Social Capital and Health: Maximizing the Benefits

Research Traditions: An Overview

Louise Bouchard, Ph.D., Researcher, Institute of Population Health, University of Ottawa; Jean-François Roy, Doctoral Candidate, Institute of Population Health, University of Ottawa; and Solange van Kemenade, Ph.D., Policy Research Division, Strategic Policy Directorate, Public Health Agency of Canada

The consideration of social relations in the field of population health has been relatively well established over the past 30 years. Recently, researchers are increasingly interested in the links between individual and collective social actors and the resources that circulate among their networks. This article traces the evolution of the research and highlights the main traditions that have emerged.

The study of social relationships, social capital and health is rooted in two main research traditions. The first, established in the 1970s, is concerned with the notion of networks of social support. The second tradition appeared during the 1990s and deals with the concept of social capital.

Social Support and Health: Deep Roots

Over the years, several studies have demonstrated that social support networks are positively associated with maintaining good health and a longer life expectancy. A pioneering study in Alameda County in the United States demonstrated in a nine-year follow-up that rates of premature death were higher among people who did not have social ties with family, friends or the community.¹

Subsequent research supported these results and showed that people without social networks had a probability of premature mortality that was two or three times greater than for people who had social networks.² This relationship was reinforced in several population studies and was demonstrated for mortality associated with various diseases (including cardiovascular diseases, cancers, respiratory and gastrointestinal diseases).

Studies also showed that social networks are related to the adoption of preventive behaviours (e.g., with respect to cancer screening, dialysis, tobacco and alcohol abuse⁵), as well as the ability to cope with existing illness by reducing isolation and increasing social integration.

What do we mean by . . . Social support refers to the beneficial elements resulting from social relationships, including: emotional aid (empathy); instrumental and concrete aid; information (counselling, mentorship); accompaniment; and/or reinforcement of a sense of belonging and solidarity. Social relationships are seen as a relational resource in their own right, with the potential to transmit or exchange other types of resources (material or information) helping to meet particular needs.3,4 Support networks are characterized by the exchanges between those people providing assistance (family, friends, neighbours, volunteers, etc.) and those receiving assistance (the elderly, those who are unwell, people lacking in various resources).

Social Networks Are Not Always Positive for Health

It is also well known that social relationships do not always function as protective mechanisms for health, but can increase levels of stress and weaken people's resilience and their ability to cope. Consider, for example, sexual abuse, family or workplace conflicts, physical and psychological violence, mental harassment and male power networks ("old boys clubs"). We also know about the influence of peer networks, especially when it comes to certain risky health behaviours engaged in by some youth (driving while impaired, alcohol and drug abuse, degrading sexual practices), and of groups that impose extreme or unreasonable rules of conformity on their members.⁶ Even though these rules allow people to be part of a group, the goals of such groups are not always in the best interests of society. ⁷

The research has also allowed us to understand the physiological mechanisms by which support networks have positive or negative effects on the health of individuals. We have a better understanding of the neuroendocrine and immune systems that condition stress responses. Research has clearly demonstrated the impact of chronic stress on aging and premature death.⁸

Social Capital and Health: Different Approaches

The concept of social capital originated in the groundbreaking work of Bourdieu,⁹ Coleman¹⁰ and Putnam^11,12 and, since then, has become a major factor for examining public health and the health of populations. Within the health field, two broad views of the concept have emerged--one defining social capital as the network of social relationships that provides access to resources; the other, as the norms of reciprocity, social and civic participation and trust.

It was the latter definition that was first used by Wilkinson¹³ to introduce the concept of social capital into health studies--with social capital linked to social cohesion. Wilkinson suggests that those societies which are more egalitarian (in terms of income distribution) and more socially cohesive also have a better life expectancy. By comparing different geographical regions--Eastern Europe, England, Japan and the American town of Roseto--he concluded that greater social cohesion equals better health. The story of Roseto, Pennsylvania (see sidebar), provides a striking illustration of the link between social cohesion and mortality.

