Social network diversity and risks of ischemic heart disease and total mortality: findings from the Copenhagen City Heart Study

The effect of social integration on outcomes after major lower extremity amputation

OBJECTIVE

Major lower extremity (MLE) amputation is a common procedure that results in a profound change in a patient's life. We sought to determine the association between social support and outcomes after amputation. We hypothesized that patients with greater social support will have better post amputation outcomes.

METHODS

From November 2011 to May 2013, we conducted a cross-sectional, observational, multicenter study. Social integration was measured by the social integration subset of the Short Form Craig Handicap Assessment and Reporting Technique. Systemic social support was assessed by comparing a United States and Tanzanian population. Walking function was measured using the 6-minute walk test and quality of life (QoL) was measured using the EuroQol-5D.

RESULTS

We recruited 102 MLE amputees. Sixty-three patients were enrolled in the United States with a mean age of 58.0. Forty-two (67%) were male. Patients with low social integration were more likely to be unable to ambulate (no walk 39% vs slow walk 23% vs fast walk 10%; P = .01) and those with high social integration were more likely to be fast walkers (no walk 10% vs slow walk 59% vs fast walk 74%; P = .01). This relationship persisted in a multivariable analysis. Increasing social integration scores were also positively associated with increasing QoL scores in a multivariable analysis (β, .002; standard error, 0.0008; P = .02). In comparing the United States population with the Tanzanian cohort (39 subjects), there were no differences between functional or QoL outcomes in the systemic social support analysis.

CONCLUSIONS

In the United States population, increased social integration is associated with both improved function and QoL outcomes among MLE amputees. Systemic social support, as measured by comparing the United States population with a Tanzanian population, was not associated with improved function or QoL outcomes. In the United States, steps should be taken to identify and aid amputees with poor social integration.

Influence of the Source of Social Support and Size of Social Network on All-Cause Mortality

OBJECTIVE

To examine associations between relative, friend, and partner support, as well as size and source of weekly social network, and mortality risk in the Aerobics Center Longitudinal Study.

PATIENTS AND METHODS

In a mail-back survey completed between January 1, 1990, and December 31, 1990, adult participants in the Aerobics Center Longitudinal Study (N=12,709) answered questions on whether they received social support from relatives, friends, and spouse/partner (yes or no for each) and on the number of friends and relatives they had contact with at least once per week. Participants were followed until December 31, 2003, or until the date of death. Cox proportional hazards regression analyses evaluated the strength of the associations, controlling for covariates.

RESULTS

Participants (3220 [25%] women) averaged 53.0 ± 11.3 years of age at baseline. During a median follow-up of 13.5 years, 1139 deaths occurred. Receiving social support from relatives reduced mortality risk by 19% (hazard ratio [HR], 0.81; 95% CI, 0.68-0.95). Receiving spousal/partner support also reduced mortality risk by 19% (HR, 0.81; 95% CI, 0.66-0.99). Receiving social support from friends was not associated with mortality risk (HR, 0.90; 95% CI, 0.75-1.09); however, participants reporting social contact with 6 or 7 friends on a weekly basis had a 24% lower mortality risk than did those in contact with 0 or 1 friend (HR, 0.76; 95% CI, 0.58-0.98). Contact with 2 to 5 or 8 or more friends was not associated with mortality risk, nor was the number of weekly contacts with relatives.

CONCLUSION

Receiving social support from one's spouse/partner and relatives and maintaining weekly social interaction with 6 to 7 friends reduced mortality risk. Such data may inform interventions to improve long-term survival.

Social Networks of Lesbian, Gay, Bisexual, and Transgender Older Adults

PURPOSE

This study examines global social networks-including friendship, support, and acquaintance networks-of lesbian, gay, bisexual, and transgender (LGBT) older adults.

DESIGN AND METHODS

Utilizing data from a large community-based study, we employ multiple regression analyses to examine correlates of social network size and diversity.

RESULTS

Controlling for background characteristics, network size was positively associated with being female, transgender identity, employment, higher income, having a partner or a child, identity disclosure to a neighbor, engagement in religious activities, and service use. Controlling in addition for network size, network diversity was positively associated with younger age, being female, transgender identity, identity disclosure to a friend, religious activity, and service use.

IMPLICATIONS

According to social capital theory, social networks provide a vehicle for social resources that can be beneficial for successful aging and well-being. This study is a first step at understanding the correlates of social network size and diversity among LGBT older adults.

Longitudinal Influences of Social Network Characteristics on Subjective Well-Being of Older Adults

Objective: To investigate the influence of social network characteristics on subjective well-being over 6 years in a population sample of older adults. Method: A total of 4,116 participants in the English Longitudinal Study of Aging provided baseline data on social network characteristics and potential confounding factors, and complete follow-up data on 2 measures of subjective well-being. Results: Social network size and network contact frequency were positively and independently associated with future life satisfaction and quality of life after controlling for confounding factors, including demographic characteristics, socioeconomic factors, and long-standing illness. In contrast, social network diversity was not independently related to future subjective well-being. Conclusion: Different aspects of people’s social networks may help sustain levels of subjective well-being in older age. The role of close relationships and frequent contact in later life may be particularly important. These results highlight the need for examining different aspects of social networks for promoting well-being of older people.

[Social support and cardiovascular health: Adaptation of a social support scale for hypertensive and diabetic patients in primary care, Chile]

GOAL

Validate an instrument to measure the Perceived Social Support in outpatients who are in treatment to hypertension and/or diabetes mellitus ii.

DESIGN

Observational and exploratory design with mixed methods, qualitative and quantitative.

SETTING

Two community health centers from the municipality of Puente Alto (Santiago, Chile).

PARTICIPANTS

Hypertensive and/or diabetic patients between 18 and 65 years old. A purposive sample was undertaken for the qualitative study, and a random sample for the final survey.

METHODS

Focus groups and semi-structured interviews were conducted to explore the constructs of social support as perceived by patients. According to expert opinion and literature review, a scale of social support was selected and a pilot study was conducted in 40 patients, then we interviewed in depth to some of those participants. The instrument was modified according the results of this process. The final version was applied to 250 participants.

