Mcpherson et al

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R E S E A R C H A R T I C L E Open Access
The association between family and community
social capital and health risk behaviours in young
people: an integrative review
Kerri E McPherson
1*
, Susan Kerr
1
, Antony Morgan
2
, Elizabeth McGee
1
, Francine M Cheater
3
, Jennifer McLean
4
and James Egan
4
Abstract
Background: Health risk behaviours known to result in poorer outcomes in adulthood are generally established in
late childhood and adolescence. These ‘risky’behaviours include smoking, alcohol and illicit drug use and sexual
risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been
explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this
integrative review was undertaken to identify and synthesise research findings on the role and impact of family and
community social capital on health risk behaviours in young people and provide a consolidated evidence base to
inform multi-sectorial policy and practice.
Methods: Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews,
Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline,
PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/
exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design
and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative
form.
Results: Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of
the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged
from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for
understanding the establishment of health risk behaviours in young people. The different elements of family and
community social capital varied in terms of their saliency within each behavioural domain, with positive parent–
child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk.
Conclusions: This review is the first to systematically synthesise research findings about the association between
social capital and health risk behaviours in young people. While providing evidence that may inform the
development of interventions framed around social capital, the review also highlights key areas where further
research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of
health risk behaviours.
Keywords: Family social capital, Community social capital, Children, Adolescents, Health risk behaviours, Wellbeing,
Health
* Correspondence: kerri.mcpherson@gcu.ac.uk
1
Institute for Applied Health Research, School of Health & Life Sciences,
Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK
Full list of author information is available at the end of the article
© 2013 McPherson et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
McPherson et al. BMC Public Health 2013, 13:971
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Background
A significant proportion of premature adult deaths are
considered to have their antecedents in late childhood
and adolescence [1]. It is during this time that young
people generally experiment with and establish health
behaviours known to result in poorer health outcomes
in adulthood, including smoking, alcohol and illicit drug
use and sexual risk taking [2]. As might be expected, ex-
posure to health risk behaviours increases as the adoles-
cent years advance, with the period between 11 and 15
years being of particular significance [3-5].
Understanding the trajectory and the underlying deter-
minants of health risk behaviours in young people is es-
sential if interventions are to be developed to reduce
uptake. The family provides the first context for infants
and very young children and families provide a vehicle
through which children become part of their local com-
munities; however, it is generally accepted that, as children
mature, the wider environment and social interaction take
on a larger role [6-8]. This wider social context, in
addition to the influence of family, is therefore crucial to
our understanding of the ways in which adolescents ex-
perience and manage their own health and wellbeing, in-
cluding how they access, generate and mobilise ‘social
capital’[9,10].
Social capital has been described as a resource for
societies [11-13]. While it has its roots in the work of so-
ciologists such as Durkheim [14], its acceptance as a
concept which has the potential to further articulate the
relationship between health and its broader determi-
nants, stems from the work of Pierre Bourdieu [15],
James Coleman [16] and Robert Putnam [17]. Each of
these theorists describes social capital through a differ-
ent disciplinary lens and this has generated considerable
debate within the literature about how social capital
should be conceptualised and measured [18-20]. How-
ever, despite its multi-dimensionality, a common thread
running through the various definitions of social capital
relates to the importance of positive social networks
and relationships in bringing about social, economic
and health development among different groups, hier-
archies and societies [21,22].
Theoretical consideration of social capital as a re-
source for the health and wellbeing of young people first
appeared in the literature in the 1990s [9,17,18,20,21],
with the empirical evidence base accumulating over the
past 10 years. Yet, to date, there have been few attempts
to consolidate the evidence in such a way as to provide a
meaningful framework upon which social capital inter-
ventions can be built to promote protective environ-
ments for young people, particularly in the context of
their health and wellbeing [23,24]. Moreover, it has been
argued that, as a construct developed within an adult
framework, traditional definitions of social capital may
be inadequate in the context of young people. Young
people’s lives may differ from adults’in terms of social
spaces and social connections [21,25] and developments
in the sociology of childhood highlight the importance
of children’s agency, autonomy and involvement in the
health process; it is therefore important to acknowledge
that they are capable of generating and using social
capital in their own right [26]. For example, schools are
often not included in definitions of social capital but
they are an important aspect of community for young
people, representing places where social networks are
formulated and exploited for support [27].
In one of the few attempts to synthesise the literature,
Ferguson “explored how social capital had been conceptu-
ally and operationally defined as a predictor variable in
empirical research on individual and collective wellbeing,
especially in relation to children and youth”[24]. Acknow-
ledging the importance of bonding relationships that exist
within families, and relationships that bond and bridge
families to local communities, Ferguson sought to identify
key indicators of both family and community social capital
(e.g. the quality of parent–child relations, extended
family support, social support networks and the quality
of school) and considered their influence on wellbeing.
However, while this review highlights the importance of
both family and community social capital in the context
of young people, the construct of wellbeing was ill-
defined and the outcomes indicators broad (e.g. physical
health, educational attainment). Importantly, for our pur-
pose, Ferguson’s review did not focus on the association
between social capital and health risk behaviours.
