Children's perspectives on health promoting living environmens: the significance of social capital

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Citation for the original published paper (version of record):

Eriksson, M., Dahlblom, K. (2020)

Children's perspectives on health promoting living environmens: the significance of social capital

Social Science and Medicine, 258: 113059

https://doi.org/10.1016/j.socscimed.2020.113059

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Children's perspectives on health-promoting living environments: The significance of social capital

Malin Eriksson ^a,∗ , Kjerstin Dahlblom ^b

a

Department of Social Work, Umeå University, Umeå, Sweden

b

Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden

A R T I C L E I N F O Keywords:

Children's perspectives

Health-promoting living environments Social capital

Photo voice Grounded theory Sweden

A B S T R A C T

This article discusses the usefulness of social capital as a conceptual tool to design neighbourhoods promoting children's health. The aim was to explore children's perspectives of health promoting environments, and we used a combination of photovoice and grounded theory. Children from two neighbourhoods in a Swedish munici- pality were invited to photograph and discuss places of importance for their well-being. They presented places facilitating togetherness, enjoyable activities and positive emotions, mostly found in their immediate environ- ments: at home, at school and in their neighbourhoods, but the access to these places was unequally distributed between the areas. The results highlight a need for ensuring all children's access to health promoting places and to include children's views in policy and planning. Investments in the physical environment need to be combined with efforts to influence norms and collective efficacy to secure local ownership and use of these investments. We found that the concept of social capital is a relevant conceptual tool for understanding what constitutes health- promoting places from children's perspectives and contributes to a deeper understanding on how physical and social environments are interlinked.

1. Introduction

It has long been known that our local environment may have an effect on health, and variations in health between different small areas, such as neighbourhoods, have been observed in many countries (Macintyre and Ellaway, 2003). Despite this, geographical health in- equalities have, until recently, mainly been understood by composi- tional explanations, i.e. that geographical health disparities are ex- clusively the result of differences between the people living in these places, rather than the result of differences in the physical and social environments to which these people are exposed (Macintyre and Ellaway, 2003). However, during the last decades we have seen a re- newed interest in the social determinants of health (SDH), i.e. ‘the conditions in which people are born, grow, live, work and age’ (CSDH, 2008). The recent Swedish Commission for Equity in Health highlights the living environment as an arena for tackling health inequalities, such as ‘housing and neighbourhood conditions’ (SOU, 2017:47).

The living environment may be particularly important for the health and wellbeing of people who spend much of their time in it (Forrest and Kearns, 2001; Weller and Bruegel, 2009). Children especially are bound to their families and neighbourhoods and are, therefore, fundamentally affected by the resources available there (Osborne et al., 2017).

Sellström and Bremberg (2004) discuss factors in the local environment that may influence children's health, and summarise them in three main areas: 1) the socio-economic status of the residential area, 2) a good

‘social climate’, and 3) access to public and private services in the area.

Macintyre et al, (2002) similarly propose that local environments may influence health both through the material infrastructure (e.g., quality of air and water, safe playgrounds and recreations areas, welfare services, and transportation) as well as through the collective social functioning of the neighbourhood (e.g., culture and norms, community integration, community support and the reputation of an area).

In addition, social capital has become a widely used concept for studying place effects on health. Social capital concerns 'social networks, the reciprocities that arise from them, and the value of these for achieving mutual goals' (Schuller et al., 2000, 1). The concept has multiple meanings; it is viewed as an individual asset, 'the ability of actors to secure benefits by virtue of membership in social networks or other social structures' (Portes, 1998, 6). In addition, it is viewed as a collective feature of local areas by levels of social participation, trust and re- ciprocity norms (Kawachi and Berkman, 2000; Putnam, 1993, 2000;

Szreter and Woolcock, 2004). This conceptualisation clearly relates to the ideas of place effects on health by its emphasis on collective social functioning. Place-specific social capital is believed to influence health

https://doi.org/10.1016/j.socscimed.2020.113059

Received in revised form 6 May 2020; Accepted 13 May 2020

∗

Corresponding author. Department of Social work, Umeå University, SE-901 87, Umeå, Sweden.

E-mail address: malin.eriksson@umu.se (M. Eriksson).

Available online 21 May 2020

0277-9536/ © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

T

by enabling a safe and supportive environment, trust and collective action (Eriksson, 2010). It may also facilitate ‘collective efficacy’ in that community members increase control over their lives and their living environment (Campbell, 2000). As such, social capital is viewed as an attractive ‘conceptual tool’ for what constitutes a health-promoting living environment (Campbell and Gillies, 2001). It can further be di- vided into different forms. Bonding social capital consists of strong ties within a network of similar people, which strengthen common (and exclusive) identities and function as a source of help and support among members. Bridging social capital consists of weaker ties that link people from heterogeneous networks, which can be an important source of information and resources (Gittell and Vidal, 1998; Putnam, 2000).

Studies of adults from different countries confirm positive health effects of living in areas high in social capital, at least for some popu- lation groups (see e.g. Kim et al., 2006; Snelgrove et al., 2009; Eriksson et al., 2011; Mohnen et al., 2011; Gilbert et al., 2013). However, studies have also found that living in high social capital communities may be harmful for the health of some people, and that these downsides of social capital seem to be more common in areas characterised by strong bonding - at the expense of bridging social capital (Villavonga-Olives and Kawachi, 2017). Strong bonding social capital seems to risk creating heavy obligations on community members to follow dominant social norms, with increased risk for social exclusion of those who do not conform to these existing norms (Villavonga-Olives and Kawachi, 2017). In addition, studies have indicated that social capital is un- equally distributed between areas. Altschuler et al. (2004), in their study from a Californian metropolitan region, found that higher socio- economic areas had more access to bridging social capital while bonding social capital was evenly distributed between areas with dif- ferent socio-economic composition.

