Contextual social capital and, in particular, small-area social capital (such as neighborhood social capital) affect health [1
]. Neighborhood social capital can be defined as the access to resources that are generated by relationships between people in a friendly, well-connected and tightly knit community. Such communities are often referred to as 'cohesive communities'. Neighborhood social capital is the outcome of a cohesive community; in Coleman's formulation, it is the resource that "inheres in the structure of relations between actors" [6
]. For example, enjoying a clean and safe playground that was organized and is supervised by the neighborhood is a resource produced by a cohesive neighborhood. One person alone would not have been able to achieve the same goal, even with a high level of human or financial capital. Neighborhood social capital is a public good and is available to all members of a community [6
]. Neighborhoods differ in regard to this public good, which explains some aspects of differences in health between neighborhoods. Although scholars have found a positive association between neighborhood social capital and individual health, the mechanism explaining this direct effect is still unclear. Until now, it has been uncertain how neighborhood social capital affects an individual's health [7
Activities undertaken to satisfy daily needs and leisure activities both start in the neighborhood; for example, the daily commute begins in the neighborhood. Daily needs can also be met entirely in the neighborhood, as by buying groceries in a neighborhood shop or by bringing children to a kindergarten in the neighborhood. At the end of a day, the neighborhood can be the site of recreational activities such as walks or gardening. These daily behaviors might explain how neighborhood social capital 'gets under the skin' [9
] of inhabitants. Figure illustrates a possible mediator effect in a traditional Baron and Kenny [10
] path diagram. The direct effect presented in Figure is as follows: the more neighborhood social capital, the better one's health (c). The mediator is the positive influence of neighborhood social capital on health-related individual behavior (a), which results in improved health, as in path (b).
Model of how neighborhood social capital may affect self-rated health.
Until now, few studies have focused on path (a). We present evidence from studies on subjects that diverge from our research interest because the data on this subject are rare. Cited studies thus differ in regard to the context, the operationalization of social capital, whether contextual social capital was measured at the neighborhood level or only at the individual level, and the health outcome variable.
Some studies indicate an association between contextual social capital and smoking [11
]. A Swedish study found a negative association between individual-level social capital (operationalized as social participation in formal or informal groups in society) and daily smoking [11
]. A multi-level study on 10,617 adults living in 19 urban and rural geographical areas (larger in size than our neighborhood units) in Minnesota, U.S.A., found evidence for a negative relationship between smoking and community social cohesion [12
]. That study used measurements of social cohesion that were similar to our neighborhood social capital measurements.
Some studies link contextual social capital to alcohol consumption [13
]. On the individual and contextual levels (27,687 students in 119 US colleges), Weitzman and Chen [13
] showed that social capital (measured as voluntarism) was significantly negatively associated with several kinds of alcohol misuse. Another study showed that contextual social capital (voting behavior; 1.1 million people in 84 Finnish regions) decreases the risk of alcohol-related mortality [14
Neighborhood social capital has been shown to stimulate physical activity in adults [15
] and children [18
]. A study from Melbourne, Australia (1,405 women in 45 suburban neighborhoods with an average of 4,000-30,000 inhabitants) showed that women who participated in local groups or events and (less consistently) women living in neighborhoods where residents trusted one another were more likely to participate in leisure-time physical activities [16
]. A study on elderly people in Portland, U.S.A., also showed promising results (582 elderly in 56 neighborhoods). Neighborhood social cohesion, in conjunction with other neighborhood-level factors, was significantly associated with increased levels of neighborhood physical activity [17
]. A study using data on the Dutch city Eindhoven and its surrounding areas (4,785 individuals in 213 small neighborhoods) showed no linear association between lack of participation in sports and neighborhood social cohesion [23
] measured on the individual level. However, people living in medium social cohesion neighborhoods were more likely to participate in sports than inhabitants of low or high social cohesion neighborhoods. A study on 6,470 children in four Dutch cities showed that neighborhood social capital (measured at the individual level) was positively associated with outdoor play [18
]. A study on 15 neighborhoods in Amsterdam found that inhabitants of neighborhoods where people do not know each other well tend to bicycle less often than people in other neighborhoods [15
]. In summary, some research literature has already focused on the neighborhood as context and indicated that contextual social capital stimulates different kinds of health-related behavior.
To our knowledge, only three studies [4
] have used behavior as the mediating factor (Figure , paths (a) and (b)) to explain the effect of contextual social capital on health (Figure , path (c)). First, Mohan et al. [24
] showed that the direct effects of several different small-area measurements of social capital on mortality became weaker once health-related behaviors were included in the models. As the authors note, however, mortality might be an insufficiently sensitive indicator of individual health. Subjective health (self-rated health) is a broader measure. Self-rated health is well established as an indicator of morbidity [26
] and a predictor of mortality [27
], and it is more responsive to recent events than other measures. Furthermore, to understand the mediating effect of health-related behavior, behaviors should not be considered all together, as in the study by Mohan et al. Neighborhood social capital might influence different health behaviors in different ways. For example, large quantities of alcohol are often consumed in groups; a well-connected neighborhood might give more opportunities for group drinking than un-connected neighborhoods. At the same time, a well-connected community might disapprove of smoking. The second study that tested behaviors as mediators also considered all behavior mediators together [4
]. Poortinga studied the association between neighborhood social capital and self-rated health using a British data set and found no mediation effect. The third study [25
] analyzed behaviors separately. While changes in exercise, smoking or weight loss were positively associated with individual-level community belonging, changes in alcohol consumption and taking vitamins were not. Some limitations of this study are the measure of community belonging solely on the individual level and the focus on changes in behavior, rather than behavior itself. Moreover, large regions (up to 2.5 million people per region) were used.
