What is the Role of Culture in the Association of Relationships with Health?

There is now widespread recognition that relationships have important implications for health. To better understand this linkage, scholars have called for greater bridging between relationship science and the study of health. The goal of this paper is to raise awareness of another factor that needs to be incorporated into this area of study: culture. I recommend three steps that researchers can take to systematically incorporate culture into the study of relationships and health. First, I suggest four possible culture patterns to study: similarity, moderation, mediation, and novel constructs. Second, I suggest that theoretically meaningful cultural variation and multiple cultures be concurrently studied. The value of this strategy is highlighted via examples from three contexts that emphasize distinct approaches to self and emotion in relationships. Third, I suggest that key relationship processes in families and couples, two relationships with extensive implications for health, be studied. Selected studies of four relationship processes known to be relevant for health – expectations, formation and maintenance, emotions, and social support – are brief ly reviewed to highlight the value of this focus. The theoretical and applied benefit of incorporating culture into the study of the association of relationships with health is discussed. There is nowwidespread recognition that relationships matter for health. The empirical evidence showing that relationships that are close, warm, and supportive are linked with psychologically healthy and longer lives is well-established and continues to grow (e.g.,Baumeister & Leary, 1995; Gable, Reis, Impett, & Asher, 2004; Holt-Lunstad & Smith, 2012; Holt-Lunstad, Uchino, Smith, & Hicks, 2007). Relationships can also be bad for health. When characterized by high levels of anger, aggression, neglect, coldness or simultaneously high levels of positivity and negativity, relationships are associated with dysregulation of psychological (i.e., emotion, cognition) and physiological systems (i.e., cardiovascular, endocrine, and immune) that are directly or indirectly tied to poor health outcomes (e.g.,Repetti, Taylor, & Seeman, 2002; Rook, 1984; Uchino, 2013; Umberson & Montez, 2010). Recently, prominent scholars have articulated the need for greater bridging between relationship science and the study of health in order to develop a more complete understanding of the complex processes through which relationships are associated with health (Feeney &Collins, 2014; Pietromonaco, Uchino, & Dunkel-Schetter, 2013; Uchino, 2013). As research moves in this direction, the many factors that shape relationships will need to be incorporated into future studies. One of these factors is culture. The goal of this paper is to prompt the needed inclusion of cultural diversity into the study of relationships and health by (a) raising awareness of sociocultural variation in relationship processes that have implications for health and (b) proposing that researchers focus on four possible ways through which culture can shape the association of relationships with health. Relationships and Health: Current Evidence Research on the association of relationships with health has yielded one clear conclusion: relationships are central to psychological and physical health. Documented instances of long-term © 2015 John Wiley & Sons Ltd 662 Culture, Relationships, and Health isolation as well as an extensive and growing body of empirical research provide powerful evidence that a lack of social relationships disrupts development and impairs psychological and physical health (e.g.,Haney, 2003; Holt-Lunstad & Smith, 2012; Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015; House, 2001; House, Landis, & Umberson, 1988; Itard, 1962; Luo, Hawkley, Waite, & Cacioppo, 2012; Steptoe, Shankar, Demakakos, & Wardle, 2013). Simply put, social isolation is associated with less healthy and shorter life. Two types of relationships have been particularly linked with health: family relationships and couple relationships. Family relationships are typically the relationships that people are born into, and extensive evidence indicates that early family environments initiate relationship-relevant processes that shape psychological and physical health for the rest of our lives (e.g.,Bowlby, 1969, 1973, 1980, 1988; Mikulincer & Shaver, 2007; Miller et al., 2011; Repetti et al., 2002). Within our family of origin relationships, we learn what to expect from our relationships, howwe should treat others with whomwe have a relationship, what rewards we should pursue, and what threats we should avoid. For the majority of people, family relationships also stand out for their longevity. More so than other relationships, family relationships are typically maintained and remain primary sources of support, throughout the life course (Cicirelli, 1995; Fingerman et al., 2010; Holt-Lunstad & Smith, 2012; Neyer, & Lang, 2003; Uchino, Cacioppo, & Kiecolt-Glaser, 1996). Couple relationships commonly begin to be formed in adolescence and