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date: 19 August 2017

Neighborhood Considerations for Social Determinants of Health and Risk

Summary and Keywords

When it comes to health and risk, “place” matters. People who live in lower-income neighborhoods are disproportionately affected by obesity and obesity-related diseases like heart disease, hypertension, and diabetes; asthma; cancers; mental health issues; etc., compared to those that live in higher-income communities. Contributing to these disparities are individual-level factors (e.g., education level, health literacy, healthcare access) and neighborhood-level factors such as the socioeconomic characteristics of the neighborhood; crime, violence, and social disorder; the built environment; and the presence or absence of health-enhancing and health-compromising resources. Social determinants of health—for example, social support, social networks, and social capital—may improve or further complicate health outcomes in low-income neighborhoods.

Social support is a type of transaction between two or more people intended to help the recipient in some fashion. For instance, a person can help provide someone who is grieving or dealing with a newly diagnosed health issue by providing emotional support. Informational support may be provided to someone trying to diagnose, manage, and/or treat a health problem. Instrumental support may come in the help of making meals for someone who is ill, running errands for them, or taking them to a doctor’s appointment. Unfortunately, those who may have chronic diseases and require a lot of support or who otherwise do not feel able to provide support may not seek it due to the expectation of reciprocity. Neighborhood features can enable or constrain people from developing social networks that can help provide social support when needed. There are different types of social networks: some can enhance health outcomes, while others may have a more limiting or even a detrimental effect on health. Social capital results in the creation of resources that may or may not improve health outcomes.

Communication infrastructure theory offers an opportunity to create theoretically grounded health interventions that consider the social and neighborhood characteristics that influence health outcomes. The theory states that every neighborhood has a communication infrastructure that consists of a neighborhood storytelling network—which includes elements similar to the social determinants of health—embedded in a communication action context that enables or constrains neighborhood storytelling. People who are more engaged in their neighborhood storytelling networks are in a better position to reduce health disparities—for example, to fight to keep clinics open or to clean up environmental waste. The communication action context features are similar to the neighborhood characteristics that influence health outcomes. Communication infrastructure theory may be useful in interventions to address neighborhood health and risk.

Keywords: built environment, communication infrastructure theory, civic engagement, collective efficacy, environmental inequities, health disparities, neighborhoods, social capital, social support

Scholars have debated whether “place” still matters in today’s globalized society. This piece draws upon the work of Sampson (2012) and others who have argued that “differentiation by neighborhood is not only everywhere to be seen, but that it has durable properties—with cultural and social mechanisms of reproduction—and with effects that span a wide variety of social phenomena. Whether it be crime, poverty, child health, protest, leadership networks, mobility flows, collective efficacy, or immigration . . . the city is ordered by a spacial logic (‘placed’) and yields differences as much today as a century ago . . . Spacially inscribed social differences . . . constitute a family of ‘neighborhood effects’ that are pervasive, strong, cross-cutting, and paradoxically stable even as they are changing in manifest form” (Sampson, 2012, p. 6).

In health and risk, this is illustrated by evidence that shows that individuals who live in lower-income neighborhoods are at an increased risk for obesity and obesity-related diseases like hypertension, heart disease, and diabetes as compared to those that live in higher-income neighborhoods (Booth, Pinkston, & Poston, 2005; Brisbon, Plumb, Brawer, & Paxman, 2005; Gordon-Larsen, Nelson, Page, & Popkin, 2006). Contributing to these disparities are individual-level factors, such as income (Wilkinson, 1997); health literacy (Rudd, Kirsch, & Yamamoto, 2004); self-efficacy (Streecher, DeVellis, Becker, & Rosenstock, 1986); amount and type of social support (Cohen & Syme, 1985); and a lack of health insurance and/or healthcare access (Lurie, 2007). However, there are also neighborhood-level factors like the amount of social cohesion, social capital, and collective efficacy (Kawachi & Berkman, 2003); crime, violence, and social disorder (Wilkinson, Kawachi, & Kennedy, 1998); healthcare access (Lurie, 2007); and the quality of healthcare (Derose, Bahney, Lurie, & Escarce, 2009); a lack of access to healthy foods (Walker, Keane, & Burke, 2010); and/or the prevalence of unhealthy fast foods (Ver Ploeg et al., 2009); aspects of the built environment (Brisbon et al., 2005; Weich et al., 2002); the conditions of housing options (Krieger & Higgins, 2002); and the like affecting health disparities.

In this piece, neighborhood-level social determinants of health are explored. First, key social determinants of health are identified. Then, neighborhood characteristics that impact health both directly, and indirectly through social determinants, are discussed. Finally, communication infrastructure theory is introduced to provide a theoretical foundation for understanding how social determinants and neighborhood characteristics interact to produce health outcomes and to offer a theoretically grounded approach for interventions to reduce health and risk in neighborhoods.

Discussion of the Literature

Social Determinants: Social Support, Social Networks, and Social Capital

Several social determinants influence health outcomes. In this section, those that are most pertinent to the field of communication—social support, social networks, and social capital—and neighborhoods are introduced.

