Disability and Health Journal 8 (2015) 200e207 www.disabilityandhealthjnl.com
Research Paper
The impact on social capital of mobility disability and weight status: The Stockholm Public Health Cohort Mattias Norrb€ack, M.Sc.a,*, Jeroen de Munter, Ph.D.a, Per Tynelius, M.Sc.a, Gerd Ahlstr€ om, Ph.D.b, and Finn Rasmussen, M.D., Ph.D.a a
Child and Adolescent Public Health Epidemiology, Department of Public Health Sciences, Karolinska Institutet, Sweden b The Swedish Institute for Health Sciences, Department of Health Sciences, Lund University, Sweden
Abstract Background: People with mobility disability are more often overweight or obese and have lower social capital than people without mobility disability. It is unclear whether having a combination of mobility disability and overweight or obesity furthers negative development of social capital over time. Objective: To explore whether there were differences in social capital between normal-weight, overweight and obese people with or without mobility disability over a period of 8 years. Methods: We included 14,481 individuals (18e64 at baseline) from the Stockholm Public Health Cohort that started in 2002. Mobility disability, weight status, and social capital (structural: social activities, voting; cognitive: trust in authorities, and trust in people) were identified from self-reports. Risk ratios with 95% confidence intervals were estimated in multivariate longitudinal regression analyses. Results: We found no significant differences in social activities and voting between the groups over time. However, when compared with the reference group, the groups with mobility disability had less trust in authorities and public institutions over time. Notably, obese people with mobility disability showed the largest decrease in trust in the police (RR 5 2.29; 1.50e3.50), the parliament (RR 5 2.00; 1.31e3.05), and local politicians (RR 5 2.52; 1.61e3.94). Conclusions: People with mobility disability experience lower cognitive social capital over time than people without mobility disability. Being burdened by both mobility disability and obesity may be worse in terms of social capital than having just one of the conditions, especially regarding cognitive social capital. This finding is of public health importance, since social capital is related to health. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Physical disability; Limitation; Obesity; Cognitive; Structural
Today, nearly one-fifth of the general population in the US live with some form of disability.1 In Sweden, based on selfreport data, the estimated prevalence is even higher, with nearly 23% of the adult population disabled. Mobility disability accounts for approximately 13% of all disabilities in the US,2 and 8% in Sweden.3 In Sweden, men and women with a mobility disability are two and three times more likely,
Funding: This research was supported by grant 2010-1828 from the Swedish Council for Working Life and Social Research, according to Finn Rasmussen. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Swedish Council for Working Life and Social Research. We hereby declare that there are no conflicts of interest. Abstract: Review oral session at ECO 2013: http://www.karger.com/ Article/Pdf/250038. * Corresponding author. Child and Adolescent Public Health Epidemiology, Department of Public Health Sciences, Karolinska Institutet, Tomtebodav€agen 18A, 171 77 Stockholm, Sweden. Tel.: þ46 737 29 30 28. E-mail address: [email protected] (M. Norrb€ack). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.09.005
respectively, to be obese than members of the general population.3 Obesity can be considered both a predictor of4,5 and a secondary condition1 associated with mobility disability. Although mobility disability6 as well as obesity7 have been associated to social capital in separate studies, much less is known about the combination of mobility disability and obesity in terms of change in social capital over time. Social capital is a multi-faceted concept that, on most definitions, has two main components, structural and cognitive. Structural social capital incorporates how social networks are influenced by what people do, and how they interact within them. Cognitive social capital incorporates what people perceive, feel, and think in their social networks and relationships. In addition, these components have been extended to include horizontal and vertical dimensions.8 The horizontal dimension is characterized by the relationships between individuals or groups at the same hierarchical level, which includes bonding and bridging social capital, e.g. relationships within or between relative similar groups (based on
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occupation, ethnicity, family ties, etc.). The vertical dimension concerns relations that differ in formal power or authority.8 Social capital is often referred to as either an individual or a group attribute.10 Because of the multi-dimensional theory underlying social capital, studies in public health are often limited to consideration of various proxy measures of social capital as, for example, determining the quality and size of networks, or trust to individuals or authorities, civic engagement or social participation.11,12 There is a well-documented literature on the association between social capital and health. For example, social capital has been negatively associated with mortality,13 and there are studies that have found an association between social capital and self-rated health.14,15 Although there is some research showing that people with mobility disability have lower social capital than people without mobility disability,6,16,17 it is unclear whether the difference in social capital is stable or whether it increases over time, which might ultimately indicate a worsening of health in the mobility-disabled group. However, there is only limited research that investigates longitudinal changes in social capital among people with mobility disability. Further, it might be that the combination of mobility disability and overweight or obesity has a particularly deleterious effect on social capital over time. The aim of the present study was therefore to explore whether there are differences in social capital over time between normal-weight, overweight and obese people with or without mobility disability.
Methods Sample selection Data were obtained from the Stockholm Public Health Cohort (SPHC). More information on the original sampling and responses is available online.18 We included 19,633 individuals aged 18e64 years who responded to questionnaires in 2002, 2007 and 2010. From this sample, we excluded those who did not answer the questions on height and weight (17%), long-term illness (1.2%), and mobility disability in 2002 and 2010 (1.6%). Weight status was established at baseline by computing body mass index (BMI) scores (kg/m2) from self-reported height and weight, according to WHO criteria.19 To minimize misclassification, we excluded individuals with implausible values: BMI 60 kg/m2, height 210 cm, weight 150 kg (1.7%), and also those who seemed to have increased in BMI by more than 15 units between any consecutive pair of the surveys in 2002, 2007 and 2010 (4.3%). Individuals with mobility disability were identified by a question on mobility derived from the EuroQol EQ-5D-3L self-rating scale.20 People who responded to one of the following two alternatives, ‘‘I have some problems in walking about’’ and ‘‘I am confined to bed’’, were categorized as mobility-disabled. Only individuals who reported mobility disability in both 2002 and
201
2010 were considered in this study. In total, the present study includes information on 14,481 individuals in the cohort (73.8%). Exposure groups Six exposure groups were created and followed from 2002 to 2010: normal weight without mobility disability (reference group), overweight without mobility disability, obese without mobility disability, normal weight with mobility disability, overweight with mobility disability, and obese with mobility disability. Outcomes Four items in the questionnaires measured aspects of structural and cognitive social capital, including their horizontal and vertical dimensions. Structural social capital, horizontal: ‘‘In the past 12 months, have you more or less regularly participated in activities together with several other people?’’ (yes/no), and structural social capital, vertical: ‘‘Will you vote/did you vote in any election this year?’’ (yes/no). Cognitive social capital, horizontal: ‘‘You can trust most of the people living in this neighborhood’’ (agree completely, agree to some extent, disagree to some extent, and disagree completely) and cognitive social capital, vertical: ‘‘How much confidence do you have in the following public institutions?’’ (considerable, fairly considerable, little, none whatsoever, and no opinion). This final item covered the health care system, police, parliament, and local politicians. ‘No opinion’ was treated in this study as the lowest level of trust, since any change over time from no opinion was regarded as an improvement in trust. The four social capital outcomes are referred to as ‘‘participation in social activities’’, ‘‘voting in elections’’, ‘‘trust in individuals’’, and ‘‘trust in authorities’’ throughout. Covariates Age, sex, level of education and country of birth were considered as potential confounding factors, and were taken from self-reports in the 2002 questionnaire. Education was categorized as primary (!9 years), lower-secondary (9e10 years), upper-secondary (!12 years), college (12e13 years), or academic (O13 years), and country of birth as Swedish or non-Swedish. Statistical analysis For the binary outcomes ‘‘participation in social activities’’ (yes/no) and ‘‘voting in elections’’ (yes/no) we used Poisson regression, with robust variance, as estimated by generalized estimating equations (GEEs), to calculate risk ratios (RRs) and 95% confidence intervals (CIs), while also accounting for within-individual correlations (unstructured). Our model included variables that defined our six groups of interest, survey years, interaction terms for group by survey
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the xtgee and mlogit commands in STATA 12.1 (Stata Corp, College Station, Texas, USA).
