Introduction to Relational Health

Even with all the extraordinary twentieth-century advances in medicine, good health is elusive to far too many in the United States. Despite health care spending that far exceeds that of other wealthy countries, technological innovations, and unprecedented knowledge about risk factors for disease, we are struggling with unacceptably high rates of chronic illness. Research from a range of disciplines including epidemiology, psychology, sociology, behavioral medicine, and population health show that the web of social relationships that surround us have significant effects on our behaviors and outcomes. An approach to health that considers these realities aligns better with how we live our lives and what we need to thrive.

The goal of this book is to provide an overview of what relational health means in the context of where we live, work, and play, and how it can be applied as a framework for achieving better health and wellbeing. Instead of considering populations as a collection of individuals, the premise of relational health suggests that populations instead should be considered as individuals who are interconnected with each other. Our relationships, including family, friends, and acquaintances, can all provide valuable information (which doctor to see, where local club sports are offered, how to find childcare), essential social support (transportation to medical appointments, loans to cushion the costs of health care, a cheerleader for health goals), and positive social norms (role modeling self-care). Of course, social relationships are not all good – many can be negative by providing bad information, encouraging bad health habits, or creating collective injury from violence. These influences, both good and bad, are essential to our understanding of how best to promote health and how to improve how care is provided.

Medical practitioners and policymakers largely do not emphasize these factors as avenues to better health, despite the deep evidence base for the important role that relationship factors play in influencing behaviors and outcomes. For a host of reasons that will be addressed in this chapter, our health care system is organized to treat patients as individuals, devoid of context. Relational health suggests that there are missed opportunities in viewing illness through only an individual lens. It offers a framework for considering how an individual’s networks of relationships can promote or undermine healthy behavior. Understanding the influence of relationships can lead to prevention and treatment efforts that are more consistent with how people live their lives.

This book focuses on three health challenges: obesity, opioid use disorder, and depression in older adults, all of which increase vulnerability to other diseases and premature mortality. These health issues are particularly poignant examples of the lost opportunities to reduce suffering and improve outcomes when the individualized approach continues to predominate prevention and treatment efforts. For decades, a wide variety of (nonrelational) medical interventions have been deployed to address these health issues, with disappointing progress. Although the research and examples provided in these chapters are centered around obesity, opioid use disorder, and depression, the list of chronic health conditions that we grapple with and suffer from continues to grow at an alarming rate, and the relational health framework can and should be applied more broadly.

Relationships as Essential Drivers of Health

A fundamental concept worth emphasizing at the outset is that our health is multiply determined. Accordingly, relationships are an important and underestimated contributor, but also need to be understood as one of many contributors that influence our health over the course of our lives. Other nonmedical drivers of health, often referred to as “social determinants of health,” include factors such as safe housing, transportation, and socioeconomic conditions such as income, wealth, and education. Despite the often complicated ways in which social factors affect health – some operate through indirect behavioral pathways, others function through more direct biological mechanisms; some have short-term effects, whereas others show their effects over the course of a lifetime; and for some it is not entirely clear how they impact health and for whom – public health and medical provider thought leaders, Drs. Paula Braverman and Laura Gottlieb have argued, it is past time to take seriously these contributions. They have noted, “The consistency and reproducibility of strong associations between social factors and a multitude of health outcomes in diverse settings and populations have been well-documented, and the biological plausibility of the influence of social factors on health has been established.”Footnote ¹ The relational health approach does not claim that relationships are the only avenue to improve health outcomes, but rather that they are a crucially important social determinant for which we have strong evidence and robust strategies to improve health beyond the entrenched individualized approaches. They are important enough to be a central component both in treating individuals and in promoting widespread population health.