Social Support

Social support, at its most basic level, is “an exchange of resources between at least two individuals that is perceived by the provider or the recipient to be intended to enhance the well-being of the recipient” (Shumaker & Brownell, 1984, p. 13). There are both potential costs and benefits associated with social support. The norm of reciprocity suggests that people who benefit from receiving social support will feel indebted to return the gesture, which can occur at a cost to themselves (Shumaker & Brownell, 1984). For example, if someone takes you to the doctor when you are sick, then you will likely feel the need to repay him or her for the act, which costs the provider time out of his or her day and gas money.

Types of social support include emotional (e.g., listening to a person’s problems, showing concern, offering words of affirmation), informational (e.g., providing knowledge/information, suggestions, advice), and instrumental (e.g., providing help in achieving goals). For instance, a person may offer informational support in the form of tips on how to reduce health symptoms or provide instrumental support by driving you to doctor’s appointments, helping pay for medical bills, watching your children while you are in the hospital, and the like.

Social support has both direct (e.g., by providing ways to help solve health problems) and indirect impact on health outcomes (Cohen & Syme, 1985). For instance, the stress-buffering model suggests that the knowledge that one has access to in terms of social resources is enough to counteract or buffer against stress, which can help both mental health and general well-being (Cohen, Underwood, & Gottleib, 2000). It is also important to note that social support does not always lead to positive health outcomes (Shumaker & Brownell, 1984). For instance, a person who is providing support to someone who is chronically ill may experience a lot of stress due to the time and emotional demands of providing social support. The person receiving support may become stressed if there is a perceived imbalance in social support and they are unable to provide support in return. Features of the neighborhood, to be discussed in more detail later, can influence one’s ability to both give and receive social support. Social support is generally provided by people within one’s social networks.

Social Networks

Social networks refer to “ties that cut across traditional kinship, residential, and class groups to explain behaviors they observed such as access to jobs, political activity or marital roles.” (Berkman, Glass, Brissette, & Seeman, 2000, p. 845). According to social network theory, people have both strong ties (i.e., the people to whom you are closest and interact with often) and weak ties (i.e., acquaintances; people who you interact with less frequently or with whom you discuss only surface level information, like the weather) in their social networks. Some research has suggested that strong ties with people who are similar can help provide emotional support, whereas weak ties with dissimilar people may provide wider access to diverse resources (Wellman & Wortley, 1990).

A key assumption of social network theory is “that the social structure of the network itself is largely responsible for determining individual behavior and attitudes by shaping the flow of resources that determine access to opportunities and constraints on behavior” (Berkman et al., 2000, p. 845). For example, an acquaintance might put you in touch with their cousin who has the same rare disease and can provide informational support. Likewise, an acquaintance who is a medical researcher or doctor at a hospital could help get your relative an appointment to see a specialist (a means of instrumental support), which may increase their odds of survival. Social network theory does not presume that people interact within the constructs of a place-based/spacially structured “community” or “neighborhood” (Berkman et al., 2000). In fact, there are occasionally news stories about people who have diagnosed rare diseases by posting pictures or information on social media and having a weak tie who is a doctor recognize the symptoms. However, ample research demonstrates the importance of social networks in improving neighborhood health outcomes (Berkman et al., 2000; Cattell, 2001). Therefore, while social networks can exist beyond the constructs of a neighborhood, they are still an important factor affecting health within neighborhoods.

Social Capital

Social networks—both informal and formal—are important for building social capital, “a resource produced when people cooperate for mutual benefit” (Cattell, 2001, p. 1502). Coleman (1988) defines social capital “by its function. It is not a single entity but a variety of different entities, with two elements in common: they all consist of some aspect of social structures, and they facilitate certain actions of actors—whether persons or corporate actors—within the structure.” (p. S98). It is essentially the resources that are created through the relations of people within a social network. Neighborhoods with higher levels of social capital are more likely to provide the types of resources that make social support possible (Kawachi & Berkman, 2003; Matsaganis, 2015). As a result, much research has explored the potential positive impact of social capital on health outcomes. The research findings, however, have been mixed; not all studies have found a statistically significant positive association between social capital and health outcomes as originally predicted (Cattell, 2001). For instance, a study in Norway found that social capital was positively associated with life satisfaction, but not with self-rated health (Maass, Kloekner, Lindstrøm, & Lillefjell, 2016). Some of the variation in research findings may be the result of differences in conceptual and operational definitions of social capital in the studies. Alternatively, it could be that the relationship between social capital and health is more complex than originally thought and, thus, affected by more variables. This latter idea is explored further in the following sections detailing neighborhood-level determinants of health.

Neighborhood-Level Determinants of Health

Several neighborhood characteristics influence health outcomes. This section discusses the role of a number of these—neighborhood socioeconomic characteristics; crime, violence, and social disorder; the built environment; and the presence of health-promoting or health-compromising resources—on health outcomes. The relationship between each neighborhood characteristic and social determinants, and thus, the relative impact on health outcomes, are discussed.

