6
Social and Personal Resources

The social and psychological resources an individual can draw on can modify behavior risk factors or even reduce the health disadvantages of low socioeconomic status. Substantial evidence that such resources reduce the risk of various morbidity and mortality outcomes has accumulated over the past 25 years (Seeman, 1996; Seeman and Crimmins, 2001). The influence of these factors does not diminish at older ages: as Mendes de Leon and Glass (2004) document, such social factors as greater social integration and social engagement, as well as such psychological characteristics as beliefs regarding one’s personal mastery and efficacy, continue to be important in old age.

SOCIAL RESOURCES

The evidence about social resources is largely observational, though studies have been replicated, have involved careful controls for the potentially confounding influence of sociodemographic, health, and life-style factors, and have used longitudinal data, with resources assessed in advance of health outcomes. As in other areas of study, however, selection factors cannot be entirely excluded. Longitudinal studies have shown that greater social integration is associated with lower risk of mortality in both middle age and old age (Mendes de Leon and Glass, 2004; Seeman et al., 1987, 1993) and of physical and cognitive impairment among older adults (Bassuk et al., 1999; Fratiglioni et al., 2000; Mendes de Leon et al., 1999, 2001; Strawbridge et al., 1996). Similar effects of social engagement—generally



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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda 6 Social and Personal Resources The social and psychological resources an individual can draw on can modify behavior risk factors or even reduce the health disadvantages of low socioeconomic status. Substantial evidence that such resources reduce the risk of various morbidity and mortality outcomes has accumulated over the past 25 years (Seeman, 1996; Seeman and Crimmins, 2001). The influence of these factors does not diminish at older ages: as Mendes de Leon and Glass (2004) document, such social factors as greater social integration and social engagement, as well as such psychological characteristics as beliefs regarding one’s personal mastery and efficacy, continue to be important in old age. SOCIAL RESOURCES The evidence about social resources is largely observational, though studies have been replicated, have involved careful controls for the potentially confounding influence of sociodemographic, health, and life-style factors, and have used longitudinal data, with resources assessed in advance of health outcomes. As in other areas of study, however, selection factors cannot be entirely excluded. Longitudinal studies have shown that greater social integration is associated with lower risk of mortality in both middle age and old age (Mendes de Leon and Glass, 2004; Seeman et al., 1987, 1993) and of physical and cognitive impairment among older adults (Bassuk et al., 1999; Fratiglioni et al., 2000; Mendes de Leon et al., 1999, 2001; Strawbridge et al., 1996). Similar effects of social engagement—generally

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda measured in terms of social activities with others—have been shown in other studies (Fabrigoule et al., 1995; Glass et al., 1999; Kiely et al., 2000). Greater social integration and more emotional support from others predict lower mortality after myocardial infarction (Berkman et al., 1992; Case et al., 1992; Williams et al., 1992). These factors also lead to lower mortality or better functional recovery after a stroke (Colantonio et al., 1993; Glass et al., 1993). More recently, higher levels of emotional support have been shown to protect against cognitive decline in the MacArthur Successful Aging Cohort (Seeman et al., 2001). The importance of social engagement is also demonstrated in studies of the effect of religious involvement, which tends to increase with age. Compared with the younger population, older persons generally express a higher degree of religiosity (Greeley, 1989). Fellow church members provide emotional and material support, as well as information, advice, and spiritual benefits (Taylor and Chatters, 1988). Religious beliefs, it is argued, are an important source of hope and comfort and provide systems of meaning to help cope with stress, disability, the loss of loved ones, and the fear of impending death (Koenig et al., 1998). A significant factor in religion is church attendance, which appears to be related to lower mortality and disability. Net of other demographic and socioeconomic factors, adults who attend church more than once a week have a one-third lower risk of death (in 8-year follow-up data of a nationally representative sample) than adults who never attend church (Hummer et al., 1999). An effect of similar magnitude has been verified for an older population (Koenig et al., 1999). Other cohort data also show that church attendance is associated with a lower risk of disability over a 12-year follow-up period, independently of the effects of a comprehensive set of other predictors of disability (Idler and Kasl, 1997). In contrast with the effects of church attendance, private religious activity and personal religiosity are not associated with better survival or reduced disability (Hummer et al., 1999; Idler and Kasl, 1997; Mendes de Leon and Glass, 2004). Evidence regarding how social engagement affects health risks is beginning to emerge. Both community studies and laboratory work show that social relationships, particularly supportive ones, are associated with lower risk biological profiles. Community studies point to lower blood pressure, serum cholesterol, and levels of stress hormones (e.g., norepinephrine, epinephrine, cortisol) among people who report greater social integration or support than others (Seeman and McEwen, 1996; Seeman et al., 2002). Attendance at religious services, for instance, is associated with lower systolic and diastolic blood pressure among both black and white elderly people (Koenig et al., 1998). Laboratory-based experiments demonstrate that the presence of supportive others reduces cardiovascular and neuroendocrine reactivity among those exposed to challenging tasks (Seeman and