So far, the vast majority of social capital and health research have been based on quantitative methods and predetermined oper- ationalisations of local social capital, which do not necessarily capture the perspectives from people living in these places. Qualitative studies can shed further light on peoples' subjective understandings and con- ceptualisations of social capital in different settings (Whitley, 2008), which is needed if social capital is to be used as a conceptual tool in the planning and design of local health promoting interventions. In parti- cular, studies on social capital and living environments from the per- spectives of children are limited (Leonard, 2005; Weller and Bruegel, 2009). Leonard (2005) found that children and childhood are less in- cluded in the conceptualisation of social capital, suggesting that it has generally been considered a by-product of childhood that may benefit them in the future. Based on their studies of inner-city and suburban locations in England, Weller and Bruegel (2009) suggest that children play an important role in the development of social capital through their own actions, such as helping neighbours, and by providing con- nections and networks for adults around them. Children might thus function as catalysts for parental social connections in a neighbour- hood, as also found in as study from Australian suburbs (Wood et al., 2011). Furthermore, as underlined by Goodwin and Armstrong-Esther (2004) in their study from rural Wales, children actively participate in their own arenas, and they develop and draw upon their own social capital in ways that may influence their well-being. When trying to understand how social capital can be used to promote children's health, it is therefore central to include children's own perspectives.

Exploring children's perspectives requires actively involving chil- dren in research using participatory methods (e.g. James et al., 1998;

Shier, 2001). The necessity of giving voice to children is clearly un- derlined in the United Nations Convention on the Rights of the Child (UNCRC, 1989), stating that children are ‘equal participants in society, differently competent to adults, but of interest for what they are now, not only what they will become’ (Childhood Studies, 2016). In a joint mani- festo from the UNICEF, WHO and The Lancet commission (Clark et al., 2020) there is a call for immediate action on child health. They speci- fically call for a new global movement driven by and for children, and

the implementation of new policies to work towards child health and rights. The initiative 'Uppsala Health Summit - Healthy Urban Child- hoods' in 2019 is a recent example of how urban planners and other stakeholders gather to discuss strategies of how to include children in the planning. Among other things, they declare the need for interven- tions that are based on what is known about suitable and attractive urban environments that influence wellbeing among children. Here, we suggest that social capital may be a tool for the planning and design of health promoting neighbourhoods for children. However, for this tool to become useful, children's own perspectives on health promoting living environments and social capital need to be further explored.

2. Aim and research questions

The aim of this study was to explore children's perspectives on health promoting living environments. The following research ques- tions were explored:

● How do children describe, perceive and portray their living en- vironments?

● What are children's views on health and what places are perceived as health promoting?

● How accessible are health promoting places for children in different neighbourhoods?

● What is the significance of social capital for children's perspectives on health-promoting environments?

3. Methods

3.1. Study design and data collection tools

We used a combination of photovoice and grounded theory in this qualitative exploratory study, building on children's active involve- ment. Photovoice was developed as a research method by Wang and Burris (1977) and is described as a process where people can identify, represent and improve their community using a photographic tech- nique. Active participation and empowerment promote well-being, and photovoice has been found to be particularly useful when children are involved in the research (Warne, 2012). Using pictures, participants can identify, interpret and portray their choices and give valuable insights of how they view their worlds.

In the analysis we used a social constructivist Grounded Theory (GT) approach, acknowledging an active role of the researcher (Charmaz, 2001, 2006; Clarke, 2005). This GT approach fits well with the photovoice approach, in that it applies ‘flexible strategies to guide qualitative data collection, and, particularly, data analysis’ (Charmaz, 2001, 6396). We adopted an emergent design based on simultaneous data collection and analysis in an abductive oscillation between data and our evolving ideas. Furthermore, we acknowledged our frames of reference (social capital and children's perspectives), while remaining open to new and unexpected topics in our data.

The data analysed in our study consist of children's photos, short written narratives, and verbatim transcripts from eight focus group discussions.

3.2. Research setting and participants

This study was carried out in Umeå Municipality, one of the fastest growing and most populated cities in northern Sweden. Because of the university, it has a relatively young (average age of 38) and highly educated population. The municipality encompasses both rural and urban areas with different characteristics (Umeå Municipality, 2018a).

Urban neighbourhoods typically contain mixed settlements with both

rental and tenant-owned apartments, as well as detached houses. The

region ranks high in social progress with regards to basic human needs

and foundations of well-being (EU, 2016). In addition, Umeå is

considered a relatively equal municipality since it has no neighbour- hoods defined as 'socially vulnerable', according to the Swedish police (who has identified 61 neighbourhoods in Sweden being characterised by high crime, insecurity and social exclusion) (The Swedish Police, NOA, 2017).

Most children attend municipal primary schools based on geo- graphical proximity and few children are enrolled in independent schools (Umeå Municipality, 2018b). Thus, the majority of children attend a primary school in their close environment.