More recently, a review undertaken by Vyncke and
colleagues [20] explored the role that neighbourhood so-
cial capital may play in levelling the social gradient in
the health and wellbeing of children and adolescents.
While this paper makes an important contribution in
the field, the outcomes of interest were behavioural
problems, self-esteem and cognitive abilities, rather than
health risk behaviours, and the synthesised evidence was
limited to neighbourhood social capital (but excluding
schools). This focus on neighbourhood means that the
influence of family social capital was not explored.
This integrative review is, therefore, the first attempt to
systematically identify and synthesise published empirical
literature exploring the role and impact of both family and
community social capital on health risk behaviours in
young people. Cognisant of the various theoretical tradi-
tions and definitions within the social capital literature we
adopted an inclusive and pluralistic approach drawing on
the work of a broad range of theorists; including, but not
limited to, Bourdieu, Coleman and Putnam. Given the
focus on young people, however, the concepts of family
social capital (FSC) and community social capital (CSC)
have been used to frame the presentation of the results.
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Methods
This paper forms part of a larger review, which explored
the association between social capital and a range of psy-
chosocial indicators of health and wellbeing (e.g. mental
health and problem behaviours and health promoting
behaviours). The method for the larger review is pub-
lished in full in the final report [23] and this includes the
single search strategy developed to capture literature from
across the range of psychosocial health and wellbeing out-
comes. We present here the elements of the method dir-
ectly relevant to collection and analysis of the health risk
behaviour data.
Criteria for considering studies for inclusion
Types of studies
Studies were included if they were published, peer-reviewed
and described primary empirical research that was quanti-
tative, qualitative or had employed mixed methods.
Types of participants
Studies were required to have focused on children and/
or adolescents. Scoping of the literature revealed incon-
sistencies in the ways that authors defined children and
adolescents so we adopted a pragmatic approach, guided
by the WHO’s definition of adolescence [28]. Samples
where the majority were 10–19 years old were de-
scribed as ‘adolescents’and samples where the majority
were 5–10 years old were described as ‘children’.We
also included ‘mixed age group’samples.
We included studies where the data had been collected
directly from the young person and where the data
about the young person had been reported by a relevant
other (e.g. parent, teacher or other professional).
Types of social capital
As noted above, we adopted a pluralistic approach to the
conceptualisation of social capital but we were guided by
Ferguson’s findings as a framework for categorising indi-
cators of family and community social capital. Thus,
studies were included if they explored the role and im-
pact of social capital at the family and community
level. The elements of FSC included: family structure
(e.g. number of parents present in the household), the
quality of parent–child relations (e.g. parent–child com-
munication), adult interest in the child (e.g. parental in-
volvement with school), parent’s monitoring of the child
(e.g. perceptions of parental monitoring/control) and ex-
tended family support and exchange (e.g. perceptions of
extended family support). The elements of CSC included:
social support networks (e.g. peer support), civic engage-
ment in local institutions (e.g. volunteering), trust and
safety (e.g. trust in others), religiosity (e.g. attendance at re-
ligious services), the quality of the school (e.g. school cohe-
sion and relationship between teachers and pupils) and the
quality of neighbourhood (e.g. neighbourhood cohesion
and social control). In addition, we included studies that
employed a composite measure of FSC and/or CSC and
studies where, although the indicator did not fit within the
definition above, the author(s) explicitly described their
work as FSC (e.g. family cohesion) and/or CSC (e.g. peer
role models) and we refer to this as ‘other measure’.
Types of outcomes
Studies were included if they assessed individual-level
health risk behaviours, including: alcohol use/misuse;
smoking/tobacco use; illicit drug use; sexual health
behaviours; and general health risk taking, where a
composite health risk behaviour score was calculated
to assess risk across a number of different domains
(e.g. smoking, alcohol and drug use). Studies were only in-
cluded where health risk behaviours were conceptualised
and/or measured as outcome variables.
Search strategy
Data sources
In April 2012, nine electronic bibliographic databases
were searched for relevant published empirical litera-
ture: ASSIA, CINAHL, Cochrane Database of System-
atic Reviews, Cochrane Central Register of Controlled
Trials, Database of Abstracts of Reviews Effects, Embase,
Medline, PsycINFO, and Sociological Abstracts.
Following the electronic database searches, the reference
lists of retrieved articles were examined for further studies.
The web-sites of organisations and groups conducting
research on the health and wellbeing of children and
adolescents, and/or research in the field of social capital,
were also searched for published empirical literature (e.g.
the Centre for Research on Families and Relationships and
the WHO).
Search terms and delimiters
Scoping of relevant electronic databases helped identify
the most appropriate search terms and a single search
strategy was developed to capture literature from across
the range of psychosocial health and wellbeing outcomes,
including health risk behaviour terms. The search strategy
included both index terms (i.e. thesaurus and subject
headings) and free text keywords. Social capital-relevant
search terms were combined with health and wellbeing
outcome-relevant search terms. The search strategy was
tailored to optimise its sensitivity within each database
[29] and the PsycINFO search strategy is presented in
Additional file 1.