RESULTS

The construct existence was verified in the population. In the adaptation, one item was eliminated. The alpha of Cronbach was 0.89 and the factorial analysis had the same four factors from the original study. Nine new items obtained from the focal groups were added to the instrument, obtaining an alpha of Cronbach of 0.92.

CONCLUSION

The final instrument has good psychometric proprieties, and is applicable in our population. The additional items from the qualitative study improve its internal consistency, but don't add new information about Perceived Social Support. This is consistent with other studies, and suggests the application of the original version of the instrument.

Personal networks and mortality risk in older adults: a twenty-year longitudinal study

BACKGROUND

Research on aging has consistently demonstrated an increased chance of survival for older adults who are integrated into rich networks of social relationships. Theoretical explanations state that personal networks offer indirect psychosocial and direct physiological pathways. We investigate whether effects on and pathways to mortality risk differ between functional and structural characteristics of the personal network. The objective is to inquire which personal network characteristics are the best predictors of mortality risk after adjustment for mental, cognitive and physical health.

METHODS AND FINDINGS

Empirical tests were carried out by combining official register information on mortality with data from the Longitudinal Aging Study Amsterdam (LASA). The sample included 2,911 Dutch respondents aged 54 to 85 at baseline in 1992 and six follow-ups covering a time span of twenty years. Four functional characteristics (emotional and social loneliness, emotional and instrumental support) and four structural characteristics (living arrangement, contact frequency, number of contacts, number of social roles) of the personal network as well as mental, cognitive and physical health were assessed at all LASA follow-ups. Statistical analyses comprised of Cox proportional hazard regression models. Findings suggest differential effects of personal network characteristics on survival, with only small gender differences. Mortality risk was initially reduced by functional characteristics, but disappeared after full adjustment for the various health variables. Mortality risk was lowest for older adults embedded in large (HR = 0.986, 95% CI 0.979-0.994) and diverse networks (HR = 0.948, 95% CI 0.917-0.981), and this effect continued to show in the fully adjusted models.

CONCLUSIONS

Functional characteristics (i.e. emotional and social loneliness) are indirectly associated with a reduction in mortality risk, while structural characteristics (i.e. number of contacts and number of social roles) have direct protective effects. More research is needed to understand the causal mechanisms underlying these relations.

Ranking of psychosocial and traditional risk factors by importance for coronary heart disease: the Copenhagen City Heart Study

AIMS

To rank psychosocial and traditional risk factors by importance for coronary heart disease.

METHODS AND RESULTS

The Copenhagen City Heart Study is a prospective cardiovascular population study randomly selected in 1976. The third examination was carried out from 1991 to 1994, and 8882 men and women free of cardiovascular diseases were included in this study. Events were assessed until April 2013. Forward selection, population attributable fraction, and gradient boosting machine were used for determining ranks. The importance of vital exhaustion for risk prediction was investigated by C-statistics and net reclassification improvement. During the follow-up, 1731 non-fatal and fatal coronary events were registered. In men, the highest ranking risk factors for coronary heart disease were vital exhaustion [high vs. low; hazard ratio (HR) 2.36; 95% confidence interval (CI), 1.70-3.26; P < 0.001] and systolic blood pressure (≥160 mmHg or blood pressure medication vs. <120 mmHg; HR 2.07; 95% CI, 1.48-2.88; P < 0.001). In women, smoking was of highest importance (≥15 g tobacco/day vs. never smoker; HR 1.74; 95% CI, 1.43-2.11; P < 0.001), followed by vital exhaustion (high vs. low; HR 2.07; 95% CI, 1.61-2.68; P < 0.001). Vital exhaustion ranked first in women and fourth in men by population attributable fraction of 27.7% (95% CI, 18.6-36.7%; P < 0.001) and 21.1% (95% CI, 13.0-29.2%; P < 0.001), respectively. Finally, vital exhaustion significantly improved risk prediction.

CONCLUSION

Vital exhaustion was one of the most important risk factors for coronary heart disease, our findings emphasize the importance of including psychosocial factors in risk prediction scores.

Whose stress is making me sick? Network-stress and emotional distress in African-American women

Research on stress-related health outcomes in African-American women often neglects "network-stress": stress related to events that occur to family, friends, or loved ones. Data from the African-American Women's Well-Being Study were analyzed to examine self-stress and network-stress for occurrence, perceived stressfulness, and association with symptoms of psychological distress. Women reported a higher number of network-stress events compared with self-stress events. Occurrences of network-stress were perceived as undesirable and bothersome as self-stress. Both types of stress were significantly associated with psychological distress symptoms. Including network-stress may provide a more complete picture of the stress experiences of African-American women.

Measuring social networks for medical research in lower-income settings

Social networks are believed to affect health-related behaviors and health. Data to examine the links between social relationships and health in low- and middle-income country settings are limited. We provide guidance for introducing an instrument to collect social network data as part of epidemiological surveys, drawing on experience in urban India. We describe development and fielding of an instrument to collect social network information relevant to health behaviors among adults participating in a large, population-based study of non-communicable diseases in Delhi, India. We discuss basic characteristics of social networks relevant to health including network size, health behaviors of network partners (i.e., network exposures), network homogeneity, network diversity, strength of ties, and multiplexity. Data on these characteristics can be collected using a short instrument of 11 items asked about up to 5 network members and 3 items about the network generally, administered in approximately 20 minutes. We found high willingness to respond to questions about social networks (97% response). Respondents identified an average of 3.8 network members, most often relatives (80% of network ties), particularly blood relationships. Ninety-one percent of respondents reported that their primary contacts for discussing health concerns were relatives. Among all listed ties, 91% of most frequent snack partners and 64% of exercise partners in the last two weeks were relatives. These results demonstrate that family relationships are the crux of social networks in some settings, including among adults in urban India. Collecting basic information about social networks can be feasibly and effectively done within ongoing epidemiological studies.

