Associations of neighborhood problems and neighborhood social cohesion with mental health and health behaviors: The Multi-Ethnic Study of Atherosclerosis
Introduction
Neighborhood-level deprivation has been consistently associated with various health outcomes (Borrell et al., 2004; Bosma et al., 2001; Diehr et al., 1993; Hart et al., 1997; Lee and Cubbin, 2002; O’Campo et al., 1995; Ross, 2000; Silver et al., 2002; Tseng et al., 2001; Centers for Disease Control and Prevention (CDC), 1999; Balfour and Kaplan, 2002). These associations tend to persist after controlling for individual-level measures of socioeconomic position, suggesting that neighborhood-level factors are independently related to health. A key feature of these studies has been to characterize neighborhoods according to census-derived socioeconomic indicators. While census-derived indicators have been critical for demonstrating the patterning of disease by levels of socioeconomic deprivation, the specific features of the neighborhood context most relevant for health remain largely unknown. Thus, identifying more specific neighborhood features would strengthen causal inferences regarding neighborhood–health associations and also help identify relevant neighborhood interventions.
Two features of the neighborhood context, namely measures of neighborhood problems and neighborhood social cohesion, have recently gained attention in the literature. Both constructs are related to the concept of social disorganization, generally defined as the inability of communities to realize common values (Sampson and Raudenbush, 1999; Taylor, 1996). Neighborhood problems is a broad term that encompasses both physical or material features of the neighborhood (e.g. abandoned buildings, litter, vandalism) as well as elements of social disorder (e.g. crime, loitering, street conflict, or illicit drug use) (Ross and Mirowsky, 2001). Researchers hypothesize that neighborhood problems may be a source of chronic stress that can contribute to unhealthy coping behaviors such as drinking and smoking, or to poor mental health outcomes (Latkin and Curry, 2003; Roberts et al., 1997; Hill and Angel, 2005). Neighborhood problems may also limit the extent to which persons can be physically active in their area of residence, and thus decrease physical activity levels necessary to maintain health (Centers for Disease Control and Prevention (CDC), 1999). For example, studies have shown that people who fear being robbed, attacked, or physically injured are less likely to report walking for pleasure, exercise, or transportation (Ross, 1993).
The concept of social cohesion (and the related concept of social capital) has gained much prominence in the public health literature in recent years, although the notion of an individual's level of connectedness to his/her community dates as far back as the 19th century (Durkheim, 1997). Sampson and colleagues (Sampson, 2003; Sampson et al., 1997) have provided important theoretical and methodological applications of this concept in recent years. The authors define social cohesion as the degree of connectedness and solidarity that exists among people living in defined geographic boundaries. However, an important distinction in Sampson et al.'s conceptualization of social cohesion is the notion that social ties are not enough to promote collective well-being. What distinguishes ‘cohesive’ neighborhoods from those with less cohesion, the authors argue, is the collective capacity of residents to translate social ties into specific goals for the common good. In this regard, the authors follow in the line of William Julius Wilson's seminal studies (Wilson, 1987, Wilson, 1996), indicating that strong local ties among residents of poor neighborhoods did not translate into the strong collective resources needed to effectively manage neighborhood conditions, and that this largely resulted from the absence of viable economic, educational, and political opportunities available to residents of disadvantaged neighborhoods.
Social cohesion is hypothesized to influence health through its role in promoting the adoption of health-related behaviors, increasing access to services and amenities, or through psychosocial processes (Kawachi and Berkman, 2000). For example, neighborhoods with a high degree of social cohesion may promote the rapid diffusion of health-relevant information (especially innovative behaviors) because of the degree of connectedness and trust that exists among neighbors (Rogers, 1983). Also, this degree of connectedness may serve to reinforce health-promoting behaviors such as walking or exercising, or in deterring others (e.g. banning smoking and drinking in public spaces). Individuals in socially cohesive neighborhoods may also be better able to advocate and effect changes in their community directly relevant to health. For example, the placement and maintenance of community health clinics, or resources such as bicycle lanes or gyms promoting exercise, is most likely to occur in neighborhoods that can effectively band together to make these amenities available. Lastly, neighborhood social cohesion may influence psychosocial processes by providing individuals with a source of meaningful connection and mutual respect (Kawachi and Berkman, 2000), and increasing residents’ sense of purpose and meaning in life and so contributing to more positive mental health outcomes (Silver et al., 2002; Driessen et al., 1998; Weich et al., 2002).