Our searches were limited to literature published
between January 1990 and April 2012 and to English
language-only. RefWorks was used to store the results of
each of the searches and to identify duplicates.
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Data collection and analysis
Selection of studies
After duplicates were removed, the title and abstract of
each retrieved study were screened independently by
two members of the research team, rejecting any that
did not fit the inclusion criteria described previously. If
no abstract was available, or the abstract did not contain
sufficient detail, the study was retained for full text
review. Again, the full text was reviewed against the in-
clusion/exclusion criteria by two independent reviewers.
At both stages, few discrepancies were identified be-
tween the reviewers and any that did arise were resolved
through discussion.
Data extraction
The full text of articles assessed as meeting the inclusion
criteria was sourced for data extraction. A review-specific
data extraction tool was developed to enable the extrac-
tion of data generated using a range of different research
designs [23]. The data extracted included: the context of
the study, such as geographical location and year(s) of data
collection; the aims and purpose of the study; methodo-
logical considerations, such as design, participants and
data collection methods; the main findings; and, the
strengths and limitations of the study. Data were extracted
from each of the studies by two reviewers who worked in-
dependently. At all stages, disagreements were resolved
through discussion, involving a third reviewer if necessary.
Quality appraisal
Concurrently with data extraction, each reviewer assessed
the methodological quality of the studies using a study-
specific quality appraisal tool (QAT). The QAT was devel-
oped drawing on published guidance [30] and unpublished
quality appraisal tools used previously by the team [23].
Made up of 11 criteria, each item was scored on a three-
point scale (0=weak; 1=moderate; 2=strong), giving a pos-
sible range of scores from 0 to 22 for each paper.
Disagreements were resolved through discussion, involv-
ing a third reviewer if necessary.
Upon consensus, each study was awarded one of three
quality ratings, studies scoring: 16–22 were awarded a
‘high quality’rating; 8–15 were awarded a ‘moderate
quality’rating; and, 0–7 were awarded a ‘low quality’rat-
ing. The ratings for each included study are presented in
Additional file 2 (column 1). Studies were not excluded
on the grounds of quality.
Data analysis and synthesis
The results are presented in narrative form. The majority
of studies were surveys and the associated design issues
(e.g. lack of control groups) and heterogeneity in the out-
come measures precluded meta-analysis. Moreover, meta-
synthesis was not possible because few qualitative studies
met the inclusion criteria.
Instead, results are summarised and then synthesised
using an approach similar to that originally described by
Ramirez et al. [31]. That is, results are grouped into
three categories: results that show a positive association
between social capital and health risk behaviours (i.e.
where social capital was associated with better outcomes
and the results were statistically significant); results that
show a negative association between social capital and
health risk behaviours (i.e. where social capital was asso-
ciated with poorer outcomes and the results were statis-
tically significant); and, results where no association
between social capital and health risk behaviours was
identified (i.e. results were not statistically significant).
Results
Study selection
In accordance with the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-analyses) guide-
lines [32] Figure 1 details the process from the initial
search and screening through to final study inclusion.
Following the searches and the removal of duplicates,
773 articles were screened against the inclusion/exclu-
sion criteria. The majority (n=627) of the articles were
excluded at the title and abstract stage and a further 44
were excluded at the full text stage. The primary reasons
for exclusion were that the article did not fit: the defin-
ition of child/adolescent (n=389); the definition of health
and wellbeing (n=115); the study design criteria (n=92);
or the definition of FSC or CSC (n=73). A total of 102
articles were retained for inclusion across the health and
wellbeing outcomes of the larger study and 34 of these
included health risk behaviours and are the focus of this
review. The outcomes of study selection processes are
detailed in Figure 1.
Description of studies
Descriptive information about each of the individual
studies is presented in Additional file 2, this includes:
the aims of the study, the geographical location and tim-
ing of the data collection, the study design, sample de-
tails, the health risk behaviour(s) assessed, the type of
social capital assessed and the key results.
The health risk behaviours explored in the 34 studies
were ordered into five outcome categories with 12 of the
studies reporting on more than one of the outcomes.
Eleven studies reported on tobacco use, 14 on alcohol
use, nine on illicit drug use and 15 on sexual risk
behaviours. Five of the studies reported on general
health risk behaviours where the outcome was a com-
posite score of risk across a number of behaviour do-
mains. Six studies included at least one indicator of
FSC and nine included at least one indicator of CSC.
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The remaining 19 studies included indicators of both
FSC and CSC (see Additional file 2).
Thirty three of the studies were surveys, including 29
cross-sectional and four longitudinal surveys. The re-
maining study was a longitudinal cohort study. Over two
thirds (n=22) were conducted in the United States, with
further studies from Canada (n=3) and the UK (n=3).
One was a multi-country study conducted in Europe
and Canada and the remaining studies were conducted
in China, El Salvador, Ethiopia, Japan and Switzerland.
Eleven studies did not report when the data were col-
lected, 14 studies began, and in some instances com-
pleted, data collection in the 1990s and nine began data
collection after 2000 (see Additional file 2).