To best understand the pathways through which relationships influence health, a multilevel perspective is a framework that situates relationships in a broader sociocultural context. Social networks have been defined as the web of social relationships that surround an individual and the characteristics of those ties. A conceptual model for how social networks impact health was created by Berkman and colleagues (Figure 1.1). Their model emphasizes dynamically linked processes beginning with the macro-social context or “upstream factors.” The assumption of this model is that social networks are contained within larger social and cultural contexts which shape and sustain the structure of networks. These macro factors help us to understand that the relationships in which we are embedded are determined by the context and culture in which we live, which include socioeconomic factors, politics, and social change.

Figure 1.1 Conceptual model of how social networks impact health.

Modified from Berkman et al.Footnote ²

The model’s downstream factors are the influences that network structure and function have on behavior and ultimately health, including the pathways of provision of social support, social influence, social engagement and attachment, and access to resources and material goods. Importantly, not all of these network influences are positive, and there is variation in the type, frequency, intensity, and extent of support provided. In this book the focus is largely on the downstream psychosocial mechanisms by which social networks impact health, but the upstream, social structural conditions that shape social networks need to be integrated into our understanding of how interventions are designed and policy is constructed. Socioeconomic factors, for example, will necessarily shape the extent to which people can benefit from social support opportunities and social influences vary by demographics.

Despite the broad health implications of relationship factors and the social contexts in which they are embedded, these influences tend to be underestimated. In a stark example of this, psychology researchers collected crowd-sourced data in the United States and United Kingdom and found that members of the public dramatically misjudge the importance of social factors for health and mortality.Footnote ³ The study participants, the majority of whom had a college education, exhibited a strong capacity to estimate the relative importance of certain behavioral risk factors, such as smoking. However, the study participants were extremely poor at estimating the impact of relationship factors such as social support and social integration and other social factors. The researchers considered whether demographic characteristics of the participants, such as age, gender, nationality, and level of contact with the medical profession, could potentially explain the results. Although their results were explained in part by sex, age, education, and ideological factors – with men, younger participants, those with lower education, and more conservative ideology all being more likely to underestimate the importance of relationship and other social factors, the effects still remained even after including these variables in the analyses. The authors concluded that, “In the Western world at least, the idea that family, friends, work colleagues, and social groups more generally have a key role to play in helping us overcome a range of stressors – including illness, traumatic life-changes, and discriminatory treatment – does not appear to be all that intuitive.”Footnote ⁴

My expertise on relational health developed from many years of studying how people’s health is affected by social devaluation. When people have identities that are devalued, such as racial minorities, women in male-dominated professions, and people with low socioeconomic status, they experience an unwelcome lack of social connection in many contexts of their lives. What my students, colleagues, and I found in our research studies is that experiences of devaluation, such as stigmatization, discrimination, and rejection, contribute to health inequalities for disadvantaged groups.

These social stigmas impose negative mental and physical health consequences.Footnote ⁵ Rejection, discrimination, and stigmatization can take a psychological toll, elevating our risk for anxiety and depression. Our bodies respond to social devaluation physically as well. Research from our lab and numerous others has found that in response to a social threat such as discrimination, the body reacts as if we are under threat by releasing stress hormones, elevating the heart rate, and subjective experiences of stress.Footnote ⁶ One explanation for why we respond this way is because these experiences of devaluation threaten our evolutionary drive to function within social groups and depend on other people for survival. This repeated over-activation of physiological systems in a stress state is ultimately one indirect pathway through which social devaluation can then increase vulnerability to certain illnesses.

My collaborators and I have also found that these particular kinds of experiences of social devaluation can lead to risky health behaviors, such as substance use and overindulging in high-caloric foods. For example, in one experiment we found that when research participants received performance feedback from a biased evaluator and immediately afterwards were offered the choice between a healthy granola bar or a high-caloric candy bar, they more often choose the candy option as compared to a neutral feedback control group.Footnote ⁷ In other research, we found similar results with an increased tendency to engage in unhealthy substance use in response to discrimination.Footnote ⁸ People may be inclined to turn to less healthy choices and behaviors in response to discrimination because they can provide comfort, are familiar, and may at least temporarily alleviate stress. Discrimination is also associated with the inhibition of health-promoting behaviors, such as exercise and other preventive care.Footnote ⁹

