China, the country with the largest ageing population on Earth [1
], is facing multiple health challenges [2
]. Health deteriorates as people age, with increasing disease risk. Healthy behaviours are expected to slow health deterioration by preventing people from becoming ill, as well as by preventing the worsening of chronic illness [3
]. Given the importance of leading a healthy lifestyle among older people in China, investigation of the factors associated with health behaviours is critical, and can be particularly useful for the prioritization of limited resources and targeting of public health interventions in the country.
Socioeconomic status (SES), conceptualised as education and income, has been found to be associated with health behaviours [4
]. Among Chinese adults, for example, less-educated people report lower levels of vegetable and fruit (VF) consumption [6
] and higher levels of smoking [7
]. People with lower incomes also reported inadequate VF consumption [8
]. Diverse mechanisms underlie the relationships between SES disparities and unhealthy behaviours [5
]. One classic explanation, termed the “healthy lifestyle” mechanism, is that adults with higher educational levels tend to avoid unhealthy behaviours (e.g., smoking) and to engage in healthy behaviours (e.g., exercise) because education enables people to be more aware of the health outcomes of their behaviours and to develop stronger self-control [9
]. Another explanation is that wealthier adults are able to afford the expenses of gym membership and other leisure time associated with physical activity (PA) [10
]. In China, however, associations among income, PA, and smoking are complex; people in rural China with lower incomes reported higher levels of work-related PA than did those with higher incomes [11
]. Another study showed that women with lower incomes reported higher levels of domestic PA compared with the higher-income group [12
]. Possible explanations are that poorer rural residents must work for longer periods to earn livings; women with lower incomes are more likely to be stay-at-home housewives and thus participate more in domestic chores. Additionally, the association between income and smoking is not straightforward. How can we explain the fact that more than half of highly educated doctors in some areas of China are smokers, despite their knowledge of the harmful effects of smoking [13
]? This phenomenon indicates that education and income alone are not sufficient to explain people’s health behaviours. Factors other than SES disparities must empower people to adopt certain health behaviours; research has suggested that social circumstances [5
] and social environmental factors such as social cohesion [14
] can greatly influence such behaviours.
Empirical studies have highlighted the significant influence of social cohesion on people’s health behaviours in Western countries [15
]. For example, higher levels of social cohesion are associated with higher physical activity (PA) levels among older adults [16
]. Social cohesion can promote PA in many ways [19
]. More cohesive societies may be more likely to organize local activities, including sports/PA, that provide more opportunities for residents to adopt and maintain healthy behaviours [20
]. Social cohesion also may reinforce healthy norms [21
]; for example, seeing neighbours jog every day might encourage others to participate in such activities when the perceived safety level (an element of social cohesion) is high [17
This mechanism may also apply to the maintenance of a healthy diet. Collective efficacy, another aspect of social cohesion, is grounded in mutual trust and describes a community’s ability to create change and exercise informal social control (e.g., promote healthy vegetable and fruit (VF) consumption through social norms) [22
]. Several scholars have found that greater social cohesion is associated with higher VF intake among adults [23
] and adolescents [24
], and benefits nutrition among children [25
]; little attention has been given to this association in older adults. In a study conducted with 5900 adults living in urban neighbourhoods in five European countries, higher levels of social cohesion were associated positively with fruit, but not vegetable, intake [26
The relationship between social cohesion and smoking appears to be less straightforward, as studies evaluating it have yielded different conclusions; some researchers found that greater social cohesion was associated with lower levels of smoking [27
], whereas Andrews and colleagues [30
] found no such association.
Apart from traditional health behaviours, social participation has also been reported recently to be a crucial health behaviour in later adulthood [31
]. Studies conducted in Western countries, such as Great Britain [22
] and the United States [33
], have revealed a clear association between social cohesion and social participation among older adults, although evidence on this subject remains scarce, and whether this association holds among older adults in China remains unknown.
Numerous attempts have been made to conceptualize social cohesion [34
]. In general, the term refers to trust levels and the absence of social conflict, interrelated societal characteristics [36
], but an internationally accepted definition remains lacking. For this study, we adopted Chan and colleagues’ [38
] (pp. 290) definition: “social cohesion is a state of affairs concerning both the vertical and the horizontal interactions among members of a society, as characterized by a set of attitudes and norms that include trust, a sense of belonging, and the willingness to participate and help, as well as their behavioural manifestations.” Researchers have proposed several indicators for its measurement [39
], including trust among citizens [17
] and perceived safety [39
], which are expected to influence health behaviours.
