Embracing complexity: towards more nuanced understandings of social capital and health

Malin Eriksson's work on social capital provides some useful insights into factors mediating between macro-social relations and health, with particular attention to community-level drivers of health and well-being. In order to contextualise Eriksson's contribution, this brief commentary has three aims: to place the rapid growth of interest in social capital in the past 15 years in its wider political context, to flag up some of the criticisms that have been levelled at the concept, and to highlight the ways in which Eriksson's work contributes to current debates.

The long-standing challenge of operationalising the slippery notion of ‘community’ in the fields of health and social development was given new life in the mid-1990s with the work of Robert Putnam, who became one of the most frequently cited English language social scientists of that decade. His work catapulted the concept of ‘social capital’ into the political and health arenas, partly due to its resonance with the political agenda's of Bill Clinton in the US and Tony Blair in the UK (both influenced by the work of British sociologist Anthony Giddens) – all of whom argued for the need to develop a ‘third way’ in politics that would steer between the previously polarised positions of capitalism and socialism.

Putnam's work 123 suggested that social capital – defined in terms of social networks (particularly involvement in local civic associations and informal community networks) and norms (particularly those related to trust and reciprocity between local citizens) – had the potential to impact positively on the economic performance and the effectiveness of government in geographically bounded areas. Public health researchers began to argue that social capital might also have the potential to impact positively on health, with the strengthening of community networks and norms being seen as an important potential public health strategy.

Although it was only in the mid-1990s that the concept of social capital became so popular, environmental influences on health had long been acknowledged in the health arena. Despite this, the practice of public health had often been dominated by approaches that focused on individual-level biomedical and behavioural approaches to illness prevention, care, and treatment. Such individual-focused approaches had often had disappointing outcomes, however, particularly in marginalised communities. As had long been argued, various forms of social inequality (linked to factors such as social class, ethnicity, gender, disability, age, and sexual orientation) often limited peoples’ freedom to control health-relevant behaviours, especially in the marginalised communities that often experienced the poorest health. Against this background, the 1990s saw renewed calls for a ‘paradigm shift’ within public health, towards approaches that sought not only to persuade people to behave in more health-enhancing ways, but also to alter the contextual determinants of health related behaviours, both in terms of lifestyle behaviours as well as those linked to accessing health services and adhering to medical advice 4.

Within this context, research into contextual determinants of health has tended to focus on one of two possible levels of analysis. The first is the macro-social level, focusing on the impacts of large-scale social relations such as gender, poverty, and ethnicity. The second, sometimes called the meso-level of analysis, has focused on community level determinants of health, either seen as determinants of health in their own right or else as mediators between macro-social relations and health. ‘Community’ is a highly contested concept. Communities may be defined in terms of common interests (e.g. groups of people with particular health problems or who engage in common leisure activities), common identities (e.g. related to religion or ethnicity), or common area of residence. For pragmatic reasons, the geographically based notion of community has tended to dominate both analysis and action in the public health arena, given that public health funding and services tend to be linked to geographically defined areas.

As attention to social capital as a possible ‘social determinant of health’ increased, some commentators sought to position macro-social and community-level factors as competing explanations of the social drivers of health. They expressed concern that the rush of attention to community-level social capital as a ‘social determinant of health’ was due to its potential to draw attention away from the impacts of poverty on health, serving as a convenient excuse for politicians seeking to cut welfare spending, or to reduce international development aid to poor countries 56. Such critics argued that linking poor health to low levels of community participation, particularly in the face of massive and conclusive evidence for the impacts of poverty on health 7, served to trivialise the problem of poverty and to sow unjustified confusion in ‘social determinants’ debates. They also feared that cynical and cost-cutting politicians might blame marginalised communities for their poor health (‘victim blaming’), saying they had only themselves to blame through their failure to participate in community life, and suggesting that better health could be achieved if poor people simply made more effort to engage in local community organisations or to relate more positively to their neighbours.

