2004 Bridges Summer Research Report Miranda Lucia Ritterman School of Public Health "Social Networks and Public Health in Cuba"

Significance: Social Networks and Public Health in Cuba is a several year joint effort between Principal Investigators Professor Miguel Angel Rodriguez, of Cuba’s Escuela Nacional de Arte in Havana, and myself, Miranda Lucia Ritterman, a doctoral student in Epidemiology at the University of California at Berkeley. The study is an examination of the anatomy of social networks and their relationship to the health and wellbeing of individuals in Cuba.

A large body of literature now exists which shows that poor social connections are related to high rates of virtually every disease. (Kawachi, Kennedy, Lochner, Prothrow-Stith (1997). Social capital, income inequality, and mortality. American Journal of Public Health. 87: 1491-1498.) However, there are two unanswered questions about these findings: (1) What is it about social connections that results in these outcomes and (2) despite the fact that we know a lot about the effects of poor social connections, we know very little about good social connections. What are the mental and physical health effects of rich social connections?

Specific Aims: Our decision to study these two unanswered questions in Cuba was based on the fact that many people in Cuba have a rich set of social connections rarely observed in the United States. According to Jose Ramon Balaguer, member of the Political Bureau and the Public Health Ministry of Cuba, Cuba is outside of the panorama of the poverty and lost hope that millions of other peoples face worldwide. This, he explained, is a result of Cuba’s “education, work, culture, sports, security, social participation, national identity, independence and sovereignty…the indispensable components of healthy development of the human being that are bread in Cuba.” (De La Osa, JA (2004). Cuba es ejemplo en el control del dengue. Granma. Martes, 1 de junio.) This setting allows us to go beyond the study of poor social ties and to observe the consequences of excellent social networks.

For the first time in the field of social epidemiology we are investigating the relative importance of social support and social settings for health. Social support is defined as emotional, instrumental and informational support, (House, JS (1981). Work stress and social support. Reading, MA: Addison-Wesley) and social settings are defined as the types and number of opportunities to socialize within a given community. By examining these social network pathways, which influence social and interpersonal behavior and individual wellbeing, (Berkman, LF, Glass, T (2000). Social integration, social networks, social support, and health. In Berkman, LF, Kawachi, I., Social Epidemiology, New York: Oxford University Press, pp. 137-173.) we are broadening current understanding of how social network structure influences health.

Past Work: Professor Rodriguez and I began exploring this issue in 2003. Data from our preliminary cross-sectional survey and in-person interviews, from December 2003-January 2004, showed that the Cuban men in our convenience sample (n=30), ages 20-55, residing in the neighborhood of La Victoria in Centro Habana, perceive themselves to be highly self-efficacious, well-integrated and influential. The mean socioeconomic status (SES) scores, both from the 10-point Perceived SES Ladder Scale compared to other Cubans residing in Cuba and to all people of the entire world, were 5.

Current Work: From May-July 2004 we began the second stage of our pilot study. The second stage of our study, which also included both a survey and in-person interview, was administered to a subset of twelve of the men from our preliminary study.

We examined the social networks, of our study participants and the extent to which the amount and quality of these social networks determine the degree to which they can participate in and be part of (social integration), contribute to (self-efficacy), influence and benefit from these connections.

Social networks are defined as the available resources, actual or perceived, that are accessible to an individual by virtue of possessing more or less institutionalized relationships of mutual acquaintance and recognition. The richer one’s social networks, the more opportunities one has to be engaged in, connected to and at one with their community. The seven theoretical components that make up rich social networks include: reciprocal links throughout the community network, frequent supportive interactions, the ability to form new associations, trust and cooperation, more horizontal than vertical ties and relationships, cooperative decision-making processes and the existence of similar network properties within and between organizations and groups. (Kreuter, MW, Lezin, N (2002). Social capital theory: implications for community-based health promotion. In DiClemente, RJ, Crosby, RA, Kegler, MC., Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health, Jossey-Bass, pp. 228-254.)