Our research has implications for the design of relational solutions for health issues that carry the weight of stigmatization, as is the case for the examples that are the focus of this book. Despite increased public understanding and public health campaigns to reduce stigma, obesity, substance use, and mental health disorders are still socially devalued. Evidence suggests that stigmatizing and shaming people toward behavior change (a strategy that is based on an individualized approach to health) is ineffective and harmful. Numerous studies show that perceived stigmatization and discrimination are associated with higher levels of unhealthy behavior, not positive behavior change. And yet this strategy is still frequently employed.

Support seeking from family, friends, neighbors, or health care providers is also more difficult when people feel devalued by their health status. Indeed, becoming socially isolated and refusing support are hallmarks of opioid use disorder, which is highly stigmatized. Although the need for social connection is strong, the limited capacity to seek out and sustain support opportunities may play a critical role in determining how members of stigmatized groups may be vulnerable to negative long-term effects on health and wellbeing. Maintaining healthy, supportive relationships can be difficult for many, particularly those who have experienced stigma, and it is crucial to build on strong examples of communities of care and services that already exist in order to connect with people who may be difficult to reach.

Recent health trends make it clear that new strategies for dealing with these health challenges are greatly needed. The current methods of treating the individual do not work in the ways we are led to believe they should. Obesity rates, for example, are predicted to only increase over time. In 2019, Harvard researchers published a study forecasting that by 2030 nearly one-half of adults will be obese and nearly one-quarter of adults will be severely obese.Footnote ¹⁰ Those who are obese have higher risks of illnesses that can compromise quality of life, such as diabetes, heart disease, and several types of cancer.

An emphasis on the individual responsibility to maintain a healthy diet and weight is not a useful mindset for most people. When repeated attempts to lose weight fall short, people often feel worthless or desperate. These feelings can lead to expensive, trendy, or sham approaches to weight loss that are not shown to be effective over time.Footnote ¹¹ More promising programs are those that use a less individualized, “go-it-alone” approach and instead incorporate supportive, nonstigmatizing, and community-based strategies to healthy eating and weight management. Weight loss programs that rely on support mechanisms rather than encouraging weight loss through sheer willpower increase weight management effectiveness. For example, when participants in a commercial weight loss program chose a weight loss “buddy,” they lost more weight and waist inches after 15 weeks of participation than those who participated in the program without buddy support.Footnote ¹² The buddy system has also shown success when it comes to sticking to an exercise program.

As with obesity, chronic pain (the most common root cause of opioid use disorder, including both physical and psychological pain) has long been treated as an individualized problem to solve within the health care system and, also like obesity, the individualized approach has had disappointing progress in improving people’s lives.

Many patients are like Jen. A 2018 CDC report indicates that approximately 50 million people in the United States suffer from chronic pain that is not responsive to medical treatment.Footnote ¹⁴ This lack of improvement can be very frustrating for physicians who recognize that many patients who present for pain are also grappling with a host of other factors that contribute to the pain. However, the opportunity to understand the context of pain is typically lost in a clinical encounter, as is the opportunity to understand the relations that amplify the pain and to develop constructive solutions to reduce its impact.

For older adults, depressive symptoms are frequently viewed as a normal part of aging, and this erroneous belief in the inevitability of depression in old age can hinder opportunities for prevention and treatment. Depression is more accurately characterized as a complex product of biological, psychological, and social factors. Social isolation and loneliness in older adults have been shown to be significant risk factors for depressive symptoms, and depression can also lead to social isolation.

