Social context can be divided into two environments: the social environment and the physical environment. Each can separately or interactively exert pressure on the ability of individuals and communities to access necessary resources to support a healthy lifestyle. Some of the components of these environments are related to SES and can be measured at the individual and community/neighborhood levels (e.g., income and educational attainment). The term social environment refers to socioeconomic factors (e.g., employment and educational attainment), social relations (e.g., within a community or workplace), and power arrangements (e.g., political empowerment, individual and community control and influence) [21]. At the community level, other aspects of the social environment include social capital (i.e., a measure of the quality of relationships among community residents), social cohesion (i.e., conditions of mutual trust and solidarity among neighbors), collective efficacy (i.e., a measure of the willingness to help out for the common good), and social control (i.e., the capacity of a group to regulate its members according to desired principles). SES is the component of the social environment that has been studied the most [22].
Social capital has been used as a measure of the social environment in order to elucidate aspects of that environment other than SES that can influence health outcomes and health behaviors. In 2014, the Office of National Statistics in the United Kingdom produced a report that aimed to unify the different measures of social capital [23]. The authors organized social capital into four major areas: (i) Personal Relationships, (ii) Social Network Support, (iii) Civic Engagement, and (iv) Trust and Cooperative Norms. Measures of personal relationships include “Have at least one close friend” and “Meeting with friends or family members at least once a week.” For social networks, measures include, “Have someone to rely on if they have a serious problem,” and “Borrow things and exchange favors with neighbors.”
The next two areas go beyond personal relationships and explore community‐level factors of social capital, including the measure of “Voted in last national election” as a proxy for civic engagement. For trust and cooperative norms, the more salient measures focus on agreeing with the following statements: “Most people can be trusted,” “People in my neighborhood can be trusted,” and “People in my neighborhood are willing to help each other.” Using these measures to understand the type of personal and community relationships from which people can draw support allows for the creation of programs and policies that can leverage these resources for improving health.
Another social construct, collective efficacy [24], measures the ability of communities to harness social environmental factors. This construct uses the concepts of informal social control and social cohesion and trust. Informal social control can be measured by asking respondents about the likelihood that their neighbors could be counted on to intervene in various ways if (i) children were skipping school and hanging out on a street corner, (ii) children were spray‐painting graffiti on a local building, (iii) children were showing disrespect to an adult, (iv) a fight broke out in front of their house, and (v) the fire station closest to their home was threatened with budget cuts, where respondents were given response options from very likely to very unlikely on a five‐point scale. Also on a five‐point scale, the social cohesion and trust construct asks respondents how strongly they agree that “People around here are willing to help their neighbors,” “This is a close‐knit neighborhood,” “People in this neighborhood can be trusted,” “People in this neighborhood generally don't get along with each other,” and “People in this neighborhood do not share the same values.” Collective efficacy and social cohesion have been found to be associated with a variety of social factors and health behaviors, including rates of violence, smoking, and obesity.
Factors in the physical environment that are important to health include harmful substances (e.g., air pollution or proximity to toxic sites), physical surroundings (e.g., neighborhood and work conditions), access to various health‐related resources (e.g., healthy or unhealthy foods, recreational resources, and medical care), and community design and the built environment (e.g., land use mix, street connectivity, and transportation systems) [25]. The built environment includes all of the physical parts of where people live and work (e.g., homes, buildings, streets, open spaces, and infrastructure) [16]. The built environment can be measured subjectively or objectively. Objective measurements include directly observing the presence of litter, the number of abandoned buildings and cars, walkability, presence of green space, and the number or duration of broken windows. Walkability is the measure that is most often used in examining the impact of the built environment on health behaviors. Measurements of walkability include proximity and accessibility to key destinations, availability of sidewalks, availability of trails and parks, safety, and number and location of complex intersections (see example of walkability data in Section 3.5.3).
Subjective measurements include self‐reported perceptions of the accessibility, usability, and condition of buildings and structures in the environment in which one lives. Whether measured separately or together, both subjective and objective measurements of the built environment have been found to affect various health behaviors, including walking, physical activity, and access to healthy foods and health services.
3.5 Selected Examples of the State of the Science in the Field to Illustrate Best Practices
3.5.1 Exploring Health Disparities in Integrated Communities Study
The Exploring Health Disparities in Integrated Communities (EHDIC) study examines health disparities within racially integrated communities among urban Blacks and Whites with similar SES in order to address the issue of confounding between race, SES, and segregation. Confounding by race and SES can be problematic, as health status varies by both factors [26]. The overlap between these factors complicates efforts to understand if it is “race and class” that produces health disparities or “race or class.”
This cohort study collected data through a structured questionnaire and blood pressure measurements from adults in two urban, low‐income, racially integrated contiguous census tracts in southwest Baltimore, Maryland. In order to identify racially comparable communities for the study, the team used the following set of criteria: (i) at least 35% each of Black and White residents, (ii) a ratio of Black to White median income between 0.85 and 1.15, and (iii) a ratio of the percentage of Black to White high school graduates age 25 and above between 0.85 and 1.15. Using these criteria allowed for the examination of health disparities with minimal confounding between race and SES measures, such as income and level of educational attainment [27].
After two contiguous census tracts were selected, every occupied dwelling was identified in the study area, and a letter was mailed to all occupied dwellings to notify residents about the study. Various recruitment methods were used, including door‐to‐door visitation, walk‐ins at the study's administrative office, and community‐based health fairs [27].
The results indicated that Blacks had lower rates of both smoking and fair or poor self‐rated health as compared to Whites. However, no race differences were observed in obesity, drinking, or physical inactivity (see Table 3.4). The results suggest that considering race differences in exposure to social conditions reduces or eliminates some health‐related disparities. Further analyses from the EHDIC study sought to determine if racial health disparities, which are typically reported in national‐level studies, persist when Blacks and Whites live in integrated settings [26]. The study results indicated that nationally reported disparities, including hypertension, diabetes, obesity among women, and use of health services, lessened or disappeared altogether in racially integrated communities. The one exception was smoking, which was higher among White residents. This study demonstrates that racial differences in social environments explain a significant portion of disparities reported in national data, and that when social factors are leveled, racial disparities are reduced.
Table 3.4 Summary of previously published findings from the Exploring Health Disparities