The Story of Roseto12,13 Beginning in the 1950s, Roseto, a small town in Pennsylvania founded by immigrants from the same southern Italian village, became the subject of more than 40 years of research. Initially, medical researchers found that the Rosetans' heart attack rate was less than half of that of those in neighbouring towns. However, none of the usual factors (e.g., diet, genetics, exercise) provided an adequate explanation. So, when researchers began looking into the social dynamics of the community, they discovered that the town had developed as a tightly-knit community with many social activities and organizations. Additionally, the residents depended on each other for resources and support. The researchers soon suspected that this level of social involvement, while not called social capital at the time, was the reason for the Rosetans' lower heart attack rate. They became concerned about what would happen if, over time, the younger generation rejected the "tight-knit" ways of their parents. As it turned out, by the 1980s, the next generation had a heart attack rate higher than residents in a nearby, demographically similar town.

The concept of social capital grew in importance in social epidemiology and was used in various studies to understand the association between social inequalities and mortality rates (see also Did You Know? on page 33).

For example:

• Further studies by Wilkinson¹⁴ revealed a strong correlation between mortality, income inequalities and violent crime.
• Putnam¹⁵ demonstrated that health status is better in American states with higher social capital.
• In Scandinavia, Hyppä and Mäki¹⁶ found that the Swedish-speaking Finnish minority had a better life expectancy and that its social capital was a contributing factor.
• Lomas¹⁷ highlighted the positive influence that social networks have on health compared to that of other types of public health interventions.
• Studies by Szreter and Woolcock²³ showed that communities with weak social capital have higher levels of stress and social isolation, and are less able to respond to environmental risks and public health interventions.

Over time, however, this conceptualization of social capital has come under criticism at a number of levels^24,25 --theoretically (because of its definition by effects), methodologically (for the diversity of its content) and politically (for its potential to transfer the responsibilities of the state to individuals and overshadow structural determinations).

Measurement Traditions In the 1970s, Berkman, a known researcher in the field of social relationships and health, developed a social network index for measuring networks of family and friends (in terms of both quantity and frequency), social participation (associative, community, religious, charitable) and social support (both emotional and instrumental).1,18 Since then, national health studies in Canada have continued to explore these different dimensions of social capital. In the tradition of epidemiological research relating to social capital, measurement relies on ecological variables such as income inequality indexes (Robin Hood Index), interpersonal trust levels, reciprocity norms and the vigour of civic society (social participation by the individual).19 Lochner et al.20 surveyed a series of such measurement instruments, including, among others, neighbourhood cohesion, and Bandura's measurement of collective efficacy-defined as a "sense of collective competence shared among individuals when allocating, coordinating and integrating their resources in a successful concerted response to specific situational demands."21 Very recently, in the "network approach," Van Der Gaag and Snijders22 have developed a tool known as "Resource Generator" which does not yet appear to have been used in health studies. This tool for measuring social capital questions respondents about their access to various resources, as well as about types of bonds that permit access to these resources (acquaintances, friends and family). The instrument covers four dimensions of resources: prestige and education, political and economic skills, social skills and social support.

More recently, the view that social capital is defined by social networks and the resources in these networks appears to be enjoying consensus²⁵ in a number of fields and, as described in the previous article, has been recommended by the federal government's Policy Research Initiative. While the network model is not without its critics, consensus on a definition is focusing federal research efforts and facilitating the development of measurement and analytical tools--an important step, since just as different definitions have emerged, so too have different measurement tools and approaches (see sidebar above).

The Potential of Social Capital

During the past three decades, researchers have explored the influence that social factors have on the health of individuals and their communities. As interest in the "determinants of health" has grown, so too has interest in the concept of social capital. While social capital has been approached in different ways, its positive connection to health suggests that it has potential as a strategy for health promotion and public policy development.

Moving forward with research--based on a common definition and approach--is an important step in achieving this policy potential. While the network-based approach has been adopted at the federal level, its use as a policy tool in health issues has yet to be fully realized. However, as described in the articles that follow, having a common definition has served as a springboard for the development of indicators for use in national health surveys, thereby permitting the first methodological effort in Canada to articulate the relationship between social networks and health.²⁶