Abstract
We provide a comprehensive picture of the health effects of social isolation using longitudinal data from 21 European countries. First, using Cox regressions, we find a significant, strong, and robust association between our social isolation index and mortality. The association is much stronger in Eastern European countries. While all of our pooled countries estimates ranged between a 20 and 30% increase in the mortality hazard for the socially isolated that number jumps to 45% for Eastern European countries. We then estimate linear regressions to study the dynamic “value-added” effects of social isolation on health and other mediator outcomes. We find that social isolation at baseline leads to worsening health in subsequent waves along all of the dimensions observed. Up to 13% of the effect of baseline social isolation on mortality can be attributed to the combined one-wave-ahead impact of social isolation on increased frailty, reduced cognitive function, and increased smoking.
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The data analyzed in this article comes from Release 8.0.0. of the SHARE data, available to registered users through the SHARE Research Data Center. To register, future users must apply here: https://share-eric.eu/data/become-a-user.
Notes
Seven years is the average of the follow-up periods across the studies analyzed in the meta-analysis.
Loneliness is also considered, but rather as a mediator in the association under study. Our focus is on objective social isolation, which we define according to objective criteria, such as living alone, participation in social activities, and frequency of contact with family.
Henceforth, we indistinctively report an “effect” of social isolation on health or an “association” between them.
Although SHARE now encompasses 29 countries and all waves are considered herein, only data on the 21 countries: that entered SHARE before the last wave can be included (since more than one observation per individual is required), and that appeared at least twice across the 8 first waves, excluding wave 3, which was dedicated to constructing life histories of SHARE respondents.
Otherwise, the minimum follow-up time until death would be 1 month, which is too short for obvious reverse causality concerns. We argue in favor of a 24-month period when presenting the Cox model in Section 2.2.
Note that this index is close to the original Berkman-Syme Social Network Index developed in (Berkman and Syme 1979) for a population aged under 70, which included (1) marital status; (2) contacts with close friends and relatives; (3) membership of a church group; and (4) memberships in other types of groups). We do not include contact with other family or friends because these items were absent from SHARE until wave 4, when a social networks module was introduced for the first time (it appears again in waves 6 and 8). We will use that module when creating an index of connectedness, but no item from that module is included in our main SI index so that we can follow respondents for a much longer time span.
See Hughes et al. (2004) for a validation of the short version of the RUCLA scale of loneliness.
This index of connectedness strives to summarize the richness of the social networks modules of SHARE waves 4, 6, and 8, which use name generators to construct respondents’ networks of confidants, into one measure.
See Malter and Börsch-Supan (2017) for details on the construction of the connectedness scale.
Socially isolated individuals might also resort less to healthcare due to lack of information, as put forward in Devillanova (2008), who documents a lower time to visit for immigrants with a strong social tie who know about healthcare opportunities.
This finding goes against some of the literature that points at lonely or socially isolated individuals using more healthcare than individuals who do not suffer from loneliness or social isolation. One example is Gerst-Emerso and Jayawardhana (2015), who find that the lonely are more likely to visit their doctor (but not to be hospitalized), even when controlling for their health, suggesting that individuals who suffer from chronic loneliness look for social support in their physician, but that the lack of healthcare use and barriers to healthcare access do not seem to drive the social isolation-health relationship.
Often referred to by the acronym OCEAN, these are openness to experience (vs. closedness), conscientiousness (vs. lack of direction), extraversion (vs. introversion), agreeableness (vs. antagonism), and neuroticism (vs. emotional stability).
Conscientiousness is positively derived in SHARE from answers to the statement “I see myself as someone who does a thorough job” and negatively derived from answers to “I see myself as someone who tends to be lazy”.
This study looks at chronically lonely individuals, according to the RUCLA scale of loneliness, rather than at socially isolated individuals.
In order to obtain this value of 1.37, we need to assume a multiplicative factor for the R-squared. This factor bounds the maximum R-squared that would be achieved if it were possible to include unobservable controls in the regression, relative to the R-squared we obtain with our observable controls. We choose a factor of 25%, which seems plausible based on Oster (2019).
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Acknowledgements
We are indebted to three anonymous referees and to editor Xi Chen, who provided insightful comments and helped us improve the manuscript. We are also very grateful to participants of the 4\(^{th}\) PHS Workshop at the University of Pennsylvania, the 2020 Alp-Pop conference, the SHARE user conference, and seminars at CEMFI and CUNEF, for their helpful feedback. We particularly thank Atheendar Venkataramani, Federico Curci, Ryan Brown, Jerome Adda, and Keith Head, for their constructive remarks and suggestions.
Yarine Fawaz and Pedro Mira acknowledge funding from the Spanish Ministry of Science and Innovation (grant PGC2018-097598-B-I00).
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Fawaz, Y., Mira, P. Social isolation, health dynamics, and mortality: evidence across 21 European countries. J Popul Econ 36, 2483–2518 (2023). https://doi.org/10.1007/s00148-023-00956-y
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DOI: https://doi.org/10.1007/s00148-023-00956-y