In conclusion, it is not clear whether different kinds of health-related behaviors are mediators of the association between contextual-level social capital and individual health. Physical activity seems to be a promising mediator because evidence on the effects of contextual social capital on physical activity is, in comparison to studies on other mediators, the best developed; however, it has not yet been studied as a mediator in a neighborhood study on health. Our study answers the research question: Do health-related behaviors explain the association between neighborhood social capital and individual health?
Neighborhood social capital and individual behavior
Neighbors live close to each other, and therefore, it is likely that neighbors observe and learn from each other's behavior [28
], especially if the individuals involved are strongly socially connected. It can be argued that personal contacts might be easier in the countryside, where every individual knows everyone else from childhood and by name. Behavior that does not conform to the norms of the community might be sanctioned more efficiently in the countryside than in cities because rural inhabitants have fewer alternative opportunities for social contacts. Urban people, however, can also be affected by social capital. Neighbors in cities have more opportunities for daily contacts because they live very close to each other. People who live close might provide 'feedback', which is essential for developing social behaviors [30
]. Norms of behavior are provided by a community and not given by one or two close friends only [9
]. Behavior is a result of internalized community norms, imitation, and social feedback.
If neighborhoods differ in regard to their level of social capital, the effects of norms on inhabitant's behavior will differ between neighborhoods as well. As argued above, focusing on specific behaviors is a necessary strategy to identify how contextual factors may improve health. This approach is especially valuable for prevention strategies and promotion of healthy lifestyles. This study distinguishes five health-related behaviors associated with a healthy lifestyle [31
]. Individual health is related to smoking, drinking, sleeping, and eating habits as well as to physical activity. Neighborhood communities might differentially affect these behaviors because a given behavior may be more common in some neighborhoods than in others. Moreover, some behaviors might be easier to disapprove of than other behaviors. We assume that health-related behavior is beneficially affected by neighborhood social capital. For example, a well-connected community with a common sense of health-related norms might disapprove of smoking. Second, a community with a high level of social capital might intervene or report underage drinking to the parents [33
]. Third, people's sleeping rhythms may adjust to coincide with the time when the lights are switched off in their neighbors' houses. Fourth, patterns of food consumption might also be influenced by the neighborhood (e.g., through the smell of dinners being prepared). Fifth, physical activity might be affected by neighborhood norms as well [17
]. Physical activity refers not only to sports (e.g., soccer or jogging) but also to walking and biking for relaxation or transportation.
We are aware that the positive influence of a well-connected community on behavior is only an assumption. We exclude the possibility that behavior might also be negatively affected by neighborhood norms. For instance, a cohesive neighborhood might provide more opportunities for alcohol consumption, and if community norms trivialized risky behaviors such as driving under the influence of alcohol, the risk of an alcohol-related accident or alcohol addiction would be increased. Norms are difficult to measure and were not included in the data used in this article. In an attempt to compensate for this gap in our knowledge, we tested in pre-analyses whether the religiosity - as an indicator for norms of moderateness- of a neighborhood is an indicator for healthy behavior. We did not find a religiosity effect on health-related behavior, and no interaction of religiosity with neighborhood social capital as influences on health was found. Therefore, we present our analysis without an indicator for health-related norms. To analyze the mediation effect of behavior, we test for each health-related behavior separately whether more neighborhood social capital is associated with more of that health-related behavior.
Behavior resulting in health
The extent to which neighborhood social capital affects health via behavior depends on the degree of influence behavior has on health (Figure , path (b)). Fortunately, a wealth of research confirms that certain behaviors affect health. Tobacco consumption, for example, is associated with morbidity and mortality. A British longitudinal study on physicians showed that non-smokers had a 10-year longer life expectancy than smokers [34
]. Moderate alcohol consumption is positively associated with subjective health in contrast to no or excessive alcohol consumption [35
]. A review by Alvarez and Ayas [36
] showed that a daily sleep routine of 7 to 8 h promotes health, as measured by all-cause mortality. Irregular breakfasts have been shown to be an important risk factor for overweight and obesity in adolescents [37
]. One warm meal per day is also advised [38
]. Regular physical activity is associated with lower morbidity and mortality rates [39
]. In summary, the literature shows that non-smoking, moderate alcohol consumption, seven or eight hours of sleep per night, regular breakfasts, warm meals, and physical activity are related to good health
The direct effect shown in Figure might be explained by behavior and its effect on individual health. The mediation might emerge fully or only partly because, along with behavior, other mechanisms (e.g., psycho-biological explanations or access to facilities) are also responsible for shaping health. To answer our research question, we analyze whether the effect of neighborhood social capital on health is (partly) mediated by health behaviors.
In this article, the moderation hypothesis illustrated in Figure was tested step-by-step. First, the effect of neighborhood social capital on five different health-related behaviors was tested. If a relationship was found, the strength of the behavior's association with self-rated health was reported. Finally, each of these behaviors was tested for whether it weakened the associations between neighborhood social capital and health.