Across the 34 studies there was considerable variation
in the reported sample sizes and some studies did not
clearly articulate dropout rates. The number of partici-
pants also varied across the different analyses conducted
in the studies and so we report on the maximum num-
ber of young people included in the analysis set; the lar-
gest being 98,340 and the smallest 61.
Thirty three studies reported on adolescent-only sam-
ples; two of these did not provide information on the
ages of the adolescents but in the remaining 31 they
ranged from 11 to 19 years. The final study reported on
a mixed sample ranging from 8 to 18 years. Five of the
studies did not report details of the sex of their sample.
In the remaining 29, the percentage of female partici-
pants ranged from 44% through to 100%.
Twelve studies either did not report on the ethnicity,
race or nationality of the sample or it was not possible
to extract these data in a meaningful way. Fifteen studies
described the majority as Caucasian, Non-Hispanic White,
Non-Hispanic Caucasian or White and we grouped these
under the single category ‘White’. Five studies described
the majority as African American or Black and we grouped
these under the single category ‘Black’for reporting. In
the two remaining studies the participants were de-
scribed as ‘Swiss’.
The quality appraisal rating assigned to each of the
studies is presented in Additional file 2 (column 1). The
majority of the studies (n=22) were assessed as ‘high qual-
ity’, nine were assessed as ‘moderate quality’and three as
‘low quality’.
Tobacco use
Eleven studies (see Additional file 2) investigated the role
and impact of FSC and/or CSC on tobacco use [33-43].
Seven studies explored FSC in the context of adolescent
tobacco use and, in the majority, FSC was associated with
better tobacco outcomes. Parent-adolescent relationships
high in closeness, trust and nurturance were associated
with less frequent, or non-use, of tobacco [34,41,42]. Two
studies assessed the quality of the communication within
Articles identified though
electronic and hand searches
n=905
Duplicates removed n=132
Articles screened for eligibility
n=773
Articles excluded at titl e/abstract screening
n=62 7
Articles excluded at full text screening n=44
Articles included in the larger
review sample
n=102
Health risk behaviour articles
included in this review
n=34
Figure 1 Flow diagram of search results.
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parent-adolescent relationships; one [33] found positive
communication between parent(s) and adolescent to be
associated with lower levels of tobacco use but the other
reported communication as being associated with in-
creased use [41]. However, in the latter study parent-
adolescent closeness diluted the risk associated with
communication, such that relationships that were high
in closeness and positive communication protected the
adolescent against tobacco use.
Further supporting the protective role of positive
intra-family relationships, two studies reported that ado-
lescents from families that engaged in more joint family
activities were less likely to use tobacco [35,37]. Parental
monitoring had limited effect on tobacco use.
There was an inconsistent pattern of results across the
six studies assessing social support networks but this
may be accounted for, in part, by the type of assessment.
Two studies assessed social support networks in terms
of adolescents’interactions with their friends/peers and
both reported that increased connectedness and frequency
of contact were associated with increased tobacco use
[41,42]. Two further studies assessed participation in
recreational clubs/groups, an indicator of wider social net-
works, and found that increased participation was associ-
ated with reduced tobacco use [33,43]. However, there
was evidence to suggest that different types of groups/
clubs may have differential impact; school-based groups
had no association with tobacco use, youth clubs were as-
sociated with increased use and religious groups/clubs
with decreased use [37,43].
Civic engagement, religious attendance and having
peer/adult mentors also provide some insight into the
reach of an adolescent’snetworks.Onestudyfoundall
three were associated with reduced tobacco use [33] but
this was not replicated across others. There was evi-
dence that higher quality school [41], but not neigh-
bourhood [39,40,42] environments were associated with
lower levels of tobacco use.
In sum, social capital amassed through an adolescent’s
interactions with other people is protective against tobacco
use in some circumstances and creates a risk factor in
others. In particular, positive relationships between the
adolescent and other family members seem to be associ-
ated with reduced likelihood of the adolescent using to-
bacco. However, relationships that extend out of the family
into the adolescent’s social sphere may in some instances
create opportunities for risk behaviour. In contrast, the
infrastructural support of the school environment ap-
pears to offer protection to adolescents in the context of
tobacco use.
Alcohol use
Fourteen studies (see Additional file 2) assessed the role
and impact of FSC and/or CSC on alcohol use and all
included mixed-sex samples of adolescents [34-39,42-49].
Eight studies explored the role and impact of FSC on alco-
hol use. Parent-adolescent relationships assessed as posi-
tive were associated with better outcomes [34,42,45,46,48].
Moreover, adolescents who reported that their families
engaged in more joint activities (e.g. family mealtimes)
reported fewer alcohol risk behaviours [35,36].
The pattern of association is less clear for parental
monitoring. Two studies [38,42] reported that parental
monitoring/control was unrelated to alcohol use while
another found having a controlling father was associated
with increased likelihood of using alcohol [37]. A further
study found monitoring to be associated with reduced
alcohol use for male adolescents only [34]. Having nego-
tiated but unsupervised time with their peers was also
associated with increased risk of males and females
reporting alcohol use [34].