The study was carried out in close collaboration with ‘Kulturverket’, within one of their projects dedicated to creating safe and inclusive environments for children. Kulturverket is a municipal function that organises creative workshops with children across all schools in Umeå Municipality to visualise and generate ideas for professional exhibi- tions, shows and concerts (Kulturverket, 2019). For this study, we in- vited children in year 5, i.e. 11–12 years old, from two urban schools that were currently involved in Kulturverket's activities. Thus, our collaboration with Kulturverket steered the sampling of schools, but also functioned as an important gatekeeper into the schools, which otherwise would have been hard to reach. The two invited schools were located quite close to each other (4 km), but the two neighbourhoods in which these schools were located also differed in some respects, which fit the purpose of our study to capture how children's perspectives on health promoting living environments may differ between neighbour- hoods.

3.3. Sociodemographic profiles of the neighbourhoods

The construction of ‘Green Fields’ started in 1990 and is ongoing. In 2016, an estimated 5801 people lived here. There is a mix of housing arrangements, but the area is lacking many amenities such as super- markets, pharmacy, coffee shops, a public library and a Primary Health Care Centre. For example, there is only one small shop. The neigh- bourhood is situated by a lake in the woods and there are facilities for leisure activities, playgrounds, and local venues. The employment rate among the adult population in Green Fields is higher than many other neighbourhoods in Umeå.

The neighbourhood we call ‘Blue River’ was constructed in 1966–1973. Because of the newly established university, many of the houses were student lodgings; both corridors and apartments. There are still many students living in Blue River. In 2016, there were around 6142 inhabitants with the majority living in rental and tenant-owned apartments. There is a well-developed centre with three supermarkets, a coffee shop, pharmacy, restaurants and a few small shops. The main secondary school has a public library and there are a few gravel football grounds nearby. Recreation areas are small and there is no park. In this neighbourhood, the employment rate in the adult population is lower compared to most other neighbourhoods in Umeå. In addition, Blue River has the municipality's highest proportion of foreign-born re- sidents.

3.4. Sociodemographic profile of participating children

Most of the children from Green Fields lived together with both parents and all of them had siblings. In Blue River, half of the children lived with one of their parents, and nearly all had siblings. Most of the children in Green Fields lived in their own houses or apartments while the families of children in Blue River lived in rental apartments. It was also more common for children in Green Fields to have their own room and around half of them had pets.

We included two whole classes; 25 pupils from one school (Green Fields) and 16 from the other school (Blue River), for a total of 41 children. There was an uneven gender distribution in both classes, with 15 girls/10 boys and 10 girls/6 boys respectively.

3.5. Procedure – data collection 3.5.1. Steps in the photovoice workshops

The photovoice workshops were carried out in three separate ses- sions in each school. During the first session we, two researchers and one facilitator from Kulturverket, met with the whole class. During each first session, all children were provided with digital cameras and in- structions for how to use them. They were asked to take photos of places they experience as positive, i.e. places where they feel comfor- table, happy and safe. We did not specify that these places should be in their immediate environments, but rather places they use to visit. The children were encouraged only to photograph places associated with positive emotions, since our aim was to explore health-promoting en- vironments. We asked them not to take photos of people and to select three photos each to discuss in the second session. They were allowed to keep the cameras for about one week.

In the second session with the researchers, the photos were used in focus group discussions where the children described the places and how they experienced those environments. We divided the children into four smaller sex-stratified groups at each school to try to ensure equal involvement of boys and girls. Each child presented one of their three photos and were asked: What place it was; Why the place was important and how they felt when they were there; what they did there, and with whom. We tried to moderate the discussion so that everybody's voice was heard and that all participants were engaged in discussions about each other's photos. In addition, everyone was asked to share their views on well-being and health by discussing the questions; 'How do you view health? What is health? Can you be in good health even if you have a disease? Do you think places and neighbourhoods affect health?

How?' We ended each focus group discussion with a pile-sorting ex- ercise, asking the groups to look at all their photos and cluster them into different groups based on the question 'Which photos fit together?'. This was done to facilitate a group activity and a joint discussion among the children about what their photographed places had in common. No further prompting or clarifications was needed, since all groups im- mediately started to sort their photos when asked to cluster them based on how they fit together. The discussions lasted around 1.5 h, including time for refreshments.

For the third session, the team again met with the whole class. All photos were compiled into slideshows with music that we discussed with the children after viewing. During this session, each child received a memory stick containing their own photos. To give the children an opportunity to reflect and possibly add more places to the ones pho- tographed, we assigned them an individual task. They were asked to write a short narrative of their favourite place (My favourite place is …. ) and why they feel good there (I feel happy there because…).

3.6. Analytical approach

Overall, the photovoice and Grounded Theory analysis was char- acterised by constant comparisons of our different data (i.e. photos, written narratives and transcribed focus group discussions), and an oscillation between data and our emerging ideas. Extensive memos were written after each photo voice session to facilitate our continuous involvement in the analysis (Charmaz, 2006). KjD carried out the analysis of the photos and children's written narratives, while ME conducted the grounded theory coding of the transcribed focus groups.

These initial analyses were then compared and discussed jointly by the researchers to come up with the final, overall results.

3.6.1. Analysis of the photos and written narratives

A total of 106 photos were analysed from two different perspectives – that of the children and that of the researchers. The clusters of photos, constructed by the children in each of the focus group discussions, were documented and mirrored against the children's written narratives.

