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Background Both theory and empirical evidence suggest that financial conditions are influential for mental health and might contribute to physical health outcomes. Methods Using longitudinal survey data and health claims data from 1,209 employees in a large U.S. health insurance company, we examined temporal associations between measures of financial safety, financial capability, financial distress, their summary index (financial security) and six subsequently measured mental and physical health outcomes. Results We found that financial safety and financial capability were positively associated, while financial distress was negatively associated, with subsequent self-reported measures of physical and mental health, even after controlling for these health measures at baseline and other confounders. Additionally, financial conditions were associated with reduced risk of depression based on medical claims data. Financial safety was also associated with anxiety. Conclusions Policy-makers might consider the introduction of more effective measures for ensuring favorable financial conditions as an important contributor to better population health. Furthermore, policy could encourage teaching adequate financial management techniques and the importance of understanding of long-term consequences of financial decisions, as those might be pivotal for health outcomes.
... Few studies investigated the relationship between psychosocial factors and longevity. Recently, two prospective cohort analyses reported a positive association between optimism and social integration and reaching the age of 85 years (Lee et al., 2019;Trudel-Fitzgerald et al., 2019). While these positive psychosocial traits seem to increase the probability of reaching longevity, analyses on negative psychosocial traits, such as loneliness, in relation to the probability of reaching longevity have not yet been performed. ...
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Objectives There is an increasing research interest in factors that characterize those who reach exceptionally old ages. Although loneliness is often associated with an increased risk for premature mortality, its relationship with reaching longevity is still unclear. We aimed to quantify the association between (social/emotional) loneliness and the likelihood of reaching the age of 90 years in men and women separately. Methods For these analyses, data from the Longitudinal Aging Study Amsterdam (LASA) was used. Loneliness, social loneliness and emotional loneliness were assessed at baseline using the 11-item De Jong-Gierveld scale in 1992-93 (at age 64-85 years). Follow-up for vital status information until the age of 90 years was 99.5% complete. Multivariable-adjusted Cox regression analyses with a fixed follow-up time were based on 1,032 men and 1,078 women to calculate Risk Ratios (RR) of reaching 90 years. Results No significant associations were observed between loneliness and reaching 90 years in both men (RR,0.90; 95%CI,0.70-1.14) and women (RR,0.98; 95%CI,0.83-1.14). Social loneliness was significantly associated with a reduced chance of reaching 90 years in women (RR,0.82; 95%CI,0.67-0.99). Discussion The current analyses, did not show support for the existence of a meaningful effect of loneliness on reaching longevity in both sexes. When investigating specific dimensions of loneliness, we observed that reporting social loneliness was associated with reaching 90 years in women. This indicates that, for women, a large and diverse personal network at an older age could increase the probability of reaching longevity. However, replication of our findings in other cohorts is needed.
... Finally, another distinctive contribution is in presenting empirical evidence on the beneficial effects of using of character strengths on having sense of meaning and purpose in life, social connectedness, as well as on reducing anxiety. While the first 2 outcomes have been acknowledged as factors contributing to improved physical health and longevity in general, 41,47,48 remarkably little is known about their determinants. 42 This study provides some insights in this respect. ...