year, and the covariates. This enabled us to establish whether patterns differed between any of the exposure groups over time (indicating interaction) and the reference group (normal-weight people without mobility disability in 2002). Using the same model, we also rescaled the RRs (post-estimation) to facilitate longitudinal comparisons within groups over time. Differences within and between groups (interactions) were tested using Wald chi-square tests. Multinomial regression models were used to estimate relative risks (RRs) with 95% CIs to analyze longitudinal changes in ‘‘trust in individuals’’ and ‘‘trust in authorities’’ between the exposure groups compared with the reference group. Using this approach, trust could go downward, upward, or remain similar between 2002 and 2010. We used Wald chi-square tests (for heterogeneity) to establish whether there were any differences in the associations between change in social capital over time and the exposure groups compared with the reference group. All models were adjusted for age, sex, country of birth, and education. Age was used as a continuous variable in the regression models. We also used pairwise-comparison testing (postestimation) to investigate whether obese people with mobility disability had a higher risk of a negative development in social capital over time compared with people with just one condition (mobility disability or overweight/ obesity). Sensitivity analyses for country of birth were also performed. The regression analyses were performed using
Results In our study sample, we observed 516 individuals who had mobility disability in both 2002 and 2010 in combination with overweight or obesity (data not shown). Data on the baseline characteristics of the various groups are shown in Table 1. People with mobility disability were more often female, older, non-Swedish, and with a lower education, participated less often in social activities, voted less in elections, and more often reported low trust in institutions and authorities and in other people in the neighborhood than people without mobility disability. People with the combination of overweight or obesity and mobility disability were more often in the oldest age category (45e64), and were more likely to have a primary or lower-secondary level of education, than people in the other groups. Participation in social activities and voting in elections At the time of the baseline survey in 2002, normalweight people without MD reported higher rates of participation in social activities when compared with all the other groups, with the exception of overweight people without MD. Over time, normal-weight people without mobility
Table 1 Baseline characteristics of the 2002 sample from the Stockholm Public Health Cohort by mobility disability and weight status No mobility disability Mobility disability
n (%) Sex, women (%) Age at baseline 45e64 25e44 18e24 Nationality Swedish Non-Swedish Missing Education Academic Upper-secondary/college Lower-secondary Primary Other Missing Structural social capital Not participating in activities Not voting in elections Cognitive social capital Low trust in individuals Low trust in health care Low trust in the police Low trust in the parliament Low trust in local politicians Values are n (%).
Normal weight
Overweight
Obese
Normal weight
Overweight
Obese
Total
8478 (57.8) 5452 (64.3)
4552 (31.1) 1956 (43.0)
1097 (7.5) 570 (52.0)
183 (1.3) 121 (66.1)
203 (1.4) 105 (51.7)
130 (0.9) 82 (63.1)
14,643 (100) 8499 (57.1)
3572 (42.1) 4118 (48.6) 788 (9.3)
2792 (61.3) 1620 (35.6) 140 (3.1)
667 (60.8) 403 (36.7) 27 (2.5)
127 (69.4) 50 (27.3) 6 (3.3)
170 (83.7) 32 (15.8) 1 (0.5)
113 (86.9) 16 (12.3) 1 (0.8)
7513 (50.5) 6350 (42.7) 1018 (6.8)
7381 (87.1) 1055 (12.4) 42 (0.5)
3867 (85.0) 672 (14.8) 13 (0.3)
907 (82.7) 184 (16.8) 6 (0.5)
124 (67.8) 58 (31.7) 1 (0.5)
139 (68.5) 62 (30.5) 2 (1.0)
86 (66.2) 43 (33.1) 1 (0.8)
12,713 (85.4) 2101 (14.1) 67 (0.5)
4219 1742 1719 718 30 50
1686 843 1276 697 17 33
347 186 338 216 3 7
(49.8) (20.5) (20.3) (8.5) (0.4) (0.6)
(37.0) (18.5) (28.0) (15.3) (0.4) (0.7)
(31.6) (17.0) (30.8) (19.7) (0.3) (0.6)
2772 (32.9) 647 (7.7)
1652 (36.6) 369 (8.2)
483 (44.4) 111 (10.1)
3330 2090 2421 4833 6171
1734 1168 1369 2795 3335
356 326 360 704 831
(39.9) (24.9) (28.9) (57.8) (73.7)
(38.6) (25.9) (30.4) (62.1) (74.1)
(32.7) (30.1) (33.2) (64.9) (76.5)
55 28 53 41 3 3
(30.1) (15.3) (29.0) (22.4) (1.6) (1.6)
97 (53.6) 33 (18.0) 47 77 90 142 151
(26.9) (43.5) (50.9) (80.7) (86.3)
44 27 70 54 2 6
(21.7) (13.3) (34.5) (26.6) (1.0) (3.0)
100 (50.0) 20 (10.1) 56 65 78 147 154
(28.6) (32.2) (39.6) (75.0) (78.6)
24 17 50 36 1 2
(18.5) (13.1) (38.5) (27.7) (0.8) (1.5)
63 (49.6) 14 (10.8) 27 51 50 86 102
(21.8) (39.2) (38.8) (67.2) (79.7)
6487 2900 3545 1786 60 103
(43.6) (19.5) (23.8) (12.0) (0.4) (0.7)
5167 (35.6) 1194 (8.2) 5550 3777 4368 8707 10,744
(38.5) (26.1) (30.2) (60.2) (74.3)
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Table 2 Associations between mobility disability and not participating in social activities over time in the Stockholm Public Health Cohort (2002, 2007 and 2010) by weight status Not participating in social activities Rescaled within groups Crude, n (%) Exposure groups 2002 Without MD Normal Overweight Obese With MD Normal Overweight Obese
RR (95% CI) 2010
2002
RR (95% CI) 2007
2010
2002
2007
2010
2772 (32.9) 3011 (35.7) 1.00 (ref) 1.07 (1.03e1.10) 1.10 (1.06e1.14) 1.00 (ref) 1.07 (1.03e1.10) 1.10 (1.06e1.14) 1652 (36.6) 1671 (37.0) 1.05 (0.99e1.10) 1.04 (0.99e1.10) 1.07 (1.01e1.12) 1.00 (ref) 1.00 (0.96e1.04) 1.02 (0.98e1.07) 483 (44.4) 479 (44.0) 1.24 (1.15e1.33) 1.22 (1.13e1.31) 1.24 (1.15e1.33) 1.00 (ref) 0.99 (0.92e1.06) 1.00 (0.93e1.08) 97 (53.6) 100 (50.0) 63 (49.6)
98 (54.4) 1.46 (1.27e1.68) 1.54 (1.34e1.76) 1.47 (1.27e1.69) 1.00 (ref) 1.05 (0.90e1.22) 1.01 (0.86e1.17) 103 (51.0) 1.32 (1.14e1.51) 1.31 (1.13e1.51) 1.33 (1.15e1.53) 1.00 (ref) 0.99 (0.85e1.16) 1.01 (0.86e1.17) 81 (62.8) 1.32 (1.11e1.57) 1.35 (1.13e1.61) 1.66 (1.44e1.91) 1.00 (ref) 1.02 (0.84e1.25) 1.26 (1.06e1.50)
Values are crude prevalence n (%), and estimated risk ratios (RR, 95% confidence interval). Estimates are adjusted for sex, age, nationality, and educational level. Ref: Reference group.
disability participated less in activities (RR 5 1.26: 1.06e1.50, Table 2, rescaled within groups), and there was also less participation among obese people with mobility disability (RR 5 1.26: 1.06e1.50, Table 2, rescaled within groups). However we found no statistically significant evidence that differences in relative risk between the groups varied over the three time points ( p test for interaction 5 0.06). Nonetheless, there was an indication that obese people with mobility disability had a higher risk of a decline in participation in social activities, RR 5 1.26 (1.06e1.50), compared with the reference group (Table 2, rescaled estimates). Further, there was an indication that obese people with mobility disability had a higher risk of a decline in participation in social activities than members of the groups with just one risk condition, i.e., obese people without mobility disability (RR 5 1.26: 1.04e1.52), and normal-weight people with mobility disability (RR 5 1.25: 1.00e1.58) (based on pairwise comparisons, data not shown). In contrast to social participation, all groups reported that they became less inclined not to vote over time (Table 3). In the adjusted analyses, and compared with
the reference group at baseline, normal-weight people with mobility disability were the only group at a higher risk of not voting in elections (RR 5 1.58: 1.16e2.16). However, there was no statistically significant difference in the pattern of voting behavior over time between the groups ( p 5 0.14, Table 3, rescaled estimates), and we found no statistically significant evidence that obese people with mobility disability differed in their voting behavior over time, compared with normal-weight people with mobility disability, or obese people without mobility disability (based on pairwise comparisons, data not shown). Trust in individuals, authorities and institutions We found no differences in trust in individuals in the neighborhood over time between the groups ( p 5 0.69). However, there were clear statistical differences (Table 4) between the six groups over time with regard to upward and downward changes in trust in institutions and authorities (health care, police, parliament and local politicians). When compared with the reference group without mobility disability, obese people with mobility disability showed the
Table 3 Associations between mobility disability and not voting in elections over time in the Stockholm Public Health Cohort (2002, 2007 and 2010) by weight status Not participating in social activities Rescaled within groups Crude, n (%) Exposure groups Without MD Normal Overweight Obese With MD Normal Overweight Obese
RR (95% CI)
RR (95% CI)
2002
2010
2002
2007
2010
2002
2007
2010
647 (7.7) 369 (8.2) 111 (10.1)
253 (3.0) 145 (3.3) 57 (5.4)
1.00 (ref) 1.01 (0.89e1.17) 1.17 (0.97e1.41)
0.66 (0.60e0.73) 0.71 (0.61e0.83) 0.88 (0.70e1.11)
0.48 (0.42e0.54) 0.48 (0.40e0.58) 0.74 (0.57e0.97)
1.00 (ref) 1.00 (ref) 1.00 (ref)
0.66 (0.60e0.73) 0.70 (0.62e0.80) 0.75 (0.61e0.93)
0.48 (0.42e0.54) 0.48 (0.41e0.56) 0.64 (0.50e0.81)
1.58 (1.16e2.16) 0.97 (0.63e1.47) 1.06 (0.65e1.73)
0.89 (0.56e1.43) 0.91 (0.57e1.45) 0.68 (0.34e1.37)
1.12 (0.73e1.73) 0.77 (0.45e1.29) 0.65 (0.31e1.32)
1.00 (ref) 1.00 (ref) 1.00 (ref)
0.56 (0.38e0.85) 0.94 (0.59e1.50) 0.64 (0.34e1.23)
0.71 (0.45e1.12) 0.79 (0.48e1.31) 0.61 (0.30e1.25)
33 (18.0) 20 (10.1) 14 (10.8)
18 (10.2) 13 (6.6) 7 (5.6)
Values are crude prevalence n (%), and estimated risk ratios (RR, 95% confidence interval). Estimates are adjusted for sex, age, nationality, and educational level. Ref: Reference group.
