By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- This observational study was designed to determine if there is an association between online social network use and mortality.
- Mortality data were obtained over a two-year period from 4 million Facebook users registered to vote in California and compared with age- and gender-matched non-Facebook user registered voters.
- The mortality rate for Facebook users was found to be about 12% less than the mortality rate for non-Facebook users.
- Hobbs et al further analyzed these data by looking at causes of mortality and Facebook user characteristics.
- The number of accepted online friendships and received photo tags (an indication of offline social activity) both were associated with lower mortality.
SYNOPSIS: An observational examination of California Facebook users suggested this population has a lower mortality rate than non-Facebook users; the lowest mortality risk is for Facebook users who combine a moderate degree of online social interaction with high offline social activity.
SOURCE: Hobbs W, Burke M, Christakis NA, Fowler JH. Online social integration is associated with reduced mortality risk. Proc Natl Acad Sci U S A 2016;113:12980-12984.
Social interactions are important to health and longevity. A 1979 landmark study persuasively documented this association, and several follow-up studies arrived at the same conclusion: People with more friends and more involvement in community tend to live longer.1,2
Although the association between social supports and health is clear, the mechanism of action remains unknown. Many researchers believe multiple factors are at work, including social and biological forces. For example, it is thought that the motivation to engage in healthy behaviors benefits from a strong social network. Evidence also suggests that healthy relationships strengthen immune factors.3,4
But as we all are aware, the world and our way of socializing and connecting has changed since 1979. As of December 2016, there were more than 1.8 billion active users of the popular social media network Facebook worldwide each month.5 Increasingly, socialization is virtual, yet we do not know if the online social connections of today provide any of the health benefits documented in studies of offline or real-world settings. The goal in the Hobbs et al study was to determine if the association between social involvement and mortality holds true for online social activity.
Additionally, the investigators decided to further analyze this association by examining mortality from specific disease states and delving deeper into social media use to determine if there was a link or connection to offline use.
The research question for this study was two-fold:
- Are online social interactions and involvement distinctly associated with decreased mortality?
- Are health benefits from online social networks actually a reflection of benefits derived from real-world social activity?
Facebook permitted de-identified aggregated data to be collected for this project. Approximately 12 million profiles of California Facebook users met inclusion criteria initially (determined by birth date between 1945 and 1989 and date of Facebook sign up). To homogenize the Facebook and non-Facebook user groups and to control for socioeconomic and educational differences, both the control group (non-Facebook users) and the Facebook user group were then selected from the California Voting Records. This shrunk the original pool of 12 million Facebook users to just more than 4 million users, who then were age- and gender-matched to non-users within the California Voting Records. California Public Health Records were used to determine mortality rates and causes of death from each of these groups.
Social media use among the age- and gender-matched Facebook users was collected over a six-month period. Mortality rates and cause of mortality were collected during a two-year period (2012 and 2013).
Data from the Facebook user population were analyzed further to determine any connection between specific types of Facebook use and mortality. Initiating and accepting friend requests were analyzed separately to determine if either of these measures of online social life was associated with longer life or health. Efforts also were made to determine if specific Facebook social interactions thought to reflect real-world social interactions carried a disproportionate measure of health benefits. The investigators measured the number of accepted photo “tags” (based on previous studies, these identified photos are thought to be a measure of real-world activity)6 and number of status updates (based on previous studies, updating activity has no known connection to real-world activity).7
Selected Results
- Comparison of Facebook users and non-users present in the California Voting Record: Mortality rate of Facebook users is 88% of non-users.
- See Table 1 for mortality by causes among Facebook users compared to non-users in the Voter Record.
Table 1: Mortality Risk Among Facebook vs. Non-Facebook Users |
||
|
Disease |
Relative Risk of Death |
95% Confidence Interval |
|
Infection |
0.72 |
0.63-0.82 |
|
Diabetes |
0.62 |
0.56-0.70 |
|
Dementia |
0.75 |
0.67-0.83 |
|
Ischemic heart disease |
0.81 |
0.76-0.86 |
|
Liver disease |
0.65 |
0.59-0.72 |
|
Stroke |
0.71 |
0.63-0.80 |
Results in the Facebook User Population
- Comparison of number of accepted friendships (people asking to be added to an online network) and number of requested friendships (asking to join someone else’s online network): Mortality rate for users with the most accepted friendships was about 66% of the rate for those with the least amount of accepted friendships. Mortality rate for users with the most requested friendships was about equal to the rate for those with the least requested friendships — there did not appear to be any association with mortality rate and requests for friendship.
- Results related to Facebook user offline (real-world) activity: Mortality rate was lowest (about 70% of average) for those with the greatest number of “tagged” photographs and the fewest status updates. In earlier studies, tagged photos were thought to represent offline activity, while status updates were less predictive and perhaps negatively associated with offline activity.6,7 Mortality rates for specific disorders among Facebook users with the highest number of accepted friends is displayed in Table 2. Hobbs et al noted the greatest decrease in mortality risk occurred in socially linked disorders. The risk of most cancers was unchanged.