Over time this argument has been partially laid to rest by those who have pointed to the folly of such a polarisation of positions. Rather than postulating either social capital or wider social inequalities (linked to poverty or gender oppression for example) as competing explanations for ill health in marginalised communities, there is now widespread acceptance that both factors are deeply intertwined in shaping people's opportunities to be healthy. Clearly the economic regeneration of poor communities is vital for possible health improvements. However, parallel efforts at social regeneration are also needed if poor people are to make the best use of increased economic opportunities or improved health services. An emphasis on social capital as one of many social determinants of health by no means justifies arguments in favour of reduced investment in poverty reduction or health service improvement. Rather it highlights that communities with high levels of social capital are most likely to be able to make best use of enhanced health and social development services and policies 8.

Against this background, Eriksson's doctoral research makes some thoughtful contributions to political debates about the links between social capital and social inequalities (with particular reference to gender and educational levels), as well as academic debates about how best to conceptualise and measure social capital, and policy debates about how best to mobilise social capital as a public health resource.

The starting point of Eriksson's work 910 is her careful recognition that of the highly context-specific nature of the constitution and potential health impacts of social capital. She emphasises that these are likely to vary from one country and context to another, with additional strong variation within and between social groups living and/or working within particular small local communities. The concept of social capital is more usefully regarded as a heuristic tool than a universal template for analysis and action, and one that needs to be carefully conceptualised on a case by case basis. Against this background, her multi-method study of social capital in Northern Sweden makes some fine-grained contributions to key areas of understanding and practice. Her survey-based work highlights the complexities of the links between social capital and self-rated health. Her first paper provides general evidence for such links 11. Yet a more detailed analysis in a second paper 12 serves to caution those who would seek to draw dogmatic conclusions from her earlier findings, showing how different measures of social capital are linked to different measures of self-reported health in men and women. This study serves as a useful contribution to on-going debates about how best to define and research social capital. Consistent with the work of Bourdieu 13, people with higher education were found to have significantly greater access to all forms of social capital. Men were found to have greater access to bonding social capital and women to bridging social capital. In the light of Granovetter's work on ‘the strength of weak ties’ 14, this difference is consistent with men's increased access to political and economic power in many settings. It is also consistent with the fact that in many cultures and contexts, women are perceived as guardians of small scale, intra-community emotional support networks, and day-to-day survival networks (for ‘getting by’ in difficult social circumstances, rather than for social advancement), as opposed to men who are seen as guardians of networks for ‘getting ahead’ [improving one's social position in the status quo 15].

Eriksson et al.'s qualitative work 1617 uses social capital as a productive analytical tool for unpacking the processes of community action enshrined in the World Health Organisation's Alma Ata (1978) and Ottawa (1986) charters. Her case study unpacks the psycho-social dynamics guiding a successful process of community mobilisation in a remote rural area, which led to the establishment of an association-driven community health centre in the face of public sector cuts to health services. Here again, her work takes careful account of complexity, showing how what was undoubtedly an effective example of social action at one level nevertheless served to reinforce existing relations of social exclusion and inclusion in a complex social setting.

As Eriksson's work reminds us yet again, the links between social relations and health are many and complex. Contrary to its enthusiastic and optimistic reception in the 1990s, the concept of social capital has failed to provide easy solutions to the challenges of reducing health inequalities. There is no doubt that social capital is a crucial thread in the complex tangle of factors that mediate the impacts of social relations on health But it is only one thread, and its impacts are by no means straightforward. Different forms of social capital may serve to advance or exclude different social groups. Particular forms of community mobilisation may serve to improve or reduce peoples’ opportunities for health. Most importantly, experience increasingly shows that the promotion of social capital is unlikely to have any positive impacts on health in the absence of political will by powerful health and political leaders to tackle the wider forms of social marginalisation (linked to the distribution of political and economic power) that drive health inequalities in so many contexts 18. In the face of such contradictory and inconclusive evidence, many public health researchers and practitioners, impatiently looking for ‘magic bullet’ solutions to the challenges of improving health in an unequal social world, lose patience with social scientists who repeatedly tell them that the impacts of social inequalities on health are too complex to be summarised in single concepts, or to be tackled in 3-year funded ‘interventions’. By refusing to shy away from complexity, Eriksson's work throws light on a few more pieces of the complex puzzle that constitutes the social determinants of health in the Swedish setting, and on the more general challenge of developing actionable insights into the factors that facilitate or hinder the promotion of health-enabling social environments.