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Purpose: We examined the impact of an orientation to promote good—one aspect of strengths of character, understood as having consistent thoughts and taking actions that contribute to the good of oneself and others—on flourishing outcomes. Design: We used data from 2 longitudinal observational studies. The primary study used 2 waves of data collected in June 2018 and July 2019. The secondary study used 3 waves of data collected in February 2017, March 2018, and March 2019. Setting: Two culturally different populations of adults were examined: (1) a large service organization based in the United States and (2) a Mexican apparel company in the supply chain of a major global brand. Subjects: 1,209 U.S. employees and 495 Mexican apparel workers were included in the study. Measures: Self-reports of orientation to promote good, Well-Being Assessment, Flourishing Index, the CDC Health-Related Quality of Life and the Job-Related Affective Well-Being Scale were used. Analysis: An outcome-wide approach and lagged regression analyses were applied. To combine the estimates across samples meta-analytic estimates were computed. Bonferroni correction was used to correct for multiple testing. Robustness of the results to potential unmeasured confounding was examined using E-values. Results: Orientation to promote good was positively associated with subsequently higher levels of life satisfaction and happiness (b 1⁄4 0.14, 95% CI: 0.09, 0.19), self-assessed mental health (b 1⁄4 0.11, 95% CI: 0.06, 0.15) and physical health (b 1⁄4 0.08, 95% CI: 0.04, 0.12), social connectedness (b 1⁄4 0.102, 95% CI: 0.06, 0.15) and purpose in life (b 1⁄4 0.07, 95% CI: 0.03, 0.11). It was also associated with decreased anxiety (b 1⁄4 -0.11, 95% CI: -0.17, -0.06), depression (b 1⁄4 -0.07, 95% CI: -0.1, -0.02) and loneliness (b 1⁄4 -0.09, 95% CI: -0.13, -0.04). Possible effects on both positive affect (feeling happy) and negative affect (feeling sad, stressed and lonely) in general and while-at-work were also identified. Conclusions: Policymakers and practitioners should consider orientation to promote good as an important factor for improving population health and human flourishing while also at work.
Purpose Globally, the COVID-19 pandemic impacts the financial condition and the mental health of millions of workers from various informal sectors. This study aims to look into the hawkers’ community’s mental health and living conditions in Bangladesh during COVID-19. Design/methodology/approach The researchers have applied the purposive sampling technique to choose ten hawkers from Khulna city, a district in the southern region of Bangladesh. An in-depth interview was taken in the Bengali language in an unstructured manner and lasted 30–40 min per respondent. Findings The findings showed that the Hawkers’ income reduced, and specifically, during the pandemic, they had earned half of what they usually made before. Besides, they could not open their stores because law enforcement agencies imposed restrictions on opening business centres during the lockdown except for some emergency necessities shops. This restriction led the hawkers to stop selling their products because there was a high chance of spreading the virus through the products they sold. Due to income reduction, they had to eat cheap food, which caused their health problems. Consequently, this community mentally got depressed. Practical implications Policymakers in Bangladesh might think about enacting more effective measures to provide some extrinsic and intrinsic support in improving the mental health of the hawkers’ community. Originality/value To the best of the authors’ knowledge, this is the first study on the mental of the hawkers’ community during COVID-19.
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Background Although social isolation has been associated with a higher mortality risk, little is known about the potential different impacts of face-to-face and non-face-to-face isolation on mortality. We examined the prospective associations of four types of social isolation, including face-to-face isolation with co-inhabitants and non-co-inhabitants, non-face-to-face isolation, and club/organization isolation, with all-cause and cause-specific mortality separately. Methods This prospective cohort study included 30,430 adults in Guangzhou Biobank Cohort Study (GBCS), who were recruited during 2003–2008 and followed up till Dec 2019. Results During an average of 13.2 years of follow-up, 4933 deaths occurred during 396,466 person-years. Participants who lived alone had higher risks of all-cause (adjusted hazard ratio (AHR) 1.24; 95% confidence interval (CI) 1.04-1.49) and cardiovascular disease (CVD) (1.61; 1.20–2.03) mortality than those who had ≥ 3 co-habitant contact after adjustment for thirteen potential confounders. Compared with those who had ≥ 1 time/month non-co-inhabitant contact, those without such contact had higher risks of all-cause (1.60; 1.20–2.00) and CVD (1.91; 1.20–2.62) mortality. The corresponding AHR (95% CI) in participants without telephone/mail contact were 1.27 (1.14–1.42) for all-cause, 1.30 (1.08–1.56) for CVD, and 1.37 (1.12–1.67) for other-cause mortality. However, no association of club/organization contact with the above mortality and no association of all four types of isolation with cancer mortality were found. Conclusions In this cohort study, face-to-face and non-face-to-face isolation were both positively associated with all-cause, CVD-, and other-cause (but not cancer) mortality. Our finding suggests a need to promote non-face-to-face contact among middle-aged and older adults.
