Social Capital and Health Inequality in European Welfare States

M. Rostila

• Publisher: Palgrave Macmillan
• Year: 2013
• Print ISBN: 9781349332892, 9780230293434
• eBook ISBN: 9781137305664
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

Drawing on cross-national European data from the European Social Survey as well as Swedish national survey data and registers, this book investigates social capital in relation to health and health inequalities in European welfare states.

1

Introduction

Despite well-developed health care systems, advanced medical technologies and sufficient material living standards, there still exists a social gradient in health in Western societies. The unequal distribution of health between social groups was first acknowledged by the British Black Report at the beginning of the 1980s (Townsend and Davidson, 1982). Recently, the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) performed a global overview of health inequalities and found that large health inequalities, both between and within countries, still persist throughout the world at the beginning of the 21st century (CSDH, 2008). The commission and research into health inequalities emphasize that such disparities are largely due to differences in people’s living conditions and life chances. Accordingly, the social determinants of health provide crucial knowledge of why health differs systematically between countries and between social groups within countries. Improving various social conditions among the disadvantaged is a key for reducing health inequalities and improving public health (Marmot, 2004; Siegrist and Marmot, 2006; Marmot and Commission on Social Determinants of Health, 2007). Nonetheless, the fact that health inequalities are stable and even tend to increase in relatively rich societies has continued to perplex scholars. A recent book – The Spirit Level – suggests that inequality in material and social circumstances between social groups in richer societies causes frustration, stress, and a wide variety of other adverse externalities among the disadvantaged, with adverse consequences for health and longevity (Wilkinson and Pickett, 2009). Accordingly, it is the psychological experience of inequality that causes ill health rather than the material conditions per se. Consequently, inequality makes people sick, irrespective of a country’s overall economic circumstances. One of the explanations for adverse health consequences resulting from inequality is that it crowds out social relationships, social cohesion, and social capital (Wilkinson, 1996; Wilkinson and Pickett, 2009; Vergolini, 2011; Lyte, forthcoming). However, research on the role of social capital in explaining health inequalities is still scarce (Pearce and Davey-Smith, 2003; Dahl and Malmber-Heimonen, 2010). This book deals with social capital, as a social determinant of health, and whether it contributes to the unfair distribution of health between and within societies.

It has often been assumed that the Nordic or social-democratic welfare state reduces health inequalities and improves public health through its ability to combat poverty and social exclusion, while health inequalities are supposed to be larger in countries with less comprehensive welfare systems located in the Eastern and Southern parts of Europe (Bambra, 2007; Eikemo et al., 2008a; 2008b; Lundberg et al., 2008; Bambra and Eikemo, 2009). Recently, it has also been argued that the welfare state and its consequences could be crucial for the creation and maintenance of social capital. Consequently, levels of social capital might vary systematically between countries depending on welfare state characteristics and the generosity of welfare systems (van Oorschot and Arts, 2005; Rostila, 2007a). Although previous studies have shown that social capital is strongly related to health and wellbeing (for a review, see Islam et al., 2006), most previous research in the field of social capital and health has so far focused on pure associations and ignored the significance of the broader institutional and political context for the creation and maintenance of social capital and its potential health consequences. The overall objective of this book is to fill this gap in the literature by studying whether the consequences of social capital on health and health inequalities vary between countries with different institutional characteristics and welfare policies. This is important when considering that many interventions that potentially stimulate social capital and health, and also reduce health inequalities, take place at the state level. Global organizations, such as the Organisation for Economic Co-operation and Development (OECD) and the World Bank, have emphasized social capital as a potential strategy to improve the health of nations and communities (The World Bank, 1998; OECD, 2001). By studying the significance of the welfare state for the social capital–health relationship, policy makers could learn much about how investments in equality and social goods (e.g. welfare) could influence social capital and its potential health consequences.