Neighborhood Socioeconomic Characteristics

Socioeconomic factors—that is, whether a neighborhood is predominantly lower, middle, higher, or mixed income—influences health outcomes. Those living in lower-income neighborhoods are disproportionately impacted by a multitude of diseases (Booth et al., 2005; Brisbon et al., 2005) and may have access to fewer health-promoting resources (Sloane et al., 2006; Walker et al., 2010), which can compound health risk. For instance, a study in Denmark found that neighborhood deprivation—operationally defined as having a high concentration of low income, low education, and unemployed residents—was associated with a lower likelihood of having a population-based health check (Bender, Kawachi, Jørgensen, & Pisinger, 2015). The health checks are designed to promote health screenings and preventative health behaviors aimed at reducing health disparities for lower-income residents. The results indicated that there are factors reducing the likelihood of those living in depraved neighborhoods from having the health check. Further, low-income neighborhoods may have more health-compromising resources like fast food and liquor stores (Sloane et al., 2006) and increased environmental health risks (Strife & Downey, 2009) as discussed in more detail below.

Research has explored how the social determinants introduced above impact health outcomes in lower-income neighborhoods. When it comes to social support, living in lower-income neighborhoods can affect both the ability to provide social support and limit the types of social support one is able to provide. First, as mentioned above, the norm of reciprocity suggests that there is an anticipation that if you receive social support, then you will need to provide support in return. People who are unable to provide social support may be less likely to ask for or accept social support (Shumaker & Brownell, 1984). While it may be difficult for people in any socioeconomic status to find the time and energy required to provide certain forms of social support, it may be particularly difficult for those in lower-income neighborhoods. For example, research shows that people with chronic health issues may be reluctant to seek assistance knowing that their disease may require long-term assistance and may prevent them from being able to provide assistance in return (Shumaker & Brownell, 1984). As indicated previously, people in lower-income neighborhoods are more likely to suffer from chronic illnesses (Booth et al., 2005; Brisbon et al., 2005), which thereby affects both their need for support and their ability to provide it.

Second, neighborhood composition can affect the type of support provided by people who live there. For instance, lower-income individuals tend to have lower levels of health literacy (Rudd et al., 2004). Health literacy is a composite term that describes the ability to obtain, process, and understand basic health information and function appropriately in the healthcare environment (Ratzan & Parker, 1999). Studies have established a link between inadequate health literacy and lower levels of health knowledge (e.g., Gazmararian, Williams, Peel, & Baker, 2003; Williams, Baker, Parker, & Nurss, 1998). Therefore, if there are lower levels of health literacy among those with lower incomes, then the people living in lower-income neighborhoods may be unable to provide adequate informational support to each other when someone is facing a health crisis. For example, residents in a low-income neighborhood in Atlanta, Georgia, with a high use of emergency health services for nonemergency care explained that while they understand conceptually that emergency means “life-threatening,” they are often unable to determine if what they or a family member are experiencing is an emergency (Wilkin, Tannebaum, et al., 2012). They generally did not have someone in their social network with the informational knowledge that was required to determine best treatment. The emergency healthcare system can also provide instrumental social support. For example, an ambulance will provide transportation to a healthcare facility if it is required, which eliminates the need to ask someone for a ride. There is an added bonus for using formal providers of support, like healthcare providers, in lower-income neighborhoods. These sources do not have the same expectation of reciprocity as found in informal networks (Shumaker & Brownell, 1984). Therefore, those facing chronic health issues who fear the inability to reciprocate may prefer seeking informational and instrumental social support from healthcare providers.

Researchers have explored social networks and social capital with relation to the socioeconomic characteristics of neighborhoods as well. Cattell (2001) sought to understand the relationship between poor neighborhoods, social networks, social capital, and health outcomes. The research, conducted in poor neighborhoods in London, England, found that it is more complex than previous research suggested. Essentially, lower-income neighborhoods do not automatically produce social networks that are incapable of providing the types of social support needed to improve health outcomes. Cattell identified multiple types of social networks within the poorer neighborhoods—the socially excluded or truncated network, the homogeneous network, the traditional network, the heterogeneous network, and the network of solidarity—and determined that they had differential impacts on health outcomes. For instance, people who are more isolated have what was termed “socially excluded networks.” This type of network was associated with more negative health perceptions and outcomes (e.g., low self-esteem and perceived behavioral control; poor physical and mental health). Meanwhile, people who participated in local activities had more opportunities to increase their social networks, which had a positive impact on health perceptions and health outcomes. Homogeneous networks tend to provide practical, or instrumental, support and operate with the expectations of reciprocity. Heterogeneous networks provide more access to resources and a larger range of support. Cattell (2001) cited examples of study participants who had moved from a more socially excluded network to a larger homogeneous or heterogeneous network as well as those who lost a key member of a social network, resulting in the person moving to a more socially excluded network. This research indicates that social support networks can either positively or negatively influence health outcomes in poorer neighborhoods. Additionally, it is possible to move from a socially isolated network to one that can provide social support.

