Beyond Money

Beyond Money: social roots of health and well-being, Nova Science Publisher, Hauppauge, 2014

Editors: Francesco Sarracino and Malgorzata Mikucka

Book description

“Beyond Money: the social roots of health and well-being” offers a comprehensive review of how social relationships foster well-being and health at various stages of life. By explicitly focusing on three main stages of a person’s life, this book guides the reader through the influences of social relationships on the quality of life in adolescence, adulthood, and old age. Moreover, the book investigates the causal, very often psychological, mechanisms linking social relationships with quality of life. Building on the works of economists, sociologists, communication experts, psychologists and public health experts, this book provides an in-depth description of the possible mechanisms that make social relationships pivotal in people’s life.

Preface

The turn of the XX and the XXI century was marked by a chain of economic crises that culminated in the deep crack of 2008. Of course, the economic crisis is not the only crisis that contemporary generations have to solve. Starting from the late 1960s, the concerns about the ecological and social sustainability of societies have been growing. However, until 2008 the public opinion was not fully aware of these worries. The crisis of 2008 and the subsequent recession of many developed and developing economies represented a turning point. The crisis was the straw that broke the camel’ s back: it suddenly became clear that the organization of contemporary societies did not deliver the promise of better lives, and that the time came to explore new solutions.

This awareness gave raise to various actions. First, the research on what is a “better life” received a new impetus. For years, this topic has been relegated to the offices of psychologists and of few other social scientists, but after 2008 the literature on quality of life bloomed. Second, also policy makers and international institutions started paying more attention to the quality of life of their citizens. For example, in 2007 the European Commission hosted the “Beyond GDP” conference aimed at identifying new tools for a comprehensive evaluation of people’s well-being. Two years later, the French Economic

Commission directed by Stiglitz, Sen, and Fitoussi published a report recommending the development of indexes of well-being to supplement the more commonly used incomebased measures. The “Better Life Initiative” launched in 2011 by the OECD goes in the same direction trying to collect internationally comparable measures of well-being, and monitoring how well people are doing in modern societies. Third, people realized that they deserved and wanted better lives, and they started actively pursuing this new perspective.

Since 2008 the number of conferences, books, public debates, community meetings, websites, and movies concerning the quality of life exploded all over the world. Indeed, while a large share of the world population progressed in satisfying its basic human needs, many countries experienced new and unexpected tensions. Two interesting examples of such a paradigmatic shift are Turkey and Brazil: two countries traditionally characterized by low political and civic involvement which have recently experienced intense mass protests. The novelty is that – in both cases – the protests objected large projects driven by real estate speculations. In Brazil, the protesters demanded that the public money allocated to the World Cup’s infrastructure were rather invested for the quality of life of Brazilians. People called for new and better schools, broader and more efficient healthcare system, and improved public transportation. In Turkey, the leitmotif was the same: people demanded a park in the heart of Istanbul rather than a new commercial center. In both Brazil and Turkey the protesters called for better quality of life, implicitly claiming that it would not be improved by the large real estate investments and by the associated boost in Gross Domestic Product (GDP). But what is quality of life? How do we measure it and which are its main determinants?

In the social sciences, defining, measuring, and identifying the components of a good life has a long-lasting tradition. Researchers attempted to provide some indicators to measure how well whole societies are doing. The Human Development Index, the Happy Planet Index, and the Index of Sustainable Economic Welfare are only some of the most renowned attempts to comprehensively evaluate the quality of life of a population. However, the most widely adopted and influential single proxy of how well a society is doing is GDP. Accounting for the value of all goods and services exchanged on the market in a given year, GDP is a reference measure for policy makers, media, and the public opinion. For as simple and powerful as GDP (and other income-based measures, such as Gross National Income, GNI) can be, it nonetheless has various shortcomings, some of which have been documented by the economic and environmental literature. Robert Kennedy offered probably the most compelling summary of why such measures provide only an approximate measure of quality of life:

Too much and too long, we seem to have surrendered community excellence and community values in the mere accumulation of material things. Our gross national product [...] if we should judge America by that – counts air pollution and cigarette advertising, and ambulances to clear our highways of carnage.