There was evidence that family relationships may
have a differential impact across different groups of
adolescents. There were conflicting results about the
impact across the sexes with one study reporting that a
positive parent-adolescent relationship was associated
with reduced alcohol use in male adolescents only [34]
and another reporting it was associated with reduced
alcohol use in female adolescents only [48]. When
broader family relationships were explored in the con-
text of ethnicity a different pattern of association was
evident across different ethnic groups; extended family
support was beneficial for Mexican and Puerto Rican
adolescents but a risk factor for Cuban adolescents [45]
(see Additional file 2).
Half of the studies exploring social support networks
and alcohol use failed to identify any association. Of the
studies reporting an association, one reported that poorer
quality peer relationships were associated with alcohol con-
sumption cross-sectionally but not longitudinally [49], and
another that peer connectedness was associated with in-
creased use [42]. A third reported that, in general, club
membership was protective but some club types were asso-
ciated with increased odds of drunkenness (e.g. youth or
sports clubs) and other types with decreased odds (e.g. cul-
tural or religious clubs) [43]. Moreover, adolescents who
reported they had peer, but not adult, role models were
more likely to report abstinence [46]. There was some evi-
dence that adolescents who engaged in active citizenship
activities [37,44,46] and who had higher levels of trust in
others [39,44] engaged in fewer alcohol risk behaviours.
Three studies showed frequency of attendance at religious
services to be associated with better outcomes but there
was no consistent evidence showing a role for religious
identity or personal importance of religion [44,46,47].
None of the studies explored the association between
alcohol use and the quality of neighbourhood, but two
found positive school attributes were associated with
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reduced alcohol use [37,42] and another that school co-
hesion was associated with better outcomes in female
adolescents but poorer outcomes for males [48].
To summarise, in the context of alcohol use the pro-
tective effects of FSC and CSC are mixed. FSC offers the
most consistent effects with positive relationships between
young people and their parents being protective. On the
other hand, parental monitoring/control appears to have
little protective value and in some instances is associated
with increased risk. The evidence for CSC is also incon-
sistent. That said, adolescents who participate in active
citizenship and/or participate more frequently in religious
services have better alcohol outcomes.
Drug use
Nine studies (see Additional file 2) explored the role
and impact of FSC and/or CSC on illicit drug use
[34-36,38,42,44,46-48]. Six studies included indicators
of FSC and a clear pattern was evident for family rela-
tionships. Adolescents who had a positive relationship
with their parent(s) [34,42,46,48], and those from fam-
ilies that spent more time together [35], were less likely
to report drug use. No role was identified for parental
monitoring/control behaviours [34,38,42]. Linked to
parental monitoring, adolescents who had negotiated
unsupervised time with their peers reported more fre-
quent marijuana use [34].
In the seven studies assessing CSC, there was limited
and inconsistent evidence available about the role of so-
cial support networks. One study assessing participation
in recreational clubs/groups, an indicator of wider social
networks, reported a protective role [46], but another
found peer connectedness was associated with poorer
outcomes [42]. In contrast, adolescents who reported
they had a peer, but not an adult, mentor had increased
odds of reporting not using drugs [46].
Four studies found that adolescents with frequent at-
tendance at religious services were less likely to report
drug use [36,44,46,47]. There were, however, inconsist-
ent findings in relation to the role of religious identity
and the personal importance of religion [44,47]. No
study explored the role of neighbourhood quality but
there was some evidence that higher quality school envi-
ronments offer some protection to students in relation
to drug use [42,48], and one study reported that this was
particularly important for females [48].
In sum, family relationships characterised by trust, sup-
port and nurturance appear to provide adolescents with
assets that protect against drug use. In contrast, parental
monitoring/control has little effect, although an indicator
of a more laissez faire approach to monitoring, negotiated
unsupervised time with peers, was associated with
increased risk. In the context of CSC, adolescents ac-
crue more protection from structural sources, religious
attendance and school, than they do from their relation-
ships with others, including their peers.
Sexual health
Fifteen studies (see Additional file 2) explored the role and
impact of FSC and/or CSC on sexual health outcomes
[34,35,48,50-61]. In thirteen studies there was evidence
that living with at least one biological parent was an im-
portant protective factor in the context of sexual health
[50,56,57]. In addition, the absence of a father may be
more important for some adolescents than others (e.g.
younger adolescents) [50,56].
In terms of the parent-adolescent relationship, there
was evidence that the quality of the relationship (e.g.
trust and ease of communication) was associated with
delay in first sexual experience [34,55] and the imple-
mentation of positive sexual behaviours, such as contra-
ception use [34,57,59]. Conversely, in the only study to
evaluate the quantity of parent-adolescent conversations
about sex, adolescents reporting more frequent conver-
sations were more likely to report having had sex [60].
The authors hypothesised that this increased frequency
of parent-adolescent conversations may have been a con-
sequence of the adolescent’s sexual behaviour rather
than increased frequency of conversations increasing the
likelihood of the adolescent having had sex.
Unlike the other risk behaviours, there was evidence
that parental monitoring can have a positive impact on
sexual health, being associated with increased likelihood
of the adolescent reporting sexual abstinence [50,60,61]
and, for sexually active adolescents, with positive sexual
behaviour such as condom use [34,50]. Negotiated un-
supervised time with peers, on the other hand, was associ-
ated with increased likelihood of having had, or intending
to have, sex but also with increased likelihood of using
contraception [34].