Crime, Violence, and Social Disorder

Social disorganization exists when a community is unable to identify common values and establish a form of social control among residents (Sampson & Groves, 1989). Social organization reduces the likelihood of gang and crime activity. Crime, violence, and social disorganization have both direct and indirect impacts on physical and mental health (Wilkinson et al., 1998). For instance, people who live in neighborhoods with higher crime rates have lower social trust and higher mortality rates, even when excluding homicide from the analysis (Wilkinson et al., 1998). A study of older adults living in Detroit, Michigan, USA, found an association between the presence of neighborhood watch signs (suggesting a perceived need for a crime watch) and older adults who reported higher levels of social withdrawal and isolation (Kim & Clarke, 2015). In a global study of youth, Mmari, Marshall, Hsu, Shon, and Eguavoen (2016) found that youth living in both Baltimore (USA) and Johannesburg (South Africa) were less likely to seek medical care when needed if they lived in neighborhoods with higher levels of community violence. However, crime was not the only indicator of healthcare seeking in these cities. Social support from an adult living in their home was more likely to increase likelihood to seek medical care, suggesting that in neighborhoods with higher crime rates, social support can have a positive impact on health outcomes for youth.

Social integration is related to reduced health risks, while isolation may increase stressors, and thus have a negative impact on health (Cohen et al., 2000). Areas with a high level of crime and violence can lead to more social isolation; people hoping to reduce their chances of being a victim of a crime may avoid places and events where crime might be high. It can also make physical activity more difficult—for example, it limits people’s ability to walk, bike, and play outside. Gang activity may prevent people from being able to access health-promoting resources. For example, residents may avoid a health clinic that is located in an area contested by rival gangs or not patronize a convenience store or restaurant where criminal behavior is taking place. Finally, if the local parks are the sight of drug deals and prostitution, parents and children are not going to go there for social events. Social organization necessitates the ability of people to gather together to form a plan to combat crime and violence (e.g., a neighborhood watch), which is more difficult when gangs are around. However, social disorganization and crime reduces the opportunities that people have to participate in the type of local activities that Cattell (2001) suggests increase social networks, social support opportunities, and relative health benefits.

Built Environment

The built environment is essentially all human-made aspects of a neighborhood, including public spaces like plazas; parks and recreation areas; and parking lots where people can gather, interact, and participate in activities. The built environment also includes commercial and residential buildings, factories, signs, and roadways. Aspects of the built environment have been linked to disparities in mental health (Kim & Clarke, 2015; Kreuter, Kegler, Joseph, Redwood, & Hooker, 2012; Weich et al., 2002) and physical health (Booth et al., 2005; Brisbon et al., 2005). For example, Kreuter and colleagues (2012) found that the vacant and overgrown properties in Atlanta, Georgia, USA neighborhoods were contributing to poor mental health. Frank and colleagues (2006) found that “people living in more walkable neighborhoods (characterized by mixed use, connected streets, high residential density, and pedestrian-oriented retail) did more walking and biking for transportation, had lower BMIs, drove less, and produced less air pollution than people living in less walkable neighborhoods” (p. 82).

Lower income, racial minority neighborhoods tend to have higher risk of exposure to both indoor and outdoor environmental hazards, increasing risk for diseases like cancer (Strife & Downey, 2009). A study of the neighborhoods in the City of Dortmund, Germany, found that environmental health risk factors (e.g., noise pollution, air pollution, and amount of green space) tend to cluster together in lower-income neighborhoods contributing to health inequities (Flacke, Schüle, Köckler, & Bolte, 2016). The purpose of the study was to map the different environmental risk factors to identify areas for urban planning and development designed to reduce health risks. They used databases that illustrated land use and pollution to identify neighborhoods with greater environmental health risks. Outdoor environmental risks can increase due to the presence of factories; illegal dumping of environmental waste; and highways, which can have a negative impact on those who experience asthma and other bronchial diseases (Brisbon et al., 2005). Due to their size, factories can also drastically reduce the amount of green space in a neighborhood, which is important for mental and physical health and for reducing environmental toxins (Strife & Downey, 2009).

If the built environment makes outdoor activities more hazardous, then people may spend more time indoors. However, lower-income neighborhoods also have increased likelihood of health risks associated with poor housing conditions (Krieger & Higgins, 2002). For example, use of lead-based paint and pipes, a lack of hot water needed to clean and sanitize dishes, the presence of cockroaches, and black mold, among other factors, contribute to health disparities (e.g., lead poisoning, infections, respiratory issues).

Built environmental factors not only directly contribute to health disparities, but they contribute indirectly through their relationship to social determinants of health. For instance, walkable communities with greater access to transit and resources and structural support for physical activity (sidewalks, street connectivity, recreation facilities) are associated with more interactions between neighbors (Child et al., 2016). This leads to greater opportunities to expand social networks and provide social support for improving health outcomes. People living in neighborhoods with well-maintained bicycling facilities (e.g., bike lanes, racks) report higher amounts of social support for physical activity from people within their social networks (Child et al., 2016), which may improve physical health outcomes. In addition, improvements to the built environment may reduce neighborhood stressors (e.g., noise pollution, crime/violence, and fear of crime) and increase social cohesion and identity among community members, which can lead to increased physical activity and better health outcomes (Brown, Werner, Smith, Tribby, & Miller, 2014).