The mix matters: complex personal networks relate to higher cognitive functioning in old age

Stronger engagement of older adults in social activities and greater embeddedness in networks is often argued to buffer cognitive decline and lower risks of dementia. One of the explanations is that interaction with other people trains the brain, thereby enhancing cognitive functioning. However, research on the relationship between personal networks and cognitive functioning is not yet conclusive. While previous studies have focused on the size of personal networks as a proxy of cognitive stimulation, little attention has been paid to the complexity of the personal network. Adults embedded in a broad range of network relationships (i.e., various relationship types) are likely to be exposed to a wider range of stimuli than adults embedded in a homogeneous network including similar relationship types. We expect that higher numbers of personal relationship types rather than a higher number of similar contacts relate to higher levels of cognitive functioning and slower cognitive decline. Data are from the Longitudinal Aging Study Amsterdam (LASA) and include 2959 Dutch participants aged 54 to 85 at baseline in 1992 and six follow-ups covering a time span of twenty years. Cognitive functioning is assessed with the Mini-Mental State Examination (MMSE), and for network complexity we use the Social Network Index. We test our expectations using fixed-effects regression models. The results reveal that a reduction in network complexity is associated with a reduction in cognitive functioning, which is neither explained by size of the network nor by presence of specific relationship types. However, enhanced complexity has only a marginal buffering effect on decline in cognitive functioning. We conclude that network characteristics and cognitive functioning are intertwined and that their association is mostly cross-sectional in nature.

Using sociometric measures to assess nonresponse bias

PURPOSE

Much attention has been given to the potential nonresponse bias that occurs in epidemiologic studies that attempt to enroll a representative sample. Most analyses surrounding nonrespondents focus on individual-level attributes and how they vary across respondents and nonrespondents. Although these attributes are of interest, analysis of the social network position of nonrespondents as defined by traditional sociometric measures (i.e., centrality and bridging) has not been conducted, and could provide further insights into the validity of the sample.

METHODS

We used data from the Secunderabadi Men's Study, a whole network of Indian men who have sex with men (MSM) generated using cell phone contact lists of men approached using Time Location Cluster Sampling. Multivariable logistic regression was used to determine whether demographic and behavioral attributes and indegree (the frequency of men who have sex with men was listed across all cell phone contact lists) were associated with being a respondent.

RESULTS

A total of 239 respondents were interviewed and 81 were approached but did not consent to the interview ("nonrespondents").

CONCLUSIONS

Respondents were more likely to have higher indegree than nonrespondents, adjusting for attribute differences (odds ratio, 1.19; 95% confidence interval, 1.07, 1.34). This analysis suggests that the network position of nonrespondents may be important when considering the potential impact of nonresponse bias.

Age, gender, social contacts, and psychological distress: findings from the 45 and up study

OBJECTIVE

The study examined the relationships between social contact types and psychological distress among mid-older adults.

METHOD

Self-completed data from 236,490 Australian adults aged 45+ years.

RESULTS

There was a consistent relationship between increased frequency in phone contacts, social visits, and social group contacts and reduced risk of psychological distress adjusted for demographic and health factors. However, stratified analyses by age showed, with one exception, that no significant associations were found between social group contact frequency and risk of psychological distress for those aged 85 years and older. Furthermore, significant interaction terms revealed that women experience a steeper reduction in risk than men at age 65 to 74 years and 75 to 84 years compared with those aged 45 to 64 years.

DISCUSSION

Social contacts have age and gender differential effects on psychological distress of mid-older Australian adults. Interventions addressing social interaction need to be sensitive to gender and age differences.

Progression of coronary artery calcification in black and white women: do the stresses and rewards of multiple roles matter?

BACKGROUND

Black women experience higher rates of cardiovascular disease (CVD) than white women, though evidence for racial differences in subclinical CVD is mixed. Few studies have examined multiple roles (number, perceived stress, and/or reward) in relation to subclinical CVD, or whether those effects differ by race.

PURPOSE

The aim of this study was to investigate the effects of multiple roles on 2-year progression of coronary artery calcium.

METHODS

Subjects were 104 black and 232 white women (mean age 50.8 years). Stress and reward from four roles (spouse, parent, employee, caregiver) were assessed on five-point scales. Coronary artery calcium progression was defined as an increase of ≥10 Agatston units.

RESULTS

White women reported higher rewards from their multiple roles than black women, yet black women showed cardiovascular benefits from role rewards. Among black women only, higher role rewards were related significantly to lower progression of coronary artery calcium, adjusting for body mass index, blood pressure, and other known CVD risk factors. Blacks reported fewer roles but similar role stress as whites; role number and stress were unrelated to coronary artery calcium progression.

CONCLUSION

Rewarding roles may be a novel protective psychosocial factor for progression of coronary calcium among black women.

Neuroethology of primate social behavior

A neuroethological approach to human and nonhuman primate behavior and cognition predicts biological specializations for social life. Evidence reviewed here indicates that ancestral mechanisms are often duplicated, repurposed, and differentially regulated to support social behavior. Focusing on recent research from nonhuman primates, we describe how the primate brain might implement social functions by coopting and extending preexisting mechanisms that previously supported nonsocial functions. This approach reveals that highly specialized mechanisms have evolved to decipher the immediate social context, and parallel circuits have evolved to translate social perceptual signals and nonsocial perceptual signals into partially integrated social and nonsocial motivational signals, which together inform general-purpose mechanisms that command behavior. Differences in social behavior between species, as well as between individuals within a species, result in part from neuromodulatory regulation of these neural circuits, which itself appears to be under partial genetic control. Ultimately, intraspecific variation in social behavior has differential fitness consequences, providing fundamental building blocks of natural selection. Our review suggests that the neuroethological approach to primate behavior may provide unique insights into human psychopathology.

Prevalence and clinical characteristics of mental stress-induced myocardial ischemia in patients with coronary heart disease

OBJECTIVES

The goal of this study was to evaluate the prevalence and clinical characteristics of mental stress-induced myocardial ischemia.