At the general level, studies assessing the quality and
quantity of adolescents’social networks reported little
association with sexual health behaviours [51,59]; how-
ever, protective effects were noted for some sub-groups
of adolescents [54,55] and for other sub-groups social
networks were associated with risk taking [54,56]. Three
studies reported that adolescents with a peer and/or
adult mentor were less likely to engage in sexual risk be-
haviours [51,55,58] and another reported that peer role
models were associated with better outcomes in adoles-
cents from one-parent households [59].
More frequent attendance at religious services was asso-
ciated with more positive sexual health behaviours [51,55].
However, results in relation to school quality were less
consistent, with some elements being associated with
better outcomes in some sub-groups of adolescents and
presenting as a risk factor in others. There was limited evi-
dence about the role of quality of neighbourhood.
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In contrast to the other risk behaviours, there is con-
siderable variation in the role and impact of both FSC
and CSC across the indicators of this outcome (e.g.
sexual abstinence, sexual experience and contraception
use) and across different sub-groups of adolescents. As
discussed, it appears that in different contexts different
elements of social capital may be more or less salient.
General risk behaviours
Five studies (see Additional file 2) explored the role and
impact of social capital on general health risk behaviours
by creating a composite health risk behaviour score that
assessed risk across a number of domains (e.g. smoking,
alcohol and illicit drug use) [62-66]. Although assessed
by five studies, there was limited evidence of the role of
FSC in relation to general risk behaviours. Only family
structure appeared to have a consistent role to play with
children and adolescents, in most instances, benefiting
from living in a two-parent household [63-65].
There was limited evidence for social support networks.
Two studies assessing peer-based networks reported no
association [63,64], but increased contact with neighbours,
another indicator of social networks, was associated with
fewer risk behaviours [63]. There were mixed findings for
civic engagement with some protective [63,65] and some
risk relationships identified [62]. Two out of three studies
reported that higher quality school environments were as-
sociated with fewer risk behaviours [62,63] and another
reported that higher quality neighbourhood environments
were predictive of better outcomes [65].
Health risk behaviours –synthesis
Table 1 shows the pattern of impact of the various ele-
ments of FSC and CSC on the full range of health risk
behaviours. In total, 165 associations between the vari-
ous health risk behaviours and elements of FSC and
CSC were investigated in the 34 included studies: 68 of
these associations were positive, showing higher levels of
social capital to be associated with better outcomes; 6
were negative, showing higher levels of social capital to
be associated with poorer outcomes; and, in 54 cases no
association was identified between social capital and the
outcome.
Discussion
This review provides evidence that social capital is an
important construct for understanding young people’s
health risk behaviours. Moreover, by delineating the vari-
ous elements of both FSC and CSC, we have been able
to demonstrate that some aspects of social capital are
more salient than others in the context of the different
behaviours.
We found robust evidence to demonstrate that, across a
range of outcomes, social capital generated within the
family can be a health asset associated with better health
risk behaviour outcomes. Parent–child relationships
assessed as being positive were associated with better out-
comes and in particular lower levels of tobacco, alcohol
and drug use and sexual risk behaviours [42,46,48,50,57].
Moreover, it appears that, in different circumstances, dif-
ferent sub-groups of young people benefited more from
this element of social capital than others [34,48,55,59,61].
These findings support those published elsewhere in the
literature. For example, there is evidence that parenting
styles associated with more positive parent–child relations
(e.g. authoritative parenting) are predictive of better edu-
cational outcomes in adolescents, and some groups of ad-
olescents appear to benefit more than others [67].
Only when health risk behaviours were assessed using
a composite risk score did this pattern fail to replicate;
the majority of the associations between the parent–child
relationship and general health risk behaviours were neu-
tral. While it was not within the scope of this review to in-
vestigate this further, it may be hypothesised that these
neutral associations reflect issues of conceptual validity
with the aggregation of risk across different behavioural
domains. Indeed there is considerable debate within the
literature about whether risk behaviours cluster together
and, if they do, the ways in which this occurs [5,68-70]. In-
appropriate clustering of the risk domains by the individ-
ual studies may have resulted in the statistical masking of
positive and/or negative associations.
In the synthesis of evidence across the outcomes, the
majority of the associations with parental monitoring were
neutral and this might lead to the conclusion that parental
monitoring, or parental control, is of little value in the
context of health risk behaviours. Indeed, this appears to
be case for tobacco, alcohol and drug use and general
health risk behaviours. However, parental monitoring was
associated with better sexual health outcomes. This differ-
ent pattern may be explained, in part, by the fact that sex-
ual activity is different to other risk behaviours where
abstinence is the preferred outcome (e.g. tobacco use). Sex
is a natural part of development for most adolescents and
at the various stages of adolescence it may be considered
more or less appropriate, by both the adolescent and
others around them. This sense of appropriateness will
necessarily interact with support structures, including
those within the family, that are designed to prevent youn-
ger adolescents from engaging in sex and promote safer
sex amongst older adolescents. Indeed, some of the stud-
ies in this review reported that parental monitoring was
only related to reduced sexual risk taking in younger age
groups [56]. The identification of a different pattern of as-
sociation between social capital and health risk behaviours
has implications for intervention development and deliv-
ery in that a single intervention may not be effective in re-
ducing risk across different outcomes simultaneously [71].