The Status Quo: Structural Causes

There are many reasons why the relational health perspective has not gotten more traction in how health care is delivered. Consider why the US health care system is organized around an individualized approach to understanding and treating patients. How we pay for health care – a complex issue that is not the focus of this book, but is clearly relevant to the persistence of the current model and a barrier to uptake of a relational approach – structurally supports the individualized model. Health care providers are compensated for services they provide; they get paid for diagnosing and treating individual patients with conspicuous medical care. Thus, there is little incentive for health care professionals to identify underlying causes of disease and disorders. The most recent International Classification of Diseases, Tenth Revision (ICD-10), which defines the codes that providers enter in their patients’ electronic health records, includes codes specifically for psychosocial risk and economic determinant-related codes, called “Z codes.” Despite the increasing use of a Z code that enables health care providers to document social needs – for example, one of the top five Z codes utilized in 2019 among fee-for-service Medicare beneficiaries was “Problems related to living alone” – providers are not able to bill for these social needs and so, most often, they are left unaddressed.Footnote ¹⁵

The United States is home to many deeply compassionate physicians and other health care providers who want to help their patients as much as possible. However, many of them report that there are limitations on their ability to understand and address the root causes of patients’ suffering. Constraints on the provider–patient relationship contribute to difficulties in identifying and addressing social needs in the context of a health care visit. To understand the personal aspects of a patient’s life requires a trusting relationship between the provider and patient and many factors constrain the development of such a relationship. A typical medical appointment is short (usually 15–20 minutes), which often doesn’t allow for attention to social factors. Establishing a trusting relationship is also impaired by limited points of contact due to, among other factors, fractured care where a patient may see a host of different providers rather than a consistent one.

The training of physicians and many other kinds of health care providers often does not include exploring social and emotional pain and other factors that are outside of biomedical influences. Many providers feel inadequately trained to do the kind of interviewing that is required to identify a complex medical issue that is caused by or coupled with significant psychosocial aspects, and their work setting is often not equipped to help them solve it.

In many ways, the health care setting is designed to focus almost entirely on biomedical factors that can be treated as efficiently as possible. This approach may seem to be a logical way to deliver health care to those who need it most. An individual comes to the doctor’s office with an ailment – not a family, a community, or a neighborhood. But, as demonstrated by the millions of people in this country who seek treatment in the health care system and fail to find relief, too much is missed with this system of delivery.

The deep-rooted American approach to dealing with health issues for each individual continues for reasons that extend far beyond traditions and constraints in the health care system. Cultural norms and cognitive biases are also important contributors.

The Status Quo: Cultural and Cognitive Causes

Self-care has become popularized as an essential set of behaviors for our mental and physical health. The Oxford Dictionary defines self-care as the practice of acting to preserve or improve one’s own health.Footnote ¹⁶ For many, self-care means preserving time in the day to focus on what are viewed as self needs such as exercise, sleep, or indulgences in consumer behavior that are intended to bring pleasure. Interestingly, the World Health Organization (WHO), a specialized agency of the United Nations responsible for international public health, defines self-care differently. While the WHO encourages higher levels of self-efficacy, autonomy, and personal responsibility, it also emphasizes the relational components of self-care: “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider.”Footnote ¹⁷ The difference here is that the WHO definition also suggests that self-care “is a broad concept” and goes on to include nutrition, lifestyle, environmental, and socioeconomic factors, among others. However, it also includes aspects “of the greater community” as a fundamental principle of self-care.

The American ideal of the “individual” teaches us to believe that each of us are solely responsible for the behaviors that lead to our poor health outcomes. The person is the one who is perceived as making poor choices through overindulging in unhealthy foods, failing to follow health guidelines, and giving in to urges. As such, our health care is logically organized to treat and manage individual patients.

Mainstream US culture amplifies the message that health depends on responsible personal lifestyle choices. Cultural psychologists Cayce Hook and Hazel Markus note that although the United States is composed of a wide range of cultures – each of which can have distinctive approaches to health and wellness – broad patterns can be observed nationally in how health tends to be conceptualized, discussed, and pursued.Footnote ¹⁸ Hook and Markus emphasize that even though the causes of ill health are complex, the answers offered by mainstream US culture are extremely narrow: poor personal choices are the primary cause of ill health, and more personal responsibility is the primary solution.