Furthermore, we examined all photos and constructed a list of what

kind of places these photos captured. This procedure resulted in the construction of six overall clusters of places captured in children's photos: at home; in the neighbourhood; at school; in public spaces such as shopping centres; other 'third' places such as relatives' homes, and;

places for leisure, sports and club activities. We then mapped out how the photos from each of the schools were distributed within these six clusters to detect potential differences between schools/neighbour- hoods. Next, this list of places was mapped out in relation to what they signify for the children, according to their own written narratives. From this we constructed five categories describing places that, from chil- dren's perspectives, facilitated ‘togetherness’, ‘enjoyable activities’,

‘relaxation’, ‘a space of one's own’, and ‘a safe haven’.

3.6.2. Analysis of the focus groups

Each focus group was transcribed verbatim and coded in line with the basic principles of Grounded Theory, in order to make 'analytic in- terpretations' (Charmaz, 2006, 43). Data from the two schools were coded separately, in order to explore potential differences between schools/neighbourhoods. Initially, an open coding was carried out word by word while remaining quite close to the text. The subsequent se- lective/focused coding involved several steps; first the open codes were sorted and grouped into clusters based on their commonalities. The most relevant codes for the purpose of our study (i.e. codes referring to places) were kept and re-grouped, resulting in five categories: codes describing places for socialising, enjoyable activities, positive feelings, safety, and a space of one's own. In addition, codes referring to chil- dren's views of health were kept as a separate category. Then, a theo- retical coding was done, in which we analysed links between the ca- tegories referring to places and the category relating to views of health.

Theoretical coding aims to 'specify possible relationships between cate- gories developed in the focused coding' (Charmaz, 2006, 63). Hence, in this step we were able to detect that four of the constructed 'place cate- gories' clearly related to children's views of health and were thus kept for further analysis. The category 'A space of one's own' proved not to be related to children's views on health and were thus dropped at this stage of the analysis. Further, the category 'safety' (as well as the categories 'relaxation' and 'a safe haven' constructed from the analysis of the photos and written narratives) was merged into the category 'positive emotions', resulting in three final categories. (see Fig. 1).

3.6.3. Comparison of photo and focus group discussions analysis to construct final categories describing children's perspectives on health promoting places

In the final step of the analysis, we compared the categories con- structed from the analysis of the children's photos and written narra- tives with the categories constructed from the coding of focus group discussions transcripts. This revealed a clear overlap, as illustrated in Fig. 1. We therefore felt that our categories were saturated and clearly grounded in our data. Finally, these three overall categories describing children's perspectives on health promoting places were compared against the actual places photographed and mentioned by the children in the different schools. We were thus able to map out differences in the accessibility of places between children in the two schools/neighbour- hoods.

4. Ethical considerations

The study was approved by the Regional Ethical Review Board in Umeå (Ref: 2016/301-31). According to the ethical guidelines for re- search involving children suggested by Morrow (2008), we first ob- tained informed verbal consent from head teachers and teachers to conduct our study. Written information to parents/guardians to the participating children was provided and written informed consent was obtained. Information was given to the children in collaboration with their teachers. Since the photo voice workshops were included in or- dinary school activities, all the children participated, but only photos

from those with informed written consent were included in the study.

Three children, or their parents in two cases, did not consent to their photos being used for further analysis.

In the discussions, we did not focus on negative feelings or experi- ences, but on positive emotions linked to specific places in their en- vironment. The discussions did not address issues of a sensitive nature, such as political opinions or sexual orientation.

Our collaboration with Kulturverket ensured that our study could be carried out within a natural and well-established setting for the children.

To avoid the risk of the children taking photos of people without con- sent, we explicitly asked them to not to photograph people. The selected photos were retained by the researchers and only discussed in the work- shop. All children received copies of their photos after sessions.

5. Results

5.1. Description of children's photos

Most of the children (27) had selected several different places to present in the group discussions. From the pile-sort exercise in the focus group discussions, each group gave at least one of their piles a home- related label (living room, inside, bed). Six groups (out of eight in total) labelled one of their piles ‘nature’ and/or ‘outdoor’ (nature, the woods),

‘outdoors’ (fresh air, school yard, downtown). All groups chose the umbrella term ‘fun activities’ for one of their piles, including: football and sports, dancing, and adventure playgrounds. These were places to meet with friends, make new friends, exercise and have fun.

From the researchers' perspective, after exploring all motifs of the photos, the photos were sorted into six clusters of places;)1) the home, 2) the neighbourhood, 3) the school, 4) a public place, 5) other places, such as a grandparent's house or summer house, and 6) sports club/

sports facility. The children from both schools had selected photos from their home, making it the most commonly shared place (Fig. 2). For the Green Fields children, living close to nature and a lake, the neigh- bourhood was present in almost half of the photos, whereas in Blue River, photos of the school and public places were more common. Here, the neighbourhood was represented only by a few photos (Fig. 2).

5.2. Children's views on health

In general, children in both schools expressed a broad and holistic view of health. Health was perceived as a state of wellbeing, to feel good and to thrive; a state that could exist even during illness; ‘You can still feel good and have fun even if you're poorly’ (Boy, Green Fields). One of the boys said that his brother with autism still was happy, enjoyed life and felt safe;

My little brother is happy in his own room. Sometimes he throws his playcards at others, he enjoys it, he likes setting traps too. Yeah, he has fun, really. (Boy, Blue River)

It was clear to all the children in both schools that health was in- fluenced by lifestyle factors such as food, sleep and physical activities.

Beyond this, they perceived health to be influenced by social relations, emotions and activities. To be healthy, you need good relationships, experience good emotions and be involved in enjoyable activities.