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Table 1 Evidence table showing pattern of investigated associations between social capital and health risk behaviours
Association Family
structure
Parent–child
relations
Adult
interest
Parental
monitoring
Extended
family
support
Composite/Other
family social
capital
Social
support
networks
Civic
engagement
Trust &
safety
Religiosity Quality of
school
Quality of
neighbourhood
Composite/
Other
community
social capital
Total
Number of
investigated
associations
8 25 2 19 4 9 25 21 4 15 20 4 9 165
Positive 5 10 6 7 4 7 3 10 7 3 6 68
Negative 1 4 16
None 1 2 2 11 4 1 10 10 3 9 1 54
Sub-group
differences
210 1 4 41 4 228
Inconclusive
results
31 3 2 09
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The evidence for the role of family structure was lim-
ited but suggests that, while young people benefit from
living with at least one biological parent, being in a two-
parent family was most protective [50,57,63-65]. A lim-
ited number of studies assessed the role of adult interest
in the child, and extended family support, but there was
no evidence to suggest that these elements of FSC had a
negative impact on health risk outcomes.
As with FSC, there were elements of CSC that were
more or less salient across the various health risk behav-
iours. However, CSC also showed evidence of the ‘down-
side’of social capital with some associations linking it to
increased likelihood of young people engaging in health
risk behaviours. Specifically, young people with indica-
tors of wider peer networks were at increased risk of
using tobacco [41,42]. We also found inconsistent pat-
terns of association between social support networks
and alcohol, drug use, sexual health and general risk
behaviours, with some studies reporting social networks
as health assets and others finding them to be health li-
abilities. Others have previously reported the ‘downside’
of social capital [72-74] and, in the context of young
people, we might hypothesise that while some social net-
works may support young people in some circumstances
(e.g. in the development of social competencies) they
may also create opportunity and encouragement to ex-
periment with behaviours that might be considered
(byadults)asundesirableforthisagegroup,including
health risk behaviours. Thus it essential that future re-
search endeavours to disentangle and characterise the
various types of social networks that young people are
embedded in and identifies those more likely to support
positive health outcomes.
Linked to this, our search did not identify any studies
that explored the role of social relationships and net-
works sustained in the online world and health risk be-
haviour outcomes. This is surprising given that online
social networking (e.g. Facebook) is recognised as being
increasingly important for children and adolescents [75]
and evidence that relationships formed and sustained on-
line are an important source of social capital, with the po-
tential to influence psychological wellbeing, for young
people in their late teens and early twenties [76]. The lack
of evidence about social capital generated online perhaps
reinforces the need, as noted above, for definitions of so-
cial capital to be reconceptualised to capture the different
social spaces and networks of young people [21,25].
In other CSC domains, this review found limited and
inconsistent evidence about the role and impact of civic
engagement and the quality of the neighbourhood the
young people live in. On the other hand, high quality
school environments were associated with reduced to-
bacco, alcohol and drug use and lower levels of general
health risk behaviours; only in the context of sexual
health behaviours was the role of school less clear.
Neighbourhoods have been identified as important social
capital arena for adults but, although there is evidence
that lower quality neighbourhoods are associated with
poorer outcomes for young people (e.g. child maltreat-
ment) [77], it is acknowledged that young people navigate
and interact with their local communities differently to
adults [27] and this is likely to result in neighbourhood
quality having a different role to play in the health and
wellbeing of youth [25]. On the other hand, school is
where young people spend a significant amount of their
time and schools that are high in social capital and/or sup-
port young people in creating and mobilising their own
social capital evidently support young people to make bet-
ter choices about behaviours that may carry health risks.
Acknowledging the importance of the school environment
in helping to develop happy, confident individuals who
will do well in life, UK curricula encourage schools to
address issues relevant to wellbeing, including making
healthy choices in relation to tobacco, alcohol, illicit drugs
and sexual health [78,79].
Finally, religiosity was identified as an asset related to
better tobacco, alcohol, drug and sexual health outcomes
[33,36,44,46,47,55,59,63]. General health risk was the
only domain where this was not consistently replicated
and this may be related to the issues of conceptual valid-
ity noted above. It is important to note, however, that
only social elements of religiosity (e.g. frequency of ser-
vice attendance) were associated with health outcomes;
there was no evidence that the personal importance of
religion was linked with health risk behaviours. It may
be hypothesised that the social elements of religiosity are
illustrative of the young person’s access to bonding social
capital through faith-based support networks. These net-
works might exert influence over the young person’s
health risk behaviours through expectations in relation
to the behavioural norms of the group [80].