BACKGROUND

Mental stress-induced myocardial ischemia is prevalent and a risk factor for poor prognosis in patients with coronary heart disease, but past studies mainly studied patients with exercise-induced myocardial ischemia.

METHODS

Eligible patients with clinically stable coronary heart disease, regardless of exercise stress testing status, underwent a battery of 3 mental stress tests followed by a treadmill test. Stress-induced ischemia, assessed by echocardiography and electrocardiography, was defined as: 1) development or worsening of regional wall motion abnormality; 2) left ventricular ejection fraction reduction ≥ 8%; and/or 3) horizontal or downsloping ST-segment depression ≥ 1 mm in 2 or more leads lasting for ≥ 3 consecutive beats during at least 1 mental test or during the exercise test.

RESULTS

Mental stress-induced ischemia occurred in 43.45%, whereas exercise-induced ischemia occurred in 33.79% (p = 0.002) of the study population (N = 310). Women (odds ratio [OR]: 1.88), patients who were not married (OR: 1.99), and patients who lived alone (OR: 2.24) were more likely to have mental stress-induced ischemia (all p < 0.05). Multivariate analysis showed that compared with married men or men living with someone, unmarried men (OR: 2.57) and married women (OR: 3.18), or living alone (male OR: 2.25 and female OR: 2.72, respectively) had higher risk for mental stress-induced ischemia (all p < 0.05).

CONCLUSIONS

Mental stress-induced ischemia is more common than exercise-induced ischemia in patients with clinically stable coronary heart disease. Women, unmarried men, and individuals living alone are at higher risk for mental stress-induced ischemia. (Responses of Myocardial Ischemia to Escitalopram Treatment [REMIT]; NCT00574847).

Social contacts and receipt of help among older people in England: are there benefits of having more children?

OBJECTIVES

To investigate whether number of children and, among parents, having a daughter is associated with older people's likelihood of at least weekly face-to-face social contact and later receipt of help if needed.

METHOD

Multivariate analysis of data from Waves 1 and 2 of the English Longitudinal Study of Ageing (ELSA).

RESULTS

Older parents in England had higher chances of at least weekly face-to-face social contact than their childless counterparts but larger family size had only a slight additional effect. For parents, having at least one daughter was more important than number of children. Larger family size was positively associated with receipt of help from a child by parents with activities of daily living (ADL) or instrumental activities of daily living (IADL) limitations. Childless women were more likely than mothers to receive help from friends but even so had lower odds of receiving help from any informal source. Contact with a child in 2002 predicted receipt of help 2 years later.

DISCUSSION

These results show some advantages for older parents compared with childless individuals in terms of social contact and receipt of help and, among parents, an additional effect of having a daughter. Changes in family size distributions have implications for the support of older people and for planners of formal services.

Impact of Social Capital on 8-Year Mortality Among Older People in 34 Danish Municipalities

Objectives: To analyze the impact of social capital measures (bonding, bridging, and linking) on all-cause mortality at 8-year follow-up among older people aged 75 and 80 at baseline. Method: Prospective cohort study on preventive home visits including 2,863 seventy-five-year-olds and 1,171 eighty-year-olds in 34 Danish municipalities. The associations of the three aspects of social capital measures with mortality were tested in Cox regression models on time to death. Results: In the 80-year-old cohort significant associations were seen between mortality and both bridging (hazards ratio (HR) = 1.24, 95% CI [1.07, 1.45]) and linking (HR = 1.21, 95% CI [1.03, 1.43]), but the associations attenuated when controlling for relevant confounders. None of the social capital measures were associated with mortality among the 75-year-olds. Conclusion: The measures of social capital used in the present study include key aspects of social capital that are associated to mortality in older populations via physical activity and mobility disability.

Marital status and outcome of patients presenting with acute coronary syndrome: an observational report

BACKGROUND & HYPOTHESIS: Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear.

METHODS

A total of 5334 patients presenting with ACS in 65 hospitals in 6 Middle East countries in the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2) were studied according to their marital status (5024 married, 100 single, and 210 widowed patients).

RESULT

When compared to married patients, widowed patients were older and more likely to be female. Widowed patients were more likely to have diabetes mellitus, hypertension, history of heart failure, and peripheral vascular disease and were less likely to be tobacco users when compared to the other groups. Widowed patients were also more likely to present with atypical symptoms and have advanced Killip class. Widowed patients were more likely to present with non-ST-elevation myocardial infarction (NSTEMI) when compared to the other 2 groups. Widowed patients were more likely to have heart failure (P = 0.001), cardiogenic shock (P = 0.001), and major bleeding (P = 0.002) when compared to the other groups. No statistically significant difference was observed in regard to duration of hospital stay, door to needle time in STEMI patients, or cardiac arrhythmias between the various groups. Widowed patients had higher in-hospital, 30-day, and 1-year mortality rates (P = 0.001). Marital status was an independent predictor for in-hospital mortality.

CONCLUSION

Widowed marital status was associated with worse cardiovascular risk profile, and worse in-hospital and 1-year outcome. Future work should be focused on whether the provision of psychosocial support will result in improved outcomes among this high-risk group.

Psychosocial risk factors and heart failure hospitalization: a prospective cohort study

Prospective studies on the role of psychosocial factors in heart failure development are virtually nonexistent. The authors aimed to address the effect of psychosocial factors on the risk of heart failure hospitalization in men and women free of cardiovascular disease. In 1991-1993, the 8,670 participants of the Copenhagen City Heart Study (Denmark) were asked comprehensive questions on major life events, work-related stress, social network, vital exhaustion, and sleep medication and were followed in nationwide registries until 2007, with less than 0.2% loss to follow-up. Almost one-fourth of the population reported some degree of vital exhaustion. The vital exhaustion score was associated with a higher risk of heart failure in a dose-response manner (P < 0.002), with high vital exhaustion being associated with a 2-fold higher risk of heart failure in both men (hazard ratio = 1.93, 95% confidence interval: 1.20, 3.10) and women (hazard ratio = 2.56, 95% confidence interval: 1.80, 3.65). Contrary to expectation, major life events, social network, and sleeping medication did not play an individual role for heart failure hospitalization. Because of the high prevalence of vital exhaustion in the population, even a modestly higher risk of heart failure associated with vital exhaustion may be of importance in the planning of future preventive strategies for heart failure.