Our unique American culture lends itself to an individualistic approach to achieving optimal health. We value making our own decisions about substances we consume or inhale. We also want to be equally unconstrained in our decisions about whether we exercise, visit a doctor, or follow instructions of any sort. We are constantly socialized to accept these messages of personal responsibility for health. Fast-food corporations present unhealthy options to their customers while emphasizing their support for people’s “freedom” to choose.Footnote ¹⁹ Burger King’s famous “Have It Your Way” slogan was recently scrapped after forty years, in favor of the more personal “Be Your Way,” which, according to Burger King, is intended to remind people that “they can and should live how they want anytime.” Alcohol companies spend millions on advertisements that promote drinking but that place the responsibility on consumers to “drink responsibly.”Footnote ²⁰ Magazines tout headlines on healthy lifestyles, such as “Nearly Half of U.S. Deaths Can Be Prevented with Lifestyle Changes.”Footnote ²¹ Public health agencies instruct that “by living a healthy lifestyle, you can help keep your blood pressure, cholesterol, and blood sugar levels normal.”Footnote ²² Regardless of political affiliation, government officials endorse personal responsibility: former President Barack Obama said “We’ve got to have the American people doing something about their own care” (emphasis added), while former Vice President Mike Pence argued for “bringing freedom and individual responsibility back to American health care.”Footnote ²³ In media and popular culture and in public statements by government and industry, these same messages of personal responsibility for health are amplified. When the effects of recommended calorie restriction and exercise increase are either negligible or only successful in the short term, the failures are attributed to poor motivation and too brief adherence to recommended lifestyle changes.

Markus and Conner offer a model of cultural influence that is represented in Figure 1.2. It shows the interacting levels of the mainstream US culture cycle of choice and personal responsibility. All four levels are assumed to be equally important, and none are assumed to take priority over the others. The arrows from one level to another indicate that cultures are dynamic, and all levels of the culture cycle continually influence each other: a change in one level can instigate changes in others.

Figure 1.2 The interacting levels of the mainstream US culture cycle of choice and personal responsibility developed by Drs. Hazel Markus and Alana Conner.Footnote ²⁴

Cultural norms influence how behavior change programs are designed. Can we nudge an individual to improve eating or exercise habits? Can we improve an individual’s access to health care? We think that the source of health comes from the individual, and so we target health problems by making individual interventions.

The problem with an overemphasis on individual factors is that these beliefs crowd out support for other factors that are more grounded in valid scientific evidence. Our day-to-day lives are filled with industry-supported temptations that are extremely hard to combat. The processed-food industry alone spends more than $4 billion a year tempting us to eat these foods that have been proven to jeopardize our health. Targeted advertising of these products to children ensures that these habits develop early, with some marketing experts finding that brand loyalty may form in children as young as two years old.Footnote ²⁵ Everyday environments can make healthy behaviors difficult and expensive, while unhealthy behaviors are often exactly the opposite: cheap, convenient, widely promoted, and habit-forming. The result of this misalignment of cultural narratives and actual behavior is that the more influential factors that shape behavior are not addressed.

Willpower is a separate – but related – cultural value that makes it difficult for policymakers to think beyond an individualized perspective on health and health care. Popular culture would have us believe that the root of healthy decision-making lies in the ability to harness our willpower. Superior willpower would enable us to override the temptation to eat the cookies our friendly coworker brought to the office and to discipline ourselves to maintain a lifelong exercise routine. The ideal of possessing an unyielding willpower has a fantastic hold on our imaginations. The cultural lore is that strong willpower will enable you to make good choices not just with food and exercise, but also with money, sex, and just about anything else in life. This logic can send us down an expensive and ineffective path to pursue our goals on our own.

The evidence supporting the supremacy of willpower in achieving all things good is disappointingly weak. Despite the hype, decades of research on the cause-and-effect relationship between willpower and a host of highly desired outcomes have been overstated. In addition to misleading or overblown conclusions, many willpower studies have been criticized for a narrow-minded perspective about the ways in which most people make decisions.