It counts special locks for our doors and the jails for those who break them. It counts the destruction of our redwoods and the loss of our natural wonder in chaotic sprawl. It counts napalm and the cost of a nuclear warhead, and armored cars for police who fight riots in our streets. It counts Whitman’s rifle and Speck’s knife, and the television programs which glorify violence in order to sell toys to our children [...] Yet the gross national product does not allow for the health of our children, the quality of their education, or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages; the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage; neither our wisdom nor our learning; neither our compassion nor our devotion to our country; it measures everything, in short, except that which makes life worthwhile.

(Robert F. Kennedy Address, University of Kansas, Lawrence, Kansas, March 18, 1968).

The growing awareness of the limits of current measures of quality of life fed the ranks of those who believed that, to obtain a reliable picture of how well a population is doing, GDP should either be integrated with other measures (see, for example: Stiglitz et al., 2009) or substituted by them (refer, for instance, to: Layard, 2005). The second view has recently entered the practice of national statistical offices, which started exploring the potential of multi-dimensional measures of quality of life. This experiment, largely supported by the OECD and the Eurostat, found one of its earliest implementations in the BES2013, the report of the Italian National Statistical Office (BES stands for “Benessere Equo e Sostenibile” which can be translated as “Fair and Sustainable WellBeing”. For more information, please, see http://www.misuredelbenessere.it/).

BES monitored the quality of life of Italians in 2013, using 12 indicators derived from over 150 different variables. These indicators covered various aspects of people’s lives: health, education, job, welfare, social relationships, politics, safety, well-being, natural and historical heritage, environment, research and development, and the quality of services. Such multidimensional approach seems to currently prevail in international institutions. For instance, the Eurostat’s expert group on quality of life employs a wide range of indicators which contribute to 10 major dimensions of quality of life, including, among others, measures of health, subjective well-being, social contentedness, and education.

Present volume adopts such a multi-dimensional approach to quality of life. Our aim is to contribute to the literature on the determinants of quality of life by analyzing the role of social relationships for people’s quality of life in the main stages of their lives: adolescence, adulthood, and the old age. The emphasis on the stages of life comes from the observation that in recent decades human aging has been significantly delayed (Vaupel, 2010). Since the mid ’90s, the life expectancy at birth has increased on average by almost 10 years in developed countries (Vaupel et al., 1998, Tuljapurkar et al., 2000). However, in the same period the portion of life expected to spend in good health has been falling down (Robine et al., 2005). This is a tremendous challenge for contemporary societies: worse average health implies less working hours, more sickness leaves, lower productivity, higher healthcare costs, etc. In times when public budgets devote less and less resources to welfare, healthcare, and social security, the perspective of longer but less healthy lives urges to investigate the conditions which build a better quality of life in all of its stages.

Among the many dimensions of quality of life, empirical research identified some which correlate well with others and can therefore be adopted as summary measures. Present volume focuses on two of them: subjective well-being and health, two well established indicators of quality of life. Without over-simplifying the complex debate, this gives us the opportunity to gain an in-depth look into the main determinants and correlates of quality of life across various stages of lives.

Below we first illustrate the dimensions of quality of life on which this book focuses, we motivate the emphasis on social relationships emphasizing the contribution of this book and, finally, we describe the structure of the volume.

Subjective well-being

Subjective well-being, sometimes also referred to as “happiness” or “life satisfaction”, refers to individuals’ evaluation of their own well-being (Frey and Stutzer, 2002). The recent development of social sciences showed that subjective well-being is a powerful and reliable measure, which also correlates with a number of determinants of quality of life. For example, people who declare higher subjective well-being are on average better educated, have higher incomes, have higher probability of being married or employed, and lower risk of being unemployed, unhealthy or widowed (Bruni and Porta, 2007).

Subjective well-being is usually measured by survey questions which ask respondents to evaluate their own well-being (van Praag et al., 2003). The wording of the questions might differ, but in general they are close to one of the following two questions, which have been in use since 1981 in the World Values Survey (WVS) (see: http://www.worldvaluessurvey.org/).

“Taking all things together, how happy would you say you are?”

or

“All things considered, how satisfied are you with your life as a whole these days?”