Psychosocial factors in the development of heart disease in women: current research and future directions

OBJECTIVE

To review the recent (1995-2009) literature on psychosocial risk and protective factors for coronary heart disease (CHD) among women, including negative emotions, stress, social relationships, and positive psychological factors.

METHODS

Articles for the review were identified using PubMed and bibliographies of relevant articles. Eligible studies included at least 100 women and either focused on a) exclusively female participants or b) both men and women, conducting either gender-stratified analyses or examining interactions with gender. Sixty-seven published reports were identified that examined prospective associations with incident or recurrent CHD.

RESULTS

In general, evidence suggests that depression, anxiety disorders, anger suppression, and stress associated with relationships or family responsibilities are associated with elevated CHD risk among women, that supportive social relationships and positive psychological factors may be associated with reduced risk, and that general anxiety, hostility, and work-related stress are less consistently associated with CHD among women relative to men.

CONCLUSIONS

A growing literature supports the significance of psychosocial factors for the development of CHD among women. Consideration of both traditional psychosocial factors (e.g., depression) and factors that may be especially important for women (e.g., stress associated with responsibilities at home or multiple roles) may improve identification of women at elevated risk as well as the development of effective psychological interventions for women with or at risk for CHD.

Residential mobility among foreign-born persons living in Sweden is associated with lower mortality

There have been few longitudinal studies on the effect of within-country mobility on patterns of mortality in deceased foreign-born individuals. The results have varied; some studies have found that individuals who move around within the same country have better health status than those who do not change their place of residence. Other studies have shown that changing one's place of residence leads to more self-reported health problems and diseases. Our aim was to analyze the pattern of mortality in deceased foreign-born persons living in Sweden during the years 1970-1999 in relation to distance mobility. Data from Statistics Sweden and the National Board of Health and Welfare was used, and the study population consisted of 281,412 foreign-born persons aged 16 years and over who were registered as living in Sweden in 1970. Distance mobility did not have a negative effect on health. Total mortality was lower (OR 0.71; 95% CI 0.69-0.73) in foreign-born persons in Sweden who had changed their county of residence during the period 1970-1990. Higher death rates were observed, after adjustment for age, in three ICD diagnosis groups "Injury and poisoning", "External causes of injury and poisoning", and "Diseases of the digestive system" among persons who had changed county of residence.

Social relationships and mortality risk: a meta-analytic review

BACKGROUND

The quality and quantity of individuals' social relationships has been linked not only to mental health but also to both morbidity and mortality.

OBJECTIVES

This meta-analytic review was conducted to determine the extent to which social relationships influence risk for mortality, which aspects of social relationships are most highly predictive, and which factors may moderate the risk.

DATA EXTRACTION

Data were extracted on several participant characteristics, including cause of mortality, initial health status, and pre-existing health conditions, as well as on study characteristics, including length of follow-up and type of assessment of social relationships.

RESULTS

Across 148 studies (308,849 participants), the random effects weighted average effect size was OR = 1.50 (95% CI 1.42 to 1.59), indicating a 50% increased likelihood of survival for participants with stronger social relationships. This finding remained consistent across age, sex, initial health status, cause of death, and follow-up period. Significant differences were found across the type of social measurement evaluated (p<0.001); the association was strongest for complex measures of social integration (OR = 1.91; 95% CI 1.63 to 2.23) and lowest for binary indicators of residential status (living alone versus with others) (OR = 1.19; 95% CI 0.99 to 1.44).

CONCLUSIONS

The influence of social relationships on risk for mortality is comparable with well-established risk factors for mortality. Please see later in the article for the Editors' Summary.

Positive and negative experiences of social support and long-term mortality among middle-aged Dutch people

This study investigated the relation between positive and negative experiences of social support and mortality in a population-based sample. Data were derived from Dutch men and women aged 20-59 years who participated in the Doetinchem Cohort Study in 1987-1991. Social support was measured at baseline and after 5 years of follow-up by using the Social Experiences Checklist indicating positive (n = 11,163) and negative (n = 11,161) experiences of support. Mortality data were obtained from 1987 until 2008. Cox proportional hazards regression models, adjusted for age and sex, showed that low positive experiences of support at baseline were associated with an increased mortality risk after, on average, 19 years of follow-up (hazard ratio = 1.26, 95% confidence interval: 1.04, 1.52). Even after additional adjustment for socioeconomic factors, lifestyle factors, and indicators of health status, the increased mortality risk remained statistically significant (hazard ratio = 1.23, 95% confidence interval: 1.01, 1.49). For participants with repeated measurements of social support at 5-year intervals, a stable low level of positive experiences of social support was associated with a stronger increase in age- and sex-adjusted mortality risk (hazard ratio = 1.57, 95% confidence interval: 1.03, 2.39). Negative experiences of social support were not related to mortality.

Major life events increase the risk of stroke but not of myocardial infarction: results from the Copenhagen City Heart Study

BACKGROUND

More attention has been paid to psychosocial conditions as possible risk factors for cardiovascular disease (CVD) and the impact of accumulated major life events (MLE) on the development of CVD has received little attention.

DESIGN

The aim of this study was to explore the influences of MLE on CVD risk in a large cohort study.

METHODS

The study population consisted of 9542 randomly selected adults free of CVD examined in the Copenhagen City Heart Study in 1991-1994 and followed up for CVD defined as myocardial infarction or ischaemic stroke until 2001. MLE were analysed using an 11-item questionnaire and hazard ratios (HR) were calculated using the Cox proportional hazards model.

