Health Behaviors
Clinical Care
Social and Economic Factors
Physical Environment
Family and Social Support
What Is It?
For the purposes of the County Health Rankings, we define family and social support as the quality of relationships among family members and with friends, colleagues, and acquaintances, as well as involvement in community life. Evidence has long demonstrated that poor family and social support is associated with increased morbidity and early mortality. Most of the literature on this topic derives from the work of 19th-century sociologist Emile Durkheim, who first introduced the concept that social integration and mortality were inversely related.[1] Since then, researchers have clarified and expanded on Durkheim’s findings on social networks, social isolation, social capital, and social support and their links to population health.[1,2] In the County Health Rankings, we represent Family and Social Support using two measures: (1) percent of adults reporting that they do not receive the social and emotional support they need and (2) percent of children living in single-parent households.
Why Do We Measure It?
Social and Emotional Support
The County Health Rankings measures social isolation because the association between socially isolated individuals and poor health outcomes has been well-established in the literature. Socially isolated individuals typically have limited access to the types of support provided by social relationships.[2] One study found that the magnitude of risk associated with social isolation is similar to the risk of cigarette smoking for adverse health outcomes.[3] The author posits that socially isolated individuals lack the psychological protective effect derived from social relationships. Without this protective effect, stress appears to have a larger negative impact on an individual’s health.[3]
Additionally, a meta-analysis identified positive health practices from empirical studies that used the Personal Lifestyle Questionnaire (PLQ). The analysis found that social support was the second most powerful predictor of positive health practices out of 14 total predictors.[4] This suggests that individuals without a social network are less likely to participate in healthy lifestyle choices.
Finally, understanding the percentage of socially isolated individuals in a community may provide a more complete perspective on a community’s collective health profile. This is because socially isolated individuals are more likely to be concentrated in communities with poorer community networks.[2] A study that compared Behavioral Risk Factor Surveillance Survey (BRFSS) data on health status to questions from the General Social Survey found that people living in areas with high levels of social trust were less likely to rate their health status as fair or poor.[2]
Single-Parent Households
Similar to socially isolated individuals, adults and children in single- or lone-parent households are both at risk for adverse health outcomes such as mental health problems (including substance abuse, depression, and suicide) and unhealthy behaviors such as smoking and excessive alcohol use.[5-8] Self-reported health among lone parents (both male and female) were found to be worse than for parents living as couples, even after controlling for socioeconomic characteristics. Several factors, such as lack of a partner in whom to confide, the stress of the circumstances under which a respondent became a single parent, and the stigma of single parenthood all may contribute to poorer perceived health.[9] Not only is self-reported health worse among single parents, but mortality risk also is higher.[8,10] Likewise, children in these households also experience increased risk of severe morbidity, and all-cause mortality.[6,11] The negative effects of growing up with a single parent may be worsened by the presence of multiple risk factors, such as a parent with mental or physical health conditions, an unemployed parent, and family conflict. Conversely, protective factors including satisfaction, optimism, positive family climate, and parental support diminish the negative effects of single-parent households on child well-being. [6]
Measurement Strategies
Social and Emotional Support
Studies in recent years have measured social isolation, social networks, and social support in a variety of ways. One study used a composite measure of social networks that considered marital status, sociability, church group membership, and membership in another organization.[12] The study found pathways through which social networks affected health, and these pathways correlated with broad categories of social support.[12]
Another study measured social isolation indirectly by looking at other network-related indicators, such as living arrangements, availability of confidants, and community involvement.[13] This allowed researchers to see a more complete picture of a person’s individual social networks.
The General Social Survey (GSS), conducted by the National Opinion Research Survey, has also been used to assess social isolation. The GSS offers interesting questions that measure social support, social networks, and social capital in the population, but the data is not available at the level necessary for the County Health Rankings.
Single-parent Households
The U.S. Census collects data on household structure during the decennial census as well as in its American Community Survey, which offers annual estimates for communities with a larger than 65,000 population, three-year estimates for communities of 20,000 population or greater, and five-year estimates for all communities. Using these data, researchers can estimate the percent of children living in single-parent households. The denominator can be either the total number of children or the number of children living in family households.
