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. Author manuscript; available in PMC: 2024 Jun 23.
Published in final edited form as: Acad Pediatr. 2020 Oct 2;21(4):594–599. doi: 10.1016/j.acap.2020.09.013

Social Capital as a Positive Social Determinant of Health: A Narrative Review

Carol Duh-Leong 1, Benard P Dreyer 1, Terry T-K Huang 1, Michelle Katzow 1, Rachel S Gross 1, Arthur H Fierman 1, Suzy Tomopoulos 1, Cecilia Di Caprio 1, H Shonna Yin 1
PMCID: PMC11194101  NIHMSID: NIHMS1999515  PMID: 33017683

Abstract

Social determinants of health influence child health behavior, development, and outcomes. This paper frames social capital, or the benefits that a child receives from social relationships, as a positive social determinant of health that helps children exposed to adversity achieve healthy outcomes across the life course. Children are uniquely dependent on their relationships with surrounding adults for material and nonmaterial resources. We identify and define three relevant aspects of social capital: 1) social support, which is embedded in a 2) social network, which is a structure through which 3) social cohesion can be observed. Social support is direct assistance available through social relationships and can be received indirectly through a caregiver or directly by a child. A child’s social network describes the people in a child’s life and the relationships between them. Social cohesion represents the strength of a group to which a child belongs (eg, family, community). Pediatric primary care practices play an important role in fostering social relationships between families, the health care system, and the community. Further research is needed to develop definitional and measurement rigor for social capital, to evaluate interventions (eg, peer health educators) that may improve health outcomes through social capital, and to broaden our understanding of how social relationships influence health outcomes.

Keywords: social determinants of health, social capital, social networks, social support, social cohesion, resilience

Social Determinants Of health, defined as the social circumstances in which people live and work, influence child health behavior, development, and outcomes. For example, housing disrepair in public housing has been associated with increased pediatric asthma diagnoses,1 adverse childhood experiences with more severe ADHD,2 and childhood food insecurity with increased risk for overweight status.3 Recognition that disparities in child exposure to poverty-driven social determinants of health result in disparities in child health outcomes has led pediatricians to champion the development of programs and policies to address social needs. The current prevailing model of intervention focuses on identifying and mitigating risk factors by optimizing clinical screening and referral programs to connect families to community resources.4 Less attention has been given to identifying and promoting resilience, positive adaptation in the face of adversity, by utilizing resources available through social relationships. The goal of this paper is to frame elements of children’s social capital, or the benefits that a child receives from their social relationships (Table), as positive social determinants of health that can allow children exposed to adversity achieve healthy outcomes and even thrive across the life course.

Table.

Glossary of Social Capital Terms

Term Definition
Collective efficacy The ability of a group to work together towards a common goal.
Resilience The ability of a person to withstand, adapt to, or recover from adversity
Social capital Benefits that a person receives from surrounding social relationships.
Social cohesion The strength of a group to which a person belongs
Social determinant of health The social circumstances in which people live and grow
Social network People in a person’s life and the relationships between them.
Social support Direct assistance received or perceived to be available through a social relationship.
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Children are uniquely vulnerable to poverty-driven social determinants of health due to their dependence on relationships with surrounding adults for the resources required to grow and thrive. While the traditional deficit-based approach focuses on meeting unmet needs,4 our goal is to broaden this model to include social capital since meeting unmet needs relies at least in part on the resources a child receives through social ties or a family/community’s ability to work together. Social capital can be measured as an individual or community attribute, and a patient-centered approach conceptualizes social capital as a resource that children can possess. Like economic resources, social capital is also modifiable; it can depreciate but also be replenished by circumstance or with intervention.

Child, Family, and Community: Social Capital and the Socioecological Model

Social capital can be understood within the context of the socioecological model (Fig. 1), which illustrates a child’s relationship with family-level and community-level systems.5,6 Children benefit tremendously from a strong relationship with a family member, specifically a parent or primary caregiver, and receive many unique assets from this bond that promote healthy development and growth.7 A national study found that in children exposed to adverse childhood experiences, the strongest protective factor for academic outcomes was “a parent who can talk to the child about things that matter and share ideas.”8 In addition, a growing body of literature demonstrates that while stress can be transmitted intergenerationally,9 resilience can be as well. For example, homeless parents with lower levels of psychological stress reported higher scores on the Benevolent Childhood Experiences scale, which includes social capital indicators such as whether or not a parent had “an adult who could provide you with support or advice.”10,11

Figure 1.

Figure 1.

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The socioecological model.

Beyond the parent-child dyad, evidence has identified other family- and community-level protective factors12 that enable children to thrive and flourish across the life course. Examples across these levels include associations between parent receipt of social support and decreased child asthma symptoms,13 high family cohesion and fewer child depressive symptoms,14 and provaccination opinions in a parent’s social network and a parent’s decision to vaccinate their child.15 While there are clear benefits to nurturing positive social determinants of health like social capital, a deeper understanding of how to quantify/qualify a child’s social relationships is needed to leverage social capital to support child resilience.

