key: cord-1019880-gp67p2hg authors: Yanagisawa, Mao; Kawachi, Ichiro; Scannell, Christopher A.; Oronce, Carlos Irwin A.; Tsugawa, Yusuke title: Association between County-Level Social Capital and the Burden of COVID-19 Cases and Deaths in the United States date: 2021-04-22 journal: Ann Epidemiol DOI: 10.1016/j.annepidem.2021.04.008 sha: d7c5732a52bad8936ee5394a173833e916c83d95 doc_id: 1019880 cord_uid: gp67p2hg nan The United States has confirmed over 15.8 million cases and 295,600 deaths from Coronavirus Disease 2019 (COVID-19) as of December 12, 2020.(1) While regional variations in the rate of infections and deaths due to COVID-19 is apparent, the underlying causes are not fully understood. (2) Effectively controlling COVID-19 outbreaks requires support from community members to maintain social distancing concerted efforts, such as delivering food to elderly neighbors or making a financial donation to local charities so that community members could stay home safely. In the United States, a major barrier to an effective, coordinated response to COVID-19 may be the lack of social solidarity. In the absence of a strong federal response, states and local municipalities have been left to devise their own policies. Ultimately, individuals are making their own decisions about whether to comply with recommendations such as wearing masks or maintaining social distancing. In turn, divergent individual choices mirror the polarization of American society and the erosion of social cohesion. A recent study found that higher social capital is associated with fewer COVID-19 cases using data from European countries (3), whereas another study suggests that higher level of social capital is associated with faster COVID-19 infection spread in the U.S. counties. (4) In this study, we hypothesized that communities with high social and emotional support exhibit lower numbers of COVID-19 cases and deaths as the community members may be more likely to trust their neighbors and participate in collective actions to contain outbreaks including social distancing and wearing masks, whereas communities with high civic engagement experience higher numbers of cases and deaths through a higher frequency of physical interactions. We examined the association between county-level social capital and the number of COVID-19 cases and deaths per 100,000 population (retrieved from the Center for Systems Science and Engineering (CCSE) at Johns Hopkins University (JHU) as of June 30, 2020 (1)) using multivariable negative binomial regression models. We investigated three measures of social capital, whose validity have been The analyses were conducted using Stata 15.1. This study was exempted from review by UCLA Institutional Review Board. After adjusting for other county characteristics and state fixed effects (within-state comparisons), we found that counties with a higher BRFSS Index had fewer COVID-19 cases (adjusted percent change, -1.9% for a 1-point increase in social capital index; 95%CI, -2.8% to -1.0%; p<0.001) and deaths (-2.7%; 95%CI, -4.4% to -1.0%; p=0.002) (Table) . We found no evidence that PSCI or PSU-SC Index were associated with COVID-19 cases and deaths. Among individual components of the PSU-SC Index, counties with higher voter turnout in presidential elections experienced a higher number of COVID-19 deaths (+1.8%; 95%CI, +0.3% to +3.3%; p=0.02). We found that counties with a higher level of social and emotional support experienced fewer COVID-19 cases and deaths, while those counties with greater civic participation (e.g., voter turnout) experienced a higher burden of COVID-19. Our findings indicate that higher social capital in a county may be a -double-edged sword,‖ i.e., counties with greater civic engagement are more inclined to have frequent communal in-person gatherings that contribute to a greater disease burden, whereas individuals living in communities with better social and emotional support may be more adherent to social distancing as they are better able to adapt to the isolation of stay-at-home orders. Limitations of our study include potential unmeasured confounding, and individual-level associations could not be inferred based on county-level data. Our estimates might be underpowered to detect true differences, especially for our analyses of PCSI measures and of the membership organizations subcategory for the PSU-SC index for which confidence intervals were large. Our findings suggest that the association between the burden of COVID-19 and social capital at county level vary depending on different measures of social capital: social and emotional support may mitigate the burden of COVID-19 while civic engagement through physical interactions may lead to an increased burden of COVID-19 outbreaks. Counties with high civic engagement may require stricter enforcement of social distancing to contain COVID-19 outbreaks while strengthening social and emotional support in the long-run may make communities more resilient for future pandemics. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. The number of cases and deaths due to COVID-19 in US counties as of June 30, 2020. Adjusted for county-level median household income, percent poverty, unemployment, female, 65+ years, and uninsured, mean household size, urbanicity, air quality, health outcome quartile, total physicians and hospital beds per capita, presence of a stay-athome policy, number of days from the first county-reported COVID-19 case, the percent of vote share won by Donald Trump in 2016 US Presidential election, and state fixed effects (effectively comparing counties within the same state). The BRFSS Index is defined as the percentage of respondents reporting availability of adequate social/emotional support calculated using BRFSS data from 2005-2010 based on the County Health Rankings from 2014. The PSCI is defined as the number of employees hired at voluntary organizations (based on the County Business Pattern dataset from 2018) divided by the total population of the county. COVID-19 Data Repository by the Geographic Differences in COVID-19 Cases, Deaths, and Incidence -United States Social Capital and the Spread of COVID-19: Insights from European Countries Community-level social capital and COVID-19 infections and fatality in the US A Comparative Analysis of the Validity of US State-and County-Level Social Capital Measures and Their Associations with Population Health The production of social capital in US counties NCHS Urban-Rural Classification Scheme for Counties Health Outcomes County Health Rankings & Roadmaps See Which States and Cities Have Told Residents to Stay at Home. The New York Times MIT Election Data And Science Lab. County Presidential Election Returns Contributors Mao Yanagisawa: Conceptualization, Methodology, Writing-Original draft preparation Ichiro Kawachi: Conceptualization, Writing -Review & Editing Christopher A. Scannell: Resources, Writing -Review & Editing Carlos Irwin A. Oronce: Resources, Writing -Review & Editing Yusuke Tsugawa: Conceptualization, Writing -Review & Editing *A composite measure calculated based on the number of establishments in religious organizations, civic and social associations, business associations, political organizations, professional organizations, labor organization, bowling center, fitness and recreational sports centers, golf courses and country clubs, and sports teams and clubs The authors have no conflicts of interest. The study was exempted from human subjects review by the institutional review board at University of California, Los Angeles. All data are publicly available.