Health-Promoting and Health-Compromising Resources

Every neighborhood is located within “a resource environment for medical care, recreation, food, and other health-promoting or health-compromising goods and services that affect the lives and health of its residents” (Sloane et al., 2006, p. 146). Features of the built environment like parks, trails, playgrounds, and other public spaces that promote physical activity are examples of neighborhood health-promoting resources. Other health-promoting resources include gyms and recreation centers, doctors’ offices, restaurants that sell healthy foods, grocery stores and farmer’s markets that sell fresh produce, drug stores and pharmacies, etc. For example, a study of rural communities in Nepal found that neighborhoods that included social resources such as schools, markets, health services, and social support groups are more likely to report better mental health outcomes on a variety of indicators (Axinn, Ghimire, Williams, & Scott, 2015).

In general, lower-income neighborhoods tend to lack health-enhancing resources that are prevalent in higher-income neighborhoods. For example, they are often considered “food deserts” due to a lack of healthy food options, like quality fruits and vegetables (Booth et al., 2005; Walker et al., 2010) and “food swamps” due to higher concentrations of unhealthy food options (Ver Ploeg et al., 2009). When a grocery store is present, there may be lower-quality foods than found in higher-income neighborhood grocery stores (Sloane et al., 2006). Additionally, health-compromising products like tobacco and fast food are marketed specifically to lower-income communities through billboards and other point-of-purchase advertisements and incentives. Studies have also found that neighborhoods with a greater percentage of African American or Latino residents tend to have fewer drug stores and greater medication costs (Matsaganis, 2015).

Lower-income neighborhoods often lack primary healthcare services. Even when the health-promoting resource is present, there are often barriers to use, such as work constraints; a lack of transportation; competing time demands, including providing social support for others; and a fear for personal safety (Diamant et al., 2004). Additionally, constraints like long wait times, having to schedule appointments far in advance, and excessive paperwork can discourage patient use of primary care facilities (Rust et al., 2008; Wetta-Hall et al., 2005). Factors of the built environment can also make it more difficult to get to primary healthcare facilities (Wilkin, Cohen, & Tannebaum, 2012). People who live in lower-income neighborhoods, as discussed above, are more likely to be affected by a number of chronic health issues. Primary healthcare could provide opportunities to manage these diseases and avoid complications that lead to use of emergency healthcare services. Long waits at both primary and emergency healthcare facilities can reduce opportunities that residents get to engage with others in their neighborhood. It may also affect residents’ ability to attend community events. This can affect their ability to connect or expand their social networks, and likewise, opportunities for social support (Cattell, 2001).

Social support networks can be particularly important in neighborhoods lacking health-enhancing resources. People who desire healthier foods or access to health facilities may need to leave the neighborhood, reducing opportunities to interact with neighbors to “problem solve” locally. However, their ability to leave the neighborhood to access health-enhancing resources may be dependent upon having a social network that can provide transportation (a noted barrier to primary healthcare access). As Cattell’s (2001) study found, it is possible for residents of low-income neighborhoods to be part of different types of social networks, some that might provide the type of social support needed to improve health outcomes, while others may not have the resources to do so. For instance, some residents may have family, friends, or neighbors who can drive them to medical appointments, to the grocery store, and/or watch children while someone is waiting at a medical facility. In some neighborhoods, community organizations and/or community leaders operate programs that pick up older residents and those with disability and take them to the grocery stores. This is one way that social organization can improve health outcomes.

Social Determinants and Neighborhood Effects: Role of the Communication Infrastructure

The introduction to this article addressed the debate about whether “place” still matters in our globalized society. Thus far, this piece has demonstrated that the socio-spacial features of neighborhoods do indeed affect health outcomes. Given this knowledge, the question becomes, how can we intervene to improve neighborhood health outcomes? Communication infrastructure theory developed out of research conducted by the University of Southern California Annenberg School for Communication and Journalism’s Metamorphosis Project (www.metamorph.org). The project aimed to address the question about whether place still mattered in 20th-century urban neighborhoods. The initial focus of the project was on civic engagement, but research has since explored the utility of the theory in other areas, such as health interventions. In this section, the basic tenants of communication infrastructure theory are introduced; how the social and neighborhood determinants discussed above are captured within the theory is discussed; and finally, how communication infrastructure theory can be used to create neighborhood-based health interventions is explored.

Communication Infrastructure Theory

Communication infrastructure theory (Ball-Rokeach, Kim, & Matei, 2001) posits that every neighborhood has a communication infrastructure that consists of two components: the storytelling system and the communication action context. The storytelling system is comprised of storytelling agents who tell stories about the macro-level (e.g., national and international media and organizations), the meso-level (e.g., community-based organizations and local and ethnic media), and micro-level (e.g., residents and their individual social networks). Within neighborhood settings, a storytelling network of meso- and micro-level storytellers—residents talking to other residents within their social networks, community-based organizations, and local and ethnic media—play an important role by telling neighborhood stories. The communication action context consists of the various factors that enable or constrain the ability of storytelling agents to interact. Communication hot spots (i.e., places people naturally gather and “meet and greet” each other) and comfort zones (i.e., organizations and businesses where people feel comfortable) are places that can enable communication (Wilkin, Stringer, O’Quinn, Hunt, & Montgomery, 2011).

