Social Connectedness as a Determinant of Health in African-American Low-Income Families with Young Children: A Cross-Sectional Cohort Study

ABSTRACT:

Objective:

This cross-sectional study aimed to assess the level of social connectedness (SC) in African-American low-income families with young children attending a pediatric primary care clinic and examine its relationships with food insecurity and parental well-being.

Methods:

This cross-sectional analysis used data from the Healthy Children and Families program, a cohort intervention study addressing food insecurity, conducted by an urban pediatric clinic serving low-income predominantly African-American families. Twenty-seven families completed baseline screening tools, including the Social Provisions Scale five-question short form (SPS-5) to measure SC, a modified version of the United States Department of Agriculture (USDA) Household Food Security Survey Module six-item short form to assess food insecurity, and the Parental Stress Index Short Form to measure parental stress. Descriptive statistics, correlations, and partial correlations were conducted to analyze the data.

Results:

The average SPS-5 composite score was 14.5 on a scale of 5 to 20. Moderate negative correlations were identified between SC and food insecurity, weaker when controlled for parental stress. Strong negative correlations were identified between SC and parental stress that held when controlled for food insecurity.

Conclusion:

In this study, we propose a conceptual framework highlighting the complex interplay of social connectedness with other social determinants of child health. The findings align with the 2023 Surgeon General's Advisory on the epidemic on the healing effects of social connection and provide insight into the value of incorporating SC assessments into routine screenings in pediatric primary care settings. Further research is needed to explore causal relationships and evaluate the effectiveness of interventions designed to enhance SC in diverse populations.

BACKGROUND

Social connectedness (SC) has been defined as an individual's sense of belonging within individual relationships, a group, or a community.¹ Research on SC as a determinant of health has been limited by a lack of consensus on definitions and assessment tools.¹ Even so, there is a growing body of research for some populations connecting SC to health outcomes. Meta-analyses have shown that strong social relationships are associated with 30% to 50% increased survival in adults.^2,3 Strong social connections in adolescence may promote long-term protective effects across health and mental health domains^4,5 and improved overall well-being.⁶

In May 2023, the US Surgeon General issued a new Advisory highlighting social connection as an important predictor of health and well-being outcomes, potentially outweighing risks like smoking, environment and preventive health care.⁷ Social connection influences educational and workplace attainment as well as subsequent economic prosperity, and there are complex cultural, community, and societal dynamics that drive connection and disconnection. Washington, D.C., like many cities in the United States, is racially divided geographically with profound health disparities by race and place⁸ (Fig. 1). These disparities are rooted in centuries of policies that have caused structural disenfranchisement in education, asset and wealth building, and representation, as well as splintering of communities and families through land seizures and inequitable mass incarceration.⁹ All these factors likely contribute to driving either connection or disconnection, with little known about the overall impact on social connection in disenfranchised communities. Importantly, social connection is likely a modifiable determinant of health that can be increased through a whole-of-society approach, including improved policies, community investments and engagement, peer mentorship, and building social networks.^1,7,10 Given the significant influence of parental well-being on child health, several studies have examined the connectedness of caregivers or families to understand its effects on young children. Higher levels of SC have been associated with decreased caregiver stress in families with children aged 7 to 11 years¹¹ and increased caregiver's sense of confidence and involvement with young children aged 0 to 5 years.^12,13 Social support demonstrated a positive association with child behavioral outcomes.^14,15 Research shows that lower SC of families may increase the risk for child abuse.^16,17 Low-income individuals may be at higher risk for social isolation because of the number of resources needed to establish and maintain social relationships, such as time, transportation, safe spaces, and other factors.¹ Social isolation has shown to be a predictive factor of food insecurity in recent immigrant families and low-income households.^18,19 There are no studies looking specifically at social connection in families with young children and its relationship with other determinants of child health. Studying SC poses challenges because of the absence of indexed and well-defined search terms and consistent validated measures.¹ The Social Provisions Scale is one of the most commonly used scales to measure social support. Originally developed with 24 items, it was recently validated as a five-question short form, the SPS-5, and is promising as a tool to reduce respondent burden.²⁰

Figure 1.

