The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Social Cohesion is a key issue in the Social and Community Context domain.
Relationships are important for physical health and psychosocial well-being.1, 2, 3, 4, 5 Relationships are conceptualized through terms such as social cohesion, social capital, social networks, and social support. Social cohesion refers to the strength of relationships and the sense of solidarity among members of a community.6 One indicator of social cohesion is the amount of social capital a community has. Social capital deals with shared group resources,6, 7, 8 like a friend-of-a-friend’s knowledge of a job opening.9 Individuals have access to social capital through their social networks,8 which are webs of social relationships.10, 11 Social networks are sources of multiple forms of social support, such as emotional support (e.g., encouragement after a setback) and instrumental support (e.g., a ride to a doctor’s appointment).10, 11 This summary will review the positive and negative health effects social cohesion has on an individual’s life.
Social capital is an important marker of social cohesion, and it has significant ramifications for health. For example, one study examined the link between 4 measures of social capital (perceived fairness, perceived helpfulness, group membership, and trust), income inequality, and mortality.12 The authors found that all 4 measures of social capital were associated with mortality. They also found that the relationship between income inequality and mortality may be partially explained by reductions in social capital as income inequality increases.12, 13
Collective efficacy, an aspect of social capital and social cohesion, is grounded on mutual trust and describes a community’s ability to create change and exercise informal social control (i.e., influence behavior through social norms).14 Collective efficacy is associated with better self-rated health,15 lower rates of neighborhood violence,14 and better access to health-enhancing resources like medical care, healthy food options, and places to exercise.16 Social institutions like religion and the family are common sources of social capital and social control, as well as social networks and social support.7, 17, 18
Social networks spread social capital, 8 but they can also spread health behaviors and outcomes, a phenomenon known as “social contagion.”19 For example, if an individual’s friend, sibling, or spouse is obese, the individual’s likelihood of also becoming obese increases.20 Similar patterns are seen for smoking21 and drinking22 behaviors.
High levels of social support can positively influence health outcomes through behavioral and psychological pathways.11, 23 For example, social support may help people stick to healthier diets 23 and reduce emotional stress.1 Both of these pathways can affect biological functioning in the cardiovascular, neuroendocrine, and immune systems.11, 23 Social support can therefore both directly benefit people and indirectly buffer them from risk factors that might otherwise damage health.24 In a study conducted on the relationship between social support and atherosclerosis (plaque in the arteries), social support contributed to lower atherosclerosis levels in women at high risk for heart disease.25 The protective nature of social support may be especially important for minority populations. One study of Mexican-origin adults in California found that social support acted as a barrier against the harmful health effects of discrimination.26
While social ties sometimes transmit negative health behaviors or add stress,5, 27 social isolation is usually detrimental to health and increases mortality.4, 28 Social isolation is a special concern for older adults, as contact with friends decreases with age.29 Older individuals in long-term care facilities or with conditions that interfere with daily activities, like arthritis, may suffer from loneliness and a lack of social cohesion,30, 31 which may negatively impact health. For example, one study conducted among older adults found an association between reduced neighborhood social cohesion and a heightened likelihood of insomnia, which can have negative health effects.32 Similarly, during natural disasters like heat waves, elderly individuals living in neighborhoods with low social cohesion may lack social support from concerned neighbors who will check on them, and they have fewer safe communal areas where they can seek refuge.33
Given the complex nature of the association between social ties and health,1, 11 social interventions designed to improve health vary significantly. These interventions can occur at multiple levels (e.g., family, group, neighborhood) and sometimes require cross-sector collaboration (e.g., education, public health, housing) to foster community building and improve health.34, 35, 36, 37 Further research is needed to better understand how social cohesion affects health, as well as how it can be used to reduce health disparities. This evidence will facilitate public health efforts to address social cohesion as a social determinant of health.
Disclaimer: This summary of the literature on social cohesion as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue.1, 2 Please keep in mind that the summary is likely to evolve as new evidence emerges.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 Thoits PA. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52(2):145–61.
2 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(2):186–204.
3 Keyes CL, Michalec B. Viewing mental health from the complete state paradigm. In: Scheid TL, Brown TN, editors. A Handbook for the Study of Mental Health: Social Contexts, Theories, and Systems. Cambridge, UK: Cambridge University Press; 2010. p. 125–34.
4 Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316.
5 Umberson D, Montez JK. Social relationships and health a flashpoint for health policy. J Health Soc Behav. 2010;51(1 Suppl):S54–66.
6 Kawachi I, Berkman L. Social cohesion, social capital, and health. In: Berkman LF, Kawachi I, editors. Social Epidemiology. New York: Oxford University Press; 2000. p. 174–90.
7 Bourdieu P. Forms of capital. In: Richardson JG, editor. Handbook of Theory for the Sociology of Education. Greenwood Press: Westport, CT; 1986. p. 241–58.