Especially for children in Green Fields, ‘nature’ was perceived as im- portant for health and well-being and a natural part of everyday life.

5.3. What characterises places perceived by the children to promote health?

The analysis resulted in the construction of three final and overall

categories describing places perceived by the children to promote

health: Places facilitating togetherness are feel-good spaces; Places for en-

joyable activities are healthy spaces; and; Places associated with positive

emotions are well-being spaces. Based on our data, we found that these

categories were the same for children in both neighbourhoods;

however, the actual places associated with these values varied between schools, as did the access to them. We account for these categories in more detail below, describing how the children's perceptions differed between neighbourhoods.

5.3.1. Places facilitating togetherness are feel-good spaces

The importance of social relations for good health was emphasised by all children, both with friends and family. Thus, places facilitating to- getherness were perceived as promoting health. One boy in Blue River expressed that health is: ‘How you feel with your family and how (inaudible) safe [you are] there.’ In one of the groups of girls, the following answers were given to the question of what is needed to be healthy:

Girl 1: Family.

Girl 1: Friends.

Girl 2: Love. Like.. not true love, but when you like someone, and yeah, this person thinks that…

Girl 5: A social life.

5.3.1.1. Green Fields. The children told us about several places in their surroundings that facilitated togetherness and thus made them feel good. The local football pitch was mentioned by many as an especially important place for socialising with friends, as they could go there almost at any time and be certain of meeting friends, without making plans. This was discussed by the girls in one of the focus group discussions:

Girl 1: So there's a football pitch where everyone can go and do things together…

Girl 2: It's pretty social too, so you meet a lot of people you can hang with and … Like on the football field, there's always people there, until late at night.

Girl 3: And playing football is fun too.

Girl 4: So you always have someone to be with, and even if you don't call anyone to go there, there's always someone there you can be with if no- one else wants to [play].

Girl 1: It's really easy, you just grab a football and go there.

Fig. 1. Steps in the analysis. Categories constructed based on our different data sets and the final categories describing places perceived to promote health.

Fig. 2. Clusters of places from all photos as categorised by the children and researchers combined.

The playgrounds were described as places for socialising and making friends, as were the nearby nature areas and woods.

Furthermore, common spaces where neighbours meet for social events were perceived as feel-good places. Those who had after-school sports activities mentioned how these venues facilitated togetherness and new friendships. The importance of the home for togetherness was also mentioned, although less prominently among children in Green Fields.

The living room was described as a place to spend time with the family, and the computer to socialise with friends.

For many children, pets contributed to their well-being, and taking the dog for a walk was a way to make contact with others in the neighbourhood:

Girl 7: It sounds great, getting together, ’cause that's what we do, and we also have animal days sometimes, where everyone with a pet brings them out on a lead, so you can meet different animals. And the animals get to know the new ones, I think that's good.

R: Right, you get to know the animals and each other perhaps.

Girl 7: Exactly. I know all the dogs in my neighbourhood.

5.3.1.2. Blue River. The children discussed different spaces at home that facilitated togetherness, not least the living room and the kitchen.

These were described as places for daily conversations; this was where the family met and talked about their day and what had happened in school. The living room was described as a cosy place where the family relaxed.

R: How important is it that you sit there with your family, that you're together?

Boy 1: Well, we sit there together and maybe sometimes we talk about how school went. Yeah. We can talk about almost everything there, but most often about school, if something happened there and stuff.

Other places facilitating togetherness were found at school, such as a particular sofa where they would spend time with friends before and after school.

R: This looks really cosy. Tell me, why did you pick this place?

Boy 1: Well, sometimes I'm there with my friends and we just take it easy before school.

R: Right, just chilling and being together.

Boy 1: [here] you're with friends [instead of] with family.

R: I see, the sofa is a place where you can sit and feel good with your friends.

Boy 1: Exactly.

On the contrary, children in Blue River complained about the lack of places to meet with friends in their neighbourhood. When asked about if there was a place in the neighbourhood where they could go and be certain of meeting friends, the boys in one of the focus groups replied;

No, only in school.

Other places for socialising were certain shopping centres, where they spend time with friends and family. Socialising online was also important, and places with computer access were considered social.

Some had access to a computer at home, while others used public computers at the local library.

5.3.2. Places for enjoyable activities are healthy spaces

The importance of enjoyable activities for good health was clear to all the children. Physical activities, especially outdoors, were con- sidered essential for ‘releasing energy’, and as such important for a healthy life. As one of the girls in Green Fields responded when we asked what they associated with the word ‘health’;

Girl 1: I normally think about football [when I think about health], because you get to be outside and move around. And you get to have a lot of fun.

5.3.2.1. Green Fields. The children described places where they would

play and have fun and how that made them feel good. Physical outdoor

activities, such as climbing trees, playing in the woods or at the

playground were also described as enjoyable activities and they could

all be carried out in their neighbourhood. Other important places for

fun activities, such as swimming, bowling and martial arts, were carried

out at sports venues or clubs. Some said that they enjoyed computer

games at home. Summer homes were also mentioned as places

facilitating enjoyable activities.

Boy 1: I spend a lot of time playing football, ’cause it's fun and I have a lot of friends who like it too. And there are older kids I hang out with in my neighbourhood who play football. And it's like you follow their lead and you become more interested in football.