Demographics in Washington DC by neighborhood. A, Percentage of population identifying as African-American. B, Life expectancy. Reference: DC Health Equity Report 2018.

The objectives of this study are to assess the level of SC in families of children receiving care from a pediatric primary care clinic which serves predominantly African-American, historically marginalized communities in D.C., using the SPS-5 and to determine whether there are relationships between social connectedness, food insecurity, and parental well-being.

METHODS

Healthy Children and Families

The Healthy Children and Family (HCF) program is a cohort intervention study conducted by an urban pediatric clinic serving low-income families with the primary objective of addressing food insecurity. Participants were recruited at an urban pediatric primary site at scheduled well-child visits. To be eligible for the study, families needed to have at least 1 child between the ages of 0 and 5 years and demonstrate food insecurity based on screening in primary care. Families enrolled between January 15, 2021 and November 23, 2021. On enrollment into the HCF study, families were asked to complete a series of baseline screening tools including demographics, social determinants of health, parental well-being, and child health and development. The tools were completed on a secure web-based platform by the primary caregiver, either remotely or during a visit with staff available to answer questions. A total of 39 families enrolled in the HCF program, out of which 27 families completed the baseline screening tools and are included in this cross-sectional study.

Screening Tools

Social Provisions Scale

Social connectedness (SC) was accessed using the Social Provisions Scale 5-question short form (SPS-5). The SPS-5 is a validated measure derived from a longer format that has been widely used in social support research. The shortened version showed high internal consistency with a Cronbach's alpha of 0.88.²⁰ The SPS-5 consists of 5 items, each rated on a four-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The items are “I feel part of a group of people who share my attitudes and beliefs,” “I have relationships where my competence and skills are recognized,” “I have close relationships that provide me with a sense of emotional security and well-being,” “There is someone I could talk to about important decisions in my life,” and “There are people I can count on in an emergency.” The scores for each item were summed to give a total composite score ranging from 5 to 20, with higher scores indicating a higher level of SC.

USDA Household Food Security Survey Module: Six-Item Short Form

The food insecurity status questionnaire was adapted from the USDA Household Food Security Survey Module 6-item short form.²¹ For this study, data for 5 of the 6 survey questions were collected. The questions with answer choices in parentheses and answers considered positive notated with an * were: “In the last 12 months I can't afford to eat balanced meals” (Often*, Sometimes*, Never), “In the last 12 months, did you ever cut the size of your meals or skip meals because there wasn't enough money” (Yes*, No), “How often did this happen” (Almost every month*, Some months but not every month*, Only 1 or 3 months), “In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food” (Yes*, No), and “In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food” (Yes*, No). The five-question version showed high internal consistency with a Cronbach's alpha of 0.877. To determine food insecurity, positive responses to these 5 questions were summed, resulting in a total score ranging from 0 to 5, with higher scores indicating greater food insecurity. Analyses were performed using responses to each individual question and the total score.

Parental Stress Index Short Form

The PSI-SF is a validated tool used to measure stress in the parent-child system.²² This tool comprises 3 distinct components that collectively capture various aspects of the parent-child relationship (Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child). The scores for each component range from 0 to 100. To determine the Total Stress score, the mean of the 3 component scores is calculated. The Total Stress score also ranges from 0 to 100, with higher scores indicating a higher overall level of stress within the parent-child system. Internal consistency, estimated by Cronbach's alpha, was α = 0.823.

Behavioral Risk Factor Surveillance System Questions

The BRFSS questions are included in an annual national phone survey overseen by the Centers for Disease Control and Prevention that collects data related to health-related risk behaviors, chronic health conditions, and use of preventive services.²³ In this study, select questions from the survey were used to assess patients' self-perceived mental health and its impact on their daily functioning. Items included were “How many days during the past 30 days was your mental health not good” and “How many days did your mental health keep you from doing your usual activities, such as self-care, work or recreation.” Answers were “None, 1 to 7, More than 7” as well as numeric answer of number of days.