What Is the County Health Rankings Measurement Strategy?
The County Health Rankings measures social isolation as one of two measures to compose the Family and Social Support focus area. The social isolation measure reports the percentage of adults without social/emotional support. This measure comes from multiple years of BRFSS data and is based on a relatively new question added in 2005. As a new question, there are no known studies to date that examine its validity as a measure for social isolation. A PubMed review on the subject found that researchers have adopted the BRFSS social isolation question as one of multiple measures to indicate conditions related to undiagnosed depression and overall quality of life. The second measure is the percent of children living in family households that are raised by a single parent. These data come from the 2005¬-2009 American Community Survey.
Measure Strengths & Limitations
One limitation of measuring social isolation is that not one single measure has been reliably used in studies on social isolation. Additionally, researchers have not yet confirmed the validity and reliability of BRFSS social and emotional support questions for assessing social isolation in a community. Finally, while anecdotal observational studies find that measures of social support predict health outcomes, no meta-analyses have conclusively confirmed these observational findings.[14]
Children in single-parent households can also be a problematic measure because households headed by single parents (as with those headed by married or cohabiting couples) can be quite heterogeneous, with differing levels of family, community, and economic support. Therefore the distribution of health risk in single-parent households can vary dramatically, particularly for children.[6,15,16] Additionally, this measure does not capture information about households in which children are raised by an adult who is not a family member.
References
[1] Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000;51:843-857.
[2] Kawachi IK, Bruce P, Glass R. Social capital and self-rated health: A contextual analysis. Am J Public Health. 1999;89:1187-1193.
[3] House JS. Social isolation kills, but how and why? Psychosom Med. 2001;63:273-274.
[4] Yarcheski A, Mahon NE, Yarcheski TJ, Cannella BL. A meta-analysis of predictors of positive health practices. J Nurs Scholarsh. 2004;36:102-108.
[5] Fergusson DM, Boden JM, Horwood LJ. Exposure to single parenthood in childhood and later mental health, educational, economic, and criminal behavior outcomes. Arch Gen Psychiatry. 2007;64:1089-1095.
[6] Wille N, Bettge S, Ravens-Sieberer U, BELLA Study Group. Risk and protective factors for children's and adolescents' mental health: Results of the BELLA study. Eur Child Adolesc Psychiatry. 2008;17:133-147.
[7] Rahkonen O, Laaksonen M, Karvonen S. The contribution of lone parenthood and economic difficulties to smoking. Soc Sci Med. 2005;61:211-216.
[8] Ringbäck Weitoft G, Burström B, Rosén M. Premature mortality among lone fathers and childless men. Soc Sci Med. 2004;59:1449-1459.
[9] Benzeval M. The self-reported health status of lone parents. Soc Sci Med. 1998;46:1337-1353.
[10] Weitoft GR, Haglund B, Hjern A, Rosen M. Mortality, severe morbidity and injury among long-term lone mothers in Sweden. Int J Epidemiol. 2002;31:573-580.
[11] Weitoft GR, Hjern A, Haglund B, Rosen M. Mortality, severe morbidity, and injury in children living with single parents in Sweden: A population-based study. Lancet. 2003;361(9354):289-295.
[12] Kawachi I, Colditz GA, Ascherio A, et al. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. J Epidemiol Community Health. 1996;50:245-251.
[13] Grenade L, Boldy D. Social isolation and loneliness among older people: Issues and future challenges in community and residential settings. Aust Health Rev 2008;32:468-478.
[14] Haber MG, Cohen JL, Lucas T, Baltes BB. The relationship between self-reported received and perceived social support: A meta-analytic review. Am J Community Psychol. 2007;39:133-144.
[15] Lipman EL, Boyle MH, Dooley MD, Offord DR. Child well-being in single-mother families. J Am Acad Child Adolesc Psychiatry. 2002;41:75-82.
[16] Serbin LA, Karp J. The intergenerational transfer of psychosocial risk: Mediators of vulnerability and resilience. Annu Rev Psychol. 2004;55:333-363.