typically become adults’ primary bond in most Western societies (Huston, 2009; Karney & Bradbury, 2005; Kiecolt-Glaser & Newton, 2001; Smith, Baron, & Caska, 2014). Historically, couple relationships became an adult’s primary bond through marriage (i.e.,Coontz, 2005). For this reason, marriage has been a main focus of research on relationships and health with extensive evidence suggesting that couples exert a uniquely important inf luence on one another’s health (e.g.,Kiecolt-Glaser & Newton, 2001; Smith et al., 2014). The pathways through which family and couple relationships can positively inf luence health are not yet well understood because this area of study has historically received less empirical attention than the study of negative processes. Psychologists’ conceptual understanding of positive relationship processes and the ability to measure the effects of positive processes on health-relevant physiology are still developing (e.g.,Feeney & Collins, 2014; Gable & Haidt, 2005; Kok et al., 2013). Nonetheless, it is understood that the benefits of relationships are primarily derived from high-quality relationships. High-quality relationships are characterized by high levels of closeness, warmth, and support and are embedded within daily life rhythms that ref lect intimacy and interdependence (e.g., Feeney & Collins, 2014; Gable & Gosnell, 2011; Lakey & Orehek, 2011; Miller, 2012). In their meta-analysis of the association of relationships with mortality, Holt-Lunstad and Smith (2012) interpreted their findings as a conservative estimate of the effect of relationships because the majority of studies did not measure relationship quality but negative relationship processes are well documented to erode health. High-quality relationships are theorized to benefit health through at least three distinct paths. First, everyday emotion-laden social interactions in which people come together, share daily life events, and affirm their social bonds are thought to generate a global sense of social connection and social support that directly benefit psychological health and physical health (e.g.,Lakey & Orehek, 2011; Thoits, 2011). Second, emotion-laden social interactions that generate and prolong positive emotions as well as undo the physiological effects of negative emotions directly benefit psychological health and may also benefit physical health (Fredrickson & Levenson, 1998; Gable et al., 2004). Both positive emotion experience and expressive display have been linked with happier and longer life (e.g.,Harker & Keltner, 2001; Pressman & Cohen, 2005, 2007). Third, high-quality relationships may motivate health-promoting behavior, such as physical activity or seeking appropriate medical care, and deter unhealthy behaviors, such as smoking and excessive drinking (Newman & Roberts, 2013). © 2015 John Wiley & Sons Ltd Social and Personality Psychology Compass 9/11 (2015): 661–677, 10.1111/spc3.12226 Culture, Relationships, and Health 663 In contrast, the pathways through which family and couple relationships adversely affect health are well studied and better understood. Two seminal reviews provide key conclusions from this research. Repetti et al. (2002) reviewed approximately 53 studies of family environments and concluded that family relationships that are high in conf lict and aggression and/or are cold, unsupportive, or neglectful set the stage for the development of poor health by promoting health-harming behaviors and disrupting health-relevant cognitive, emotional, and biological systems. Kiecolt-Glaser and Newton (2001) reviewed 64 studies of marriage and concluded that marital interactions characterized by negative emotion, negative cognitions, and negative communication directly impact biological systems (e.g., cardiovascular, endocrine, and immune) that inf luence health outcomes and increase the likelihood of poor psychological health as well as health-harming habits (e.g., smoking, excessive eating, excessive drinking). Notably, the overwhelming majority of the studies reviewed by Repetti et al. (2002) and Kiecolt-Glaser and Newton (2001) were derived from samples of Americans of European background. This is not surprising. It ref lects the reality that most research on the association of relationships with health has been generated from this distinct cultural context. Altogether, extensive evidence indicates that relationships can promote emotions, cognitions, and behaviors that shape both psychological and physical health outcomes. Under the best of circumstances, relationships are associated with better health at the beginning of life (i.e., birth outcomes; Collins, Dunkel-Schetter, Lobel, & Scrimshaw, 1993), social behaviors that foster and protect health throughout the life course (i.e.,meaningful social integration, self-care; Mason & Sbarra, 2013), and the length of life itself (Holt-Lunstad & Smith, 2012). Under the worst of circumstances, the opposite pattern prevails. As yet, though, culture variation in relationship processes that have implications for the association of relationships with health is a topic that has received very limited empirical attention.