We studied male centenarian Veterans using VA health care to understand the impact of social characteristics on their annual mortality rate, adjusting for prevalent health conditions. This longitudinal study used VA Electronic Health Record data from 1997 to 2012 ( n = 1,858). Covariates included age, race, marital status, and periods of military service. The mean age was 100.4 ± 1.4 years, 76% were white, and 49% were married. The average annual mortality rate was 32 per 100 person-years. The annual mortality rate was stable and not affected by race but did vary by marital status. Divorced or separated centenarians had a 21% higher rate of death than married centenarians. A diagnosis of dementia or of congestive heart failure each increased the mortality risk by 37%. Providers should consider prevalent health conditions, as well as marital status, in managing care of centenarian Veterans.
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Research into the relationship between happiness and health is developing rapidly, exploring the possibility that impaired happiness is not only a consequence of ill-health but also a potential contributor to disease risk. Happiness encompasses several constructs, including affective well-being (feelings of joy and pleasure), eudaimonic well-being (sense of meaning and purpose in life), and evaluative well-being (life satisfaction). Happiness is generally associated with reduced mortality in prospective observational studies, albeit with several discrepant results. Confounding and reverse causation are major concerns. Associations with morbidity and disease prognosis have also been identified for a limited range of health conditions. The mechanisms potentially linking happiness with health include lifestyle factors, such as physical activity and dietary choice, and biological processes, involving neuroendocrine, inflammatory, and metabolic pathways. Interventions have yet to demonstrate substantial, sustained improvements in subjective well-being or direct impact on physical health outcomes. Nevertheless, this field shows great potential, with the promise of establishing a favorable effect on population health.
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Women with larger personal social networks have better breast cancer survival and a lower risk of mortality. However, little work has examined the mechanisms through which social networks influence breast cancer outcomes and cancer outcomes more generally, potentially limiting the development of feasible, clinically effective interventions. In fact, much of the emphasis in cancer research regarding the influence of social relationships on cancer outcomes has focused on the benefits of the provision of social support to patients, especially through peer support groups, and only more recently through patient navigation. Though critically important, there are other ways through which social relationships might influence outcomes, around which interventions might be developed. In addition to social support, these include social resources, social norms, social contagion, social roles, and social burdens and obligations. This narrative review addresses how social networks may influence cancer outcomes and discusses potential strategies for improving outcomes given these relationships. The paper (a) describes background and limitations of previous research, (b) outlines terms and provides a conceptual model that describes interrelationships between social networks and relevant variables and their hypothesized influence on cancer outcomes, (c) clarifies social and psychosocial mechanisms through which social networks affect downstream factors, (d) describes downstream behavioral, treatment, and physiological factors through which these subsequently influence recurrence and mortality, and (e) describes needed research and potential opportunities to enhance translation. Though most literature in this area pertains to breast cancer, this review has substantial relevance for cancer outcomes generally. Further clarification and research regarding potential mechanisms are needed to translate epidemiological findings on social networks into clinical and community strategies to improve cancer outcomes.