The contribution of societal features for social capital and its health consequences has roots that go far back in the social sciences. Durkheim (1897/1997) argued that aspects of social capital can vary systematically between countries and that such differences could explain country-level suicide rates. Yet, it was the introduction of the concept of “social capital” by some sociologists (Bourdieu, 1986; Coleman, 1988), and especially the ensuing work by the political scientist Robert Putnam on the subject (Putnam et al., 1993; Putnam, 2000), that contributed to a dramatically increased interest in social capital in the health-related sciences. Accordingly, the number of published articles on social capital and health in the most influential journals in epidemiology and public health has increased enormously in recent years (Kawachi et al., 2008). Hence, the concept might be considered one of the most successful conceptual “exports” from sociology (Portes, 2000).

The work of Robert Putnam is often considered the most influential in the field of social capital. His books Making Democracy Work–Civic Traditions in Modern Italy (1993, together with Leonardi and Nanetti) and Bowling Alone: The Collapse and Revival of American Community (2000) received a lot of attention and introduced social capital as a phenomenon that makes societies work better through its ability to facilitate coordinated actions between individuals in society. In Making Democracy Work Putnam et al. examined regions of Italy in a historical perspective and argued that high levels of social capital explained the economic, social, and political success of North Italy, while the scarcity of social capital had contributed to the negative economic and political trend in the southern region of Italy. In Bowling Alone Putnam continued to study social capital in the American context and found declining rates of social capital in the United States during the post-war era – a trend that Putnam also expected to be found in other Western societies. Accordingly, some studies have confirmed declining levels of social capital in other non-American Western societies (Hall, 2002) while others have found no such evidence (de Hart and Dekker, 1999; Torpe, 2003). However, even the declining levels of social capital in the United States have been challenged (Paxton, 1999).

In Putnam’s book Bowling Alone it is argued that welfare states and welfare state features have no major role in stimulating or perhaps destroying social capital in society. In its place, Putnam argued that increased levels of television watching, the middle-class movement to the suburbs, the increasing female labour market participation, and a new generation of less “civic” individuals were the most important factors underlying the decline of social capital in America (Putnam, 2000). Arguments that emphasize the significance of the welfare state and its features for social capital have, however, become increasingly popular. Yet, there have also been controversies regarding the impact of welfare on social capital. Some argue that universal and comprehensive welfare states have negative consequences on social capital, as such societies “crowd out” social relationships, social trust, and civic activities (Wolfe, 1989; Fukuyama, 2000; Scheepers et al., 2002). The basic argument is that the need and incentives for the creation and maintenance of social contacts and civic activities decreased when the welfare state took over many of the responsibilities and duties that were previously located in people’s social networks and associations (van der Meer et al., 2009). At the other end of the spectrum, others suggest that universal welfare states primarily have positive implications for various aspects of social capital (Klausen and Selle, 1995; Torpe, 2003; van Oorschot and Arts, 2005) and that people’s ability and incentives to take part in social life are encouraged and supported by the welfare state and its institutions. However, the relationships between the welfare state and different dimensions or subtypes of social capital could also vary. It has, for instance, been suggested that the exchange of social resources in the networks of citizens is crucial in societies that lack comprehensive and generous welfare systems, while the success of universal welfare states builds on solidarity and trust among citizens (Rose, 1995; Rothstein, 2001; Völker and Flap, 2001; Jensen and Tinggaard Svendsen, 2011). Another important objective of this book is hence to scrutinize the relationship between welfare and different forms of social capital, as high social capital, in turn, could be a foundation for a healthy society.

The concept of social capital has, however, also received a lot of criticism and could be considered one of the most questioned concepts in the social sciences (Portes, 1998). There is a present theoretical disagreement on whether social capital should be considered a property of individuals or social structures. Some researchers, for instance, adhere to the perspective that social capital is more than the aggregated characteristics of individuals, and that it is a feature of social structures rather than of individual actors within a social structure (Putnam et al., 1993; Lochner et al., 1999; Kawachi and Berkman, 2000; Putnam, 2000). Still, the concept has also been considered and defined as an individual good (Bourdieu, 1986; Coleman, 1988; Portes, 1998; Lin, 2000; 2001; Carpiano, 2006). The importance of structure versus individuals has, however, long been debated within the social sciences (e.g. Durkheim, 1897/1997; Parsons, 1951; Weber, 1983). One of the chapters within this book (Chapter 2) will discuss the theoretical foundations of social capital and tackle some of the conceptual confusion in the field.