5.3.2.2. Blue River. The children similarly told us about the importance of outdoor places for enjoyable activities, but also expressed that there were few of these in their neighbourhood. However, some told us that they would go to a nearby wood in their spare time, mainly on weekends. Other places described as facilitating enjoyable activities were the local library, where you could borrow books, but also use the computers.

Girl 5: Sometimes I get a little bored at home, and my siblings are loud, and I get a headache, so then I go to the library to read books.

R: Ok, I see, but the rest of you don't go to the library?

Girl 1: Sometimes, to use a computer.

Girl 3: Not use a computer, but maybe return a book, or borrow one.

Girl 2: Me too. I usually go there, I'm reading a book called Dork Diaries.

Stories about places at home that facilitated enjoyable activities were prominent, like watching movies, just ‘chilling out’ or computer gaming. Stories about being active in sports or other associations were less common. However, some were engaged in a dance group and many participated in free activities arranged in school halls and other public venues in the area by a non-profit organisation, thereby providing healthy places to have fun.

5.3.3. Places associated with positive emotions are well-being spaces Concerning emotions, children in both schools expressed that in order to be healthy, it was important to have fun, to be happy, to feel safe, and to love. During one focus group discussions in Blue River, the girls expressed it like this:

R: What do you need to feel good, to be in good health?

Girl 3: To feel safe.

Girl 2: To feel happy.

Girl 5: To be comfortable.

5.3.3.1. Green Fields. The children had taken photos of several places that made them feel happy, safe, calm, and relaxed. The local football pitch, sports venues and local playgrounds were all described as places that made them feel happy. Being with friends and doing fun things there generated positive emotions. Nature, not least the close-by wood, was described as a place that not only made them happy, but also calm and relaxed. The wood was described as a cosy and even magical place:

Girl 6: I mean, I feel like I could never live where I couldn't see the forest outside the window. Or if I see a tree at least, cause it calms me.

—

Girl 2: I think the trees also make, like, when there are trees and people you feel calm.

Girl 2: You feel safe, or something.

Similarly, a boy in Green Fields expressed how he felt happy in the forest: ‘ … Maybe you get to see some animals … and you usually have fun in nature, and if you're with others you have fun too.’

Feeling safe was also described as essential, and the children felt safe in most of the favourite places, at least in the day. At night, the wood, the football pitch or the schoolyard were not perceived as safe places by all the children, since the darkness was scary. They had heard of scary things going on at night, such as littering and vandalism.

However, they always felt safe in their home, and it was described by some as a ‘safe haven’.

5.3.3.2. Blue River. Here the children similarly told us about places that generated positive emotions. Several children told us how visiting shopping centres and McDonald's always made them happy.

Boy 2: I like going to McDonald's. I like the food and it's tasty. And you feel safe in there.

R: You feel safe in McDonald's? Where is that? Is it McDonald's in the city centre?

Boy 2: Yeah, that one.

Narratives about places that generated feelings of relaxation, peace and calm were prominent. Even though they showed few photos of nature, it was described by some as comforting. A few of the children showed photos of places at school where they felt particularly calm and safe. Others described the local library as somewhere they felt happy and calm. However, their own home was the most important place, where they could relax, rest and feel at ease. Several children had taken photos of the closed apartment door to illustrate their home as a safe haven. Being able to lock the door and look through the peep-hole before letting someone in was perceived as being safe.

Girl 1: I have only taken a photo of the door, but I live here. And I took this photo to show that I feel safe at home, and well, I feel safe with my family, yeah.

———

R: So why do you feel safe there?

Boy 2: Because it's mine.

Boy 1: Yeah, like, I live one floor up so no-one can come through the glass [window] or anything.

Boy 3: I always think that someone could come through the balcony.

Boy 1: And I won't open … everything will be fine, if I hear the doorbell, I

shouldn't open. And it's completely safe at home …

5.4. How accessible are these places to the children?

By comparing the children's stories and the distribution of photos (Fig. 2), we could analyse the children's access to the places they per- ceived to facilitate togetherness, enjoyable activities and positive emotions. It was clear from our data that perceiving a place to promote health did not necessarily imply access to that place.

Table 1 below shows that all children in Green Fields had high ac- cess to the local football pitch, nature/wood, playgrounds and various meeting places in their neighbourhood. Most of their photos showed places from their neighbourhoods (48%) or their homes (36%) (see Fig. 2). These places were local, public, free of charge and easily available for all. Some of the Green Fields children also had access to places outside the neighbourhood that were considered to promote health. Several of them described holiday homes, relative's places, sports venues and similar, and 14% of their photos showed this kind of place (Fig. 2).

The Blue River children had equally high access to places at home that were considered to promote health. Their narratives often involved their homes, and almost half (48%) of their photos showed their home (Fig. 2). In addition, they had high access to their school, shopping

centres and the local library, which were all considered to promote health in that they offered togetherness, enjoyable activities and posi- tive emotions. Nearly half of the Blue River children's photos showed places at school, public spaces or the neighbourhood, which were also easily available for all children living there. However, they complained about the lack of fun playgrounds and meeting places in their neigh- bourhood other than the library. The football pitches in the area were not perceived as safe for example. Furthermore, nature and venues for sports and activities were perceived as positive and health promoting, but the actual access to these was quite low in Blue River, and they were only seen in two of the photos.

6. Discussion

6.1. Summary of main results

Our results illustrate that places where children live, grow and play clearly have an influence on their self-perceived health and wellbeing.