RESULTS

During follow-up there were 443 myocardial infarctions (MI) and 350 ischaemic strokes. Financial problems in both childhood and adulthood were associated with risk of stroke with an HR of 1.71 (95% CI: 1.29-2.26) and 1.60 (1.12-2.30), respectively. Accumulation of MLE was also associated with risk of stroke with HR reaching a maximum of 1.41 (95% CI: 1.06-1.90) for more than one event in childhood and 1.49 (95% CI: 1.09-2.04) for more than one event in adulthood. MLE accumulated over a life course showed a dose-response relationship with stroke. Associations were somewhat attenuated by adjustment for vital exhaustion suggesting a mediating role, but not by adjustment for behavioural risk factors. There were no associations between MLE and MI.

CONCLUSION

In this population-based cohort study, we found that MLE conveyed a moderately increased risk of stroke partly mediated through vital exhaustion. We found no association between MLE and the risk of MI.

Social integration, social contacts, and blood pressure dipping in African-Americans and whites

OBJECTIVE

Both the size and diversity of an individual's social network are strongly and prospectively linked with cardiovascular morbidity and mortality. Social relationships may influence cardiovascular outcomes, at least in part, via their impact on physiologic pathways influenced by stress, such as daytime blood pressure (BP) levels. However, scant research has examined whether social relationships influence key nocturnal pathways, such as nocturnal BP dipping.

METHODS

The current study examined the degree to which social integration, as measured by participants' reported engagement in a range of different types of social relationships, and the frequency of daily social contacts influence the ratio of night/day mean arterial pressure (MAP) in a community sample of African-American and white men and women (N = 224). In addition, we examined the degree to which observed associations persisted after statistical adjustment for factors known to covary with nocturnal BP, including objective measures of sleep, catecholamines, health behaviors, and comorbidities.

RESULTS

In fully adjusted models, there was a significant association between both social integration and frequency of social contacts and the ratio of night/day MAP, indicating that socially isolated individuals were more likely to have blunted nocturnal BP-dipping profiles. There was also a significant interaction between social contact frequency and ethnicity, suggesting that the benefits of social relationships were particularly evident in African-Americans.

CONCLUSIONS

These findings contribute to our understanding of how social integration or conversely, social isolation, influences cardiovascular risk.

Types of social capital resources and self-rated health among the Norwegian adult population

Background

Social inequalities in health are large in Norway. In part, these inequalities may stem from differences in access to supportive social networks - since occupying disadvantaged positions in affluent societies has been associated with disposing poor network resources. Research has demonstrated that social networks are fundamental resources in the prevention of mental and physical illness. However, to determine potentials for public health action one needs to explore the health impact of different types of network resources and analyze if the association between socioeconomic position and self-rated health is partially explained by social network factors. That is the aim of this paper.

Methods

Cross-sectional data were collected in 2007, through a postal survey from a gross sample of 8000 Norwegian adults, of which 3,190 (about 40%) responded. The outcome variable was self-rated health. Our main explanatory variables were indicators of socioeconomic positions and social capital indicators that was measured by different indicators that were grouped under 'bonding', 'bridging' and 'linking' social capital. Demographic data were collected for statistical control. Generalized ordered logistic regression analysis was performed.

Result

Results indicated that those who had someone to talk to when distressed were more likely to rate their health as good compared to those deprived of such person(s) (OR: 2.17, 95% CI: 1.55, 3.02). Similarly, those who were active members in two or more social organisations (OR: 1.73, 95% CI: 1.34, 2.22) and those who count a medical doctor among their friends (OR: 1.51, 95% CI: 1.13, 2.00) report better health. The association between self-rated health and socio-economic background indicators were marginally attenuated when social network indicators were added into the model.

Conclusion

Among different types of network resources, close and strong friendship-based ties are of importance for people's health in Norway. Networks linking people to high-educated persons are also of importance. Measures aiming at strengthening these types of network resources for socially disadvantaged groups might reduce social inequalities in health.

Social network types and functional dependency in older adults in Mexico

BACKGROUND

Social networks play a key role in caring for older adults. A better understanding of the characteristics of different social networks types (TSNs) in a given community provides useful information for designing policies to care for this age group. Therefore this study has three objectives: 1) To derive the TSNs among older adults affiliated with the Mexican Institute of Social Security; 2) To describe the main characteristics of the older adults in each TSN, including the instrumental and economic support they receive and their satisfaction with the network; 3) To determine the association between functional dependency and the type of social network.

METHODS

Secondary data analysis of the 2006 Survey of Autonomy and Dependency (N = 3,348). The TSNs were identified using the structural approach and cluster analysis. The association between functional dependency and the TSNs was evaluated with Poisson regression with robust variance analysis in which socio-demographic characteristics, lifestyle and medical history covariates were included.

RESULTS

We identified five TSNs: diverse with community participation (12.1%), diverse without community participation (44.3%); widowed (32.0%); nonfriends-restricted (7.6%); nonfamily-restricted (4.0%). Older adults belonging to widowed and restricted networks showed a higher proportion of dependency, negative self-rated health and depression. Older adults with functional dependency more likely belonged to a widowed network (adjusted prevalence ratio 1.5; 95%CI: 1.1-2.1).

CONCLUSION

The derived TSNs were similar to those described in developed countries. However, we identified the existence of a diverse network without community participation and a widowed network that have not been previously described. These TSNs and restricted networks represent a potential unmet need of social security affiliates.

Social ties and risk for cancer--a prospective cohort study

BACKGROUND

Poor social support and small social networks have been associated with increased risks for conditions such as coronary heart disease as well as with overall mortality. We investigated the association between social ties and risk for cancer.

MATERIAL AND METHODS

The study sample consisted of 8 548 Danes who had been examined in 1991-1994 within the Copenhagen City Heart Study. The median length of follow-up was 9.3 years (range, 0-11.2 years). Social ties were measured from answers to a questionnaire on social networks. Regression analyses for cancers at the most frequent sites (breast, lung, prostate and colon and rectum) were conducted with the Cox proportional hazards model, with adjustment for a number of well-known risk factors for cancer.

