Social Capital and Health: Maximizing the Benefits

Applying Social Capital Research in Community-Based Evaluations

Carl Bertoia, Departmental Performance Measurement and Evaluation Directorate, Chief Financial Officer Branch, Health Canada, and Lauranne Matheson, Division of Childhood and Adolescence, Centre for Healthy Human Development, Public Health Agency of Canada

Evaluating the long-term results of community-based health programs in terms of improved health outcomes poses many challenges. This article draws on social capital research to support community-based program evaluation that is both timely and effective and makes use of intermediate outcomes, such as the ability to influence the social networks of participants and communities.

Confronting the Challenges

In an era of increased accountability and transparency, initiatives funded by all levels of government must demonstrate effectiveness and bring value to citizens. In support of this, the Government of Canada recommends that a Results-Based Management and Accountability Framework (RMAF) be completed at the outset of any new policy, program or initiative. An RMAF defines the logical sequence of results that is expected to occur from a given investment over the immediate, intermediate and long term.

Traditionally, evaluations of health initiatives have been compelled to demonstrate long-term results. However, carrying out the long-term evaluations necessary to show improvements in health outcomes is challenging. Moreover, it is difficult to attribute an improvement in a specific health outcome (e.g., a decrease in the proportion of Canadians who acquire HIV/AIDS or diabetes) to a single initiative, particularly within the time-sensitive pressures that shape government plans, priorities and resource allocations. In this context, it may be useful to also measure those intermediate changes that will logically lead to long-term impacts.

Social Capital: A Useful Tool

As discussed in earlier articles, while it is difficult to establish causality in the relationship between social capital and health, researchers have clearly demonstrated an empirical link between increased levels of social capital and improved health outcomes.^1,2 Putnam¹ has put forward a number of plausible explanations: social networks may provide tangible assistance (e.g., money, convalescent care or transportation), they may reinforce healthy norms and they may help people to mobilize health resources.

Since some community-based health initiatives have already adopted principles and strategies with the potential to influence social capital, measuring this impact over time may strengthen both the evaluation and delivery of these programs. To this end, social capital is an effective conceptual tool that can be incorporated into a program's logic framework, explaining how the key elements of a program will achieve the intended outcomes.

The example of a community-based breastfeeding program helps to illustrate the dynamics involved (see page 30). An overview of a logic framework shows how social capital can be considered both an outcome of program activity and a determinant of longer term behavioural and health outcomes.

Showing by Example: Applying Social Capital Theory to Community-Based Breastfeeding Programs

The link between exclusive and sustained breastfeeding and positive health outcomes for both mother and baby has been clearly established.⁵ Promoting breastfeeding, therefore, has become an important component of many community-based prenatal programs. Such programs employ multiple strategies, some of which may have the potential to enhance the social capital stock of program participants (e.g., peer support, access to professional support).

Traditionally, program effectiveness has been assessed by tracking and measuring the breastfeeding practices of participants. However, in light of recent evidence suggesting that the decision to initiate and sustain breastfeeding may be influenced by social capital,⁶ programs are designing evaluations to also detect changes in social capital--in this case, changes to the level and nature of support for breastfeeding.

The logic framework below helps to illustrate the value of and approach to applying social capital to community-based programs--both to inform and shape the program, and as an intermediate outcome that can be measured.

Social Capital Theory in Program Logic ( view larger image)

Evaluating CAPC and CAPC

Several community-based programs of Health Canada and the Public Health Agency of Canada actively incorporate a "determinants"³ approach to health and demonstrate an affinity to the concept of social capital. These include, among others, the Community Action Program for Children (CPAC) and the Canada Prenatal Nutrition Program (CPNP). These two programs provide long-term funding to community-based organizations and coalitions with the aim of strengthening the social connections and improving the health of potentially isolated pregnant women, mothers, children and families. Both foster the development of networks and partnerships, thereby increasing the community's capacity to provide access to a comprehensive range of services for a population living in conditions of risk.

Three Dimensions of Social Capital and Types of CAPC /CPNP Evaluation Questions

Social Capital Dimensions4	Types of CAPC and CAPC Evaluation Questions
Bonding Social networks of people from similar backgrounds--such as family, loved ones, friends and similar acquaintances--homogeneous communities that bond together with strong, close ties.	Questions related to style of program delivery, including opportunities for participants to gather in collective activities with their children, partners or peers, provide information on enhancing bonding social capital.
Bridging Relationships with people from diverse backgrounds where ties are weaker--heterogeneous networks that bridge social differences and often act as key sources of social leverage, providing access to resources that are quite different from one's own.	Questions about the make-up of project committees, the number and types of volunteers, and the communities served reveal information about the opportunities for creating more diverse networks that extend beyond strict geographic or cultural boundaries.
Linking Relationships with people in positions of power--enables individuals to leverage resources, ideas, information and knowledge within a community or groups. Partnering also creates potential for organizations to leverage resources and influence policy decisions.	Questions on the specific roles of participants and the nature of partnerships provide information about participants' access to power and the development of vertical networks at the community level.

