The relationship between social cohesion and population health has intrigued many researchers in the past two decades, and many policymakers regard social cohesion as a solution to the increasing health inequality and decline of civil culture. Nevertheless, social cohesion has invoked debate due to the vagueness of its definition and an inability of current measurements to capture the full meaning of the concept. Green and colleagues referred to social cohesion as “the property by which the whole society, and individuals within, are bound together through the action of specific attitudes, behaviors, rules, and institutions, which rely on consensus rather than pure coercion”. In this definition, attitudes and behaviors of citizens and governments, together with institutional and structural features, foster a consensus by society. However, most recent research measured social cohesion by way of trust and association participation. The problem with this approach is that only those limited aspects of attitudinal and behavioral measurements are covered, and thus, it is indistinguishable from the concept of social capital. Moreover, measurements, such as institutional features (i.e., a welfare state) and attitudes toward social exclusion, were not considered. To further clarify the concept of social cohesion, this paper used indicators from several global datasets and attempted to reexamine and develop the measurements of social cohesion.
Prior studies have regarded social cohesion as an important determinant of population health. With widening income inequality in worldwide, researchers and policy makers were concerned about the negative impact of income inequality on social trust and community structure (i.e., public education and social welfare program), which may further worsen population health. To address the extent of influence of social cohesion on individual health, this study used a multilevel study design to analyze the relationship between social cohesion and individual health above and beyond individual characteristics.
From social capital to social cohesion
Many prior studies, particularly in the field of health research, used the concepts of social capital and social cohesion interchangeably. Social capital was typically defined as resources imbedded in social networks such as norms and trust that can facilitate coordination and cooperation for people to achieve interests[8–10]. Some researchers have suggested that although there are some broad similarities between social capital and social cohesion, they operate at different levels. Researchers generally agree that social capital, with its emphasis on norms derived from networks, has its foundations in groups and communities. Social cohesion, on the other hand, usually refers to cohesion at a societal level, which is normally taken to be at the level of a nation or state[6, 12]. Some other researchers have examined the relationship between social capital and social cohesion[13, 14]. They regarded social capital as an aggregation comprising three stages, with each stage building on the one that came before. In the first stage, social capital describes trust and social participation among face-to-face, horizontal networks like personal contacts with neighbors and friends. In the second stage, social capital further includes larger communities and is not restricted to face-to-face networks. The third stage is where social capital meets social cohesion, which includes trust, networks at the societal level, plus connections to formal and institutionalized power in a society. The above integration is also similar to the categorization of social capital proposed by Szreter and Woolcok, which separate social capital into three stages of bonding, bridging, and linking forms of social capital.
Integrated models of social cohesion
To construct social cohesion as a macro- and societal-level concept, Bernard proposed an integrated model of democratic dialectic, which combines social and relational characteristics and institutional characteristics. The model contains three principles (liberty, equality, and solidarity) that interact in complex dialectical relationships, and a cohesive society can only exist when the three principles reach a good balance. For instance, a society without liberty is in danger of coercion and enslavement; however, a society that predominantly emphasizes liberty, in particular economic liberty, can lead to polarization and social dislocation. Countries that emphasize liberty and equality, but not solidarity, may have government policies and regulations to provide basic state-run health welfare and educational services, but the economic inequalities fostered by entrepreneurial liberty may enable the rich to get even better provisions than others. This model is referred to as “inclusive democracy”. Under this context, government efforts are usually too uniform and private services are too expensive. Therefore, it is the call to solidarity, such as by community sectors, through which resources are organized and services provided to people in need.
Berger-Schmitt and Noll took Bernard’s model one step further and provided a useful framework to operationalize the concept of social cohesion[17, 18]. They suggested that social cohesion comprises two main dimensions. The first concerns the reduction of disparities, inequalities, and social exclusion. Examples are government efforts to provide equal employment opportunities for minorities. The second concerns strengthening social relations, interactions, and ties. They believe that a cohesive society needs to simultaneously consider both dimensions because a society only focusing on strong and intimate social relationships can lead to social exclusion. Berger-Schmitt and Noll also stressed that the availability and the quality of these relationships are both important[17, 18].
There is a similarity between Bernard’s model and Berger-Schmitt and Noll’s conceptualization of social cohesion. Both emphasize social justice, social relationships, and social exclusion. Many of the recent debates on social cohesion revolve around issues of social exclusion and value diversity as well as appropriate responses to these issues. The fundamental dilemma is how far social and value diversity is compatible with social cohesion and whether it may result in social exclusion such as excluding minority groups from certain job markets. Some researchers suggested that a high level of social cohesion entails a high level of social exclusion. They believe that a degree of cultural and value homogeneity is a necessity for a cohesive society. In contrast, many other researchers with liberal attitudes argued that diversity is not a problem for social cohesiveness. They believe that in many Western societies, political institutions are sufficiently robust to mediate conflicting interests, and societies are well equipped with values of tolerance and respect for other cultures.
Wilkinson and Pickett’s well-known book “The spirit level: why more equal societies almost always do better” initiated debates and dialogues regarding the impact of income inequality and the function of social cohesion. The book claimed that different health and social problems (i.e., mental health, drug use, obesity, teenage pregnancies et al.) were more prevalent in countries with higher degree of income inequality. The authors analyzed data in a sample of 23 developed countries and found that income inequality was associated with lower life expectancy, higher rates of infant mortality, higher prevalence of low birth weight, and higher rates of AIDS and depression. For instance, in Japan and Scandinavian countries where the income inequality was low, the life expectancy was significantly better than in U.S. and U.K. where the income inequality was high among developed countries. One of the proposed mechanisms was through social cohesion, implying that in unequal societies people become less likely to trust each other or to be involved in community life, and thus, the negative outcome on health.