RESULTS

While we found no significant association between social ties and risk for cancer in men, women with high social network scores had an increased risk for lung cancer of borderline significance (HR, 2.16; 95% CI, 1.02-4.60). The risks for breast cancer and colorectal cancers were not significantly increased in the same group of women.

DISCUSSION

The results of this study do not support the hypothesis that social network size is associated with a decreased risk for cancer.

Engagement in cultural activities and cause-specific mortality: prospective cohort study

OBJECTIVE

To determine the relation between engagement in cultural activities and main causes of mortality among full-time employees.

METHODS

Finnish industrial employees (N=7922) completed a questionnaire about engagement in cultural activities (arts and culture, activities in associations, societal action, reading literature, and studying) in 1986 and were followed-up for mortality rates until 1986-2004.

RESULTS

High engagement in cultural activities was independently associated with decreased all-cause mortality (hazard ratio 0.71, 95% CI 0.57-0.88) and external causes of death (hazard ratio 0.46, 95% CI 0.24-0.90) after adjustment for socio-demographic factors, socio-economic status, work stress, social characteristics, diabetes, and hypertension. High engagement was also associated with a reduced risk of cardiovascular mortality after controlling for socio-demographic factors and stress (hazard ratio 0.68, 95% CI 0.49-0.95). The associations with all-cause mortality and deaths from external causes remained after further adjustment for behavioral risk factors. Of the forms of engagement, solitary cultural activities were related to all-cause mortality while socially shared cultural activities were more closely linked to external mortality.

CONCLUSION

Better overall survival of culturally engaged employees is largely attributable to their lower risk of death from external causes.

Measuring social isolation among older adults using multiple indicators from the NSHAP study

OBJECTIVES

The National Social Life, Health, and Aging Project (NSHAP) data contain multiple indicators of social connectedness, social participation, social support, and loneliness among older adults. We suggest that these indicators can be combined to measure two aspects of social isolation: social disconnectedness (i.e., physical separation from others) and perceived isolation (i.e., feelings of loneliness and a lack of social support). We use the NSHAP data to create scales measuring social disconnectedness and perceived isolation and examine their distribution among older adults.

METHODS

We assess the reliability of the scales using Cronbach's alpha and item-total correlations and perform confirmatory factor analysis to test the model against the data. Finally, we test differences in scale means across subgroups to assess the distribution of social disconnectedness and perceived isolation among older adults.

RESULTS

We find that 17 indicators combine into two reliable scales. The social disconnectedness scale has a two-factor structure, including the restricted social network dimension and the social inactivity dimension. The perceived isolation scale also comprises two dimensions: lack of support and loneliness. We find that social disconnectedness does not vary across age groups, but the oldest old feel more isolated than the young old. Social disconnectedness and perceived isolation are greater among those who have worse health. Discussion The creation of scales measuring social disconnectedness and perceived isolation provides one way to utilize the wide variety of indicators of social isolation collected in the NSHAP study. Although individual indicators of social connectedness or isolation are useful in their own right, these scales provide parsimonious, continuous variables that account for a variety of aspects of social isolation, which may be especially useful for inclusion in multivariate analyses predicting health outcomes.

Social disconnectedness, perceived isolation, and health among older adults

Previous research has identified a wide range of indicators of social isolation that pose health risks, including living alone, having a small social network, infrequent participation in social activities, and feelings of loneliness. However multiple forms of isolation are rarely studied together making it difficult to determine which aspects of isolation are most deleterious for health. Using population-based data from the National Social Life, Health, and Aging Project, we combine multiple indicators of social isolation into scales assessing social disconnectedness (e.g., small social network, infrequent participation in social activities) and perceived isolation (e.g., loneliness, perceived lack of social support). We examine the extent to which social disconnectedness and perceived isolation have distinct associations with physical and mental health among older adults. Results indicate that social disconnectedness and perceived isolation are independently associated with lower levels of self-rated physical health. However, the association between disconnectedness and mental health may operate through the strong relationship between perceived isolation and mental health. We conclude that health researchers need to consider social disconnectedness and perceived isolation simultaneously.

Independent association between lower level of social support and higher coagulation activity before and after acute psychosocial stress

OBJECTIVE

To investigate the relationship between social support and coagulation parameter reactivity to mental stress in men and to determine if norepinephrine is involved. Lower social support is associated with higher basal coagulation activity and greater norepinephrine stress reactivity, which in turn, is linked with hypercoagulability. However, it is not known if low social support interacts with stress to further increase coagulation reactivity or if norepinephrine affects this association. These findings may be important for determining if low social support influences thrombosis and possible acute coronary events in response to acute stress. We investigated the relationship between social support and coagulation parameter reactivity to mental stress in men and determined if norepinephrine is involved.

METHODS

We measured perceived social support in 63 medication-free nonsmoking men (age (mean +/- standard error of the mean) = 36.7 +/- 1.7 years) who underwent an acute standardized psychosocial stress task combining public speaking and mental arithmetic in front of an audience. We measured plasma D-dimer, fibrinogen, clotting Factor VII activity (FVII:C), and plasma norepinephrine at rest as well as immediately after stress and 20 minutes after stress.

RESULTS

Independent of body mass index, mean arterial pressure, and age, lower social support was associated with higher D-dimer and fibrinogen levels at baseline (p < .012) and with greater increases in fibrinogen (beta = -0.36, p = .001; DeltaR(2) = .12), and D-dimer (beta = -0.21, p = .017; DeltaR(2) = .04), but not in FVII:C (p = .83) from baseline to 20 minutes after stress. General linear models revealed significant main effects of social support and stress on fibrinogen, D-dimer, and norepinephrine (p < .035). Controlling for norepinephrine did not change the significance of the reported associations between social support and the coagulation measures D-dimer and fibrinogen.

CONCLUSIONS

Our results suggest that lower social support is associated with greater coagulation activity before and after acute stress, which was unrelated to norepinephrine reactivity.

Suicide and marital status in Italy

BACKGROUND

Completed suicide has been reported as being linked to marital status, with being unmarried associated with a higher suicide rate as compared with being married or living with a partner.