Although the answers to these two questions are sometimes used interchangeably, or summarized in an index of well-being, they are regarded as two distinct concepts. Happiness is seen as “a more emotional, situational and mood-related aspect of subjective well-being, which is more volatile and subject to short-term fluctuations” (Brockmann et al., 2009, p. 395). Life satisfaction, on the contrary, refers to a more cognitive and less transitory evaluation of well-being (Diener et al., 2009). Independently from this distinction, subjective well-being measures became increasingly available at the individual level for various countries and periods, and they have been increasingly adopted in applied research.

The popularity of these measures hinges on the solid evidence that they provide reliable information about people’s well-being. For example, subjective well-being correlates with objective measures of well-being such as the heart rate, blood pressure, duration of Duchenne smiles, and neurological tests of brain activity (Blanchflower and Oswald, 2004, van Reekum et al., 2007). Happier people are less likely to come down with a cold, and if they become sick, they recover more quickly (Diener and Biswas-Diener, 2011). Subjective well-being is also strongly correlated with other indicators of subjective well- or bad-being, such as chronic pain, sleep quality, self-reported health, age, religiosity, unemployment, income and rank in the income distribution, sociability, and extraversion (Schwarz and Strack, 1999, Wanous and Hudy, 2001, Schimmack et al., 2010). Finally, subjective well-being is also positively correlated with the judgments of the respondent’s happiness provided by friends, relatives, or clinical experts (Schneider and Schimmack, 2009, Kahneman and Krueger, 2006, Layard, 2005).

Another important feature of subjective well-being data is their wide availability, even in less developed countries. This allowed to explore various social and economic aspects of social lives and revealed interesting stories about contemporary societies. Happiness data have been employed in many domains: from macro- to microeconomics (Di Tella and MacCulloch, 2008, Alesina et al., 2004), from policy evaluation (Diener et al., 2009) to the analysis of non-economic aspects such as age, gender, marital, or employment status (Clark and Oswald, 1994), including also studies of the relationship between political institutions and subjective well-being (Frey and Stutzer, 2006).

Health

Similarly to the case of subjective well-being, also the literature on health relies on both subjective and objective measures of individual’s health. Also in this case the advantage of subjective measures is that they are easier and cheaper to collect than objective data, as they can be obtained through large-scale surveys and their collection does not require specialized personnel. However, the cost is some loss in precision compared to objective measures and whether the costs off-set the benefits is an aspect that should be considered case by case. Whereas objective measures of health directly record medical states or observe events (such as being diagnosed with an illnesses, or, in the most extreme case, death), the subjective measures of health are grounded on self-reported assessments. An example of selfreported measure of health is the answer to the question:

“All in all, how would you describe your state of health these days?”

with the answers typically ordered on a Likert scale ranging from ‘very good’ to ‘very poor’ health. The objective measures of individual’s health contain information directly referring to the functioning of the body. This may include physical measurements (such as Body Mass Index or measures of abdominal obesity), lung function measurement, measures of fitness and strength, blood pressure, or bio-markers derived from blood or saliva samples, and many others.

Some objective health measures are also defined at the level of populations (Borghesi and Vercelli, 2012). Morbidity and mortality rates, life expectancy and, more recently, the quality-adjusted health indexes (e.g., Healthy Life Expectancy) are among the most commonly used aggregated measures of health (Quality-adjusted health indexes combine mortality and morbidity indexes with other indexes of quality of life, to combine the quantity and quality of an individual’s existence.). The advantage of objective measures is their independence from personality factors or cultural traits.

The social dimension

Present volume looks at people’s quality of life from an individual perspective. The chapters composing this book shed light on the importance of social relationships for the quality of individuals’ lives: subjective well-being and/or health. The traditional approach to assuring better and healthier lives hinges on investments in medical technologies and infrastructure as well as a wide range of comfort goods and services, ultimately increasing public and private expenditures. However, beyond a given threshold of approximately 12,000-15,000 US$ per capita, additional wealth contributes only marginally to the improvement of people’s health and well-being. What can be done in these contexts? An extensive body of research documented the importance of social relationships for quality of life.

