System Design and Social Connectedness
Community matters.
Healthcare system design is more than hospital operations; it includes population and public health because health and wellness start in the community long before reaching the hospital. With this understanding, healthcare system design must take into account the important reality that humans are social beings and health systems must foster social connectedness between staff and patients if they are to make the dramatic transformational change needed to modernize healthcare. Social connectedness is a sense of belonging, and it has material impacts on our health and well-being. As House, Landis and Umberson wrote in Science over 30 years ago, “Social relationships, or the relative lack thereof, constitute a major risk factor for health – rivaling the effect of well established health risk factors such as cigarette smoking, blood pressure, blood lipids, obesity, and physical activity.”1 Since that report 30 years ago, multiple studies have chronicled the evidence. Holt-Lunstad2 summarized decades of research in this area and found studies that clearly demonstrate a protective effect of social relationships3 and a risk where social connectedness is lacking.4,5 Holt-Lunstad summarized this data with the following comment that calls to mind the earlier quote from 1988. She wrote, “We now have robust evidence indicating that being socially connected has a powerful influence on longevity, such that having more and better relationships is associated with protection, and, conversely, that having fewer and poorer relationships is associated with risk.”2 In fact, there is so much evidence that the National Academies of Sciences, Engineering, and Medicine convened a panel to review all of the data and make recommendations.6
Take a moment and think about this. Social relationships impact morbidity and mortality on the level of obesity and cigarette smoking! Think about communities – social connectedness – and how people are drawn to them to find community. People need community, and we create health problems when we ignore the critical importance of social connectedness. A study in 1964 by Stout and colleagues points directly to social connectedness. They published a strange finding that started when a primary care provider in Roseto, PA noted that cardiovascular mortality was lower among that town.7,8 The usually accepted risk factors were present in Roseto and two comparator communities. It was the 1950’s and 1960’s. The prevalence of fat intake, obesity, smoking, and serum cholesterol did not significantly differ among the towns studied.9 Whatever was unique about Roseto, the epidemiologists concluded that dietary, ethnic, or genetic factors were not the etiology. What was distinct was their social connectedness.8,9 Wolf and colleagues summarized the uniqueness of the community: “Unlike inhabitants of most American towns, Rosetans were found to be cohesive and mutually supportive, with strong family and community ties.”9
Why? Two possible reasons. First, Roseto was founded in the 1880s by a group of people who moved from Roseto, Italy to Pennsylvania. They were already a connected community prior to their move, and they moved into a world that did not speak Italian and discriminated against Italians. So, there was a disincentive to go outside of the Roseto community. Second, even into the 50’s and 60’s, families were able to recall societal structures of generations of families living together which reinforced the social connectedness. This was an incentive to stay within the community.
As the generational linkages dating back to the 1880s became weaker, the new generations of Roseto began to push off the ‘old ways’ as they became more “American.” Anticipating this, researchers hypothesized that if the social connectedness hypothesis was correct, then a “loosening of family ties and community cohesion would be accompanied by loss of relative protection of Rosetans from death due to myocardial infarction.”8 By the late 60’s / early 70’s that prediction came true.9
Community matters. Social connections matter. And one reason is that community helps families address the social determinants of health. Today, health systems are counting social determinants of health, but we miss the larger importance of social connectedness. The real work of this century is to address social determinants of health and to do so in a manner that increases social connectedness. The hospital can provide a family with food, but it lacks the power of a social network where friends and family share a meal together. Hospitals cannot replace social networks, but hospitals need to find ways to support social networks. We need to move beyond addressing issues for the person in clinic today (though we should certainly do that), and we need to start supporting the networks in the communities where our patients live. We must take seriously the words of Rev. Dr. Martin Luther King, Jr. when he said, “Whatever affects one directly, affects all indirectly. I can never be what I ought to be until you are what you ought to be. This is the interrelated structure of reality.”
Bibliography
1. House JS, Landis KR, Umberson D. Social relationships and health. Science. Jul 29 1988;241(4865):540-5. doi:10.1126/science.3399889
2. Holt-Lunstad J. Why Social Relationships Are Important for Physical Health: A Systems Approach to Understanding and Modifying Risk and Protection. Annu Rev Psychol. Jan 04 2018;69:437-458. doi:10.1146/annurev-psych-122216-011902
3. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. Jul 27 2010;7(7):e1000316. doi:10.1371/journal.pmed.1000316
4. Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. Mar 2015;10(2):227-37. doi:10.1177/1745691614568352
5. Holt-Lunstad J, Smith TB. Loneliness and social isolation as risk factors for CVD: implications for evidence-based patient care and scientific inquiry. Heart. Jul 01 2016;102(13):987-9. doi:10.1136/heartjnl-2015-309242
6. National Academies of Sciences Engineering and Medicine (U.S.), National Academies of Sciences Engineering and Medicine (U.S.). Board on Health Sciences Policy., National Academies of Sciences Engineering and Medicine (U.S.). Health and Medicine Division., National Academies of Sciences Engineering and Medicine (U.S.). Board on Behavioral Cognitive and Sensory Sciences., National Academies of Sciences Engineering and Medicine (U.S.). Division of Behavioral and Social Sciences and Education. Social isolation and loneliness in older adults : opportunitiies for the health care system. Consensus study report. the National Academies Press; 2020:xvii, 298 pages.
7. STOUT C, MARROW J, BRANDT EN, WOLF S. UNUSUALLY LOW INCIDENCE OF DEATH FROM MYOCARDIAL INFARCTION. STUDY OF AN ITALIAN AMERICAN COMMUNITY IN PENNSYLVANIA. JAMA. Jun 08 1964;188:845-9. doi:10.1001/jama.1964.03060360005001
8. Egolf B, Lasker J, Wolf S, Potvin L. The Roseto effect: a 50-year comparison of mortality rates. Am J Public Health. Aug 1992;82(8):1089-92. doi:10.2105/ajph.82.8.1089
9. Wolf S, Grace KL, Bruhn J, Stout C. Roseto revisited: further data on the incidence of myocardial infarction in Roseto and neighboring Pennsylvania communities. Trans Am Clin Climatol Assoc. 1974;85:100-8.