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Table 4 Associations of mobility disability and weight status with aspects of cognitive social capital (low trust in individuals, and low trust in institutions and authorities) over time in the Stockholm Public Health Cohort Unchanged in 2010 Up in 2010 Down in 2010 Upward change Downward change p for hetero- geneityc Exposure groups % % % RR (95% CI) RR (95% CI) Low level of trust in individuals in neighborhooda Without MD Normal Overweight Obese With MD Normal Overweight Obese
p 5 0.69 57.8 59.5 57.6
30.2 29.0 29.3
12.0 11.5 13.0
1.00 (ref) 1.00 (0.91e1.09) 1.03 (0.89e1.19)
1.00 (ref) 0.94 (0.84e1.07) 1.08 (0.89e1.32)
56.7 57.4 56.7
26.6 31.3 28.3
16.8 11.3 15.0
0.96 (0.67e1.38) 1.20 (0.87e1.66) 1.04 (0.68e1.59)
1.40 (0.91e2.14) 0.91 (0.57e1.47) 1.25 (0.73e2.12)
Low level of trust in authorities and public institutionsb Health care Without MD Normal Overweight Obese With MD Normal Overweight Obese Without MD Normal Overweight Obese With MD Normal Overweight Obese Without MD Normal Overweight Obese With MD Normal Overweight Obese Without MD Normal Overweight Obese With MD Normal Overweight Obese
p 5 0.09 60.2 59.3 57.7
27.2 28.7 30.0
12.6 12.0 12.4
1.00 (5ref) 1.05 (0.96e1.14) 1.15 (0.99e1.33)
1.00 (ref) 0.94 (0.84e1.07) 1.07 (0.87e1.31)
50.6 56.3 49.2 Police
33.0 28.6 31.3
16.5 15.1 19.5
1.39 (0.99e1.95) 1.06 (0.76e1.48) 1.38 (0.92e2.07)
1.48 (0.96e2.29) 1.28 (0.84e1.95) 1.88 (1.16e3.05)
59.1 58.4 54.4
22.8 23.0 24.0
18.1 18.6 21.6
1.00 (ref) 0.99 (0.90e1.08) 1.10 (0.94e1.29)
1.00 (ref) 0.99 (0.89e1.10) 1.21 (1.03e1.43)
50.0 52.8 39.7 Parliament
28.2 22.1 27.0
21.8 25.1 27.0
1.31 (0.92e1.88) 0.91 (0.63e1.33) 1.61 (1.03-2.51)
1.18 (0.80e1.76) 1.31 (0.92e1.86) 2.29 (1.50e3.50)
46.5 45.1 44.9
37.0 36.4 33.4
16.5 18.6 21.6
1.00 (ref) 1.00 (0.92 1.09) 0.93 (0.80 1.08)
1.00 (ref) 1.11 (1.00e1.24) 1.24 (1.04e1.47)
40.8 42.2 37.9 Local politicians
34.5 30.7 26.6
24.7 27.1 35.5
1.04 (0.73 1.48) 0.92 (0.65 1.29) 0.85 (0.54 1.34)
1.33 (0.90e1.97) 1.46 (1.01e2.10) 2.00 (1.31e3.05)
42.4 41.8 40.8
36.9 35.4 34.0
20.6 22.8 25.1
1.00 (ref) 0.99 (0.91 1.08) 1.00 (0.86 1.16)
1.00 (ref) 1.13 (1.02e1.25) 1.24 (1.05e1.47)
34.9 43.2 28.8
33.7 26.6 32.8
31.4 30.1 38.4
1.26 (0.87 1.82) 0.77 (0.54 1.11) 1.56 (0.99 2.46)
1.70 (1.16e2.48) 1.34 (0.94e1.89) 2.52 (1.61e3.94)
p 5 0.005
p ! 0.001
p ! 0.001
Values are n (%) or estimated risk ratios (RR, 95% confidence interval). Estimates are adjusted for age, sex, nationality and educational level, and obtained from multinomial regressions. a The proportion of people who responded at the two lowest levels (‘‘not at all’’ and ‘‘not particularly’’) on a 4-point response scale. b The proportion of people who responded at the three lowest levels (‘‘no opinion,’’ ‘‘none whatsoever,’’ and ‘‘little’’) on a 5-point response scale. c Wald p (heterogeneity) test for difference in upward or downward change across all six groups.
largest risk of downward change (lower trust) with regard to health care, the police, the parliament and local politicians, with risk ratios ranging from RR 5 1.88 (1.16e3.05) for health care to RR 5 2.52 (1.61e3.94) for local politicians (Table 4).
We also found that obese people with mobility disability showed a significantly decreased trust in the police (RR 5 1.93: 1.09e3.42) over time, compared with normal-weight people with mobility disability (Table 4, pairwise comparisons, data not shown). They also showed
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a higher risk, though not statistically significant, of a decreased trust in parliament (RR 5 1.50: 0.85e2.66) and in local politicians (RR 5 1.49: 0.83e2.64) over time, compared with normal-weight people with mobility disability (Table 4, pairwise comparisons, data not shown). Further, when compared with obese people without mobility disability, obese people with mobility disability showed a higher risk of not trusting the police (RR 5 1.89: 1.21e2.95), the parliament (RR 5 1.61: 1.03e2.52) and local politicians (RR 5 2.03: 1.28e3.24) (based on pairwise comparisons, data not shown). The other groups showed less consistent risks of downward changes, and the changes were of lesser magnitude. Normal-weight people with mobility disability showed a significant decrease in trust in local politicians over time (RR 5 1.70, 1.16e2.48), and overweight people with mobility disability showed a significant decrease in trust in parliament over time (RR 5 1.46, 1.01e2.10), compared with the reference group (Table 4). Considering groups without mobility disability, obese people showed a decreased trust in the police (RR 5 1.21, 1.03e1.43), the parliament (RR 5 1.24, 1.04e1.47), and local politicians (RR 5 1.24, 1.05e1.47). No group showed any clear upward change.