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Background Social relationships, which are contingent on access to social networks, promote engagement in social activities and provide access to social support. These social factors have been shown to positively impact health outcomes. In the current systematic review, we offer a comprehensive overview of the impact of social activities, social networks and social support on the cognitive functioning of healthy older adults (50+) and examine the differential effects of aspects of social relationships on various cognitive domains. Methods We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, and collated data from randomised controlled trials (RCTs), genetic and observational studies. Independent variables of interest included subjective measures of social activities, social networks, and social support, and composite measures of social relationships (CMSR). The primary outcome of interest was cognitive function divided into domains of episodic memory, semantic memory, overall memory ability, working memory, verbal fluency, reasoning, attention, processing speed, visuospatial abilities, overall executive functioning and global cognition. ResultsThirty-nine studies were included in the review; three RCTs, 34 observational studies, and two genetic studies. Evidence suggests a relationship between (1) social activity and global cognition and overall executive functioning, working memory, visuospatial abilities and processing speed but not episodic memory, verbal fluency, reasoning or attention; (2) social networks and global cognition but not episodic memory, attention or processing speed; (3) social support and global cognition and episodic memory but not attention or processing speed; and (4) CMSR and episodic memory and verbal fluency but not global cognition. Conclusions The results support prior conclusions that there is an association between social relationships and cognitive function but the exact nature of this association remains unclear. Implications of the findings are discussed and suggestions for future research provided. Systematic review registrationPROSPERO 2012: CRD42012003248.
Significance Optimism is a psychological attribute characterized as the general expectation that good things will happen, or the belief that the future will be favorable because one can control important outcomes. Previous studies reported that more optimistic individuals are less likely to suffer from chronic diseases and die prematurely. Our results further suggest that optimism is specifically related to 11 to 15% longer life span, on average, and to greater odds of achieving “exceptional longevity,” that is, living to the age of 85 or beyond. These relations were independent of socioeconomic status, health conditions, depression, social integration, and health behaviors (e.g., smoking, diet, and alcohol use). Overall, findings suggest optimism may be an important psychosocial resource for extending life span in older adults.
Background Late-life depression has become an important public health problem. Available evidence suggests that late-life depression is associated with all-cause and cardiovascular mortality among older adults living in the community, although the associations have not been comprehensively reviewed and quantified. Aim To estimate the pooled association of late-life depression with all-cause and cardiovascular mortality among community-dwelling older adults. Method We conducted a systematic review and meta-analysis of prospective cohort studies that examine the associations of late-life depression with all-cause and cardiovascular mortality in community settings. Results A total of 61 prospective cohort studies from 53 cohorts with 198 589 participants were included in the systematic review and meta-analysis. A total of 49 cohorts reported all-cause mortality and 15 cohorts reported cardiovascular mortality. Late-life depression was associated with increased risk of all-cause (risk ratio 1.34; 95% CI 1.27, 1.42) and cardiovascular mortality (risk ratio 1.31; 95% CI 1.20, 1.43). There was heterogeneity in results across studies and the magnitude of associations differed by age, gender, study location, follow-up duration and methods used to assess depression. The associations existed in different subgroups by age, gender, regions of studies, follow-up periods and assessment methods of late-life depression. Conclusion Late-life depression is associated with higher risk of both all-cause and cardiovascular mortality among community-dwelling elderly people. Future studies need to test the effectiveness of preventing depression among older adults as a way of reducing mortality in this population. Optimal treatment of late-life depression and its impact on mortality require further investigation. Declaration of interest None.
Facets of positive psychological well-being, such as optimism, have been identified as positive health assets because they are prospectively associated with the 7 metrics of cardiovascular health (CVH) and improved outcomes related to cardiovascular disease. Connections between psychological well-being and cardiovascular conditions may be mediated through biological, behavioral, and psychosocial pathways. Individual-level interventions, such as mindfulness-based programs and positive psychological interventions, have shown promise for modifying psychological well-being. Further, workplaces are using well-being–focused interventions to promote employee CVH, and these interventions represent a potential model for expanding psychological well-being programs to communities and societies. Given the relevance of psychological well-being to promoting CVH, this review outlines clinical recommendations to assess and promote well-being in encounters with patients. Finally, a research agenda is proposed. Additional prospective observational studies are needed to understand mechanisms underlying the connection between psychological well-being and cardiovascular outcomes. Moreover, rigorous intervention trials are needed to assess whether psychological well-being–promoting programs can improve cardiovascular outcomes.