Findings: Our study results show that study participants perceive Cuba to be highly evolved in each of the rich social network components. All of the men in our study reported having good or excellent relationships and daily communication with their neighbors. Everyone reported greeting or being greeted by a minimum of fifteen people from their neighborhood every day. All of the men reported that they are invested in their community and have a responsibility to help resolve neighborhood-based problems. Most interesting perhaps is the ladder component, the concept that similar network properties within and between groups must exist for a given social network to be vibrant and sustainable.

Study participants do not perceive their community as being made up of separate social networks, each consisting of similar network properties, but rather one fluid social network, made up of indistinguishable smaller networks. This one fluid social network is their definition of community itself. In other words, the social networks of Cuba are tightly interwoven. Community members are not divided into relatively separate groupings—the elderly, the youth, the dark skinned, the light skinned, the white collar, the blue collar, the highly educated, the less educated, but rather one greater diverse grouping. This in part is a result of their perceived SES, and the relative socioeconomic equality, which is still observed in present-day Cuba.

In order to deepen our understanding of how the Cuban neighborhood is not constructed of distinct social networks, but rather one grand fluid social network, we had to consider not only the relative socioeconomic equality, but further study and observe the daily oral signals and body gestures, the spontaneous and internal mechanisms of communication, which persist from generation to generation in La Victoria. It is this mechanism of communication—which occurs on street corners, at bus stops, in snack bars, through apartment windows, in outdoor markets, in domino huts, at rumba gatherings, in work environments—that forms the backbone of social network structure in La Victoria and makes possible the transmission of pertinent information, retro-nourishment (Spanish, retro-alimentacion, refers to the sharing of food between neighbors), social support, mutual help, and reciprocal connections in general. It is this mechanism of communication—the daily oral signals and body gestures—that promote cultural stability, traditional and spontaneous methods of resolution and individual significance.

Specific statements given by study participants regarding the rich fluid social network of their neighborhood, La Victoria, are:
• “Despite the material problems, we are a dynamic and creative generation, hard working and festive. We play dominos together, discuss information from the newspaper and the neighborhood, we practice sports in the park, we help each other when someone has a problem, or just wants to paint their house. We help each other regarding the problem of food, clothing, finding work. We invite each other out for drinks or to our homes. Given our limitations we have created a reciprocal system in which we support each other through our work, our spirit. It is for this that our generation has remained intact.”
• “The salutation is a form of daily supportive interactions. If someone from the neighborhood is missing everyone becomes concerned. The salutation is a mechanism which gives importance to each person every day.”
• “The facility in making new relationships is largely a result of the salutation, which is a mechanism of community unification, which manifests itself over time. Because everyone knows each other by sight and greets one another orally or through body gestures, relationships develop and are continually and routinely strengthened.”
• “The daily communication between the residents of La Victoria function as a cohesive element, a way of thinking and behaving, and reflects the identity of our people and culture.”

Lessons Learned: Strong fluid social networks are how community neighborhoods are defined and understood to be interconnected. Beyond the perceived socioeconomic equality in Cuba, the daily mechanisms of communication between community members systematically build and renew relationships and facilitate collaborative efforts between neighbors in La Victoria.

Degree Goal: This research on the relative importance rich social networks have in determining perceived individual health and wellbeing will be used to inform both my dissertation in social epidemiology at UC Berkeley and my practice in the field of public health. It is my hope that these interviews will enhance our understanding of the pathways between social connections and perceived individual wellbeing.
The information we gather will hopefully be useful in designing interventions that help strengthen social capital in communities in the United States and that work toward bringing people together for their mutual benefit.

Future Directions: I, under the guidance of UC Berkeley Emeritus Professor and Epidemiologist Leonard Syme, plan to further research social networks in Cuba and specifically the influence of social networks on health care-seeking behavior in Havana.