Discussion Main findings We found no changes over time between the mobility disability and weight-status groups in structural social capital (participation in social activities, and voting in elections) compared with normal-weight people without mobility disability. However, concerning cognitive social capital (as measured by trust in individuals, and trust in authorities and institutions), obese people with mobility disability comprised the group with the largest decrease in trust in institutions and authorities over time, compared with the reference group. Such a decrease was not seen to a similar extent in people with obesity only or mobility disability only. Our findings in relation to other studies The differences in participation in social activities and level of voting in elections did not seem to change over time between the groups. People with mobility disability have lower-income occupations21 and socioeconomic status,22 than people without mobility disability. One possible and hypothetical explanation why we did not observe any significant difference in social participation between the groups over time may be due to a marginal change in the financial situation for people with a mobility disability over time, e.g. a substantial change in the financial situation (through job opportunities or policy changes) might have stimulated social participation in these groups. Further
205
research could investigate how changes in the financial situation over time are related to social capital. Another explanation for the lack of change over time in participation in social activities and voting might be a lack of change in the structural environment during the period of follow-up, which is influenced by policy decisions to improve and sustain a supportive urban setting for these individuals. Changes in the environment have been shown directly to affect their participation in the community.23,24 As a consequence, people using wheelchairs, or other mobility aids, may have difficulties attending social events or polling stations because of problems getting to and/or accessing the facilities. However, there was some indication that the obese people with mobility disability participated less in social activities over time, and we also found that the groups with mobility disability showed lower participation in social activities over time than groups having only one of the conditions. This may be due to the presence of more frequent or more intense physically or mentally limiting conditions, potentially as a result of weight gain over time, such as increasing (joint) pain,25 which make the overweight or obese less likely to be able to participate in social activities. We did not observe any significant difference in change in trust in individuals over time when comparing the exposure groups with the reference group. Research has shown that interpersonal trust within neighborhoods is mediated by both social determinants, such as education and class,26 and contextual characteristics, such as shared attitudes, norms and values, and a reciprocity of good will among community members in daily life.27 Therefore, we would like to argue that relative stable contextual characteristics are underlying our observation of no changes in interpersonal trust over time between the groups. Trust in authorities and institutions decreased over time, mainly for the groups with mobility disability compared with the reference group. The people in our study with the combination of obesity and mobility disability reported less trust in the health care system than those in the reference group. It may be that negative experiences of the health care system affect their trust in it. According to a previous study, people with disabilities are more likely to report that they have not received adequate health care.28 Also, overweight and obese people may have higher health care expenditures or make more frequent visits to health care providers in general,29 which may make them more likely to have negative experiences. Our results are in line with this idea; the people with the combination of obesity and mobility disability showed the steepest decrease in trust in the health care system over time. We also found that obese individuals with mobility disability showed the largest decrease in trust over time in politicians and the parliament. Vulnerable groups in society have been observed to have a worse situation on the labor market.30,31,32 During our follow-up period there was a substantial financial crisis in 2009, which might have
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affected people with mobility disability and overweight/ obesity more negatively than people without mobility disability and normal weight, for example, trust in politicians may have decreased in the more severely affected groups because of the crisis. We attempted to look into whether unemployment could be a potential confounder or mediator in our models, which did not seem to affect our main findings substantially (data not shown). But it may still be the case that other measures of a worsened labor market situation explain the lower trust in politicians and parliament over time in the vulnerable groups. Strengths and limitations It is a strength of our study that it is based on a large sample with substantial follow-up from the general population, which enabled us to identify reasonably large groups of individuals with mobility disability in an observational setting, and to make comparisons with people without mobility disability and overweight/obesity. In population-based cohorts there is always some degree of selection due to non-participation. Non-participation in the SPHC (approximately 40%) was rather similar to that in other large-scale population-based cohorts.18 Non-responders were more often non-Swedish, and overweight or obese, and more often had a mobility disability and a lower education. Based on our findings and this non-response pattern, we speculate that the strength of the association between mobility disability and social capital observed in this study is likely to be underestimated. Another limitation of the study is that exposure and outcome were based on self-reports. It is well-known that obese individuals tend to under-report their weight in comparison with normal-weight individuals.33 Further, people with mobility disability may have a different body composition from people without mobility disability, and bioelectrical impedance and waist circumference (WC) may provide more accurate measures of weight status than BMI from self-reports. One study has shown that there is a higher prevalence of obesity in people with disability when using waist circumference rather than the combination of selfreported height and weight (BMI) as a measure.34 Therefore, we have most likely underestimated the prevalence of overweight or obesity in our cohort of people with a mobility disability, and it is not improbable that alternative measurements would have strengthened the associations we found between mobility disability, obesity and social capital. We were restricted to using crude categories, i.e., ‘‘walking with difficulty’’ and ‘‘confined to bed’’, to classify people with mobility disability. Being confined to bed can be interpreted as reflecting a severe disability, and may include individuals in hospices and/or long-term care.35 Only six individuals reported being confined to bed in both 2002 and 2010, which was too small a number to report on separately. However, the interpretation of our
main findings did not change when these individuals were excluded in sensitivity analyses. Additionally, we did not know onset of mobility disability prior to 2002, which may have influenced the development of social capital over time. It is not unlikely that the people in this cohort had a long-term mobility disability well before 2002. As a result, any change in social capital for this group prior to 2002 might have gone undetected, which might be an explanation why we were unable to detect any clear difference over time in structural social capital for members of the disability groups compared with the people without mobility disability. The measurement and operationalization of social capital are complex tasks. In this study, we were unable to be more precise about types of social activity, e.g. reports on online activities were not available. It would have been more informative to consider types of social activities with regard to duration and frequency. One third of the people in our study with mobility disability were of non-Swedish origin, compared with approximately one sixth of those without a mobility disability. Additional adjustment for country of birth in sensitivity analyses did not change the results substantially. Regarding the generalizability of our results, the presented patterns are likely to be very similar to those in other northern European countries, because mobility disability and social capital are highly context-dependent concepts.36 But, we should be cautious in generalizing these patterns to societies with larger social inequalities, or places that are very different contextually from the wider Stockholm region in which our data were collected.
Conclusion This study gives us further understanding of the longitudinal development of social capital in groups of people who are normal weight, overweight or obese, and with or without mobility disability. The study explored both structural and cognitive social capital, but we only observed a clear worsening over time in cognitive social capital among normal-weight, overweight and obese people with mobility disability, and also obese people without mobility disability, compared with normal-weight people without mobility disability. The greatest deterioration in cognitive social capital was in the group with both obesity and mobility disability. Due to worsening cognitive social capital over time, people with mobility disability and obesity may experience health that is worse than that attributable to the health problems directly related to their medical conditions. References 1. Liou TH, Pi-Sunyer FX, Laferrere B. Physical disability and obesity. Nutr Rev. 2005;63(10):321e331. 2. Brault MW. Americans with Disabilities: 2010. U.S. CENSUS BUREAU; 2012:24.
M. Norrb€ack et al. / Disability and Health Journal 8 (2015) 200e207 3. Swedish National Institute of Public Health. Health on Equal Terms? Health and Living Conditions Among People With Disabilities. Stockholm: Swedish National Institute of Public Health; 2008. 4. Dowd JB, Zajacova A. Long-term obesity and physical functioning in older Americans. Int J Obes (Lond); 2014. 5. Vincent HK, Vincent KR, Lamb KM. Obesity and mobility disability in the older adult. Obes Rev. 2010;11(8):568e579. 6. Guilcher SJT, Casciaro T, Lemieux-Charles L, Craven C, McColl MA, Jaglal SB. Social networks and secondary health conditions: the critical secondary team for individuals with spinal cord injury. Journal of Spinal Cord Medicine. 2012;35(5):330e342. 7. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357(4):370e379. 8. Murayama H, Fujiwara Y, Kawachi I. Social capital and health: a review of prospective multilevel studies. J Epidemiol. 2012;22(3):179e187. 9. Islam MK, Merlo J, Kawachi I, Lindstrom M, Gerdtham UG. Social capital and health: does egalitarianism matter? A literature review. Int J Equity Health. 2006;5:3. 10. Portes A, Landolt P. Social capital: promise and pitfalls of its role in development. Journal of Latin American Studies. 2000;32:529e547. 11. Harpham T, Grant E, Thomas E. Measuring social capital within health surveys: key issues. Health Policy Plan. 2002;17(1):106e111. 12. Engstrom K, Mattsson F, Jarleborg A, Hallqvist J. Contextual social capital as a risk factor for poor self-rated health: a multilevel analysis. Soc Sci Med. 2008;66(11):2268e2280. 13. Nyqvist F, Pape B, Pellfolk T, Forsman AK, Wahlbeck K. Structural and cognitive aspects of social capital and all-cause mortality: a meta-analysis of cohort studies. Soc Indic Res. 2014;116(2):545e566. 14. Kawachi I, Kennedy BP, Glass R. Social capital and self-rated health: a contextual analysis. Am J Public Health. 1999;89(8):1187e1193. 15. Giordano GN, Lindstrom M. The impact of changes in different aspects of social capital and material conditions on self-rated health over time: a longitudinal cohort study. Soc Sci Med. 2010;70(5):700e710. 16. Schur L, Adya M. Sidelined or mainstreamed? Political participation and attitudes of people with disabilities in the United States. Soc Sci Quart. 2013;94(3):811e839. 17. Chenowath L, Stehlik D. Implications of social capital for the inclusion of people with disabilities and families in community life. Int J Inclusive Education. 2004;8(1):59e72. 18. Svensson AC, Fredlund P, Laflamme L, et al. Cohort profile: the Stockholm public health cohort. Int J Epidemiol. 2013 Oct;42(5): 1263e1272. 19. World Health Organization. Global Database on Body Mass Index. World Health Organization. Accessed 29.02.12, http://apps.who.int/ bmi/index.jsp?introPage5intro_3.html; 2013.