Epidemiologists have focused for decades on the quality of social relationships and their implications for people’s health and well-being (Wilkinson and Pickett, 2009). People more involved in social networks, having frequent interactions with persons they like or love, and those who have someone with whom to speak and share their difficulties are happier, tend to get sick less often and, when sick, they recover faster (Levy et al., 2002). A classical study of Alameda county (Berkman and Syme, 1979) showed that married people, people declaring stronger ties with friends and relatives, and people belonging to religious and other social groups had lower mortality. People low on “social network” index were twice as likely to die from various causes than people high on the index. Another study showed that people in meaningful social relationships who engaged in social activities were less likely to die than those leading solitary lives (House et al., 1982) (Both these studies controlled for standard biomedical risk factors).

The risk of developing Alzheimer’s disease was more than doubled in persons with smaller social networks and lower social participation (Wilson et al., 2007). Similarly, Glass et al. (2006) found that social engagement predicted lower levels of depression over time in adults aged 65 and over. Not only sociability, but also subjective well-being seems to bring serious health benefits. Keyes (2004) documents that people affected by depression or other mental illnesses have a probability of developing cardiovascular diseases – the first cause of death in rich countries – two times higher than others. Similarly, this probability is 1.5 times higher among unhappy people. Another example is provided by an interesting study about a group of nuns. In the 1930s, a group of young nuns was asked to write short autobiographies. These diaries have been recently analyzed under the profile of expressed emotions. The study revealed a strong correlation between the amount of positive emotions and longevity of the nuns: 90% of the nuns in the quarter that had expressed the most positive emotions was still alive at the age of 85, while only 34% of the quarter that had expressed the least positive emotions lived to this age. This study is particularly relevant because the nuns shared very similar life conditions and they can therefore be considered similar in many regards except their emotions (Danner et al., 2001). Some studies have also analysed the effects of subjective well-being on health, compared to other more commonly recognized factors. For example, Levy et al. (2002) estimates the effects of happiness for health as larger and more significant than those related to smoking or physical activity.

Summarizing, this literature suggests that promoting people’s social relationships is a strategy to foster well-being and health, because social relationships are among the determinants of well-being and contribute to reduce the risks of developing serious illnesses at later stage of life. However, despite the large body of research and the impressive number of publications on the topic, some aspects are still not adequately organized and presented in the literature. For example, an in-depth description of the mechanisms behind the association of quality of life with social relationship is still missing. Similarly, the literature misses a comprehensive overview of how this relationship changes in the various stages of life.

“Beyond Money: the social roots of health and well-being” contributes to this knowledge by focusing on two aspects: the first one concerns a comprehensive review of how social relationships can foster well-being and health at various stages of life. Previous works have analyzed the importance of social relationships for quality of life in various settings, but it is plausible that this relationship is not homogeneous and that at different stages of life different mechanisms or different components of social relationships matter. By explicitly focusing on three main stages of a person’s life, this book tries to provide a systematic account of the link between social relationships and quality of life in adolescence, adulthood, and old age. The second, related aspect concerns the causal – very often psychological – mechanisms linking social relationships with quality of life. Much of the empirical research on the topic adopts statistical techniques to identify this relationship, but does not provide a detailed account of the mechanisms behind this outcome. Building on the works of economists, sociologists, communication experts, psychologists and public health experts, this book provides an in-depth description of the possible mechanisms thatmake social relationships pivotal in people’s life.

Organization of the book

“Beyond Money” offers an accessible overview of the up-to-date findings concerning the role of social relationships for subjective well-being and health at various stages of life, along with the exploration of the psychological mechanisms behind this relationship. The 12 chapters guide the reader from the studies concerning adolescents, to those focusing on adults and, finally, on elderly people. The last chapter concludes this journey by providing an account of how social relationships, and more generally social capital, have been changing in Europe over the last decades. Indeed, if social relationships matter for quality of life, then it is pivotal to monitor how they change over time in various countries. On this topic, with the exception of the US, we do not know much.

The lead chapter starts by focusing on the importance of ethnic identity for subjective well-being in Middle Eastern countries. Although much is known about the salience of ethnic identity in Western and multicultural societies, our knowledge on the consequences of ethnic identity in Middle Eastern countries is still scarce. In this chapter, Amina Abubakar, Said Aldhafri, and Fons van de Vijver describe the findings from a recent study on a population of high school and university students in Oman, where the strong emphasis on a single Arab identity exists in an ethnically heterogeneous environment. The results confirm previous findings from other countries suggesting that ethnic identity, and particularly ethnic belonging, is positively associated with life satisfaction and mental health.

