Social Capital and Health: Maximizing the Benefits

Did You Know?

Did You Know? is a regular column of the Health Policy Research Bulletin examining aspects of health information, data and research that may be subject to misconception. In this issue we focus on "trust" and examine some interesting observations and viewpoints on its relationship to social capital and health.

Social Capital, Trust and Health Inequalities

Richard Duranceau, Policy Division, Health Policy Branch, Health Canada

The author would like to acknowledge the input of Mark Wheeler, Linda Senzilet, Derek McCall and Talia DeLaurentis, all from the Policy Division, Health Policy Branch, Health Canada.

Trust is defined as "the belief or confidence in the . . . skill, or safety of a person, organization or thing."¹ Social capital theorists describe trust as a relationship that creates both an obligation and expectation, in which trust is seen as a type of "credit" that imparts a sense of security in relationships.¹

When looking at social capital, it is important to consider trust at two sub-levels:

• interpersonal relationships
• relationships with institutions¹

While trust has been identified as an indicator of social capital, measurement has proven to be challenging because the precise nature of the relationship is disputed. However, some interesting evidence suggests that trust is a factor in social capital, good health, and individual and societal prosperity.

Trust and Social Capital: Outcome or Precondition?

While some researchers see trust as an outcome of social capital, others consider it to be a precondition. This difference in viewpoints may depend upon the distinction between interpersonal trust and trust in institutions. Robert Putnam² defines social capital as: "The characteristics of the social organization such as networks, norms and social trust that facilitate coordination and cooperation for mutual benefit." Putnam's view of trust is society-centred, as he is interested in how interpersonal trust is created through social interaction. Alternatively, Woolcock³ argues that: "trust . . . is important in its own but [it] . . . is more accurately understood as an outcome of repeated interactions, of credible legal institutions, or reputations." Woolcock views trust as being created through institutions--that credible political institutions can build trust. While both authors see social capital and trust as closely related concepts, Putnam argues that trust (interpersonal or institutional) can be seen as an indicator of social capital. Therefore, variations in the levels of interpersonal trust or trust in institutions may reflect differences in the level of social capital.

Interpersonal Trust and Health: Is There a Relationship?

Drawing on social capital research regarding the norms of reciprocity, social and civic participation, and trust, social epidemiological studies have investigated the relationship between trust, mortality rates and self-reported health status. Research by Kawachi et al.,⁴ for example, has shown a link between levels of interpersonal trust and age-adjusted mortality by region in the United States, with higher mortality rates in states that had high percentages of respondents indicating that: "Most people would try to take advantage of you if they got the chance." Southern U.S. states such as Louisiana, Mississippi, Alabama, Georgia and Oklahoma had the highest percentage of respondents reporting lower levels of interpersonal trust. Kawachi and Kennedy⁵ suggest that these states are characterized by values that support a minimal role for government in the reduction of health inequalities. The authors state that: "The social and political culture of these places truncate the range of social opportunities available to people with lower incomes, and thereby increase their vulnerability to ill health."

Figure 1: Social Expenditures as a Percent of GDP for Selected Countries, by Level of Trust
( view larger image)

Source: Adapted with permission from Schwabish et al., 2004.⁶

Trust and Socioeconomic Inequalities: Is There a Link?

Interestingly, societies with low levels of trust also appear to have greater socioeconomic inequities and lower levels of social expenditures. In cross-national studies on the effects of inequality and trust on social expenditures, Schwabish et al.⁶ found that there was a strong and positive association between different measures of trust and social spending. For example, as Figure 1 illustrates, the Scandinavian countries (Denmark [DK], Sweden [SW], Finland [FIN] and Norway [NOR]) that have devoted considerable resources for social expenditures have also reported a higher level of trust compared to Canada (CAN), Australia (AUS), the United Kingdom (UK) and the United States (US). The position of the Czech Republic (CH) in the mid-range of the graph is interesting, given that it was part of the former Communist bloc and is comparable with some Western European countries on the graph. Some of the countries such as Spain (SPA), France (FR), Italy (ITA), Germany (GER), Belgium (BEL), the Netherlands (NL) and Luxembourg (LUX) have lower levels of trust but higher levels of social expenditures. Further research is needed to understand the dynamic at play in these countries.

It should also be noted, however, that the issue of reverse causality cannot be ruled out. Social expenditures may well influence the levels of trust and social capital within these societies. More research will be needed to understand the causal pathways between trust and social expenditures. However, Figure 1 does provide some provocative, if tentative, conclusions.

Trust, Inequality and Health: What Are the Dynamics?

While research on the "gradient" has established a link between the level of socioeconomic and health inequalities within a society, the dynamic of this relationship has been the subject of much discussion and debate.⁷ However, the research on "trust" offers some interesting insights.

Researchers have noted that people living in societies that accept inequalities and social hierarchy as natural are at greater risk for health problems as a result of their social location. Richard Wilkinson⁸ has theorized that competition, conflict and high stress levels can contribute to poorer health outcomes. Wilkinson concluded that societies with high levels of income inequality and low levels of trust are important contributors to health inequalities. But why?

A Question of Institutional Trust

Research has indicated that there are numerous social factors (stress, social exclusion, work, unemployment, social support and food) which can contribute to poor health outcomes for people of low socioeconomic status. As a consequence, social expenditures to reduce labour market disparities and unemployment, improve the stock of housing and enhance neighbourhood social supports may also enhance the health and well-being of a given population.

As Figure 1 on page 34 shows, more cohesive and trusting societies appear willing to support social expenditures. In less trusting societies, people may have decreased confidence in the abilities of institutions to make investments in social programs that will be effective in reducing inequalities. On the other hand, societies that view social inequalities as unjust and intolerable are more likely to implement policies to reduce income inequality and its harmful effects upon the well-being (including the health) of individuals and families.

A Question of Interpersonal Trust

The work of Wilkinson and Kawachi,^4,5,7,8 among others, suggests that social values which are supportive of social inequalities can create competition, stress and conflict, which in turn may lead to lower levels of interpersonal trust (and lower levels of social capital). Societies with high levels of interpersonal distrust may lack the capacity to create the kind of social supports and connections that may promote population health. However, societies that value more egalitarian social and economic relations may be more likely to have higher levels of interpersonal trust and higher levels of social capital, which have been linked to improved health outcomes. It may be easier to create the kind of social supports and networks that may promote the collective health and well-being of their communities when individuals trust each other.

To Sum Up

Some researchers suggest that trust is a useful indicator of the presence or absence of social capital. A number of studies have revealed some interesting findings on the influence that both interpersonal and institutional trust may have over the extent of health inequalities within society. Ideally, future research will determine the nature of the relationship between social capital (trust) and health inequalities.