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20. Williams A. Euroqol e a new facility for the measurement of healthrelated quality-of-life. Health Policy. 1990;16(3):199e208. 21. Kaye HS. Stuck at the Bottom Rung: occupational characteristics of workers with disabilities. J Occup Rehabil. 2009;19(2):115e128. 22. Association AP. Disability & Socioeconomic Status. American Psychological Association; 2014:2. 23. Clarke P, Ailshire JA, Bader M, Morenoff JD, House JS. Mobility disability and the urban built environment. Am J Epidemiol. 2008;168(5):506e513. 24. Tokaji D, Colker R. Absentee Voting by People with Disabilities: Promoting Access and Integrity., Vol 38. McGeorge School of Law, University of the Pacific; 2007:2007. 25. Holmgren M, Lindgren A, de Munter J, Rasmussen F, Ahlstrom G. Impacts of mobility disability and high and increasing body mass index on health-related quality of life and participation in society: a population-based cohort study from Sweden. BMC Public Health. 2014;14:381. 26. Letki N. Does diversity erode social cohesion? Social capital and race in British neighbourhoods. Polit Stud. 2008;56(1):99e126. 27. Lewicki RJ, Tomlinson EC, Gillespie N. Models of interpersonal trust development: theoretical approaches, empirical evidence, and future directions. J Manag. 2006;32(6):991e1022. 28. Katz E, DeRose R. The ADA 20 Years Later: the 2010 survey of Americans with disabilities. J Spinal Cord Med. 2010;33(4):345. 29. Lehnert T, Sonntag D, Konnopka A, Riedel-Heller S, Konig HH. Economic costs of overweight and obesity. Best Pract Res Clin Endocrinol Metab. 2013;27(2):105e115. 30. Office for Disability Issues. In: Disability Employment Factsheet: Employment Rates. DWP; 2008:5. 31. Holland P, Burstrom B, Whitehead M, et al. How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part I: the impact of recession and deindustrialization. Int J Health Serv. 2011;41(3):395e413. 32. Baldwin ML, Schumacher EJ. A note on job mobility among workers with disabilities. Ind Rel. 2002;41(3):430e441. 33. Roberts RJ. Can self-reported data accurately describe the prevalence of overweight. Public Health. 1995;109(4):275e284. 34. Salem R, Bamer AM, Alschuler KN, Johnson KL, Amtmann D. Obesity and symptoms and quality of life indicators of individuals with disabilities. Disabil Health J. 2014;7(1):124e130. 35. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern-Cooperative-Oncology-Group. Am J Clin Oncol. 1982;5(6):649e655. 36. Eriksson M. Social capital and healtheimplications for health promotion. Glob Health Action. 2011;4:5611.
Research Paper
The impact on social capital of mobility disability and weight status: The Stockholm Public Health Cohort Mattias Norrb€ack, M.Sc.a,*, Jeroen de Munter, Ph.D.a, Per Tynelius, M.Sc.a, Gerd Ahlstr€ om, Ph.D.b, and Finn Rasmussen, M.D., Ph.D.a a
Child and Adolescent Public Health Epidemiology, Department of Public Health Sciences, Karolinska Institutet, Sweden b The Swedish Institute for Health Sciences, Department of Health Sciences, Lund University, Sweden
Abstract Background: People with mobility disability are more often overweight or obese and have lower social capital than people without mobility disability. It is unclear whether having a combination of mobility disability and overweight or obesity furthers negative development of social capital over time. Objective: To explore whether there were differences in social capital between normal-weight, overweight and obese people with or without mobility disability over a period of 8 years. Methods: We included 14,481 individuals (18e64 at baseline) from the Stockholm Public Health Cohort that started in 2002. Mobility disability, weight status, and social capital (structural: social activities, voting; cognitive: trust in authorities, and trust in people) were identified from self-reports. Risk ratios with 95% confidence intervals were estimated in multivariate longitudinal regression analyses. Results: We found no significant differences in social activities and voting between the groups over time. However, when compared with the reference group, the groups with mobility disability had less trust in authorities and public institutions over time. Notably, obese people with mobility disability showed the largest decrease in trust in the police (RR 5 2.29; 1.50e3.50), the parliament (RR 5 2.00; 1.31e3.05), and local politicians (RR 5 2.52; 1.61e3.94). Conclusions: People with mobility disability experience lower cognitive social capital over time than people without mobility disability. Being burdened by both mobility disability and obesity may be worse in terms of social capital than having just one of the conditions, especially regarding cognitive social capital. This finding is of public health importance, since social capital is related to health. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Physical disability; Limitation; Obesity; Cognitive; Structural
Today, nearly one-fifth of the general population in the US live with some form of disability.1 In Sweden, based on selfreport data, the estimated prevalence is even higher, with nearly 23% of the adult population disabled. Mobility disability accounts for approximately 13% of all disabilities in the US,2 and 8% in Sweden.3 In Sweden, men and women with a mobility disability are two and three times more likely,
Funding: This research was supported by grant 2010-1828 from the Swedish Council for Working Life and Social Research, according to Finn Rasmussen. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Swedish Council for Working Life and Social Research. We hereby declare that there are no conflicts of interest. Abstract: Review oral session at ECO 2013: http://www.karger.com/ Article/Pdf/250038. * Corresponding author. Child and Adolescent Public Health Epidemiology, Department of Public Health Sciences, Karolinska Institutet, Tomtebodav€agen 18A, 171 77 Stockholm, Sweden. Tel.: þ46 737 29 30 28. E-mail address: [email protected] (M. Norrb€ack). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.09.005
respectively, to be obese than members of the general population.3 Obesity can be considered both a predictor of4,5 and a secondary condition1 associated with mobility disability. Although mobility disability6 as well as obesity7 have been associated to social capital in separate studies, much less is known about the combination of mobility disability and obesity in terms of change in social capital over time. Social capital is a multi-faceted concept that, on most definitions, has two main components, structural and cognitive. Structural social capital incorporates how social networks are influenced by what people do, and how they interact within them. Cognitive social capital incorporates what people perceive, feel, and think in their social networks and relationships. In addition, these components have been extended to include horizontal and vertical dimensions.8 The horizontal dimension is characterized by the relationships between individuals or groups at the same hierarchical level, which includes bonding and bridging social capital, e.g. relationships within or between relative similar groups (based on
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occupation, ethnicity, family ties, etc.). The vertical dimension concerns relations that differ in formal power or authority.8 Social capital is often referred to as either an individual or a group attribute.10 Because of the multi-dimensional theory underlying social capital, studies in public health are often limited to consideration of various proxy measures of social capital as, for example, determining the quality and size of networks, or trust to individuals or authorities, civic engagement or social participation.11,12 There is a well-documented literature on the association between social capital and health. For example, social capital has been negatively associated with mortality,13 and there are studies that have found an association between social capital and self-rated health.14,15 Although there is some research showing that people with mobility disability have lower social capital than people without mobility disability,6,16,17 it is unclear whether the difference in social capital is stable or whether it increases over time, which might ultimately indicate a worsening of health in the mobility-disabled group. However, there is only limited research that investigates longitudinal changes in social capital among people with mobility disability. Further, it might be that the combination of mobility disability and overweight or obesity has a particularly deleterious effect on social capital over time. The aim of the present study was therefore to explore whether there are differences in social capital over time between normal-weight, overweight and obese people with or without mobility disability.