A closer look at the programs provides insight into the strategies being employed to influence social capital and the evaluation efforts undertaken to detect influence on social capital. CAPC and CAPC have employed multiple methods to monitor their performance and evaluate their reach, relevance, implementation and impact. For example, both programs require each funded project to complete an annual administrative survey--the National Project Profile (NPP) for CAPC and the Individual Project Questionnaire (IPQ) for CAPC . While these survey instruments were not intentionally designed to measure social capital, a closer examination shows that both surveys include questions related to the capacity of projects to foster the three dimensions of social capital--bonding, bridging and linking (see sidebar above).

A further analysis of the evaluation tools provides quantitative and qualitative data that both CAPC and CAPC are having an impact on the social capital at the individual (program participant) and collective (project) levels.

Building the "Bonding" Dimension

In the delivery of activities, CAPC and CAPC both provide physical and social spaces for participants to engage in group activities (e.g., food preparation, community gardens, collective kitchens, sewing circles) and encourage opportunities for reciprocal exchange of experience and information. In CAPC , 96% of projects responding to the IPQ (2003-2004) reported offering some form of social group programming. In addition, 99% provided food supplements, 90% transportation and 71% on-site child care. Each of these supports helps overcome barriers so that otherwise isolated women can increase their social networks.

Comments from CAPC parents suggest how forming these close social ties can build social capital:

"The program gave me an opportunity to make friends too. When I moved into (the city) from (the town), I was in a 'shell.' The program helped me to meet people who had things in common with me."

"When I am at the Centre I feel like I am a part of something. It has also extended my social life on a personal level by meeting other parents that I could relate to . . . the motto that the people go by is that 'it takes a village to raise a child'. "

Enhancing the "Bridging" Dimension

CAPC and CAPC collect data on the extent to which participants are involved, as volunteers, with project activities, committees or governing bodies. Through such involvement, participants are exposed to a more diverse group of people than they may have otherwise met. Data from CAPC 's NPP (2004-2005) show that participants:

• volunteered with project activities in 75% of projects
• were involved on committees in 54% of projects
• were members of the project's governing body in 55% of projects

Many CAPC projects have developed formal roles for trained peers (outreach workers) or "resource mothers." A project coordinator explains:

"The Peer Outreach Worker has 'been there, done that' and provides a sincere and trusted bridge to the program. Her training . . . converge[s] effectively with personal experience. The outcome is that she has become a valued resource for both the participants and her team."⁷

A CAPC Participant's Story "I went to a convention in the city in 1999 as a program parent representative. While there, I took in a session which dealt with the learning disability that my son has since been diagnosed with . . . As a result of attending the convention, I was able to obtain information that directed me to the right resources that could be of help to my son. It has been a battle ever since but at least I know now what to do. There is not enough praise that I can give to the program. They supported me through all of this and I will never forget it. The program helped me in so many ways. Not only was I a resource mother and volunteer, I had the chance to serve on the Board as well and to take part in such things as the Annual General Meeting and planning days."

Expanding the "Linking" Dimension

CAPC and CAPC projects are encouraged to partner with other organizations as a way to help manage, coordinate and deliver activities. Partnering also broadens the potential networks of program participants. The NPP shows that an average project has 16 partners, the most common being health organizations, educational institutions, neighbourhood community organizations and family/early childhood resources. The linking aspect of social capital is also demonstrated through referrals. In the 2003-2004 IPQ data, 95% of 181 CAPC projects surveyed made 46,000 referrals to other agencies or services, including health professionals, food banks, prenatal classes, early childhood intervention programs, parenting courses, social services, housing agencies and substance abuse programs.

Implications and Benefits

By establishing empirical links between increases in social capital and improved health outcomes, social capital research supports the efforts of community-based programs to measure and report changes in social capital as intermediate outcomes that may lead to long-term improvements in health outcomes. For example, in addition to the longer term efforts required for measuring child health functioning, parent caretaking skills and attributes of parents and families,⁸ community-based programs could benefit from a more deliberative approach to measuring social capital. By reviewing their evaluation measures in light of social capital indicators, such programs could strengthen and increase the usefulness and reliability of their evaluation instruments and results.

Social capital questions and variables from the General Social Survey (GSS), Cycle 17, as well as tools such as the Social Capital Impact Assessment⁹ provide a good starting point. Questions from these sources could be adapted to suit the evaluation needs of community-based programs like CAPC and CAPC . Additionally, the construction of program theory could take advantage of what is being learned about the links between social capital and health and build this knowledge into RMAFs, logic models or other evaluation tools. Finally, the increasing interest in the network approach to social capital and related body of research holds promise for community-based programs interested in strengthening and measuring their network-building capacity at the participant and project level.