Places perceived as having a positive influence on their health and well- being were the places that facilitated togetherness, enjoyable activities and positive emotions. Despite differences between their neighbour- hoods (for example built up areas and proximity to nature) and family socioeconomic position (for example overcrowding), the children va- lued the same aspects of a health promoting place. However, the access to such places was unequally distributed between Green Fields and Blue River. Our results indicate that these inequalities could partly be un- derstood by neighbourhood conditions, i.e. differences in the material infrastructure and the collective social functioning between these neighborhoods (Macintyre and Ellaway, 2003). Social capital can shed further light on how material and social factors in a local community are interlinked and influence each other. In this final section, we discuss how the results can be understood from a social capital perspective, and the potential usefulness of this knowledge for the planning and design of neighborhoods that promote children's equal access to health pro- moting places.

6.2. Children's views of health promoting places and the significance of social capital

In line with other studies (Priest et al., 2017; Dominguez-Serrano et al., 2018), we found that children had a broad and inclusive view of health. It was clear from their stories that health is not just the absence of disease, but a state of physical, mental, and not least, social well- being. Even if it was clear to them that health is influenced by lifestyle factors such as diet, sleep and physical activity, they also emphasised the importance of social relations and emotions. Hence, our results confirm that the concept of social capital is a relevant conceptual tool for understanding what constitute health-promoting places from chil- dren's perspective.

Two of the three categories describing children's perspectives of health promoting places identified in this study are evidently related to social capital, namely ‘places facilitating togetherness’ and ‘places as- sociated with positive emotions'. Since social capital is about the oc- currence of social networks characterised by reciprocity and trust, places facilitating togetherness, trust and safety could be arenas where social capital is generated. Our study thus contributes to an under- standing of how children conceptualize social capital and on what arenas they develop and draw upon their own social capital.

The children described their home as a place where they enjoyed being together with their families, and sometimes friends. As such, home constitutes an arena for building bonding social capital. Putnam (2000) underlines the crucial social and psychological support that can be gained from strong bonds with family and friends. Positive health effects of bonding social capital are also found in several studies (Ferlander, 2007; Eriksson et al., 2010; Gilbert et al., 2013). Robert Putnam (2000) and James Coleman (1988) refer to family Table 1

Comparison of access to places the children perceived as health promoting places.

Access to places facilitating togetherness, enjoyable activities, and positive emotions

Places Access

Green Fields At home

Own room Nature/Wood Playgrounds

Meeting places in the neighbourhood

Sports facilities and clubs

Holiday homes

With relatives

Blue River At home

At school The local library Shopping centres McDonald’s

Own room

Nature

Sports facilities and clubs Playgrounds

Meeting places in the neighbourhood

connectedness as one of the most important sources of social capital.

Given how dependent children are on their families and immediate environment, bonding social capital might be one of the most important forms of social capital for children's health and well-being. The children in our study included their pets as important family members. Other studies have also found that pets can support coping, resilience, and recovery in a family, and facilitate the building of social capital by stimulating interactions between neighbours (Hodgson et al., 2015;

Wood et al., 2005).

The children in our study identified several places to socialise with friends, and these arenas could be viewed as facilitating the building of bonding social capital between peers. The significance of the school as a site of social interactions among children has been underlined in other studies. In a study conducted in England, Morrow (2001) utilised children's photos, maps and stories to understand children's perspec- tives on their living environments and found that spaces around the school were common places to spend time with friends. This confirms that children actively participate in their own arenas to develop their own social capital in ways that influence their health and well-being (Goodwin and Armstrong-Esther, 2004). Our results further indicate that places in school were especially important for the children in Blue River, maybe due to a general lack of other arenas in the neighbour- hood to meet with friends. Many of them also named the library as an important place for socialising and fun activities, indicating that such public services are particularly important in neighbourhoods were po- sitive meeting places are generally perceived to be lacking. The im- portance of a local library in developing social capital, not least among vulnerable groups, has also been found in other studies (Vårheim, 2011).

The children in our study expressed that places associated with positive emotions promote health; places where you feel happy, relaxed and safe. The Blue River children had fewer places in their neigh- bourhoodthat they considered safe. Since a place high in social capital is believed to constitute a safe and supportive environment (Eriksson, 2010), this finding could indicate that the level of social capital was generally lower in Blue River. Children from both schools described nature as a place associated with positive emotions, but it was also clear that children in Green Fields had more access to nature in their im- mediate environment. The emotional advantages for children of being in nature was also found in a Canadian study (Tillman et al., 2018) underlining the importance of constructing school grounds that chil- dren perceive as having large amount of nature.

6.3. Inequality in health promoting places and social capital between children in different neighbourhoods

Our results illustrate how children in Green Fields had access to more health promoting places in their immediate environment com- pared to children in Blue River. Even if we were aware of some socio- economic differences between Green Fields and Blue River (e.g. housing and employment) in advance, we did not expect that the children's stories about their everyday lives, and their photos of available positive places would differ as much as they did between the schools. This in- dicated that children's 'lived inequality' cannot be captured in public records but needs to be discovered by listening to the voices of children themselves. Despite the closeness to a local centre and the library, the perceived lack of attractive meeting places in their neighbourhood could be one possible explanation why several children in Blue River mentioned spots in the city centre as places they enjoyed visiting with friends and family. From a public health perspective, these places are not immediately associated with ‘health promotion’, such as McDonald's and shopping centres. It is clear from our results that the material infrastructure (Macintyre and Ellaway, 2003) in Green Fields, i.e. access to attractive playgrounds and the proximity to nature, fa- cilitated the access to health promoting places as well as the develop- ment of bonding social capital for children living there.