In the second chapter, Radosveta Dimitrova explores the role of religiosity for life satisfaction in two samples of young adults in Italy and in the Netherlands. This chapter hinges on a four-dimensional model of religiosity, and adopts a comparative approach to explore how religiosity affects youth’s life satisfaction. Results show that Italians compared to Dutch report higher scores of religious believing, bonding, behaving, and belonging, whereas no group differences were found for life satisfaction. This result is further confirmed by a structural equation model showing that life satisfaction is not affected by religiosity among Italian and Dutch groups of young people.

Health risk behaviors and their impact on health consequences and well-being experienced by adolescents are the subject of the third chapter by Robert Valois, Jelani C. Kerr, and Sandra K. Kammermann. The authors note that the outcomes of risk behaviors on adolescents’ ability to effectively function in traditional social and occupational domains have been frequently neglected. To fill this gap, they adopt the lenses of self-determination theory to review the evidence on the association among selected health risk behaviors, developmental assets, and their relationship with adolescent life satisfaction.

Celeste Sangiorgio, Warren A. Reich, and Jason Young further the analysis of health risk behaviors in chapter four. The authors identify the correlates of the adoption of potentially harmful behaviors. In particular, they explore whether negative self-beliefs and self-evaluations push young people towards risky behaviors as well as towards low life satisfaction. To address this issue, they analyze a sample of undergraduate students, interviewed and re-interviewed within a span of 60 days. The results suggest that high (vs. low) negative self-elaboration predicts both lower life satisfaction scores as well as more frequent risk behaviors.

In chapter five, Finbarr Brereton, Peter Clinch, and Susana Ferreira focus the attention on the salience of social relationships for health and well-being in the adulthood, by examining the subjective well-being of single parents in Ireland. Their results document a large negative effect on life satisfaction of being a parent in a single parent household. This result is robust to the inclusion of various controls for the objective disadvantages characterizing many single parent households. However, remarkably, the negative relationship is present only in households where the single parent is the only adult. This evidence provides ground to argue that it is a lack of social, as opposed to financial, support that is the cause of single parents’ unhappiness.

From family life, our attention shifts to work life in chapter six. Tatiana Karabchuk, Natalia Soboleva, and Marina Nikitina explore how various forms of employment affect the well-being of workers under various employment protection schemes. They use the last wave of the European Social Survey and perform a multilevel regression analysis for 27 countries. The authors hypothesize that non-typical employment, often associated with lower wages, income instability, uncertainty about the future, displacement, and less time to devote to friends and relationships, may be a source of low life satisfaction. In other words, flexible working relations can contribute to unhappiness and life dissatisfaction through many channels, including the relational one. Their results confirm that temporary and informal employment negatively affect subjective well-being, whereas self-employment positively correlates with subjective well-being. This leads the authors to conclude that strict employment protection legislation has negative impact on subjective well-being, especially for informal workers and temporary contractors.

The topic of chapter seven addresses the issue of well-being on the workplace through the psychological lenses of identity construction. Sunny Hubler and John C. Sherblom discuss the importance of achieving identity congruence simultaneously across the personal, social, and cultural dimensions. The work place, interactions with colleagues and clients, the attitudes and expected behaviours on the workplace deeply affect the development of a congruent identity – on the workplace as well as on the personal one. The conflict among the many identities that workers have to deal with can be a source of stress, low job performance, bad health and unhappiness. The good news is that such conflict can be addressed using communication practices and techniques. In this chapter the authors argue that constructive conflict management, interrogation of assumptions, personal storytelling, active listening, and reflective thinking are practices that help an employee communicate within a workgroup in creative ways, constructing personally satisfying identity performances within organizational constraints. Within this workplace environment employees can construct and communicate their identity in ways that are congruent, satisfying, and conducive to long-term personal health.