Despite China’s rapid economic growth in recent decades, the income gap (reflected by the Gini coefficient) in the country is ranked even higher than that in the United States [43
]. It peaked in 2008 and then began to decline in 2010 [43
]. According to the Committee on Social Affairs, Health and Sustainable Development (Council of Europe), a substantial body of evidence has shown that income inequality is a major threat to social cohesion [44
]. The drastic economic development that has occurred in the past few decades in China has likely affected social cohesion. Thus, the investigation of social cohesion in China during the period of 2008–2010 is of particular interest.
Research investigating associations between social cohesion, SES, and health behaviours among older people in China is very limited; only one study revealed an association between social cohesion and leisure-time physical activity (LTPA) among older adults in Shanghai [21
]. No study to date has explicitly examined associations of social cohesion and SES with multiple health behaviours in a national sample of older Chinese people. Although the importance of SES has been well documented in developed nations [5
], less evidence is available for developing countries such as China. To fill this gap, we investigated associations of social cohesion and SES with various health behaviours (smoking, physical activity, VF consumption, and social participation) among middle-aged and older adults in China using a large nationwide database. As previous studies have revealed gender differences in health behaviours such as smoking in China [45
], we also conducted a gender-stratified analysis of these associations.
shows the characteristics of the study participants. Of the 13,367 participants included, the mean age (SD) was 63.2 (9.44) years; 53.1% of participants were female, 83.1% were not single, 50.9% were from rural areas, and 61.7% had lower educational levels. Overall, the prevalence of smoking was 24.5%, but a much higher proportion of smokers was male (48.9% vs. 3.0% female). The prevalence of inadequate VF consumption was 35.0%, and 32.8% of participants reported insufficient PA. The mean social participation scale score was 1.7 (standard deviation, 0.4).
presents the results of the multivariate linear regression model and logistic regression models. In the analysis adjusted for age, gender, marital status, and residence, each unit of increase in the social cohesion score was associated with a 30% increase in the likelihood of adequate VF consumption (OR = 1.300; 95% CI, 1.192–1.417; p
< 0.001); higher social cohesion was associated with lower odds of being a daily smoker (OR = 0.839; 95% CI, 0.754–0.934; p
< 0.01); also, higher mean score of social cohesion was positively associated with higher levels of social participation (B = 0.074, p
< 0.001). Regarding education, less-educated respondents were associated with lower odds of having adequate VF consumption (OR = 0.806; 95% CI, 0.730–0.890; p
< 0.001), lower-educated respondents had a 31% higher likelihood of being daily smokers (OR = 1.314; 95% CI, 1.166–1.480; p
< 0.001), and were less likely to be socially active (B = −0.052, p
< 0.001) compared with people with higher levels of education. With respect to income, individuals with higher income were less likely to have sufficient PA (OR = 0.606; 95% CI, 0.552–0.665; p
< 0.001), less likely to be daily smokers (OR = 0.790; 95% CI, 0.699–0.891; p
< 0.001), more likely to have adequate VF consumption (OR = 2.650; 95% CI, 2.396–2.932; p
< 0.001), and tend to be more socially active (B = 0.101, p
< 0.001) compared with people with lower income.
Analyses controlled for key background characteristics (age, marital status, and area of residence) revealed significant gender differences in the associations of daily smoking and PA with social cohesion (Table A3
, Appendix C
). Higher levels of social cohesion were associated significantly with decreased odds of being a daily smoker among men (OR = 0.805, p
< 0.001), but not among women. Such levels were associated significantly with sufficient PA only among men (OR = 1.178, p
< 0.01). In addition, gender differences were found in the associations of education with adequate VF consumption and daily smoking (Table A3
, Appendix C
). Lower educational levels were associated significantly with reduced odds of adequate VF consumption among women (OR = 0.723, p
< 0.001), but not men. Such levels were associated significantly with greater odds of being a daily smoker only among men (OR = 1.320, p
< 0.001). In addition, higher incomes were associated significantly with reduced odds of being a daily smoker only among men (OR = 0.807, p