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda McEwen, 1996; Uchino et al., 1996). Importantly, studies also indicate negative health effects from social ties when those ties are a source of conflict and criticism (Kiecolt-Glaser, 1999; Kiecolt-Glaser et al., 1994; Seeman and McEwen, 1996). The limited intervention research to date that attempts to enhance social networks and social support (Glass, 2000) has been disappointing, though this may demonstrate only how complex social relationships are and how difficult it is to alter them. A few studies have targeted patient populations—those recovering from myocardial infarction (Berkman et al., 2003) or stroke (Glass et al., 2000)—or caregivers for those with chronic conditions, such as Alzheimer’s (Pillemer et al., 2000). These studies have shown little evidence of positive effects on subsequent health outcomes, possibly because of the severity of the health problems involved. The recently completed Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial (a major intervention study designed to assist socially isolated or depressed myocardial infarction patients) exemplifies the difficulties inherent in intervention efforts. The intervention, designed to build social skills and reduce depression, could not be fully implemented. Because of logistical and scheduling problems, participants randomized to the intervention had fewer than half the planned “social/cognitive intervention” sessions, and less than one-third of them actually received group therapy in addition to the initial individual therapy (Powell, 2002). The inability to provide all the group therapy intended may have substantially weakened the trial; preliminary evidence indicates that those who did have a group experience had a lower recurrence rate of fatal or nonfatal myocardial infarction than those who did not, after adjusting for important confounder variables (Saab, 2002). Intervention efforts such as ENRICHD have largely focused on individual patients or their families, leaving untouched their larger social worlds. As has been shown for other efforts at behavior change, the broad environment constrains people’s ability to maintain behavior change over time (Syme, 2002). Modifying an environment and changing social institutions is of course a substantial task, but for institutions that already play an important role in maintaining health, some interventions may be productive. In recent years, some religious institutions have become important sites for health screening and health interventions. Church-based interventions have increased fruit and vegetable consumption (Resnicow et al., 2001); increased weight loss (McNabb et al., 1997; Oexmann et al., 2001); lowered blood pressure (Oexmann et al., 2001); reduced energy intake, dietary fat, and sodium intake (Yanek et al., 2001); and increased screening for breast, cervical, colon, and prostate cancer (Erwin et al., 1999; Mann et al., 2000). It is not known whether they are more effective at this than other community organizations.

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda PERSONAL RESOURCES Personal psychological characteristics are also related to health risks. Personal mastery beliefs, beliefs that one has the ability to control outcomes, have been shown to predict lower mortality in both U.S. and European populations (Bobak et al., 1998; Dalgard and Lund Haheim, 1998; Seeman and Lewis, 1997). Given that most adults spend a large portion of their time in a work setting, it is not surprising that aspects of control with respect to one’s job are particularly consequential with respect to risks for cardiovascular disease (Bosma et al., 1997; Marmot et al., 1997a; Siegrist et al., 1990), as well as mortality (Amick et al., 2002; Theorell et al., 1998). The biological plausibility of a link between perceptions of control and health is suggested by a number of experimental studies showing that exposure to situations characterized by lower control is associated with enhanced physiological stress reactivity (Bohlin et al., 1986a, 1986b; Breier et al., 1987; Frankenhaeuser and Johansson, 1986). Interventions designed to enhance perceptions of control in both work environments and nursing homes provide suggestive evidence that enhancing control can reduce health risks. Several studies in Sweden have suggested that interventions within the work environment can lower cardiovascular risk profiles (Orth-Gomer et al., 1994; Theorell et al., 2001). In nursing home studies, Langer and Rodin (1976; Rodin and Langer, 1977) demonstrated increased activity and well-being and reduced mortality among residents who are given greater opportunities to control their environment. Self-efficacy beliefs represent a similar construct to control beliefs, focusing on the perception of one’s ability to successfully perform various activities. Stronger self-efficacy characterizes individuals who believe they have more power to affect events and alter outcomes in their lives. Individuals with weaker self-efficacy beliefs are at significantly greater risk, at older ages, of cognitive (Albert et al., 1995; Seeman et al., 1996) and physical impairments (Mendes de Leon et al., 1996; Seeman et al., 1999). One possible reason for this finding is that older adults with stronger self-efficacy beliefs are more likely to exercise regularly (McAuley, 1993). Such exercise has potentially far-reaching health effects because regular physical activity reduces risks for many health outcomes, including heart disease and physical and cognitive impairment, as well as overall mortality. Interventions to encourage adoption and persistence of regular exercise of some type—especially needed given that 40 percent or fewer older adults report regular physical activity (Darnay, 1994)—may need to consider whether self-efficacy beliefs can be reinforced.