One example is the “marshmallow test,” which has been canonized in American culture as a demonstration of the power and deep importance of willpower.Footnote ²⁶ The series of experiments was devised in the late 1960s at Stanford by psychology professor Walter Mischel. The basic paradigm is that children are given a single marshmallow that they can eat right away. They are also told that if they want to, they can wait for a predetermined amount of time and if they don’t eat the first marshmallow, then they will get a second marshmallow. There are adorable video recordings of children agonizing over the decision to take the prize in front of them or to delay gratification. You can see the kids turning their backs to the table with the marshmallow, coaching themselves to resist, and contorting their faces in agony over their choices (Figure 1.3).

Figure 1.3 The marshmallow test.

A follow-up study on the same participants in the 1990s found astounding results: Those people who as children were able to delay gratification by resisting eating the marshmallow to hold out for the promise of two had better school performance and overall better economic success.Footnote ²⁷ The much-touted conclusion was that the capacity to delay gratification was a particularly important trait for success in life. However, follow-up studies from other researchers call these strong conclusions into question. Replication of these studies with children from varying socioeconomic backgrounds find that socioeconomic status was an overlooked explanatory variable. Higher socioeconomic status was actually a better determinant of future long-term success than whether participants held out for a second marshmallow.Footnote ²⁸

Moreover, growing evidence in psychology and public health finds that intense striving – what many would consider to be highly skilled willpower – can also be toxic for health. This seems to be especially the case for low-income Black men, as shown in pioneering research by social epidemiologist Sherman James in what he has coined “John Henryism.”Footnote ²⁹ Other studies have found that among African-American adolescents who come from low socioeconomic backgrounds, exhibiting high levels of self-control is associated with high academic achievement but worse physical health. In an analysis of almost 10,000 participants from the National Longitudinal Study of Adolescent to Adult Health (Add Health), Black youth from the most disadvantaged backgrounds who showed high levels of striving and perseverance in academic pursuits at age 16 were more likely to suffer from type 2 diabetes at age twenty-nine, despite exhibiting better mental health and higher socioeconomic status compared to their less-striving counterparts. However, this pattern was not observed in the White subsample, where striving was associated with better mental and physical health. This phenomenon has been labeled “skin-deep resilience” to reflect the connection between striving for success (defined as graduating college, having a greater personal income, and fewer symptoms of depression) and the heightened chance of having a chronic disease.Footnote ³⁰

Willpower clearly helps us to set goals and follow through on them, but the scientific evidence points to a much smaller role than other factors, which do not lend themselves to easy fixes. Willpower has limited success in maintaining individual behavior change when community behaviors stay the same. Yet, the perceived benefits of superior willpower continue to guide our judgments about what matters most for good health. If the predominant view is that developing individual willpower is the key to achieving health, the result is that other types of approaches (e.g., relational approaches) can seem less relevant.

A consequence of us placing personal responsibility and willpower over everything else is that health conditions are often described in terms of individual moral failings. People who are overweight or fall into chronic substance use to manage pain and are commonly viewed either as lacking self-control or the morals necessary to make good decisions. Isolated older adults are often regarded not so much in moral terms, but more as an inevitability for which little can be done. These negative judgments reinforce arguments for individual solutions, even when structural changes are necessary. What would it look like if we saw these conditions as not merely individual moral failings, but conditions that are consequences of environmental conditions that could be mitigated with proper attention? Could acknowledging the relational dimensions of individuals bring greater health improvements than just treating the “moral failure” alone? It would mean not only improving the condition of the individual but of the people around that individual, family, and community. Strategies that consider relational health may help us do that.