Defining and Measuring Social Capital

Measures of social capital used in pediatrics do not yet have the specificity, rigor nor the portfolio of evidence that accompany other social determinants of health measures. For example, food insecurity, or the limited availability of nutritionally adequate food, has validated tools on the adult, household, and child level,16 a clinically useful 2-item version of the tool,17 and has also already been studied in the context of infant feeding styles, maternal locus of control, and toddler sleep.18–20 Due to social capital’s broad applicability, scientists studying its impact come from a diverse array of disciplines, including sociology, political science, and psychology. The process of defining and measuring social capital has been frustrated by variable terms and definitions that can create confusion and prevent meaningful discussion.21 Therefore, to operationalize social capital, we find it helpful to discuss definitions and measurement tools for 3 aspects that have been associated with pediatric health outcomes (Fig. 2): 1) social support, which is embedded in a 2) social network, which is a structure through which 3) social cohesion can be observed.

Figure 2.

Figure 2.

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Visualization of social network, social support, social cohesion using family as an example.

Social Support

Social support refers to direct assistance received or perceived to be available through a social relationship (Fig. 2A).22 This support can be material (eg, food, money, or babysitting), emotional (eg, feeling loved and cared for), or informational (eg, advice). Within the broader context of addressing poverty-related social determinants of health, measuring social support allows child health advocates to identify relationships through which children and families receive material and nonmaterial resources. The science substantiating social support as a resilience factor is well-known in pediatrics, and has been studied both in parents who transmit the benefits of social support to young children, as well as in adolescents who are able to receive social support directly.22,23 Instruments that measure social support assess source of social support (eg, family, peer) or type of social support (eg, material, informational, emotional).

In an example measuring source of support, investigators used the Multidimensional Scale of Perceived Social Support to measure social support by source (family, friends) as part of a study of mental health in adolescents with obesity.24 In this sample of adolescents, where child-level social support was the focus of measurement, social support from family or friends moderated the association between peer victimization and depression in girls with obesity.25 These results suggest that social support originating from either source may provide adequate emotional support to buffer depression symptoms in girls stigmatized for obesity.

In an example measuring type of support, the Medical Outcomes Study Social Support Scale measures emotional, informational, and material types of social support.26 Parent receipt of informational social support as measured by whether the parent had “someone to give you information to help you understand a situation” was associated with lower odds of asthma symptoms in children with nonallergic asthma.13 This suggests that informational social support may help parents access information on monitoring and managing asthma for their children.

Social Network

A child’s social network describes the people in a child’s life and the relationships between them (eg, members of a family as shown in Fig. 2B). Measuring social networks allows child health advocates to look beyond one social support relationship to examine how a child’s family and community are structured. Social network analysis, which characterizes social networks in terms of actors (individual entities) and links (relationships),27 is a systematic approach that gathers a description of a child’s social network. The method allows researchers to draw conclusions about whether an increased quantity of connections overall or whether connections to specific people are associated with particular outcomes.28 An example of a social network analysis technique called “name generator” asks respondents to list individuals that fall within a relationship type (eg, family member, classmate).29 In pediatrics, using social network analysis techniques in isolation to describe a child’s social network is a helpful start, but has limited utility without the ability to measure relationship quality. For example, a parent may belong to a social network with numerous members but this information alone provides no sense of whether a parent receives social support from any of these members, nor does it account for negative or even potentially abusive relationships which can be harmful to health.30

Current analytical methods in pediatrics tend to measure social network in combination with a measure of the quality of social relationships like social support to draw meaningful conclusions about the value that a child is receiving from the social network. For example, the Maternal Social Support Index asks “How many people can you count on in times of need?” and allows numerical responses to quantify an individual’s social support network.31 In a study of mothers of young children, having at least 2 people in response to this question independently predicted lower infant adiposity over the first 18 months of life.32 This suggests that increased maternal social relationships may have a protective effect on child obesity because an increased number of perceived social support contacts likely translates into increased material (eg, food) or nonmaterial (eg, emotional) social support.

Social Cohesion

Social cohesion (Fig. 2C) refers to how individuals feel about the strength of the specific group to which they belong (eg, family, community).33 Within the context of the socioecological model, social support indicates the quality of a relationship, social network indicates the quantity of relationships, and social cohesion indicates the strength of relationships within each level (eg, family, community). The sum of many social support links can be understood as synergistic building blocks of social cohesion.34 Figure 3 shows how constructs measured by various tools often lie on a gradient depending on the strength, structure, and products of the relationships. For example, a dense community social network has many people, but it does not mean the community has the social cohesion to work together.

Figure 3.

Figure 3.

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Examples of social capital constructs measured in pediatrics.