Background: Many factors contribute to exceptional longevity, with genetics playing a significant role. However, to date, genetic studies examining exceptional longevity have been inconclusive. This comprehensive review seeks to determine the genetic variants associated with exceptional longevity by undertaking meta-analyses. Methods: Meta-analyses of genetic polymorphisms previously associated with exceptional longevity (85+) were undertaken. For each variant, meta-analyses were performed if there were data from at least three independent studies available, including two unpublished additional cohorts. Results: Five polymorphisms, ACE rs4340, APOE ε2/3/4, FOXO3A rs2802292, KLOTHO KL-VS and IL6 rs1800795 were significantly associated with exceptional longevity, with the pooled effect sizes (odds ratios) ranging from 0.42 (APOE ε4) to 1.45 (FOXO3A males). Conclusion: In general, the observed modest effect sizes of the significant variants suggest many genes of small influence play a role in exceptional longevity, which is consistent with results for other polygenic traits. Our results also suggest that genes related to cardiovascular health may be implicated in exceptional longevity. Future studies should examine the roles of gender and ethnicity and carefully consider study design, including the selection of appropriate controls.
A robust body of scientific evidence has indicated that being embedded in high-quality close relationships and feeling socially connected to the people in one's life is associated with decreased risk for all-cause mortality as well as a range of disease morbidities. Despite mounting evidence that the magnitude of these associations is comparable to that of many leading health determinants (that receive significant public health resources), government agencies, health care providers and associations, and public or private health care funders have been slow to recognize human social relationships as either a health determinant or health risk marker in a manner that is comparable to that of other public health priorities. This article evaluates current evidence (on social relationships and health) according to criteria commonly used in determining public health priorities. The article discusses challenges for reducing risk in this area and outlines an agenda for integrating social relationships into current public health priorities.
Significance Life skills such as persistence, conscientiousness, and control are important in early life. Our findings suggest that they are relevant in later life as well. Higher scores on five life skills (conscientiousness, emotional stability, determination, control, and optimism) were associated both cross-sectionally and longitudinally with economic success, social and subjective wellbeing, and better health in older adults. No single attribute was especially important; rather, effects depended on the accumulation of life skills. Our results suggest that fostering and maintaining these skills in adult life may be relevant to health and wellbeing at older ages.
Rationale: Higher social integration is associated with lower cardiovascular mortality; however, whether it is associated with incident coronary heart disease (CHD), especially in women, and whether associations differ by case fatality are unclear. Objectives: This study sought to examine the associations between social integration and risk of incident CHD in a large female prospective cohort. Methods and results: Seventy-six thousand three hundred and sixty-two women in the Nurses' Health Study, free of CHD and stroke at baseline (1992), were followed until 2014. Social integration was assessed by a simplified Berkman-Syme Social Network Index every 4 years. End points included nonfatal myocardial infarction and fatal CHD. Two thousand three hundred and seventy-two incident CHD events occurred throughout follow-up. Adjusting for demographic, health/medical risk factors, and depressive symptoms, being socially integrated was significantly associated with lower CHD risk, particularly fatal CHD. The most socially integrated women had a hazard ratio of 0.55 (95% confidence interval, 0.41-0.73) of developing fatal CHD compared with those least socially integrated (P for trend <0.0001). When additionally adjusting for lifestyle behaviors, findings for fatal CHD were maintained but attenuated (P for trend =0.02), whereas the significant associations no longer remained for nonfatal myocardial infarction. The inverse associations between social integration and nonfatal myocardial infarction risk were largely explained by health-promoting behaviors, particularly through differences in cigarette smoking; however, the association with fatal CHD risk remained after accounting for these behaviors and, thus, may involve more direct biological mechanisms. Conclusions: Social integration is inversely associated with CHD incidence in women, but is largely explained by lifestyle/behavioral pathways.