Obesity appears to spread through social ties. That's the bottom-line of a study in this week's New England Journal of Medicine (The Spread of Obesity in a Large Social Network over 32 Years - free pdf) that puts the spotlight on social networks and health determinants for chronic diseases. I had to laugh when I saw a glossary of terms on the second page of the article (not at the end) - ego, alter, node, degree of separation, homophily - I guess to help people understand what they were reading (why don't they do that for more articles in NEJM?). And for those of you who have never seen social network analysis and graphs before, hang on - you will never go back to crosstabs. Hello medicine - welcome to the real world! It's about people, relationships, connectedness and engagement. Oh, and health.
Here is the front page coverage of the results in the Washington Post and the New York Times (and for the truly interested, there were over 275 reader comments on the article on the NYTimes site when I posted).
What I expect will have many people puzzling about the results is that social networks do not necessarily refer to your work mates and neighbors; in fact, geographical proximity was not the important factor for the effect of social networks on weight gain. Social distance is the important variable, and for those of you who have heard my talk, read the blog and otherwise pay attention to such things, you know what that means for interventions. For the newly tuned in, these data demonstrates perfectly why social media and mobile technologies will be such important tools for social marketing in the future.
To put these new findings into a context, here's an excerpt from my article that will be appearing soon in Social Marketing Quarterly:
What’s Social about Behavior?
An important point to reiterate about the new media world is that it is a networked one, not unidirectional or linear. This reality does not just pertain to how we depict our communication processes; it also reflects people’s reality. Just a cursory look at some of the health behaviors that are the focus of social marketing programs reinforces the fact that all health behaviors are, to a greater or lesser degree, social. New media now allows people to explore these social aspects with greater freedom than ever before. Freedom from geographic and temporal boundaries, open access to sources and information, and the ability to create the digital and social contours that surround health conversations, information-seeking, decision-making and behavioral choices.
Encouraging screening behaviors for conditions and diseases that presently do not bother someone has been the subject of much work since at least the 1950s when the Health Belief Model emerged as a way to conceptualize the process for tuberculosis screening. Over the years, HBM and other individual models of screening behavior have predominated much of our thinking despite the evidence that social influences are likely much more important. Whether my health care professional recommends that I get screened for high blood pressure or blood cholesterol levels; breast, cervical, skin or prostate cancer; and other potential (and silent) problems is a social communication process – not simply a perception of perceived risk and severity of the disease. Whether I know other people who have been screened for the condition, what their experiences were, whether they suggest to me that I should have it done too, are much more powerful influences on my decision-making than some theorists would have us believe. That I can sit down at with my desktop, laptop or smart phone, connect to the internet and now find like-minded others who want to share their experiences can have a tremendous impact on how social my treatment-seeking behavioral determinants become. The web is changing the weights in our models of determinants of health behavior.
The same types of issues hold true for other health behaviors. Consider the person who is trying to make lifestyle modifications that might include diet modifications or increasing her/his level of physical activity. How are those decisions to make such changes arrived at – in isolation in front of a mirror or lying in bed in the morning? How does the person decide how to begin to prepare for or address the problem? What are some of the stronger sources for motivation and inspiration? Where does the reinforcement for positive changes usually come from? Where does s/he go when they feel a weak moment or frustration with their progress? How do they celebrate success?
I venture to say that in at least 80% of all cases the answer is “other people.” The key questions for social marketing programs are not just what behaviors to focus on, how to create incentives and reduce barriers to engaging in them, opening up more opportunities to try them and sustain them, and then promote them – it is answering the ‘who’ question. Not just the relatively simple one of ‘who is the credible source of information,’ or the more complex one of ‘how do we change social norms and acceptability,’ but the audience-centric one: who does s/he interact with on a daily or weekly basis as part of their daily routines and are influential in the choices they make about health behaviors.
The same types of questions are also important when we address the cessation of addictive behaviors (where social support becomes such an important determinant of short-term and long-term success), compliance with medical regimens (where friends and family care-givers play a huge role), precaution adoption - taking actions or changing behaviors to avoid or reduce the threat of intentional and unintentional injuries, health information seeking (where over 66% of online searches involve looking for other people’s opinions, reading blogs, visiting social network sites), and taking collective action and advocacy – where the rise of mobile technologies have taken these activities to a whole new level of sophistication and effectiveness (see Smart Mobs).
In case you missed it - the paradigm has shifted.
P.S. [added 27 July AM]: For an introduction to network theory, see the book I have been featuring under 'New Reads:' Linked: The new science of networks by Barabasi.