8 Lin N. Building a network theory of social capital. Connect (Tor). 1999;22(1):28–51.
9 Granovetter M. The strength of weak ties: a network theory revisited. Sociol Theory. 1983;1:201–23.
10 Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000;51(6):843–57.
11 Berkman LF, Glass T. Social integration, social networks, social support and health. In: Berkman LF, Kawachi I, editors. Social Epidemiology. New York: Oxford University Press; 2000.
12 Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality. Am J Public Health. 1997;87(9):1491–98.
13 Gilbert KL, Quinn SC, Goodman RM, Butler J, Wallace J. A meta-analysis of social capital and health: a case for needed research. J Health Psychol. 2013;18(11):1385–99. doi: 10.1177/1359105311435983
14 Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. Science. 1997;277(5328):918–24.
15 Browning CR, Cagney KA. Neighborhood structural disadvantage, collective efficacy, and self-rated physical health in an urban setting. J Health Soc Behav. 2002;43(4):383–99.
16 Matsaganis MD, Wilkin HA. Communicative social capital and collective efficacy as determinants of access to health-enhancing resources in residential communities. J Health Commun. 2015;20(4):1–10. doi: 10.1080/10810730.2014.927037
17 Idler E. Religion: The invisible social determinant. In: Idler E, editor. Religion as a Social Determinant of Public Health. New York: Oxford University Press; 2014. p. 1–30.
18 Maselko J, Hughes C, Cheney R. Religious social capital: its measurement and utility in the study of the social determinants of health. Soc Sci Med. 2011;73(5):759–67.
19 Christakis NA, Fowler JH. Social contagion theory: examining dynamic social networks and human behavior. Stat Med. 2013;32(4):556–77.
20 Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357(4):370–79.
21 Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. N Engl J Med. 2008;358(21):2249–58. doi: 10.1056/NEJMsa0706154
22 Rosenquist JN, Murabito J, Fowler JH, Christakis NA. The spread of alcohol consumption behavior in a large social network. Ann Intern Med. 2010;157(7):426–33. doi: 10.7326/0003-4819-152-7-101004060-00007
23 Uchino B. Social support and health: a review of physiological processes potentially underlying links to disease outcomes. J Behav Med. 2006;29:377–87.
24 Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98(2):310.
25 Knox SS, Adelman A, Ellison CR, Arnett DK, Siegmund KD, Weidner G, et al. Hostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study. Am J Cardiol. 2000;86:1086–89.
26 Finch BK, Vega WA. Acculturation stress, social support, and self-rated health among Latinos in California. J Immigr Health. 2003;5(3):109–17.
27 Marsden P. Memetics and social contagion: two sides of the same coin?. JoM-EMIT. 1998;2(2):171–85.
28 Berkman LF. The role of social relations in health promotion. Psychosom Med. 1995;57(3):245–54.
29 Van Tilburg T. Losing and gaining in old age: changes in personal network size and social support in a four-year longitudinal study. J Gerontol B Psychol Sci Soc Sci. 1998;53(6):S313–23.
30 Cooney A, Dowling M, Gannon ME, Dempsey L, Murphy K. Exploration of the meaning of connectedness for older people in long‐term care in context of their quality of life: a review and commentary. Int J Older People Nurs. 2014;9(3):192–99. doi: 10.1111/opn.12017
31 Tomaka J, Thompson S, Palacios R. The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. J Aging Health. 2006;18(3):359–84.
32 Chen-Edinboro LP, Kaufmann CN, Augustinavicius JL, Mojtabai R, Parisi JM, Wennberg AMV, et al. Neighborhood physical disorder, social cohesion, and insomnia: results from participants over age 50 in the health and retirement study. Int Psychogeriatr. 2015;27(2):289–96. doi: 10.1017/S104161021400182
33 Klinenberg E. Heat wave: a social autopsy of disaster in Chicago. Chicago: University of Chicago Press; 2015.
34 Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE. The Community Guide’s model for linking the social environment to health. Am J Prev Med. 2003;24(3 Suppl)12–20.
35 Hunter BD, Neiger B, West J. The importance of addressing social determinants of health at the local level: the case for social capital. Health Soc Care Commun. 2011;19(5):522–30. doi: 10.1111/j.1365-2524.2011.00999.x
36 Liao Y, Siegel PZ, White S, Dulin R, Taylor A. Improving actions to control high blood pressure in Hispanic communities—Racial and Ethnic Approaches to Community Health Across the US Project, 2009–2012. Prev Med. 2016;83:11–15.
37 Buckner-Brown J, Sharify DT, Blake B, Phillips T, Whitten K. Using the Community Readiness Model to examine the built and social environment: a case study of the High Point Neighborhood, Seattle, Washington, 2000–2010. Prev Chronic Dis. 2014;11:e194.