More children in Green Fields were involved in sports or other clubs located outside their neighbourhood. It can be assumed that these ac- tivities brought together children from different places and back- grounds. These arenas could be facilitating the development of bridging social capital and provide links to socially dissimilar people (or/and people from similarly advantaged circumstances). Bridging social ca- pital has been proposed as important for ‘getting ahead’, since these kinds of networks might give invaluable access to information and opportunities to change and improve life circumstances (Briggs, 1997, 2003; Putnam, 2000). In line with our results, Altshuler et al. (2004) found in their study from California, USA, that social capital was un- evenly distributed between different neighbourhoods in that people living in areas at higher socioeconomic levels also had more access to bridging social capital, i.e. links to organisations and agencies outside the immediate neighbourhood. This relates to Bourdieu's power per- spective of social capital, which underlines that inclusion in social networks is controlled by the exchange of values, and those with fewer resources are thus more likely to be excluded from powerful networks (Bourdieu, 1986). Our results confirm that children living in households with lower socioeconomic position have fewer opportunities to be in- volved in organised leisure activities. That civic life comes with a cost that not everyone can afford has often been neglected in social capital studies (Leonard et al., 2005) but must be considered, especially re- garding children's lives. Our results thus illustrate how children in Blue River were limited in a double sense; they had less access to paid leisure activities outside their neighbourhoods, and consequently fewer op- portunities to build bridging social capital. They also had fewer op- portunities to meet with friends in their neighbourhood, i.e. fewer arenas for building bonding social capital. Previous research proposes that socioeconomic factors at the individual and area level interact to influence health (Stafford and Marmot, 2003). The 'collective resource model' proposes that people living in more affluent areas have better health than people living in deprived areas due to more collective re- sources (both material and social) to draw on (Stafford and Marmot, 2003). These collective resources could be e.g. services, job- or other opportunities as well as social and material support. Since poorer people are likely to be more dependent on locally provided resources, the positive health effects of collective resources might also be greater for poorer people. Consequently, investment in collective resources could reduce health inequalities between different places.

Research has also shown how the physical and social environments

are clearly interlinked (Baum and Palmer, 2002; Eriksson and Emmelin,

2013). Thus, investing in attractive playgrounds and recreations areas

(i.e. material infrastructure) could potentially increase Blue River

children's access to health promoting places and arenas for building

social capital in their local environment. Moreover, our results also

indicate, in line with Macintyre et al. (2002), that inequalities between

neighbourhoods are not only a matter of composition (i.e. differences in

socioeconomic position between people in different places) or context

(inequality in services and material resources between places), but also

a matter of collective social functioning. Evidently, there existed a local

football pitch and some playgrounds in Blue River; however, these

places were not perceived as safe and/or available for the children

living there. A Dutch study similarly found that adolescents' leisure

time sports participation was associated with levels of neighbourhood

social capital, but not with the availability of parks and sports facilities

(Prins et al., 2012). Similarly, Hayball et al. (2018), in their study from

Glasgow, found how children in the ages of 10–12 years avoided

playgrounds since they felt that the play equipment was not “meant for

them”. The authors (Hayball et al., 2018) use Gibson's theory of af-

fordances to discuss their results; i.e. in order for activities to be pos-

sible, the individual must perceive them as such. Consequently, in-

vestments in material infrastructure might not be enough as a strategy

to design health promoting places, unless attempts to influence the

collective social functioning/social capital is done simultaneously. This

implies trying to influence norms, perceptions of availability and

ownership, collective efficacy and safety. So far, quite few studies have explored how social capital can be mobilized in a local community.

However, those that exist underline the importance of an identified joint problem/issue to unite around (e.g. lack of safety). Further, it has been suggested that action for a desired change needs to be led by trusted local leaders and that all citizens should get a personal invita- tion to become involved, to ensure that everyone feels included in the process (Eriksson et al., 2013).

In conclusion, our results confirm the usefulness of social capital as a conceptual tool in the planning of health promoting living environ- ments for children. In addition to family socioeconomic position, chil- dren's access to health-promoting places is clearly influenced by the available resources and the social climate, i.e. social capital, in their neighbourhood. A socially sustainable urban planning could compen- sate for children living in lower socioeconomic circumstances through investments in the physical and social environment. Investments in the physical environment, such as attractive meeting places, playgrounds and parks, may also lead to investments in neighbourhood social ca- pital, since there is a clear interaction between the physical and social environment. However, investments in the physical environment need to be combined with efforts to influence norms and collective efficacy to secure local ownership and use of these investments. In doing so, identifying local needs and problems, allowing trusted local leaders to lead and involving voices from all inhabitants are crucial.

Consequently, using social capital as a conceptual tool for the planning and design of health promoting neighbourhoods for children requires efforts to include children's views and voices in the process.

Credit author statement

Malin Eriksson: Conceptualization, Methodology, Data collection, Analysis, Writing of draft.

Kjerstin Dahlblom: Conceptualization, Methodology, Data collec- tion, Analysis, Writing of draft.

Acknowledgement

The authors would first like to thank Fredrik Oskarsson, Kulturverket, for invaluable input in the fieldwork. We also would like to thank all children and school personnel involved in the project. This project was funded by the Marianne and Marcus Wallenberg Foundation (grant number 2014.0156).

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