Data Analysis

Descriptive statistics included the mean ± 1 SD for continuous variables and n (%) for categorical variables. Associations were assessed using Pearson correlations. Strength of association was interpreted as no relationship < ±0.1, weak for r coefficient ±0.1 to 0.3, moderate ±0.3 to 0.5, and strong ±0.5 to 1.0. Further assessment of associations was made with partial correlations of Social Connectedness, Food Insecurity total score, and Total Parental Stress.

RESULTS

Healthy Children and Families

Twenty-seven families completed the assessments. The average age of children enrolled was 3.4 years. 96% of children enrolled identified as African-American, 93% receive Medicaid, and 7% were uninsured (Table 1). Most families live in areas with low incomes. Figure 2 shows the distribution of enrolled families in each ZIP Code Tabulation Area (ZCTA) of the District of Columbia with the corresponding map of per capita income for each ZCTA. The average SPS-5 composite score was 14.5 on a scale of 5 to 20. Forty-eight percent of families could not afford balanced meals, and 25% of caregivers had gone hungry in the last year. Seventeen percent of caregivers experienced poor mental health for at least 7 days in the past month. Social connectedness (SC) was negatively correlated with total food insecurity (r = −0.43, p = 0.03) and negatively correlated with not being able to afford balanced meals (r = −0.53, p = 0.004). SC was negatively correlated with parental stress (r = −0.65, p < 0.001) and parental mental health affecting activities of daily living (r = −0.54, p = 0.004). When adjusted for parental stress, SC had a weaker negative correlation with food insecurity (r = −0.13, p = 0.57), whereas SC retained a negative correlation of similar magnitude with parental stress controlling for food insecurity (r = −0.5, p = 0.015). Unadjusted and adjusted (partial) correlations of Social Connectedness Total Score with study variables are presented in Table 2.

Table 1.

Demographics and Descriptive Statistics

Variable	Summary Statistic	Variable	Summary Statistic
Number of families w/baseline data	29	Food insecurity (*scored positive)	n (%)
Demographics	n (%)	Could not afford balanced meals
African-American	28 (96)	Yes*	14 (48.3)
Other	1 (4)	No	15 (51.7)
Insurance	n (%)	Cut or skip meals because there was not enough money for food?
Medicaid	27 (93)	Yes*	10 (34.5)
Uninsured/self-pay	2 (7)	No	19 (65.5)
Mean number of children in household	2.9	Eat less because not enough money?
Mean age of children (y)	3.2	Yes*	8 (27.6)
		No	21 (72.4)
Social Provisions Scale-5 (0–5)	Mean (±SD)	Hungry but did not eat because not enough money?
I feel part of a group of people who share my attitudes and beliefs	2.6 ± 0.8	Yes*	7 (24.1)
I have relationships where my competence and skills are recognized	3.0 ± 0.7	No	22 (75.9)
I have close relationships that provide me with a sense of emotional security and well-being	2.9 ± 0.8
There is someone I could talk to about important decisions in my life	3.0 ± 0.8	BRFSS perception of mental health	n (%)
There are people I can count on in an emergency	3.0 ± 0.8	In past month, how many days of poor mental health?
Total score	14.5 ± 3.2	None	15 (51.7)
		1–7	7 (24.1)
Parental Stress Index-SF (0–100)	Mean (±SD)	More than 7	7 (24.1)
Distress	57.4 ± 33.6	In past month, how many days of poor mental health keep you from doing your usual activities, such as self-care, work, or recreation?
Dysfunction	41.7 ± 27.8	None	21 (72.4)
Difficult child	37.7 ± 27.9	1–7	3 (10.3)
Total score	46.8 ± 28.0	More than 7	5 (17.3)

Figure 2.

A, Heat map of residences of enrolled families by ZCTA. B, Per capita income in DC by ZCTA. Reference: 2013 5 year American Community Survey.

Table 2.