Residents who indicate that they are more integrated into the neighborhood storytelling network—that is, they have discussions with other neighbors and connect to local/ethnic media and community organizations—have higher levels of civic engagement. They are more likely to indicate feeling and acting like they belong to the neighborhood, have higher levels of collective efficacy, and greater levels of political participation (Kim & Ball-Rokeach, 2006). Research on communication infrastructure theory and health outcomes has demonstrated a positive association between integrated connections to the neighborhood storytelling network and various health outcomes, such as increased knowledge about certain health issues (Kim, Moran, Wilkin, & Ball-Rokeach, 2011), greater levels of exercise (Wilkin, Katz, Ball-Rokeach, & Hether, 2015), and emergency preparedness behaviors (Kim & Kang, 2010). However, integrated connections to the neighborhood storytelling network is not always positively associated with better health outcomes. Studies found no relationship to integrated connections to the neighborhood storytelling network and amount of fruits and vegetable consumed (Wilkin et al., 2015) or to knowledge about health topics that are more taboo (e.g., prostate cancer) and thus, less likely to be discussed among neighborhood storytellers (Kim et al., 2011). There were also mixed results when it comes to access to healthcare resources (Wilkin, 2013).

Social Determinants and Communication Infrastructure Theory

One of the storytelling agents identified as an integral part of a neighborhood storytelling network within communication infrastructure theory is the residents and their social networks (Ball-Rokeach et al., 2001). The more people interact with others within their social networks to tell neighborhood stories, the more they think and act like they belong to a neighborhood. As discussed earlier, social networks can have a positive influence on health to the extent to which they are able to offer positive forms of social support (Berkman et al., 2000; Cattell, 2001).

Matsaganis and Wilkin (2014) argue that individuals’ integration into their neighborhood storytelling network is similar to the concept of communicative social capital, which shifts the conceptualization of social capital from a “source of social control, social support, or societal benefits . . . to a source of social integration” (Rojas et al., 2011, p. 694). Another distinction between social capital and communicative social capital lies in the recognition of the role that media and other communication resources play in developing neighborhood-level social capital resources. Essentially, individuals’ level of communicative social capital is determined both by their own effort to connect to other neighborhood storytelling agents, but also by the extent to which the neighborhood storytellers collectively discuss issues and concerns that are of shared interest to those living in the neighborhood (Matsaganis & Wilkin, 2014).

A key factor in this conceptualization is that neither an individual’s effort to connect to a neighborhood storytelling network, nor the extent to which the various neighborhood storytellers themselves are connected to each other, is sufficient to lead to beneficial health outcomes. It is the extent to which the different neighborhood storytellers work together to both identify and solve neighborhood health issues that is going to make a difference in neighborhood health outcomes. For instance, if a neighborhood is located in a food desert, then one cannot expect integrated connections to the storytelling network to increase fruit and vegetable consumption; neighborhood storytellers would need to identify a lack of healthy food options within the neighborhood as a problem worth collectively solving (Wilkin et al., 2015). In the case of healthcare access, Matsaganis and Wilkin (2014) found that for residents in South Los Angeles, California, USA neighborhoods who were in poorer health and those that lacked health insurance, integrated connections to the neighborhood storytelling network was associated with a greater perceived difficulty accessing health-enhancing resources. A major trauma center in their neighborhood was closing and the different neighborhood storytellers had been actively working together to try to prevent the closure (as it was not the first health resource to close). Thus, connections to the integrated network highlighted the potential problem of accessing healthcare for those most in need of the health resources. The same was not true for those who were in good health and/or who had adequate health insurance, and thus, were more likely to have other healthcare options. Connecting to the neighborhood storytelling network was not associated with their perceptions of access to health resources.

Neighborhood Factors and Communication Infrastructure Theory

As mentioned above, the communication action context is full of factors that may enable or constrain one’s ability to connect to storytelling agents (Ball-Rokeach et al., 2001). The various neighborhood factors discussed above as having an impact on health outcomes—for example, neighborhood socioeconomic characteristics; crime, violence, and social disorder; the built environment; and neighborhood health-enhancing or health-compromising resources—can act to enable or constrain communication between neighborhood storytellers (Wilkin, 2013). For instance, a neighborhood’s socioeconomic composition may affect the extent to which there are local media, including newsletters or social media sites that tell stories about the neighborhood. It may also affect the number and type of community-based organizations or the accessibility of these organizations via the walkability of the neighborhood. In neighborhoods in which there is high crime or violence, fear of victimization may limit the number of places that people go or the amount of time they spend in places where they might interact with other neighborhood storytellers. In other words, it may limit their ability to expand their social networks (Cattell, 2001), as well as their ability to connect to other neighborhood storytellers like community-based organizations and health-promoting resources.

Built environment features can likewise enhance or reduce opportunities to connect to other neighborhood storytellers (Wilkin, 2013). For instance, parks and recreation areas can be a place where people can gather and talk about their neighborhood. They have the potential to be a communication hot spot—that is, a place where people naturally gather and communicate with each other (Wilkin et al., 2011). However, if they are nonexistent, unkempt, hazardous, or crime-ridden, then they might not function as a communication hot spot within the communication action context. Likewise, a healthcare resource like a neighborhood healthcare clinic could serve as a community comfort zone—that is, a business or organization that people trust/where they feel comfortable (Wilkin et al., 2011). Though if there are too many barriers to using the facility (e.g., wait times, hours of operation, transportation issues, etc., as discussed above), then the healthcare facility may not be able to serve that function within the communication action context. Likewise, some of the barriers identified earlier as creating barriers to primary healthcare access—for example, a lack of transportation, work constraints (Diamant et al., 2004)—may also prohibit residents’ ability to connect with neighborhood storytellers.