Chapter eight marks the transition to the section of the book devoted to elderly people. In this chapter Cristina Calvi uses qualitative interviews to analyze the in-depth channels through which social relations can lead to better health. In particular, the author emphasizes from a psychological and introspective viewpoint the role of social networks to support and promote health, or to recover from sicknesses. As such, the chapter provides an important validation test of the general result that social environment matters for people’s quality of life. Specifically, the chapter presents the results of an empirical study of people suffering from Class I obesity, who have begun a course of medical treatment. On one hand, the research reconstructs the representations of health and illness by analyzing the behaviours and routines that the respondents adopted in everyday lives. On the other hand, the chapter reconstructs also the subjects’ identities, paying particular attention to aspects concerning the changes of self-perception. The results show that the network of relationships with others, including relatives, friends, and doctors in the national health system, all play important roles in helping people realize the risk that obesity constitutes for their health. Moreover, they also provide impulses that allow people to change their lives. Indeed, as the next two chapters illustrate, doctors and nurses can play a very important role in enhancing people’s quality of life. Their work can be of particular importance for elderly people, who often face a high risk of both social isolation and deterioration of health.

Chapter nine, by Francesco Miele, Claudio Coletta, Enrico Maria Piras, Attila Bruni, and Alberto Zanutto, introduces the reader into the complexity of the role played by General Practitioners (GPs) in the care of elderly patients. The recent emphasis on decentralized organization of health care assigned new functions to primary care doctors, in providing direct assistance and helping the patients to autonomously manage their conditions. The material collected in the course of focus groups conducted in a province of Northeast Italy allowed the authors to identify several strategies adopted by GPs in their work. Overall, this chapter deals with an important transition taking place in many health care systems. The GPs are forced to redefine their roles from the position of authority, to being a guide and a partner of patients and their families. In such context, managing relationships with the patients gains new importance. From another viewpoint, this chapter contributes to the research showing how relationships and strategies at the very basic level of care, rather than new expensive medical technologies, may contribute to safeguarding people’s health and life satisfaction. This line of reasoning also calls for a broader training of the medical personnel, encompassing the effective and supportive interactions as tools of sustaining quality of life.

This approach is further explored and refined in the work by Gorill Haugan who in chapter ten focuses on the multi-dimensional role of nurses for the well-being of cognitively intact residents of nursing homes. The author emphasizes that nursing is a relational process and practice, and that nurse-patient interaction may affect the quality of life through several channels, including spirituality, meaning in life, hope, and self-transcendence. Although these dimensions are usually provided by religion, the chapter by Haugan presents nurse-patient interactions as an important source of these dimensions. The results show that meaning-in-life, intra-personal self-transcendence, and nurse-patient interaction are all powerful health-promoting resources, and they significantly influence quality of life of nursing home patients. These results call for new pedagogical approaches, that would equip nursing home caregivers not only with the competences to manage pain and other symptoms, but also to be present with their patients through supportive interactions enhancing the patients’ meaning-in-life.

In the eleventh chapter of the collection, Cristina Gagliardi investigates the broader social activity and integration of the aging population. Several lines of evidence pointed to the importance of social relationships for health promotion and well-being of the elderly. Gagliardi develops this idea by analyzing the relationship between social integration of the elderly and the self-assessed health of a sample of 3,950 older people living in Finland, Hungary, The Netherlands, Germany, and Italy. The social integration variables include the size of the individual social network, participation and voluntary work in civic associations,

as well as the perception of neighborhood safety. The results demonstrate the unequal distribution of both health and social resources among the elderly in Europe. Moreover, the chapter suggests that participating in association and neighborhood safety positively affect the health of the elderly people, whereas the tight family network seems to be the resource activated in case of bad health.

The final chapter of the collection, by Francesco Sarracino and Małgorzata Mikucka, takes a broad perspective on the social determinants of health and well-being. The authors investigate if, consistently with the observation formulated by Robert Putnam, social capital in contemporary societies indeed undergoes a gradual erosion. The chapter describes how social capital – a catalyst of economic success, a precondition of democratic functioning of states, and an important determinant of people’s quality of life – has changed across Europe between years 1990 and 2008-09. This contribution provides an encompassing account of how the trends of 10 measures of social capital have been changing across 30 Western and Eastern European countries.

Collectively, this book looks at the role of social relationships for well-being and health, organizing and providing a systematic account of the contributions from many disciplines. We hope that the reader might find it enjoyable and insightful. At the same time we hope that it might contribute to consolidate the knowledge on an important component of people’s quality of life. Social relationships are a powerful, as well as neglected, dimension of people’s life and many initiatives can be adopted to promote quality of life by allowing people to organize their daily lives in ways which are more compatible with their relational needs.

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