Methods Sample selection Data were obtained from the Stockholm Public Health Cohort (SPHC). More information on the original sampling and responses is available online.18 We included 19,633 individuals aged 18e64 years who responded to questionnaires in 2002, 2007 and 2010. From this sample, we excluded those who did not answer the questions on height and weight (17%), long-term illness (1.2%), and mobility disability in 2002 and 2010 (1.6%). Weight status was established at baseline by computing body mass index (BMI) scores (kg/m2) from self-reported height and weight, according to WHO criteria.19 To minimize misclassification, we excluded individuals with implausible values: BMI 60 kg/m2, height 210 cm, weight 150 kg (1.7%), and also those who seemed to have increased in BMI by more than 15 units between any consecutive pair of the surveys in 2002, 2007 and 2010 (4.3%). Individuals with mobility disability were identified by a question on mobility derived from the EuroQol EQ-5D-3L self-rating scale.20 People who responded to one of the following two alternatives, ‘‘I have some problems in walking about’’ and ‘‘I am confined to bed’’, were categorized as mobility-disabled. Only individuals who reported mobility disability in both 2002 and
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2010 were considered in this study. In total, the present study includes information on 14,481 individuals in the cohort (73.8%). Exposure groups Six exposure groups were created and followed from 2002 to 2010: normal weight without mobility disability (reference group), overweight without mobility disability, obese without mobility disability, normal weight with mobility disability, overweight with mobility disability, and obese with mobility disability. Outcomes Four items in the questionnaires measured aspects of structural and cognitive social capital, including their horizontal and vertical dimensions. Structural social capital, horizontal: ‘‘In the past 12 months, have you more or less regularly participated in activities together with several other people?’’ (yes/no), and structural social capital, vertical: ‘‘Will you vote/did you vote in any election this year?’’ (yes/no). Cognitive social capital, horizontal: ‘‘You can trust most of the people living in this neighborhood’’ (agree completely, agree to some extent, disagree to some extent, and disagree completely) and cognitive social capital, vertical: ‘‘How much confidence do you have in the following public institutions?’’ (considerable, fairly considerable, little, none whatsoever, and no opinion). This final item covered the health care system, police, parliament, and local politicians. ‘No opinion’ was treated in this study as the lowest level of trust, since any change over time from no opinion was regarded as an improvement in trust. The four social capital outcomes are referred to as ‘‘participation in social activities’’, ‘‘voting in elections’’, ‘‘trust in individuals’’, and ‘‘trust in authorities’’ throughout. Covariates Age, sex, level of education and country of birth were considered as potential confounding factors, and were taken from self-reports in the 2002 questionnaire. Education was categorized as primary (!9 years), lower-secondary (9e10 years), upper-secondary (!12 years), college (12e13 years), or academic (O13 years), and country of birth as Swedish or non-Swedish. Statistical analysis For the binary outcomes ‘‘participation in social activities’’ (yes/no) and ‘‘voting in elections’’ (yes/no) we used Poisson regression, with robust variance, as estimated by generalized estimating equations (GEEs), to calculate risk ratios (RRs) and 95% confidence intervals (CIs), while also accounting for within-individual correlations (unstructured). Our model included variables that defined our six groups of interest, survey years, interaction terms for group by survey
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the xtgee and mlogit commands in STATA 12.1 (Stata Corp, College Station, Texas, USA).
year, and the covariates. This enabled us to establish whether patterns differed between any of the exposure groups over time (indicating interaction) and the reference group (normal-weight people without mobility disability in 2002). Using the same model, we also rescaled the RRs (post-estimation) to facilitate longitudinal comparisons within groups over time. Differences within and between groups (interactions) were tested using Wald chi-square tests. Multinomial regression models were used to estimate relative risks (RRs) with 95% CIs to analyze longitudinal changes in ‘‘trust in individuals’’ and ‘‘trust in authorities’’ between the exposure groups compared with the reference group. Using this approach, trust could go downward, upward, or remain similar between 2002 and 2010. We used Wald chi-square tests (for heterogeneity) to establish whether there were any differences in the associations between change in social capital over time and the exposure groups compared with the reference group. All models were adjusted for age, sex, country of birth, and education. Age was used as a continuous variable in the regression models. We also used pairwise-comparison testing (postestimation) to investigate whether obese people with mobility disability had a higher risk of a negative development in social capital over time compared with people with just one condition (mobility disability or overweight/ obesity). Sensitivity analyses for country of birth were also performed. The regression analyses were performed using
Results In our study sample, we observed 516 individuals who had mobility disability in both 2002 and 2010 in combination with overweight or obesity (data not shown). Data on the baseline characteristics of the various groups are shown in Table 1. People with mobility disability were more often female, older, non-Swedish, and with a lower education, participated less often in social activities, voted less in elections, and more often reported low trust in institutions and authorities and in other people in the neighborhood than people without mobility disability. People with the combination of overweight or obesity and mobility disability were more often in the oldest age category (45e64), and were more likely to have a primary or lower-secondary level of education, than people in the other groups. Participation in social activities and voting in elections At the time of the baseline survey in 2002, normalweight people without MD reported higher rates of participation in social activities when compared with all the other groups, with the exception of overweight people without MD. Over time, normal-weight people without mobility
Table 1 Baseline characteristics of the 2002 sample from the Stockholm Public Health Cohort by mobility disability and weight status No mobility disability Mobility disability
n (%) Sex, women (%) Age at baseline 45e64 25e44 18e24 Nationality Swedish Non-Swedish Missing Education Academic Upper-secondary/college Lower-secondary Primary Other Missing Structural social capital Not participating in activities Not voting in elections Cognitive social capital Low trust in individuals Low trust in health care Low trust in the police Low trust in the parliament Low trust in local politicians Values are n (%).
Normal weight
Overweight
Obese
Normal weight
Overweight
Obese
Total
8478 (57.8) 5452 (64.3)
4552 (31.1) 1956 (43.0)
1097 (7.5) 570 (52.0)
183 (1.3) 121 (66.1)
203 (1.4) 105 (51.7)
130 (0.9) 82 (63.1)
14,643 (100) 8499 (57.1)
3572 (42.1) 4118 (48.6) 788 (9.3)
2792 (61.3) 1620 (35.6) 140 (3.1)
667 (60.8) 403 (36.7) 27 (2.5)
127 (69.4) 50 (27.3) 6 (3.3)
170 (83.7) 32 (15.8) 1 (0.5)
113 (86.9) 16 (12.3) 1 (0.8)
7513 (50.5) 6350 (42.7) 1018 (6.8)
7381 (87.1) 1055 (12.4) 42 (0.5)
3867 (85.0) 672 (14.8) 13 (0.3)
907 (82.7) 184 (16.8) 6 (0.5)
124 (67.8) 58 (31.7) 1 (0.5)
139 (68.5) 62 (30.5) 2 (1.0)
86 (66.2) 43 (33.1) 1 (0.8)
12,713 (85.4) 2101 (14.1) 67 (0.5)
4219 1742 1719 718 30 50
1686 843 1276 697 17 33
347 186 338 216 3 7
(49.8) (20.5) (20.3) (8.5) (0.4) (0.6)
(37.0) (18.5) (28.0) (15.3) (0.4) (0.7)
(31.6) (17.0) (30.8) (19.7) (0.3) (0.6)
2772 (32.9) 647 (7.7)
1652 (36.6) 369 (8.2)
483 (44.4) 111 (10.1)
3330 2090 2421 4833 6171
1734 1168 1369 2795 3335
356 326 360 704 831
(39.9) (24.9) (28.9) (57.8) (73.7)
(38.6) (25.9) (30.4) (62.1) (74.1)
(32.7) (30.1) (33.2) (64.9) (76.5)
55 28 53 41 3 3
(30.1) (15.3) (29.0) (22.4) (1.6) (1.6)
97 (53.6) 33 (18.0) 47 77 90 142 151
(26.9) (43.5) (50.9) (80.7) (86.3)
44 27 70 54 2 6
(21.7) (13.3) (34.5) (26.6) (1.0) (3.0)
100 (50.0) 20 (10.1) 56 65 78 147 154
(28.6) (32.2) (39.6) (75.0) (78.6)
24 17 50 36 1 2
(18.5) (13.1) (38.5) (27.7) (0.8) (1.5)
63 (49.6) 14 (10.8) 27 51 50 86 102
(21.8) (39.2) (38.8) (67.2) (79.7)
6487 2900 3545 1786 60 103
(43.6) (19.5) (23.8) (12.0) (0.4) (0.7)
5167 (35.6) 1194 (8.2) 5550 3777 4368 8707 10,744
(38.5) (26.1) (30.2) (60.2) (74.3)
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Table 2 Associations between mobility disability and not participating in social activities over time in the Stockholm Public Health Cohort (2002, 2007 and 2010) by weight status Not participating in social activities Rescaled within groups Crude, n (%) Exposure groups 2002 Without MD Normal Overweight Obese With MD Normal Overweight Obese
RR (95% CI) 2010
2002
RR (95% CI) 2007
2010
2002
2007
2010
2772 (32.9) 3011 (35.7) 1.00 (ref) 1.07 (1.03e1.10) 1.10 (1.06e1.14) 1.00 (ref) 1.07 (1.03e1.10) 1.10 (1.06e1.14) 1652 (36.6) 1671 (37.0) 1.05 (0.99e1.10) 1.04 (0.99e1.10) 1.07 (1.01e1.12) 1.00 (ref) 1.00 (0.96e1.04) 1.02 (0.98e1.07) 483 (44.4) 479 (44.0) 1.24 (1.15e1.33) 1.22 (1.13e1.31) 1.24 (1.15e1.33) 1.00 (ref) 0.99 (0.92e1.06) 1.00 (0.93e1.08) 97 (53.6) 100 (50.0) 63 (49.6)
98 (54.4) 1.46 (1.27e1.68) 1.54 (1.34e1.76) 1.47 (1.27e1.69) 1.00 (ref) 1.05 (0.90e1.22) 1.01 (0.86e1.17) 103 (51.0) 1.32 (1.14e1.51) 1.31 (1.13e1.51) 1.33 (1.15e1.53) 1.00 (ref) 0.99 (0.85e1.16) 1.01 (0.86e1.17) 81 (62.8) 1.32 (1.11e1.57) 1.35 (1.13e1.61) 1.66 (1.44e1.91) 1.00 (ref) 1.02 (0.84e1.25) 1.26 (1.06e1.50)
Values are crude prevalence n (%), and estimated risk ratios (RR, 95% confidence interval). Estimates are adjusted for sex, age, nationality, and educational level. Ref: Reference group.
