Evidence suggests a need to rethink social capital and social capital interventions
Introduction
Social capital first appeared in the public health literature in the late 1990s (Kawachi et al., 1997). Kawachi's ground-breaking study, co-authored with Kennedy, Lochner and Prothrow-Stith, examined the relationship between income inequality, mortality and social capital, which, following Putnam (Putnam et al., 1993), they defined as “the features of social organization, such as civic participation, norms of reciprocity, and trust in others, that facilitate cooperation for mutual benefit.” Using ecological, cross-sectional data drawn from 39 US states, their results showed strong negative correlations between two indicators of social capital (per capita group membership and social trust), and all-cause mortality, suggesting that social capital offered a protective effect. This study was soon supported by further work confirming the protective effects of social capital (Kawachi, 1999; Kawachi et al., 1999).
Commentators were quick to pick up on the potential of this evidence. Social capital offered new insights and opened new avenues to improve population health and to reduce health inequalities (Baum, 1999; Drevdahl et al., 2001; Leeder and Dominello, 1999; Lomas, 1998). Early reviews of the social capital literature echoed the cautious optimism in these commentaries (Hawe and Shiell, 2000; Macinko and Starfield, 2001). One particular attraction of social capital was the rhetorical power of the idea. By embracing both the social and the economic, there was hope that this would help to restore focus on some of the social determinants of health at a time when more proximal, lifestyle explanations for ill-health (lifestyle drift) were gaining prominence (Hunter et al., 2009).
The evidence base has expanded considerably in the 21 years since that first study by Kawachi and colleagues. Subsequent empirical work has extended the analysis to countries beyond the USA (Campbell and McLean, 2002; Drukker et al., 2003a; Harpham et al., 2004; Hyyppa and Maki, 2001; Mohan et al., 2005; von dem Knesebeck et al., 2005), to a wider range of health conditions (Fitzsimon et al., 2007; Hamano et al., 2010), to health risk behaviours (Chuang et al., 2015; Gagne et al., 2015; Kaljee and Chen, 2011; Moore et al., 2009b), to specific age-groups (Drukker et al., 2005; Drukker et al., 2003b; Eriksson et al., 2012; Kishimoto et al., 2013; Ramlagan et al., 2013), and to the implications for healthcare access, health inequality and health policy (Altschuler et al., 2004; Hendryx and Ahern, 2001; Ziersch, 2005). Methodological issues to do with measurement, analysis and the identification of causal pathways have also been examined (Cattell, 2001; Harpham et al., 2002; Poortinga, 2006; van der Linden et al., 2003; Wind and Komproe, 2012).
It is timely therefore to reflect on the evidence that has been produced over the past 21 years, to see whether that early promise has been fulfilled and to identify what practical lessons or insights it provides for public health policy and practice. In the section that follows we discuss the insights provided by a review of systematic reviews of the social capital and health literature. Subsequent sections consider two questions that arise from the inconclusive nature of the evidence. First, why is the social capital literature elusive and inconsistent, and second, why will the evidence on social capital interventions also prove to be elusive and inconsistent. The answers we provide to these questions provide further support for calls for the co-production of context-specific research with local, experimental adaptation of interventions supported by academic search for generalizable patterns that emerge from local variation. We also call for more cognisance of the boundaries within which actors set out to solve problems.
Section snippets
Evidence on the impact of social capital on health
A search of Google and Google Scholar using the terms ‘social capital’, ‘health’ and ‘systematic review’, plus follow up of associated references uncovered 28 systematic reviews of studies linking social capital to health, including five that explore conceptual or methodological aspects (Table 1).
The reviews encompass more than 850 studies, though this includes an unknown number of duplicates. They cover a wide range of topics relating social capital to physical health, mental health, the
Why is the evidence on the relationship between social capital and health, and guidance on policy elusive and inconsistent?
In part, the answer to this question is because of shortcomings in methods, which means that it is still not clear whether social capital is a determinant of health, whether it is caused by health, or whether health and social capital are correlated with each other, each being driven jointly but independently by a third factor such as social circumstances or economic policy (Fine, 2001).
In addition, the concept of social capital is an expansive one, and its operationalization has embraced a
The evidence on social capital interventions will remain elusive unless we change the way we design and evaluate interventions
The lack of studies evaluating interventions related to social capital and health is disappointing though not unexpected. More intervention research is warranted but only if it embraces new ways of thinking about interventions.
From the existing literature on social capital, the best that we can say with confidence in response to the question ‘does social capital improve health?’ is that ‘it depends’, and since it depends on lots of things, many of which are interconnected, the implications for
Concluding remarks
At 21 years old, the social capital has reached the age of maturity but not yet a conclusion strong enough to guide population health policy.
Several reasons for this have been discussed. There are problems with the design and methods used in the empirical work, and problems also in the way that social capital has been operationalized and measured. The literature has also been criticised for its neglect of power and politics, and its inadequate treatment of context. In none of these regards is
Acknowledgements
The research described here was partially funded by the Australian Prevention Partnership Centre from a grant provided by the National Health and Medical Research Council (GNT 9100001)
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