Communication Infrastructure Theory-Informed Neighborhood Health Interventions

Communication infrastructure theory lends itself to serving as a basis for theory-driven neighborhood health interventions because it brings together the socio-structural elements typically found to influence neighborhood health outcomes. Initially scholars proposed that neighborhood health interventions follow these basic steps when using communication infrastructure theory as the basis for an intervention: (1) identify neighborhood storytellers; (2) strengthen the connections between the storytellers; and (3) encourage health storytelling about issues pertinent to the neighborhood (Wilkin, 2013). This basic methodology was based on the assumption that integrating residents into a neighborhood storytelling network that was telling stories about relevant health issues would lead to residents being more able to take action—either as individuals or collectively—to improve health outcomes. The rationale is based on findings that individuals with greater integration into the neighborhood storytelling network had higher levels of collective efficacy and neighborhood belonging (Kim & Ball-Rokeach, 2006). Collective efficacy could lead to actions to improve neighborhood health (e.g., by creating a community garden to provide fresh fruits and vegetables in a food desert). Neighborhood belonging—feeling and acting like you belong to a community—may reduce social isolation, reduce stress, and increase opportunities for social support (Cattell, 2001).

It was assumed that increasing connections to the neighborhood storytelling network could both directly, and indirectly through civic engagement, influence health outcomes. In fact, the study mentioned above in South Central Los Angeles, California, USA found positive relationships between integrated connections to the storytelling network and collective efficacy, which was positively associated with perceptions of access to health-promoting resources (Matsaganis & Wilkin, 2014). In other words, those that were more connected to the neighborhood storytelling network had higher levels of collective efficacy, and those with higher levels of collective efficacy were more likely to perceive greater access to health-enhancing resources. Since the study was cross-sectional, it is impossible to determine the directionality of the relationship (i.e., does collective efficacy increase perceptions that you have the social capital or social support necessary to improve access to health-enhancing resources or can those who already have more access afford the time necessary for collective action?). Another study in rural Alabama, USA, found that the relationship between individuals’ connections to the storytelling network and taking hurricane preparedness actions before Hurricane Ivan in 2004 was mediated by neighborhood belonging (Kim & Kang, 2010). Using the terminology from earlier in this article, this would mean that people with greater connections to the storytelling network are more integrated into their neighborhoods, which is associated with being more likely to take hurricane preparedness actions. This could be because these individuals are more aware of the impending weather risk and/or having the social support necessary to take the precautions (e.g., help to board up their windows or to get to a gas station to purchase gas for power generators or water).

In practice, the general plan to identify and strengthen connections between neighborhood storytellers and turn them to discussing pertinent health stories proved too simplistic. Two neighborhood health interventions aimed to reduce healthcare access disparities through using communication infrastructure theory-based approaches. One took place in a smaller city in Upstate New York, USA, and aimed to improve reproductive healthcare access and use by lower-income African American women (Matsaganis, Golden, & Scott, 2014). The other took place in lower-income, historically African American neighborhoods located within Atlanta, Georgia, USA. That project aimed to redirect nonemergency patients seeking care at the hospital to the primary healthcare center located in their neighborhood (Wilkin et al., 2011; Wilkin, Cohen, et al., 2012; Wilkin, Tannebaum, et al., 2012). When initially starting the project and identifying neighborhood storytellers, Matsaganis et al. (2014) found that the neighborhood storytellers identified as integral to the neighborhood storytelling network in early research—residents in their social networks, local/ethnic media, and community organizations—are not always equally important for the purpose of health interventions. For instance, they found the local media did not focus on the neighborhoods they were working in, but rather on a nearby, larger city. While the local newspaper on occasion did feature stories about the local neighborhoods, many residents could not afford to buy it. Thus, it did not make sense to begin the intervention by trying to strengthen connections between the local media and other neighborhood storytellers. Instead, they focused on the storytellers that were pertinent to local neighborhood storytelling. They introduced the concept of “interstitial” actors, individuals who are in a unique position to help bridge the connections between micro- and meso-level actors. In this case, people who lived in the neighborhood were hired by the health intervention collaborative to serve as peer health advocates. As a result, the peer health advocates helped build connections between the residents and the healthcare collaborative (i.e., research team and healthcare service providers) that were heading up the intervention. It is important to note that peer health advocates in this type of intervention are trained in relevant health knowledge. That means that they are able to help increase health literacy among their peers and within their social networks, as well as within the larger storytelling network. The intervention was successful at increasing health screenings for African American women living in the neighborhoods.