Regimes of social cohesion
While the above theories analyzed the theoretical dimensions and compositions of the concept of social cohesion, scholars recently suggested a contrasting approach of examining social cohesion by regimes[4, 12, 21]. The reason for using a typological approach is because countries or regions are not always homogeneous in possessing these dimensions of social cohesion (i.e., liberty, equality, and solidarity), but a diversity of countries with different combinations of these dimensions likely exist. There is a long tradition of understanding lasting differences between countries by regimes in which countries under the same regime are usually economically, socially, culturally, and sometimes geographically close to each other. For instance, Esping-Anderson identified regimes of welfare states in Western societies based on welfare capitalism.
Instead of identifying general dimensions of social cohesion applicable to all Western states, Green[4, 21] and Janmaat sought to empirically verify the unique and durable “regimes” of social cohesion. Green et al. performed cluster analyses among 18 countries and found evidence for distinct English-speaking liberal and distinct Scandinavian social-democratic regimes, while little empirical support was found for the existence of a social market regime. To verify Green et al.’s results, Janmaat conducted cluster analyses among 16 countries and reported a reasonably distinctive and stable Scandinavian model characterized by high trust, high equality, and low crime rates. He also identified a continental European cluster, which exhibited unexpectedly low levels of social hierarchy and high levels of value pluralism and ethnic tolerance, but found no evidence of a distinctive liberal English-speaking regime of social cohesion.
Those studies generally reported that when a country is socioeconomically wealthy, it is usually more trusting, equal, safe, and tolerant toward minorities. Some studies suggested that liberal English-speaking countries had the strongest liberal attitudes and highest levels of individual freedom and thus had higher value diversity. However, some others observed that liberty is also strong in Scandinavia[4, 12]. They thought high taxes and strong government intervention in Scandinavian countries form an egalitarian welfare state providing equal opportunities for different populations, which can foster liberal attitudes and value diversity. The key issue here might be the extent to which the relational and institutional systems, in particular democratic systems, are well structured and can provide equitable access and opportunities for people from different social groups.
Empirical studies of social cohesion and health
How does social cohesion influence individual health? Some researchers suggested that social cohesion, underpinned by national policies and political decisions, may influence individual health through providing equal opportunity and mitigating poverty, disparity, and social exclusion. For example, relevant policies provide opportunities for citizens to participate in social, economic, and political activities within communities, which would further enhance well-being. Social cohesion, manifested in policies that deliberately intervene unemployment, poverty, and health inequality, can also have positive effect on health through the re-allocation of social and health resources. A more cohesive society may invest more in public infrastructure such as education, social welfare, and health services, which narrow down health inequality and reduce unequal access to health services. On the other hand, from the psychological and behavioral perspectives, social cohesion may exert an influence through social norms to reduce risky behavior and to diffuse health information. A higher level of social cohesion may also provide more social support and mutual respect, which can buffer the adverse effects of stress[24, 25].
Some research, based on an ecological study design, looked at the relationship between national-level social cohesion and national-level health outcomes, such as mortality and morbidity. Some found strong effects of trust on mortality, while others found only modest or insignificant effects of trust and social participation on health[27, 28]. Few studies used a multilevel study design to examine the impact of social cohesion on individual health above and beyond individual characteristics, but they produced inconsistent results. Mansyur and Poortinga showed that individual-level social participation and trust do not affect self-rated health; however, national-level social participation and trust do affect self-rated health. Using data from 69 countries, Jen and colleagues showed that social trust at both the national and individual levels was positively associated with self-rated health after controlling for individual sociodemographic and income variables.
Some other relevant studies were published from the aspect of welfare states. Prior studies generally reached agreement that population health varies according to the type of welfare state regime, and a regime advocating more-egalitarian welfare policies (i.e., public medical services) is more likely to maintain and improve a nation’s health. Most empirical studies identified Scandinavian welfare states as having the best population health status. Although Asian welfare states had lower social expenditures compared to Western countries, studies found that they did not have higher infant mortality or lower life expectancy, probably because of a strong reliance on family to provide care[34, 35]. Very few studies used a multilevel study design to examine the regimes of welfare states on individual health. Eikemo et al. used a multilevel analytical approach and found that Scandinavian and Anglo-Saxon welfare regimes reported better self-rated health than Southern and Eastern European welfare regimes, after taking into account individual sociodemographic characteristics and social relationships.
This study intends to further understand the relationship between social cohesion and health. At present, most of the literature on social capital focused on small groups (i.e. neighborhoods) or used only two aspects, trust and social participation, to measure social cohesion. As we have emphasized, social cohesion should be characterized as features of a whole society incorporating attitudes, behaviors, institutional and structural dimensions that bound citizens together for better life quality. Therefore, we implemented a series of procedures to comprehensively measure and analyze the relationship between social cohesion and individual health. We first followed theoretical frameworks and identified multiple dimensions of social cohesion using a factor analysis. Then, we developed a typology of social cohesion regimes with a cluster analysis to further understand the spatial patterning of social cohesion in different countries. Finally, using a multi-level statistical design, we assessed the effects of dimensions of social cohesion on an individual’s self-rated health after controlling for individual characteristics.