Social Environment and Physical activity: A review of concepts and evidence
Introduction
Links between environmental conditions and health-related behaviors have long been recognized in social and behavioral science models and theories (Bandura, 1986; McLeroy, Bibeau, Steckler, & Glanz, 1988), and generally supported by empirical evidence. Historically, much of this research focused on aspects of the physical environment. However, in 1976 Cassel suggested that other factors in our surroundings, “certain aspects of the social environment,” also had an impact on health (Cassel, 1976). The influence of social factors is now widely recognized in health behavior research (Emmons, 2000) and formally recognized by federal health agencies as an important determinant of health (U.S. Department of Health and Human Services, 1996). Although there is no definition of “social environment” that is universally agreed upon by social scientists, the social environment in which individuals live influences behavior by “shaping norms, enforcing patterns of social control, providing or not providing environmental opportunities to engage in particular behaviors, reducing or producing stress, and placing constraints on individual choice” (Institute of Medicine, 2003).
Most health outcomes and behaviors are socially patterned or distributed in society, negatively impacting those that live in resource-deficient social and physical environments (Berkman & Kawachi, 2000a). Individuals that live in these environments are at increased risk of engaging in unhealthy behaviors, such as physical inactivity, often as a response to stressful and hazardous environments (Geronimus, 2000; King, 1997). Physical inactivity is a growing public health problem associated with increased risk for heart disease, diabetes, high blood pressure, obesity, and some cancers (U.S. Department of Health and Human Services, 1996). Several psychosocial, cognitive, and emotional factors have been identified that help to explain why some people are active and others are inactive (Sherwood & Jeffery, 2000). However, in addition to selected individual factors, the social, economic, political, and physical environments in which individuals live also play important roles in health outcomes and behaviors. There is broad agreement that effective public health approaches to promoting physical activity must address modifiable social environmental factors that can support behavior change (Schmid, Pratt, & Howze, 1995), and there have been increasing efforts to understand the relative influence of each on physical activity (Giles-Corti & Donovan, 2003). Greater attention to social environmental factors is a necessary next step in research on physical activity. It is a behavior that is inherently shaped by one's social environment in that most activity occurs within the bounds of families, communities, and neighborhoods (Li et al., 2005). Advising individuals to be more physically active without considering social norms for activity, resources and opportunities for engaging in physical activity, and environmental constraints such as crime, traffic or unpleasant surroundings, is unlikely to produce behavior change. Physical activity research has tended to focus on individual-level factors, partly due to the complexity of addressing social and structural determinants of health (Smedley, 2000); however, there is an increased emphasis on the role of social and physical environmental contexts as key modifiable determinants of physical activity.
Social cognitive theory (Bandura, 1986) and other social ecological and contextual models (McLeroy et al., 1988; Sorenson et al., 2003; Stokols, 1992) illustrate the interactive relationship between individuals and environments, and emphasize the need to address behavior at multiple levels of influence. A main premise of these theories and models is that environmental factors and individual factors simultaneously shape behavior. Social environmental characteristics can influence health and behavior directly or indirectly through mediating mechanisms, and these mechanisms likely differ for distinct outcomes. For instance, having supportive social relationships can reduce the probability of individuals adopting unhealthy behaviors by minimizing the impact of daily stressors or stressful events (Berkman & Glass, 2000; Heaney & Israel, 1997). At the same time, social inequalities, such as the unequal distribution of income, can influence health via differential exposure to carcinogens and pathogens, decreased access to healthcare and health facilities, and increased exposure to stressful events (Adler, 2001).
