Elsevier

Annals of Epidemiology

Volume 17, Issue 4, April 2007, Pages 258-269
Annals of Epidemiology

U.S. State-Level Social Capital and Health-Related Quality of Life: Multilevel Evidence of Main, Mediating, and Modifying Effects

https://doi.org/10.1016/j.annepidem.2006.10.002Get rights and content

Purpose

The aim of this study was to investigate the relation between state-level social capital and adult health-related quality of life (HRQOL) in the United States.

Methods

Using data from the 2001 Behavioral Risk Factor Surveillance System survey and other surveys and administrative sources, we conducted a two-level, multivariable analysis of 173,236 adults in 48 U.S. states to estimate the associations of state-level social capital (along two scales) with individual-level self-rated general health and the numbers of recent days of poor physical health, poor mental health, and activity limitation.

Results

For each social capital scale, living in a state intermediate or high (vs. low) in social capital was each associated with 10% to 11% lower odds of fair/poor health. Higher state-level social capital also predicted fewer recent days of poor physical and mental health and activity limitation. Differential returns of social capital to HRQOL according to state-level mean income and individual-level age and race/ethnicity were observed. Furthermore, evidence was found compatible with mediation by social capital of income inequality effects on HRQOL.

Conclusions

This study yields new evidence consistent with protective effects of state-level social capital on individual HRQOL. Promoting social capital may provide a means of improving the health-related quality of life of Americans.

Introduction

Apart from physical resources and amenities, broad social characteristics of the environment, including social capital, are hypothesized to play critical roles in the development of disease and promotion of health (1). Social capital has been conceptualized at both the collective and individual levels, while its greatest currency resides at the collective level (2), where it has been defined as the features of social organization, including social trust, civic participation, and norms of reciprocity that facilitate cooperation for mutual benefit 3, 4.

Several hypotheses have been postulated for how collective social capital produces health benefits 1, 5. Rogers' diffusion of innovations theory (6) has been used to posit that within communities and neighborhoods, social capital may promote the diffusion of knowledge about health-related innovations (e.g., smoking cessation). Drawing on evidence relating collective efficacy to crime (7), social capital may further contribute to informal social control over health-related behaviors, and may plausibly facilitate collective action among residents to ensure access to local services and amenities that may be relevant to health (e.g., green spaces). Additionally, social capital may act through psychosocial processes, including the provision of affective support and mutual respect 1, 5. At higher levels of aggregation such as states, social capital may conceivably improve health through greater political participation, leading to social policies that support spending on public goods such as education and health care 4, 8.

Recent studies have investigated the health effects of state-level social capital by using a comprehensive index developed by the political scientist Robert Putnam (4). These investigations have primarily focused on specific disease or behavioral end points 9, 10, 11 rather than health-related quality of life (HRQOL) outcomes (e.g., self-reported activity limitation). Raising HRQOL and the life expectancy of Americans correspond to one of the two overarching goals of Healthy People 2010 (12). HRQOL measures have also been incorporated into several national and state-based report cards to identify and track health disparities and population trends (13).

Individual-level characteristics including older age, lower income and lack of social support, and behaviors such as smoking and sedentarism have been shown to predict poorer HRQOL 14, 15, 16, 17. Furthermore, mean HRQOL estimates vary by state and region within the United States (14). Such variations may be partly attributed to geographic differences in socioeconomic deprivation, which at the neighborhood level have been empirically linked to HRQOL (18).

To date, only one multilevel analysis (19) has examined the potential mediation of the effects of state-level income inequality on individual health via the erosion of social capital. Moreover, few studies have explored potential interactions between collective social capital and individual-level predictors of health [e.g., race/ethnicity (20)] or area-level socioeconomic status. Identifying such interactions are important because the effects of social capital may not necessarily apply uniformly across population subgroups or geographic regions.

In the present study, applying a multilevel approach, we addressed gaps in the literature by examining whether: 1) U.S. state-level social capital is associated with better individual-level HRQOL outcomes, after accounting for individual- and other state-level characteristics; 2) state-level social capital potentially mediates the association between state-level income inequality and HRQOL; and 3) the estimated returns of state-level social capital to HRQOL are modified (i.e., vary) by state-level mean income and individual-level age and race/ethnicity.

Section snippets

Data Sources

All individual-level measures were obtained from the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey (21). State-level measures for 48 U.S. states (all states except Alaska and Hawaii) were created using data from the Roper Social and Political Trends Archive (years 1990–1994) (22), General Social Surveys (GSS; 1974–1994) (4), DDB Needham Life Style Archive (1994–1998) (23), New Non-Profit Almanac and Desk Reference (1998) (24), U.S. Statistical Abstract (1996, 2000), U.S.

Results

Table 1 provides descriptive statistics for the final sample (173,236 individuals within 48 states); 14.3% of the sample reported being in fair to poor general health, whereas on average there were 3.5, 3.4, and 2.0 days of poor physical health, mental health, and activity limitation over the previous month, respectively.

Discussion

The results of this U.S. study suggest state-level contextual effects of social capital on the HRQOL of adults. Adjusting for individual- and state-level factors, living in a state intermediate or high (vs. low) in social capital of each type was associated with 10% to 11% lower odds of fair to poor self-rated health. Residing in a state higher in ‘SC1’ and in ‘SC2’ was each associated with fewer recent days of poor physical health, poor mental health, and activity limitation. While these

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