Thus, while measures of neighborhood problems and neighborhood social cohesion have emerged as potentially important features of the neighborhood context (Roberts et al., 1997; Browning and Cagney, 2002; Fisher et al., 2004), little work has been done to empirically determine their association with health outcomes generally, and to test if each of these attributes is independently related to health. In the present study, we examine associations between neighborhood problems and neighborhood social cohesion and depression, smoking, drinking, and walking for exercise. These outcomes were selected because prior theory suggested clear mechanisms through which neighborhood problems and social cohesion could affect their prevalence.
Using cross-sectional data from the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based cohort composed of White, African-American, Latino and Chinese participants, we tested the following hypotheses: (1) high levels of self-reported neighborhood problems and low levels of neighborhood social cohesion are associated with increased depression, smoking, drinking, and low levels of walking for exercise, after adjusting for individual and neighborhood-level indicators; and (2) neighborhood problems and neighborhood social cohesion capture distinct aspects of the neighborhood context and are each independent predictors of depression and health behaviors. Because the use of self-reported measures of the neighborhood context may introduce biases not typically encountered when using measures derived from other sources (such as a census) we also examined if any observed associations remained robust to alternate ways of measuring neighborhood problems and neighborhood social cohesion. Further, we tested for differences in neighborhood effects by race/ethnicity. We hypothesized that effects might differ due to the strong residential segregation by race/ethnicity in the United States (US), where neighborhoods with similar measures of problems or cohesion could have very different qualitative characteristics for different race/ethnic groups, and therefore influence health in different ways. In the US context, where race/ethnicity is strongly correlated with socioeconomic factors, different race/ethnic groups could also have differential resources to buffer the effects of adverse neighborhood environments, providing an additional rationale for possible effect modification.
Section snippets
Methods
MESA is a prospective cohort study investigating the development of subclinical cardiovascular disease in a multi-ethnic, population-based sample of 6814 men and women. Details of the study design have been published elsewhere (Bild et al., 2002). Briefly, study participants were 45–84 years of age at enrollment, free of clinically apparent cardiovascular disease and recruited from six communities in the US: Baltimore City and Baltimore County, Maryland; Chicago, Illinois; Forsyth County, North
Results
White participants had higher levels of income and education and tended to live in more advantaged neighborhoods than all other racial/ethnic groups (Table 1). Mean scores for neighborhood problems were slightly higher for African-Americans and Latinos than for Whites, and social cohesion scores were slightly lower for African-Americans and Latinos compared to Whites. Chinese participants reported lower levels of neighborhood problems than all other racial/ethnic groups. Latinos generally had
Discussion
The MESA cohort allowed us to examine the association of neighborhood problems and neighborhood social cohesion with depression and health behaviors in a large and ethnically diverse population-based sample. Our findings suggest that neighborhood problems are positively associated with depression, current smoking and alcohol drinking whether individual or aggregate measures are used. These associations were statistically independent of individual-level socioeconomic factors, neighborhood
Acknowledgments
This work is supported by R01 HL071759 (Diez-Roux). MESA is supported by Contracts N01-HC-95159 through N01-HC-95165 and N01-HC-95169 from the National Heart, Lung, and Blood Institute. The authors thank the other investigators, the staff, and the participants of the MESA study for their valuable contributions. A full list of participating MESA investigators and institutions can be found at 〈http://www.mesa-nhlbi.org/〉. Dr. Echeverria was supported by a supplement to N01-HC95161 and by a W.K.
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