disability participated less in activities (RR 5 1.26: 1.06e1.50, Table 2, rescaled within groups), and there was also less participation among obese people with mobility disability (RR 5 1.26: 1.06e1.50, Table 2, rescaled within groups). However we found no statistically significant evidence that differences in relative risk between the groups varied over the three time points ( p test for interaction 5 0.06). Nonetheless, there was an indication that obese people with mobility disability had a higher risk of a decline in participation in social activities, RR 5 1.26 (1.06e1.50), compared with the reference group (Table 2, rescaled estimates). Further, there was an indication that obese people with mobility disability had a higher risk of a decline in participation in social activities than members of the groups with just one risk condition, i.e., obese people without mobility disability (RR 5 1.26: 1.04e1.52), and normal-weight people with mobility disability (RR 5 1.25: 1.00e1.58) (based on pairwise comparisons, data not shown). In contrast to social participation, all groups reported that they became less inclined not to vote over time (Table 3). In the adjusted analyses, and compared with
the reference group at baseline, normal-weight people with mobility disability were the only group at a higher risk of not voting in elections (RR 5 1.58: 1.16e2.16). However, there was no statistically significant difference in the pattern of voting behavior over time between the groups ( p 5 0.14, Table 3, rescaled estimates), and we found no statistically significant evidence that obese people with mobility disability differed in their voting behavior over time, compared with normal-weight people with mobility disability, or obese people without mobility disability (based on pairwise comparisons, data not shown). Trust in individuals, authorities and institutions We found no differences in trust in individuals in the neighborhood over time between the groups ( p 5 0.69). However, there were clear statistical differences (Table 4) between the six groups over time with regard to upward and downward changes in trust in institutions and authorities (health care, police, parliament and local politicians). When compared with the reference group without mobility disability, obese people with mobility disability showed the
Table 3 Associations between mobility disability and not voting in elections over time in the Stockholm Public Health Cohort (2002, 2007 and 2010) by weight status Not participating in social activities Rescaled within groups Crude, n (%) Exposure groups Without MD Normal Overweight Obese With MD Normal Overweight Obese
RR (95% CI)
RR (95% CI)
2002
2010
2002
2007
2010
2002
2007
2010
647 (7.7) 369 (8.2) 111 (10.1)
253 (3.0) 145 (3.3) 57 (5.4)
1.00 (ref) 1.01 (0.89e1.17) 1.17 (0.97e1.41)
0.66 (0.60e0.73) 0.71 (0.61e0.83) 0.88 (0.70e1.11)
0.48 (0.42e0.54) 0.48 (0.40e0.58) 0.74 (0.57e0.97)
1.00 (ref) 1.00 (ref) 1.00 (ref)
0.66 (0.60e0.73) 0.70 (0.62e0.80) 0.75 (0.61e0.93)
0.48 (0.42e0.54) 0.48 (0.41e0.56) 0.64 (0.50e0.81)
1.58 (1.16e2.16) 0.97 (0.63e1.47) 1.06 (0.65e1.73)
0.89 (0.56e1.43) 0.91 (0.57e1.45) 0.68 (0.34e1.37)
1.12 (0.73e1.73) 0.77 (0.45e1.29) 0.65 (0.31e1.32)
1.00 (ref) 1.00 (ref) 1.00 (ref)
0.56 (0.38e0.85) 0.94 (0.59e1.50) 0.64 (0.34e1.23)
0.71 (0.45e1.12) 0.79 (0.48e1.31) 0.61 (0.30e1.25)
33 (18.0) 20 (10.1) 14 (10.8)
18 (10.2) 13 (6.6) 7 (5.6)
Values are crude prevalence n (%), and estimated risk ratios (RR, 95% confidence interval). Estimates are adjusted for sex, age, nationality, and educational level. Ref: Reference group.
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Table 4 Associations of mobility disability and weight status with aspects of cognitive social capital (low trust in individuals, and low trust in institutions and authorities) over time in the Stockholm Public Health Cohort Unchanged in 2010 Up in 2010 Down in 2010 Upward change Downward change p for hetero- geneityc Exposure groups % % % RR (95% CI) RR (95% CI) Low level of trust in individuals in neighborhooda Without MD Normal Overweight Obese With MD Normal Overweight Obese
p 5 0.69 57.8 59.5 57.6
30.2 29.0 29.3
12.0 11.5 13.0
1.00 (ref) 1.00 (0.91e1.09) 1.03 (0.89e1.19)
1.00 (ref) 0.94 (0.84e1.07) 1.08 (0.89e1.32)
56.7 57.4 56.7
26.6 31.3 28.3
16.8 11.3 15.0
0.96 (0.67e1.38) 1.20 (0.87e1.66) 1.04 (0.68e1.59)
1.40 (0.91e2.14) 0.91 (0.57e1.47) 1.25 (0.73e2.12)
Low level of trust in authorities and public institutionsb Health care Without MD Normal Overweight Obese With MD Normal Overweight Obese Without MD Normal Overweight Obese With MD Normal Overweight Obese Without MD Normal Overweight Obese With MD Normal Overweight Obese Without MD Normal Overweight Obese With MD Normal Overweight Obese
p 5 0.09 60.2 59.3 57.7
27.2 28.7 30.0
12.6 12.0 12.4
1.00 (5ref) 1.05 (0.96e1.14) 1.15 (0.99e1.33)
1.00 (ref) 0.94 (0.84e1.07) 1.07 (0.87e1.31)
50.6 56.3 49.2 Police
33.0 28.6 31.3
16.5 15.1 19.5
1.39 (0.99e1.95) 1.06 (0.76e1.48) 1.38 (0.92e2.07)
1.48 (0.96e2.29) 1.28 (0.84e1.95) 1.88 (1.16e3.05)
59.1 58.4 54.4
22.8 23.0 24.0
18.1 18.6 21.6
1.00 (ref) 0.99 (0.90e1.08) 1.10 (0.94e1.29)
1.00 (ref) 0.99 (0.89e1.10) 1.21 (1.03e1.43)
50.0 52.8 39.7 Parliament
28.2 22.1 27.0
21.8 25.1 27.0
1.31 (0.92e1.88) 0.91 (0.63e1.33) 1.61 (1.03-2.51)
1.18 (0.80e1.76) 1.31 (0.92e1.86) 2.29 (1.50e3.50)
46.5 45.1 44.9
37.0 36.4 33.4
16.5 18.6 21.6
1.00 (ref) 1.00 (0.92 1.09) 0.93 (0.80 1.08)
1.00 (ref) 1.11 (1.00e1.24) 1.24 (1.04e1.47)
40.8 42.2 37.9 Local politicians
34.5 30.7 26.6
24.7 27.1 35.5
1.04 (0.73 1.48) 0.92 (0.65 1.29) 0.85 (0.54 1.34)
1.33 (0.90e1.97) 1.46 (1.01e2.10) 2.00 (1.31e3.05)
42.4 41.8 40.8
36.9 35.4 34.0
20.6 22.8 25.1
1.00 (ref) 0.99 (0.91 1.08) 1.00 (0.86 1.16)
1.00 (ref) 1.13 (1.02e1.25) 1.24 (1.05e1.47)
34.9 43.2 28.8
33.7 26.6 32.8
31.4 30.1 38.4
1.26 (0.87 1.82) 0.77 (0.54 1.11) 1.56 (0.99 2.46)
1.70 (1.16e2.48) 1.34 (0.94e1.89) 2.52 (1.61e3.94)
p 5 0.005
p ! 0.001
p ! 0.001
Values are n (%) or estimated risk ratios (RR, 95% confidence interval). Estimates are adjusted for age, sex, nationality and educational level, and obtained from multinomial regressions. a The proportion of people who responded at the two lowest levels (‘‘not at all’’ and ‘‘not particularly’’) on a 4-point response scale. b The proportion of people who responded at the three lowest levels (‘‘no opinion,’’ ‘‘none whatsoever,’’ and ‘‘little’’) on a 5-point response scale. c Wald p (heterogeneity) test for difference in upward or downward change across all six groups.
largest risk of downward change (lower trust) with regard to health care, the police, the parliament and local politicians, with risk ratios ranging from RR 5 1.88 (1.16e3.05) for health care to RR 5 2.52 (1.61e3.94) for local politicians (Table 4).