METHOD

Data were obtained from the Italian Data Base on Mortality, collected by the Italian Census Bureau (ISTAT) and processed by the Italian National Institute of Health-Statistics Unit. The Italian population in the last Italian census (October 2001) was used to estimate age-standardized mortality rates from suicide by marital status (ICD-9 revision: E950-E959) and "natural" causes (ICD-9 revision: 0-280; 320-799). Rate ratios and 95% confidence intervals were calculated using married individuals as a reference. All analyses were conducted separately for men and women and for three different age groups (25-44 years, 45-64 years and 65 years and over) for 2000-2002, the most recent years with data available. Logistic regression analysis was used to compare differences by marital status for suicide versus death from natural causes.

RESULTS

Being married appears to be a protective factor for suicide, but the impact of being never-married, divorced/separated or widowed varies with age and gender. It is noteworthy that the differences between married and non-married women were less consistent than those among men, especially for elderly women. The results confirm that the protective impact of marriage is higher for suicide than for natural causes of death, and the comparison between the risks of suicide and natural causes of death reveals that the groups relatively more at risk for suicide are divorced/separated women, divorced/separated men (under the age of 64) and widowed men.

CONCLUSIONS

Both among men and women, being unmarried, widowed or divorced/separated is associated with a higher suicide rate. This study, however, adds information on suicide mortality in specific age-groups compared to mortality from natural causes of death. Overall, these findings support the notion that marital status may dramatically influence the risk of suicide.

The influence of close relationships on nocturnal blood pressure dipping

This study examined the influence of relationship-specific dimensions of social support (i.e., support, depth, conflict) on nocturnal blood pressure (BP) dipping and mental health (i.e., satisfaction with life, stress, and depression) among 303 normotensive and un-medicated hypertensive males and females ages 20-68. Results revealed that support was associated with better, and conflict with poorer, mental health; however, neither was associated with BP dipping. In contrast, relationship depth was associated with greater life satisfaction and greater systolic and diastolic BP dipping, and the effect on dipping was independent of sleep quality, age, hypertensive status, marital status, and level of perceived network support. Relationship conflict was moderated by marital status and gender. Low conflict for females, or with one's spouse, is associated with greater nocturnal diastolic BP dipping. Overall, this study found an association between close relationships and BP dipping, thus identifying one virtually unexplored mechanism by which close relationships may have a protective influence on health.

Predictors of perceived togetherness in very old men and women: A 5-year follow-up study

Although a considerable amount of research has been carried out on older adults' social ties, most of it has focused on quantitative aspects and on cross-sectional samples. In this study, the subjective aspect of social interaction is described by the concept of perceived togetherness. The aim of this study was to examine the extent to which different factors predict perceived togetherness in men and women over a 5-year period. It also addresses the question of whether it is possible to identify different subgroups in perceived togetherness. The data were collected with structured interviews and laboratory tests from 225 elderly people at ages 80 and 85. The results showed that the predictors of perceived togetherness partly differed between sexes as well as within the groups of males and females. Predictors common to both genders were contacts with friends, less depressive symptoms, higher education level and better coping with instrumental activities of daily living (IADLs). The findings indicated the importance of friends. Widowhood and self-rated health were predictors in women but not in men. Moreover, there appeared to be two subgroups of women and men in perceived togetherness; these were labeled "socially embedded", "socially isolated", "socially active" and "solitary". The results indicate diversity in perceived togetherness and its predictors. More attention should be paid to individual differences in order to prevent loneliness and to promote older adults' well-being.

Cohabitation Status and Onset of Disability Among Older Danes

Objectives: To investigate the effect of cohabitation status in older men and women on (a) onset of disability at 3- and 4.5-year follow-up and (b) changes in functional ability between 3- and 4.5-year follow-up, and to analyze whether this effect was mediated by social participation. Method: A total of 2,533 nondisabled older men and women enrolled in the Danish Intervention Study on Preventive Home Visits constituted the study population. Data were collected by mailed questionnaires in 1998-1999, 2000, 2001-2002, and 2003. Results: Living alone significantly increased the risk of onset of disability (T3 OR = 1.60[1.06-2.43], T4 OR = 1.74[1.22-2.47]) and the risk of sustained poor functional ability (OR = 2.35[1.44-3.84]) among men, but not among single-living women. Social participation mediated only a small part of the effect of cohabitation status on functional ability. Discussion: Our results underline the importance of cohabitation/marriage for maintaining a high functional ability among older men.

The health effects of emigration on those who remain at home

BACKGROUND

The health effects of emigration on relatives staying behind has received little attention in the recent literature. Our aim was to assess the association of spouse and offspring emigration with acute coronary syndrome (ACS) in Albania, a country which is undergoing a particularly rapid socio-economic transition accompanied by intensive emigration.

METHODS

A population-based case-control study, conducted in Tirana, Albania, in 2003-06, included 467 non-fatal consecutive ACS patients (370 men, 97 women; 88% response) and 737 population-representative controls (469 men, 268 women; 69% response) aged 35-74 years. Information on emigration of family members and financial support, socio-demographic characteristics and conventional coronary risk factors was obtained by a structured questionnaire and examination. Associations of emigrational variables with ACS were assessed by logistic regression.

RESULTS

Forty five percent of female and 25% of male patients, and 17 and 15% of controls, respectively, reported emigration of a close family member. These were younger and of lower education, income and social status than controls without emigrants. Forty nine percent of patient emigrants vs 76% of control emigrants remitted funds. Excess risk of ACS was confined to individuals whose emigrant relatives did not remit monies home [multivariable-adjusted odds ratio (OR) = 10.8, 95% confidence interval (CI) = 2.6-44.8 in women, and OR = 2.0, 95% CI = 0.9-4.3 in men; P for sex-interaction = 0.03] and was attributable largely to spouse emigration.

CONCLUSIONS

Our findings, which require confirmation, suggest that emigration of close family, but especially of spouses, coupled with non-remittance of financial support is associated with marked health effects in the spouse or parent left behind, and that women are more vulnerable than men.