Table 2: Mortality Risk Among Facebook Users with Highest Number of Accepted Friends |
||
|
Relative Risk |
95% Confidence Interval |
|
|
Cardiovascular disease |
0.91 |
0.87-0.96 |
|
Drug overdose |
0.78 |
0.70-0.87 |
|
Suicide |
0.73 |
0.66-0.80 |
COMMENTARY
This large-scale, observational study was designed to determine if online socialization via Facebook was associated with any of the health benefits provided by offline or real-world socialization, including a reduced mortality risk.
Hobbs et al were very clear about the limitations of this study. They noted that despite attempts to control for socioeconomic differences between the Facebook user and non-user groups, it was likely that these differences not only existed but also influenced the results, given that socioeconomic factors are known to affect longevity. Hobbs et al also noted that this study did not imply or establish causality. That may come later, but for now, caution is advised to distinguish causality from correlation.
Also of note is that while the number of subjects was impressively large, the time period to study longevity was too short. Two years simply is not long enough to study mortality rates conclusively. Following these groups over a lifetime will give much more valuable and meaningful information and a chance to see if the numbers and trend persist after two years. Additionally, it should be mentioned that there are other social media outlets in addition to Facebook. Although we know the control group was non-Facebook users, we do not know any other information about their social media use. Any conclusions drawn about social media use from this study must account for this narrow perspective.
Hobbs et al noted more valuable information was found from the in-depth look at Facebook users. Initially, they hypothesized that a larger friend network in general would be associated with lower mortality. They were surprised to learn that while more accepted friend requests was associated with reduced mortality rates, requests for friends had no such association.
It is difficult to know what to make of this finding. Hobbs et al interpreted this information to mean that seeking support from others may not be as significant in lowering health risk as accepting support. While this may be accurate, other valid explanations may emerge as we better understand what friend requests and acceptance represents in an online world.
Working with findings from another study, Hobbs et al used receiving photo tags as a measure of offline activity. Although it seems that a linear relationship exists here, with more received photo tags corresponding with a decreased mortality rate, the conclusion is not as convincing. Although receiving photo tags may represent an offline life, it is not as clear that the converse is true; that is, there is no evidence that fewer received photo tags mean less offline socialization. It may be that photos are sent more often within specific social groups determined by factors such as age, socioeconomic status, possession of a smartphone, and interest in taking photos.
This study is innovative in approach and produced suggestive findings, but the clinical usefulness is not readily apparent. Certainly, there is no evidence that urging patients to send more photos or accept more friend requests will improve longevity. But there are some valuable takeaways. If we look at this study as a pioneering approach to identify health implications of Facebook use, possibilities for future clinical application arise. There have been many negative studies regarding online activity and health. These findings give us hope that specific use of online social media may bestow health benefits.8,9
For now, a clinician is on solid ground recommending use of social media in moderation to enhance rather than replace offline or real-world social involvement. Although results imply that accepting friends as opposed to reaching out online is more valuable for health, there seems to be little harm (and perhaps even greater rewards) in both accepting and requesting friendships in the real world. Finally, this study serves as a reminder of the importance of taking a fresh look at established findings as our society and norms change and develop over time.
REFERENCES
- Berkman LF, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol 1979;109:186-204.
- .Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: A meta-analytic review. PLoS Med 2010;7:e1000316. doi: 10.1371/journal.pmed.1000316.
- Umberson D, Crosnoe R, Reczek C. Social relationships and health behavior across life course. Annu Rev Sociol 2010; 36:139-157.
- Loucks EB, Berkman LF, Gruenewald TL, Seeman TE. Relation of social integration to inflammatory marker concentrations in men and women 70 to 79 years. Am J Cardiol 2006;97:1010-1016.
- Statista. Number of daily active Facebook users worldwide as of 4th quarter 2016 (in millions). Available at: https://www.statista.com/statistics/346167/facebook-global-dau/. Accessed Feb. 26, 2017.
- Jones JJ, Settle JE, Bond RM, et al. Inferring tie strength from online directed behavior. PloS One 2013;8:e52168.
- Burke M, Kraut RE. The relationship between Facebook use and well-being depends on communication type and tie strength. J Comput-Mediat Comm 2016;21:265-281.
- Muench F, Hayes M, Kuerbis A, Shao S. The independent relationship between trouble controlling Facebook use, time spent on the site and distress. J Behav Addict 2015;4:163-169.
- Wegmann E, Brand M. Internet-communication disorder: It’s a matter of social aspects, coping, and internet-use expectancies. Front Psychol 2016;7:1747.
An observational examination of California Facebook users suggested this population has a lower mortality rate than non-Facebook users; the lowest mortality risk is for Facebook users who combine a moderate degree of online social interaction with high offline social activity.
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