Unadjusted and Adjusted (Partial) Correlations of Social Connectedness Total Score With Study Variables

	Unadjusted Correlation with Social Connectedness r (p)	Adjusted Correlation r (p)
Food insecurity (last 12 mo)
Food insecurity total	−0.43 (0.03)	−0.13 (0.57)
I cannot afford to eat balanced meals	−0.53 (0.004)
Did you ever cut the size of your meals or skip meals because there was not enough money for food?	−0.34 (0.08)
Did you ever eat less than you felt you should because there wasn't enough money for food?	−0.26 (0.2)
Were you ever hungry but did not eat because there was not enough money for food?	−0.23 (0.25)
Parental stress
PSI total score	−0.65 (<0.001)	−0.5 (0.015)
Parental distress score	−0.72 (<0.001)
Difficult child score	−0.29 (0.17)
Dysfunction in parent/child interaction score	−0.43 (0.04)
Perception of mental health
How many days during the past 30 d was your mental health not good?	−0.48 (0.05)
How many days did your mental health keep you from doing your usual activities such as self-care, work, or recreation?	−0.54 (0.004)

PSI, Parental Stress Index.

DISCUSSION

This study assessed social connectedness (SC) in a cohort of low-income, predominantly African-American families using the newly validated Social Provisions Scale 5-question short form (SPS-5). To our knowledge, this is the first study to apply this validated tool in this context. The mean SPS-5 score in our cohort was 14.5. In the scale's validation study conducted across Canada with 22,486 participants, the average composite score was 17.93.²⁰ This study showed a negative relationship between SC and 2 other important health-related social determinants for children: food insecurity and parental mental health.^24,25 Notably, when controlling for parental stress, the association between social connectedness and food insecurity weakened. While causality cannot be determined, we propose a conceptual framework for these findings, highlighting the complex interplay of social connectedness with other social determinants of child health (Fig. 3). Relational cultural theory posits that quality relationships contribute most to a person's ability to be resilient when faced with challenges.²⁶ Families with low SC have fewer financial buffers in place through friends and family or their communities to close the gaps when food is running low and may engage in less meal sharing. In families with young children, parental mental health may be an important mediator in this model. Low SC can decrease a parent's ability to buffer individual or structural stress.²⁶ Increased stress and poor mental health can disrupt the completion of activities of daily living and attainment of basic needs. Similarly, families experiencing food insecurity may experience social stigma that can exacerbate their social isolation²⁷ and increased caregiver anxiety around the capacity to provide adequate food for their children. This framework aligns with the construct laid out in the Advisory of complex interplay of biological, psychological, and behavioral pathways that link social connection to health⁷ and sheds light on the role that caregiver social connection may play as social determinants of child health. Our study also highlights the intersectionality of race, place, socioeconomic status, and social connection in D.C. and the importance of seeing solutions through this lens. The Advisory presents a National Strategy to Advance Social Connection with 6 foundational pillars to “support a whole-of-society approach to advancing social connection. In Pillar 3, “Mobilize the Health Sector,” the report recommends “integrating social connection into primary, secondary, and tertiary level prevention and care efforts,” specifically educating health care providers on the risks of social disconnection; developing health systems and incentivization models to assess and respond to social disconnection; and include social connection in population health models and community health solutions. The field of pediatrics has been on the forefront of incorporating social determinants of health screening into routine care²⁸ and can leverage the ongoing research and potential resources that may follow this Advisory to include social connectedness in screening and interventions.

Figure 3.

Conceptual framework for the relationship between food insecurity, social connectedness, and parental mental health.

Limitations of this study include a small sample size and targeted population which may limit the findings from being extrapolated to other populations.

CONCLUSION

This study, focusing on families with young children who have been historically disenfranchised, adds to the growing body of research supporting the inclusion of social connectedness in the holistic paradigm of health on an individual and community levels, particularly as we aim toward decreasing health disparities. The findings of this study also carry practical implications for screening and interventions in health care settings. The SPS-5 is a short screening tool that can be incorporated into routine health care screenings in the pediatric setting. The results can provide valuable insight for the patient and health care team and provide a framework for discussions on increasing social connectedness on both the patient and population levels. Furthermore, these findings lay the groundwork for future research aimed at elucidating the causal relationships and evaluating the outcomes of interventions designed to enhance SC in different populations.