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda RACIAL AND ETHNIC VARIATION Despite the evidence of effects of social and personal resources on health, the contribution of these effects to racial and ethnic health differences has received little systematic study. Some studies of religious involvement do suggest that its effects can be different between groups. Steffen et al. (2001) found that attempts to cope through religion (through prayer, trusting in God and seeking God’s help, and finding comfort in religion) were related to lower blood pressure during normal daily activities and during sleep for blacks but not whites. And Musick et al. (1998) determined that religious activity was linked to fewer depressive symptoms among elderly blacks with cancer but not among whites. Culture may in some cases lead to psychological dispositions having opposite effects among different groups. A few studies suggest that, for Korean Americans in contrast with whites, a perceived external locus of control rather than higher self-efficacy is more effective at relieving psychological distress (Bjorck et al., 1997; Kim, 2002; Sastry and Ross, 1998). Whether other social and personal resources also have different implications for the health of different groups is difficult to say. And what such studies add up to—what health differences might be accounted for—has not been investigated. The lack of research on group differences is somewhat surprising in light of occasional suggestions that such factors may explain racial and ethnic differences. For instance, a lack of social and psychological resources in poor communities may be postulated to contribute to poorer health outcomes, or, in the case of Hispanics and Asians, social cohesiveness may be postulated to lead to unexpectedly good health outcomes. Nevertheless, the vast majority of research to date on health effects of social and psychological factors does not focus on ethnicity, treating it instead as a covariate to be controlled in multivariate models. As outlined by Mendes de Leon and Glass (2004), available evidence does not point to large or systematic differences in social resources by race or ethnicity. An important caveat here is that the evidence largely involves comparisons of whites and blacks, with only minimal information on Hispanics and little or no information about other growing ethnic populations, such as Asian subgroups. NEEDED RESEARCH While evidence accumulates that social and psychological resources affect health in old age, their contribution to racial and ethnic differences remains largely unstudied. Though it is plausible to postulate that such resources contribute to health differences, evidence is essential for understanding and designing possible interventions.

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda Research Need 9: Characterize the distribution of social and psychological resources in different older populations and investigate whether their effects on health vary by race and ethnicity. Research on such resources, particularly for groups other than whites and blacks, is presently quite limited, leaving it unclear whether or not there are important differences that could have consequences for health. Even in the unlikely circumstance that patterns of social support, religious involvement, and psychological coping styles are found to be similar across groups, it is still plausible that they would have different implications for promoting healthy behavior, deterring risky behavior, facilitating care, and ultimately improving health. Social and psychological factors are not identical, though they are probably interdependent. Such factors as social support and the social environment of individuals may condition the health effects of psychological coping styles, and vice versa. The degree of interdependence may vary across ethnic groups. Research should attend to the role of these processes over the life course. Social environments and coping styles evolve and adjust as people age, being modified by and modifying individual choices. For instance, one’s social network shrinks in old age, tending to focus increasingly on those who can satisfy emotional and physical needs (Mendes de Leon and Glass, 2004). The consequences of this change for health, and particularly how such dynamics play out for different racial and ethnic groups, is poorly charted.