In as much as different mechanisms have been proposed for different social environmental characteristics and health outcomes, the rapidly growing and evolving literature on social environmental characteristics and health currently lacks a taxonomy to help make these important distinctions. Consequently, what is meant by “social environment” can vary considerably from one study to the next, making it difficult to build and interpret a base of evidence. Toward this end, we sought to identify aspects of the social environment that were: (1) commonly studied or cited in the research literature, (2) empirically or theoretically associated with physical activity, and (3) amenable to change through structural or health promotion interventions. We identified three broad overarching categories that represent five social environmental dimensions. These dimensions are not intended to be exhaustive, but represent the most commonly studied “social determinants” or “social factors” cited in the research literature. Broadly, they include: interpersonal relationships (e.g., social support and social networks), social inequalities (e.g. socioeconomic position and income inequality, racial discrimination), and neighborhood and community characteristics (e.g., social cohesion and social capital, neighborhood factors) (Berkman & Kawachi, 2000b; Brennan, Baker, Haire-Joshu, & Brownson, 2003; Faresjo, 1992; Institute of Medicine, 2001; Kaplan, 1999; Stokols, 1992; Yen & Syme, 1999). We readily acknowledge that these dimensions at times overlap and operate at multiple levels; however, this highlights the interconnectedness among many of these dimensions and their shared influence on behavior. Next, we discuss the pathways through which these dimensions may influence physical activity. To date, there have been many proposed hypotheses put forth for how social environmental characteristics influence health and behavior (see Table 1). This paper will illuminate mechanisms specific to physical activity, allowing us to better understand how social environmental factors exert their effects on activity behavior. Following this, we discuss conceptual and methodological challenges posed when investigating environmental effects. We conclude with suggested research and intervention opportunities for social epidemiologists and intervention researchers interested in physical activity.
Section snippets
Interpersonal relationships
Social interactions and interpersonal relationships are an important aspect of the social environment, such that “the degree to which an individual is interconnected and embedded in a community—is vital to an individual's health and well-being…” (Berkman & Glass, 2000). Social support and social networks are two common indicators of interpersonal relationships, respectively describing their composition and structure (Berkman & Glass, 2000; Heaney & Israel, 1997).
Social Inequality
It is well established that the health status of individuals and communities tends to improve with increasing social and economic status (Institute of Medicine, 2003; Lynch & Kaplan, 2000). From the landmark Whitehall studies which found health gradients based on occupational class (Marmot, Shipley, & Rose, 1984) to current health disparities research, social and health scientists have sought to understand how social inequalities, or the unequal distribution of resources based on social status,
Neighborhood and Community Characteristics
Macintyre, Ellaway, and Cummins (2002) asked, “Should we be focusing on places or people?,” raising the question of whether “place” has an independent effect on health. Researchers are trying to answer this question in community and neighborhood studies that control for individual-level factors that place people at risk for adverse health (Cohen et al., 2000; Pickett & Pearl, 2001; Sloggett & Joshi, 1994). This is a broad category representing many characteristics; however, the purpose of this
Challenges and advancements in measuring social environmental characteristics
Recent papers have explored the measurement of environmental factors and their associations with physical activity (Baker, Brennan, Brownson, & Housemann, 2000; Cheadle et al., 1991). To discuss all of the methodological challenges related to measuring each of the social environmental dimensions described would be beyond the scope of this paper; however, a brief discussion of measurement and methodological issues and advancements with respect to measuring social environmental factors is
Conclusion
Research has shown that many health behaviors are determined by not only individual-level factors, but also social environmental characteristics (Emmons, 2000; Sorensen et al., 2003). Yet, few physical activity studies address the social environment in which people live, limiting our understanding of its impact (Emmons, 2000). Though influence of individual-level factors on physical activity is well-studied, research on social environmental influences is understudied but growing. To help
Acknowledgements
This project was supported by the Centers for Disease Control and Prevention contract RO6/CCR717216-02, including dissertation support from the Centers for Disease Control/Prevention Research Center Minority Fellowship. S.V. Subramanian is supported by the National Institutes of Health/National Lung, Blood Institute Career Development Award (1 K25 HL081275-01). We would also like to thank Ross Brownson, Eddie Clark, Kathy Wyrwich, Nancy Weaver, Nancy Krieger, and Karen Emmons for their
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