Strengths and limitations
As with any review, the results need to be considered in
relation to the strengths and weaknesses both of the re-
view process itself and the included studies. In relation
to the process, a major strength of this review lies in the
integrative approach which enabled the capture and syn-
thesis of a large body of evidence generated from across
different study designs. That said we are cognisant that,
as with any review, relevant literature may not have been
captured. For example, publication bias, the tendency
for journals to publish studies reporting statistically sig-
nificant results, may have limited our access to studies
that did not find a relationship between social capital and
health risk behaviour outcomes. In addition, we were
constrained by the adequacy of the indexing within each
of the databases and, while we placed no geographic
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restrictions on the selection of studies, employing an
English language-only criterion may have resulted in the
exclusion of relevant studies published in other languages.
We did, however, employ a number of strategies to
broaden the reach of our search, including hand searching
relevant references lists and web-sites.
In terms of the individual studies, while the synthesised
results offer a strong body of evidence demonstrating the
association between FSC and CSC and health risk be-
haviour outcomes, the majority of the included studies
were cross-sectional surveys. This design limits our
ability to make inferences about the direction of caus-
ation in these associations and the mechanisms of ac-
tion. It might be hypothesised, for example, that social
capital acquired in the context of family and community
isanassetthathelpsprotectyoungpeoplefromen-
gaging in health risk behaviours [21,37]. Conversely, it
could be argued that experimenting with behaviours
that transgress the boundaries of social acceptability
(at least in the eyes of adults), young people are more
likely to report negative relationships within and be-
tween their family and community. In order to develop
social capital interventions that effect better health
outcomes, further evidence that demonstrates both the
mechanisms that link social capital to health and the
direction of causation is needed.
There was considerable heterogeneity in the definition
and measurement of social capital across the studies.
While this made synthesising the available evidence
challenging, all data were extracted using well defined
study-specific inclusion/exclusion criteria and by a mini-
mum of two reviewers. There was also heterogeneity in
the individuals asked to report on social capital; data
were obtained variously from the young people them-
selves and adults, such as their parents. While it was not
possible within the remit of this review to give full con-
sideration to the impact of the different reporters, it is
important to be mindful of this. Previous research ex-
ploring the relationship between parenting style and
adolescent outcome variables has demonstrated that
there can be considerable divergence in the reports of
parenting style offered by young people and their par-
ents and these different reports share different relation-
ships with the outcome variables [81].
Finally, in terms of the individual studies, although the
purpose of this review was to consider the role and im-
pact of social capital on the health risk behaviour out-
comes of young people, all accept one of the studies had
adolescent-only samples and the focus was very much
on mid- to late-adolescence. Given the nature of the be-
havioural outcomes, the lack of evidence about pre- and
early adolescent years is perhaps understandable; how-
ever, it limits our capacity to draw conclusions about
these age groups.
Conclusions
This is, to the best of our knowledge, the first systematic
review to synthesise empirical evidence linking social
capital to a range of health risk behaviour outcomes and
our findings have important implications for future policy,
practice and research. Health risk behaviour interventions
targeted at young people have traditionally failed to take
account of the importance of social capital but this review
demonstrates that both family and community social cap-
ital have an important role to play. Moreover, by looking
within and across the various health risk behaviours we
have been able to identify and highlight the elements of
social capital that present as supportive health assets irre-
spective of the behavioural domain (e.g. positive parent–
child relations) and highlight elements of social capital that
may in some instances present as a health liability (e.g.
peer-based social support networks) and thus need careful
consideration in the context of intervention development.
International policy emphasises the need for early inter-
vention as a means of reducing inequalities and promoting
health and wellbeing across the lifespan, and priorities for
Europe include the promotion of resilient families and
communities [82]. Our findings illustrate ways in which
family and community social capital might be generated
and exploited to promote resilience and, ultimately, better
health outcomes.
Additional files
Additional file 1: Search strategy (PsycINFO).
Additional file 2: Description of studies included in the review
(ordered by outcome).
Competing interests
KEM, SK, AM, EM and FC were commissioned to undertake this work by the
Glasgow Centre for Population Health. JM and JE commissioned the work on
behalf of the Glasgow Centre for Population Health.
Authors’contributions
All authors were involved in developing the scope of the project and in
determining the search strategy. The search was conducted by KEM. The
study selection process, data extraction and quality appraisal was undertaken
by KEM, SK, EM and FC. Data analysis and synthesis was conducted by KEM.
All authors contribution to the drafting of the manuscript and read and
approved the final version of the manuscript.
Author details
1
Institute for Applied Health Research, School of Health & Life Sciences,
Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.
2
GCU London, 40 Fashion Street, Spitalfields, London E1 6PX, UK.
3
School of
Nursing Sciences, Faculty of Medicine and Health, University of East Anglia,
Norwich Research Park, Norwich NR4 7TJ, UK.
4
Glasgow Centre for
Population Health, 1st Floor, House 6, 94 Elmbank Street, Glasgow G2 4DL,
UK.
Received: 15 May 2013 Accepted: 11 October 2013
Published: 19 October 2013
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doi:10.1186/1471-2458-13-971
Cite this article as: McPherson et al.:The association between family
and community social capital and health risk behaviours in young
people: an integrative review. BMC Public Health 2013 13:971.
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