In this population-based cohort of older adults, greater neighborhood-level social cohesion was associated with significantly reduced risk of stroke mortality but not incident stroke. The association with stroke mortality was independent of known stroke risk factors and neighborhood-level SES, and was not attenuated by the control for individual-level measures of social network and engagement. Findings suggest that aspects of the neighborhood social environment may affect stroke risk among older adults, a demographic group in which neighborhood effects may be particularly salient.(11
The observed protective effect of neighborhood cohesion on stroke mortality is consistent with previous studies. Neighborhood-level cohesion has been linked to heart disease,(24
) all cause mortality,(25
) self-rated health,(26
) physical activity,(29
) and measures of mental health.(26
) The findings of this study are also consistent with the overlapping literature on the health effects of social capital.(33
) However, we failed to find a significant association between neighborhood cohesion and incident stroke in our cohort. The reason for this pattern of mixed findings is unclear; one possibility is that neighborhood conditions deemed cohesive may be more related to rapid access to acute care, thereby reducing mortality, but less related to onset of stroke. Social support and access to services have been theorized as potential mechanisms linking neighborhood conditions and individual health (36
) and recent longitudinal research has found a significant protective relationship between social support and stroke mortality but not stroke incidence(37
) offering a credible explanation for why cohesion may be related to stroke mortality but not incidence. In this study, the size of one’s social network was not a mediator of the relationship. However, a much more robust measurement of social support is needed to examine it as a potential pathway. An important area for future research will be to investigate potential pathways by which neighborhood cohesion can protect health.
The protective effect of cohesion on stroke mortality did not extend to older blacks in this cohort. We did not observe a similar interaction between race and cohesion with respect to first-ever strokes. Blacks reported lower neighborhood social cohesion than whites, but the reasons for the observed racial differences in the effect of cohesion on stroke mortality are not clear. The literature on race/ethnicity differences in the health-protective effects of neighborhood cohesion is mixed. While similar beneficial effects of neighborhood social cohesion on hypertension risk have been reported across racial and ethnic categories,(31
) other studies have found that neighborhood cohesion is only related to poor mental health(13
) and cardiovascular mortality(12
) among whites. Further research is warranted to examine the mixed pattern of black-white differences such as those observed here.
The results of this study must be tempered by its limitations. We relied on participants’ own perceptions of the neighborhood social climate and aggregated them to the census block level, potentially conflating neighborhood conditions and individual perceptions. The fact that the effect of neighborhood social cohesion on stroke mortality did not change when we controlled for individual measures that are related to social cohesion, i.e., social network and social engagement, suggests that the social cohesion measure captured a phenomena distinct from individual level attributes. However, despite being theoretically-based, and having demonstrated good construct validity and internal reliability in previous research, the neighborhood-level measure of social cohesion also demonstrated poor agreement among residents in the same neighborhood.(15
) This is not uncommon among neighborhood level measures(15
) and may be caused by incongruity between neighborhood perceptions and block group boundaries, spatial correlation among the neighborhoods, or genuine differences among individuals living in the same block group.(15
) The fact that the aggregated measure operated as expected, even when related individual measures were controlled for and despite potentially low correlation among individuals in the same block group, supports its usage as a viable neighborhood level construct. Nevertheless, more research is needed to examine reasons for such low correlation and a more direct control of individual level perceptions of social cohesion would strengthen the results. In addition, the generalizabilty of the study’s findings may be limited to black and white elders residing in stable, urban neighborhoods. Further research on a broader range of ages, race/ethnicities, and locations is needed.
This study found that neighborhood level social cohesion was protective against stroke mortality but not stroke incidence in a cohort of older adults. Moreover, the benefits of cohesion on mortality risk were evident among whites but not blacks. Given the importance of neighborhood environments to older individuals and that fact that the population is rapidly aging, the characteristics of neighborhoods are and will continue to be of relevance to public health policies.