In comparison to the science around social support and social networks, the science of social cohesion requires definitional rigor to validate its impact on child-level outcomes. Its properties depend on the level of collective efficacy (eg, family’s ability to organize together toward a goal), group participation (eg, reciprocation of social support, participation in community activities), group affiliation (eg, how strongly a child identifies with a family), as well whether the group actions reflect individual needs (eg, family’s ability to advocate for child services).35–37 In addition, when examining social cohesion within a risk/resilience framework, there may be associations or interactions between these elements and social risks that also shape health outcomes. The complexities of social cohesion are all valuable to consider, but challenging to quantify and describe in a systematic manner. Organizations like the World Bank and UNICEF recognize that increased social cohesion drives survival of families living in poverty,38 and they use lengthy integrated community and child-led measures of social cohesion to evaluate programs across diverse regions.38–41 However, this methodology is unconventional to clinical pediatric research due to its resource-intensive nature.

In pediatrics, the ability to measure family-level social cohesion can assist in assessing family readiness for change or intervention. A high level of family cohesion is associated with improved pediatric outcomes such as dietary quality,42 glycemic control,43 and academic outcomes.44,45 In an example distinguishing the impact of social cohesion from social support, higher levels of family cohesion as measured by the Family Resilience Scale was associated with improved clinical and academic outcomes in children with ADHD while caregiver receipt of social support was not.46,47 While parental receipt of social support may decrease stress or increase knowledge, family cohesion likely facilitates the ability of families to navigate complicated medical or school systems and manage daily routines. In addition, for outcomes like ADHD, family cohesion likely improves symptoms because child mental health outcomes are also mediated through family functioning.

On the community level, social cohesion informs the pediatric advocacy agenda for programs and policies that promote child well-being. Research has linked cohesive neighborhoods (ie, strong communities) to the following child outcomes: Improved behavioral functioning,48,49 lower odds of overweight or obese status,50 and improved asthma control.51,52 Children living in cohesive neighborhoods as measured by the Supportive Neighborhood Scale had lower odds of being overweight and obese as compared to peers living in non-cohesive neighborhoods. One potential mechanism may be that a cohesive neighborhood fosters trust, promoting outdoor activity, which may support obesity prevention habits like exercise.

While these studies have identified associations between indicators of social cohesion and significant pediatric outcomes like childhood obesity,50 future research is needed on more proximal outcomes such as exercise or dietary habits so researchers can identify mediators and delineate pathways. Furthermore, studying other aspects of social capital such as social support alongside social cohesion would allow researchers to parse whether or not social support related to exercise or healthy diet is as effective as establishing programs that support a cohesive neighborhood which can provide consistent reinforcement to maintain healthy habits.

Finally, using a social capital approach toward social needs screening and referral programs would broaden our goals beyond resource provision into strengthening relationships between families, the health care system, and the community. Pediatric primary care practices already engage in relationships building interventions that demonstrate results. For example, studies have found that WIC programs that go beyond providing material resources and who use peer nutrition educators have improved breastfeeding outcomes.53 Healthy Steps, a behavioral and developmental services program that screens for social needs, relies on building meaningful partnerships with families, and this strategy has been found to increase parent-child activities such as reading books together.54,55 If we are able to purposefully measure our efforts to deliver social support, increase a family’s social network, and strengthen family and community cohesion, we may be able to document meaningful strategies that build long-term resilience.

Limitations and Negative Externalities

While a social capital framework may allow pediatricians to have a broader perspective of a child’s relationships, pediatricians should be prepared for social capital constructs to be difficult to modify and that extremely vulnerable patients, such as foster children, may have little to no social capital to start with. In addition, while social relationships can promote healthy norms, they can also be sources of conflict, misinformation, and unhealthy behaviors. For example, friendships are the most proximal determinant of adolescent substance use,56 and outcomes may be mixed as friendships may have beneficial mental health outcomes while increasing dangerous substance use at the same time. Still, identifying the mechanisms through which social capital impacts health allows child health advocates to further a broader understanding of the social determinants of health, positive and negative.

Conclusion

Social capital, the value that a child receives from their social relationships, is an understudied positive social determinant of health that may help promote improved child health outcomes across the life course in children exposed to risk. Aspects of social capital include social support, social networks, and social cohesion, which have overlapping concepts. Further research is needed to develop definitional and measurement rigor for social capital to evaluate interventions that may improve health outcomes through this mechanism and to broaden our understanding of how social relationships influence health outcomes.

What This Narrative Review Adds.

Social capital, the benefits that a child receives from social relationships, may promote healthy child outcomes in children exposed to adversity. Further research is needed to study relevant aspects of social capital: social support, social networks, and social cohesion.

Acknowledgments

We thank Joey Nicholson, MLIS MPH, Vice Chair for Education at the NYU Health Sciences Library for his expertise in guiding the literature review and synthesizing the cross-disciplinary material with our team. This work was supported by HRSA T32HP22238 and CTSI NCATS 1UL 1TR001445 training grants (Dr. Duh-Leong). These funding sources had no involvement in conducting the research or in preparing this article.

Footnotes

The authors have no conflicts of interest relevant to this article to disclose.

Financial statement. The authors have no financial relationships relevant to this article to disclose.

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