Our individualized perspective on health is also a product of cognitive biases that guide how we judge behavior. Cultures (like that of the United States) that value self-determination and individualism tend to teach that we live in a fair world – one in which people are responsible for their life situations and get what they deserve. Furthermore, when we are attributing causes to our own behaviors, such as why we made unhealthy food choices yesterday, we are more likely to make external (circumstantial) attributions than when we are explaining the behavior of others, particularly when the behavior is undesirable. In other words, the judgments we make about ourselves and others are based on different perspectives and different information, which can lead to incorrect assumptions. For influences on eating behavior, strong evidence suggests that even though there are large variations in what and how people eat, certain universals exist across race, social class, gender, age, and geographic location. Factors that include who you eat your meals with, how much time you have for meals, and what access you have to healthy food impact what and how much you eat. In short, abundant research finds that we make less healthy food choices when we feel stress, time pressure, or have limited options.Footnote ³¹

But although we can recognize these connections in our own behavior, we tend to have trouble considering how similar factors influence decision-making for others. These biases help to explain how the allowances we give for our own lapses of healthy behavior (“I was rushing to meetings all day,” “I was feeling stressed”) are especially difficult to see in people who have vastly different life experiences than our own. The disconnect between how we view our own behavior and how we attribute the behavior of others to internal causes (lack of willpower) encourages maintaining individual solutions, regardless of whether they work. Untrammeled individualism is the cultural status quo that hurts our individual health and the health of populations.

Although individual factors such as strength of will, grit, motivation, and related constructs all contribute to better health, what has been underestimated, and therefore missing the mark when it comes to addressing behavior change and health maintenance, is the relational basis for these personality characteristics. The evidence clearly establishes that social relationships significantly contribute to the development and maintenance of these personal strengths. More broadly, understanding the science behind relational health should force us to resist an individualized view of ourselves. We tend to credit the healthy for good habits and discipline and assign blame to the sick. All too often, and to our detriment, we view our health as a product of individual inputs rather than through a lens of interconnected, relational health.

Relational Health in Action

The relational health perspective offers a different lens through which to view how our health is shaped and what the most productive avenues are for achieving long-term positive health outcomes. This book draws on empirical research into how social relationships affect health outcomes, with a focus on three specific health problems – obesity, opioid use disorder, and depression in older adults – and incorporates examples of the untapped potential of community resources, social networks, and varied partnerships. This research presented in the book is supplemented by perspectives from health care providers, patients and their families, and health policy experts to examine the role of relationships in health production and maintenance.

Chapter 2 describes four types of relational features: social support, social integration, social capital, and social norms, collectively referred to as the “four socials.” The ways in which each of these relational factors impact health can be understood as operating through psychological, behavioral, and biological pathways. This chapter presents the definitional distinctions between the four socials and describes the scientific evidence for their pathways.

Chapter 3 focuses specifically on research findings for how obesity, opioid use disorder, and depression in older adults are impacted and shaped by the four socials. The wide range of research contexts and methods are highlighted to provide a clear understanding of the scope of work in these areas.

Chapter 4 examines the historical trends of how these three health issues have increased in prevalence over the last several decades. The chapter describes the current guidelines and practices for how health care is delivered for these patient populations and draws from perspectives and stories from health care settings.

Chapter 5 examines how a relational approach addresses avenues for prevention and sustainable solutions with a focus on four areas of emphasis. These include: improving community-level prevention efforts through building on social resources in the community through place-based strategies and communication infrastructure; reducing structural stigma in representations of health issues and individual-level stigma in provision of care; social prescribing that identifies risk and protective network characteristics in the clinical encounter and bridges primary care and community resources; and relationship building between the provider and patient and among providers. The chapter describes strategies and examples of successful programs that effectively integrate relational health themes in their treatment approaches with examples derived from interviews with patients and providers.

Chapter 6 focuses on policy priorities centered around the themes of better integration of social and medical services, improving community assets, and health care workforce improvements that include training in identifying and responding to relational needs.

Chapter 7 concludes with the broad potential for relational health to improve health and wellbeing. It considers challenges and lessons from COVID-19 and what we have learned to improve population health in the future. Priorities of prevention, mitigation, and provision of care are emphasized along with reflections on obstacles to change.