In Atlanta, Georgia, USA, Wilkin and colleagues (2011) started by having neighborhood residents who joined the research project team as part of a larger community-based participatory research project identify pertinent neighborhood storytellers. These highly civically engaged residents had strong connections to the neighborhood storytelling network. Unfortunately, the residents who qualified for the healthcare assistance program proved to be a little less engaged in the community, and thus, less connected to the neighborhood storytelling network. Thus, they revised their initial strategy to locate residents with limited healthcare access from focusing on the storytelling network to exploring the potential of the communication action context for outreach. They identified the communication hot spots located in the neighborhood, and then reached out to residents in those locations, who then connected the research team to family and neighbors who qualified for the healthcare program. In other words, they used places where people were already gathering and interacting to identify people who qualified for the program and to outreach through a wider array of social networks by asking people in those locations to help identify people who might qualify.

The option to use communication hot spots or even comfort zones for outreach was not available to the project described above (Matsaganis, Golden, et al., 2014). That project was unable to identify shared spaces where people were meeting and greeting in the neighborhoods where their intervention was taking place. There were also a lack of local organizations and businesses providing comfort zones. Therefore, part of that intervention involved creating a comfort zone within the public housing facility. It then served as a location for healthcare classes and for providing healthcare screenings.

Both projects started with the basic approach suggested by prior work on communication infrastructure theory (Wilkin, 2013). However, several lessons were learned that should be considered in future neighborhood health intervention projects (Wilkin, Matsaganis, & Golden, 2016). First, each neighborhoods’ communication infrastructure is unique. Communication infrastructure theory does recognize that there is a wide array of potential storytellers in each communication infrastructure, but the majority of research related to the theory has focused on the micro- and meso-level storytellers found to be positively associated with increased civic engagement. These communication resources comprise the neighborhood storytelling network and include residents’ social networks, local/ethnic media, and community organizations. The two projects found that it is important to start by identifying the most important storytellers to the residents that the project is trying to reach/influence. These may or may not be those identified by past research. Second, it is important to identify potential interstitial actors who can help build connections between the storytelling agents most relevant to the project. The project in New York formally hired residents to act in this role. The residents hired in Atlanta helped identify some, but not everyone in the target intervention group was connected to the neighborhood residents on the project team or the neighborhood storytellers utilized. Thus, outreach happened through other residents’ social networks. This leads to the third lesson: The projects highlight the importance of considering the elements of the communication action context that may enable or constrain connections to the neighborhood storytellers and, thus, the intervention project (Wilkin et al., 2016). This means identifying and/or creating communication hot spots and comfort zones. It may involve identifying elements of the built environment that makes different aspects of the neighborhood more or less accessible to people living in the community, that is, walkability (Frank et al., 2006) and considering aspects like perceived safety of different businesses and organizations in the neighborhood.

Conclusions

This article demonstrated the many ways that socio-spacial characteristics of a neighborhood can affect health outcomes. In general, social determinants like social support is seen to improve health outcomes, to the extent to which it does not add stress to either the person giving or receiving social support (Cohen et al., 2000; Shumaker & Brownell, 1984). Social support is also impacted by whether or not there is anyone in the social network who is able to provide the type of social support needed. While lower-income neighborhoods may offer barriers to giving and receiving social support and limit the types of support available, Cattell (2001) found that people living in poorer neighborhoods can still have the types of social support networks needed to improve health outcomes. For example, those in heterogeneous networks might have weak ties who are able to connect them to health information or health-enhancing resources. Characteristics of neighborhoods—for example, crime, violence, and social disorder and features of the built environment—might impact the ability of people to connect to other people in their neighborhoods, attend community events, connect to neighborhood health-enhancing resources and neighborhood organizations that act a neighborhood storytellers, and the like. These features can have both a direct or indirect impact on health outcomes.

Communication infrastructure theory was introduced as a means to conduct theoretically grounded health interventions aiming to address the socio-spacial determinants of health in neighborhoods. Communication infrastructure theory incorporates the social determinants discussed as influencing health outcomes—including social networks and neighborhood organizations believed to enhance social capital—as well as local and ethnic media. In the theory, these determinants are identified as storytelling agents. The connections between storytelling agents are influenced by neighborhood determinants similar to those that impact health outcomes. Thus, neighborhood health intervention projects can incorporate strategies based upon communication infrastructure theory to improve neighborhood health outcomes.

Further Reading

Coleman, J. S. (1988). Social capital in the creation of human capital. American Journal of Sociology, 94, S95–S120.Find this resource:

Kawachi, I., & Berkman, L. F. (Eds.). (2003). Neighborhoods and health. New York: Oxford University Press.Find this resource:

Matsaganis, M. D. (2015). How do the places we live in impact our health?: Challenges for, and insights from, communication research. Annals of the International Communication Association, 39, 33–65.Find this resource:

Strife, S., & Downey, L. (2009). Childhood development and access to nature: A new direction for environmental inequality research. Organization and Environment, 22, 99–122.Find this resource:

Walker, R. E., Keane, C. R., & Burke, J. G. (2010). Disparities and access to health food in the United States: A review of food deserts literature. Health & Place, 16, 876–884.Find this resource:

Wilkin, H. A. (2013). Exploring the potential of communication infrastructure theory for informing efforts to reduce health disparities. Journal of Communication, 63, 181–200.Find this resource:

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