We also found that obese people with mobility disability showed a significantly decreased trust in the police (RR 5 1.93: 1.09e3.42) over time, compared with normal-weight people with mobility disability (Table 4, pairwise comparisons, data not shown). They also showed
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a higher risk, though not statistically significant, of a decreased trust in parliament (RR 5 1.50: 0.85e2.66) and in local politicians (RR 5 1.49: 0.83e2.64) over time, compared with normal-weight people with mobility disability (Table 4, pairwise comparisons, data not shown). Further, when compared with obese people without mobility disability, obese people with mobility disability showed a higher risk of not trusting the police (RR 5 1.89: 1.21e2.95), the parliament (RR 5 1.61: 1.03e2.52) and local politicians (RR 5 2.03: 1.28e3.24) (based on pairwise comparisons, data not shown). The other groups showed less consistent risks of downward changes, and the changes were of lesser magnitude. Normal-weight people with mobility disability showed a significant decrease in trust in local politicians over time (RR 5 1.70, 1.16e2.48), and overweight people with mobility disability showed a significant decrease in trust in parliament over time (RR 5 1.46, 1.01e2.10), compared with the reference group (Table 4). Considering groups without mobility disability, obese people showed a decreased trust in the police (RR 5 1.21, 1.03e1.43), the parliament (RR 5 1.24, 1.04e1.47), and local politicians (RR 5 1.24, 1.05e1.47). No group showed any clear upward change.
Discussion Main findings We found no changes over time between the mobility disability and weight-status groups in structural social capital (participation in social activities, and voting in elections) compared with normal-weight people without mobility disability. However, concerning cognitive social capital (as measured by trust in individuals, and trust in authorities and institutions), obese people with mobility disability comprised the group with the largest decrease in trust in institutions and authorities over time, compared with the reference group. Such a decrease was not seen to a similar extent in people with obesity only or mobility disability only. Our findings in relation to other studies The differences in participation in social activities and level of voting in elections did not seem to change over time between the groups. People with mobility disability have lower-income occupations21 and socioeconomic status,22 than people without mobility disability. One possible and hypothetical explanation why we did not observe any significant difference in social participation between the groups over time may be due to a marginal change in the financial situation for people with a mobility disability over time, e.g. a substantial change in the financial situation (through job opportunities or policy changes) might have stimulated social participation in these groups. Further
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research could investigate how changes in the financial situation over time are related to social capital. Another explanation for the lack of change over time in participation in social activities and voting might be a lack of change in the structural environment during the period of follow-up, which is influenced by policy decisions to improve and sustain a supportive urban setting for these individuals. Changes in the environment have been shown directly to affect their participation in the community.23,24 As a consequence, people using wheelchairs, or other mobility aids, may have difficulties attending social events or polling stations because of problems getting to and/or accessing the facilities. However, there was some indication that the obese people with mobility disability participated less in social activities over time, and we also found that the groups with mobility disability showed lower participation in social activities over time than groups having only one of the conditions. This may be due to the presence of more frequent or more intense physically or mentally limiting conditions, potentially as a result of weight gain over time, such as increasing (joint) pain,25 which make the overweight or obese less likely to be able to participate in social activities. We did not observe any significant difference in change in trust in individuals over time when comparing the exposure groups with the reference group. Research has shown that interpersonal trust within neighborhoods is mediated by both social determinants, such as education and class,26 and contextual characteristics, such as shared attitudes, norms and values, and a reciprocity of good will among community members in daily life.27 Therefore, we would like to argue that relative stable contextual characteristics are underlying our observation of no changes in interpersonal trust over time between the groups. Trust in authorities and institutions decreased over time, mainly for the groups with mobility disability compared with the reference group. The people in our study with the combination of obesity and mobility disability reported less trust in the health care system than those in the reference group. It may be that negative experiences of the health care system affect their trust in it. According to a previous study, people with disabilities are more likely to report that they have not received adequate health care.28 Also, overweight and obese people may have higher health care expenditures or make more frequent visits to health care providers in general,29 which may make them more likely to have negative experiences. Our results are in line with this idea; the people with the combination of obesity and mobility disability showed the steepest decrease in trust in the health care system over time. We also found that obese individuals with mobility disability showed the largest decrease in trust over time in politicians and the parliament. Vulnerable groups in society have been observed to have a worse situation on the labor market.30,31,32 During our follow-up period there was a substantial financial crisis in 2009, which might have
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affected people with mobility disability and overweight/ obesity more negatively than people without mobility disability and normal weight, for example, trust in politicians may have decreased in the more severely affected groups because of the crisis. We attempted to look into whether unemployment could be a potential confounder or mediator in our models, which did not seem to affect our main findings substantially (data not shown). But it may still be the case that other measures of a worsened labor market situation explain the lower trust in politicians and parliament over time in the vulnerable groups. Strengths and limitations It is a strength of our study that it is based on a large sample with substantial follow-up from the general population, which enabled us to identify reasonably large groups of individuals with mobility disability in an observational setting, and to make comparisons with people without mobility disability and overweight/obesity. In population-based cohorts there is always some degree of selection due to non-participation. Non-participation in the SPHC (approximately 40%) was rather similar to that in other large-scale population-based cohorts.18 Non-responders were more often non-Swedish, and overweight or obese, and more often had a mobility disability and a lower education. Based on our findings and this non-response pattern, we speculate that the strength of the association between mobility disability and social capital observed in this study is likely to be underestimated. Another limitation of the study is that exposure and outcome were based on self-reports. It is well-known that obese individuals tend to under-report their weight in comparison with normal-weight individuals.33 Further, people with mobility disability may have a different body composition from people without mobility disability, and bioelectrical impedance and waist circumference (WC) may provide more accurate measures of weight status than BMI from self-reports. One study has shown that there is a higher prevalence of obesity in people with disability when using waist circumference rather than the combination of selfreported height and weight (BMI) as a measure.34 Therefore, we have most likely underestimated the prevalence of overweight or obesity in our cohort of people with a mobility disability, and it is not improbable that alternative measurements would have strengthened the associations we found between mobility disability, obesity and social capital. We were restricted to using crude categories, i.e., ‘‘walking with difficulty’’ and ‘‘confined to bed’’, to classify people with mobility disability. Being confined to bed can be interpreted as reflecting a severe disability, and may include individuals in hospices and/or long-term care.35 Only six individuals reported being confined to bed in both 2002 and 2010, which was too small a number to report on separately. However, the interpretation of our
main findings did not change when these individuals were excluded in sensitivity analyses. Additionally, we did not know onset of mobility disability prior to 2002, which may have influenced the development of social capital over time. It is not unlikely that the people in this cohort had a long-term mobility disability well before 2002. As a result, any change in social capital for this group prior to 2002 might have gone undetected, which might be an explanation why we were unable to detect any clear difference over time in structural social capital for members of the disability groups compared with the people without mobility disability. The measurement and operationalization of social capital are complex tasks. In this study, we were unable to be more precise about types of social activity, e.g. reports on online activities were not available. It would have been more informative to consider types of social activities with regard to duration and frequency. One third of the people in our study with mobility disability were of non-Swedish origin, compared with approximately one sixth of those without a mobility disability. Additional adjustment for country of birth in sensitivity analyses did not change the results substantially. Regarding the generalizability of our results, the presented patterns are likely to be very similar to those in other northern European countries, because mobility disability and social capital are highly context-dependent concepts.36 But, we should be cautious in generalizing these patterns to societies with larger social inequalities, or places that are very different contextually from the wider Stockholm region in which our data were collected.
Conclusion This study gives us further understanding of the longitudinal development of social capital in groups of people who are normal weight, overweight or obese, and with or without mobility disability. The study explored both structural and cognitive social capital, but we only observed a clear worsening over time in cognitive social capital among normal-weight, overweight and obese people with mobility disability, and also obese people without mobility disability, compared with normal-weight people without mobility disability. The greatest deterioration in cognitive social capital was in the group with both obesity and mobility disability. Due to worsening cognitive social capital over time, people with mobility disability and obesity may experience health that is worse than that attributable to the health problems directly related to their medical conditions. References 1. Liou TH, Pi-Sunyer FX, Laferrere B. Physical disability and obesity. Nutr Rev. 2005;63(10):321e331. 2. Brault MW. Americans with Disabilities: 2010. U.S. CENSUS BUREAU; 2012:24.
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