Disagreements about the appropriate level of analysis have also contributed to controversies over whether the health benefits of social capital lie on an individual level (e.g. Moore et al., 2005; Carpiano, 2006) or a collective level (e.g. Lochner et al., 1999; Kawachi and Berkman, 2000). The collective notion of the concept, in line with the work by Putnam and followers, has so far dominated the health-related sciences. Accordingly, this notion argues that social capital is a collective good and that social capital, as a feature of contextual units such as countries, states, or neighbourhoods, is decisive for health. Yet there have been some recent tendencies for a revival of individual-level notions of the concept in the health-related sciences (Altschuler et al., 2004; Moore et al., 2005; Carpiano, 2006; Stephens, 2008). These consider social capital as an individual resource that can be used by single individuals in order to achieve health and longevity.

Despite the controversies, social capital will be regarded within this book as a concept including both individual and collective features (see Chapter 2 for a full description). Given that there is no consensus in previous research on whether the main health benefits lie on the individual or collective level, such an approach seems reasonable. It also seems plausible that individuals’ health and wellbeing could be affected by both their own personal social capital as well as the social capital that characterizes the surrounding social environment. Such a perspective seems particularly important in health research. Without considering social capital on different levels of aggregation we cannot understand the full health benefits of social capital. Moreover, there might be important interactions across levels. Low social capital in a society might, for instance, primarily influence the health of those with poor individual social capital. However, the social capital–health relationship on different levels of aggregation may also depend on the specific dimension studied. High social trust might be a highly valuable resource for the health of societies, while citizens’ personal social relationships primarily influence individual health.

Finally, most scholars accentuate the positive consequences of social capital, whereas they often ignore the dark sides of the concept. Nevertheless, the use of social capital might, in some instances, have negative consequences (Portes, 1998; Kunitz, 2004) and might rather contribute to poor health and larger health inequalities. Social capital may, for instance, reinforce unhealthy behaviours and norms leading to drug abuse, obesity, criminality, and risky sexual behaviour (Gambetta, 1993; Friedman and Aral, 2001; Christakis, 2004; Christakis and Fowler, 2007; Maycock and Howat, 2007). Some also maintain that social networks can be coercive and constitute sources of strain as well as support (Rook, 1984; Due et al., 1999). Furthermore, it is also important to regard the unequal distribution of social capital in society as a downside of social capital (Pearce and Davey-Smith, 2003; Szreter and Woolcock, 2004) that, in turn, might contribute to health inequalities (Dahl and Malmberg-Heimonen, 2010). In a similar way to economic or human capital, it is reasonable to believe that the wealthier segments of the population and those with higher status have larger social networks and higher levels of trust, and receive social resources of higher quantity and quality from their networks (Lin, 2000; Dahl and Malmberg-Heimonen, 2010). Social capital can then be used by these groups in order to obtain additional advantages in society. Few studies have raised interest in the dark sides of social capital and the contribution to health inequalities. Therefore, one part of this book is devoted to examining this issue empirically.

Next, I will give some background to the central concepts of health and health inequalities within this book, as well as the meaning of welfare and welfare regimes. The theoretical foundations of social capital will, however, be treated separately in Chapter 2.

1.1 The health concept

This book is not merely focused on social capital and its development as such; it will also study the consequences of an individual’s or a country’s social capital on health and health inequalities. Health can be examined in many different ways, ranging from people’s own feeling about their state of health to physicians’ diagnoses based on medical science. Hence, it is important to clarify the meaning of the concept of health and how health will be examined within this book. The WHO suggests that “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 2006). This very broad definition of health is, however, difficult to study empirically. Therefore, health research often focuses on states that deviate from good health in the form of disease, sickness, or mortality. The difference between disease and sickness is, however, of importance for this book. Disease concerns the medical or biological aspects of ill health, traditionally diagnosed by health care professionals, while sickness refers to the individual experience of health problems. Hence, it is possible that an individual can have a disease without being sick and vice versa. It is, however, reasonable to believe that disease and sickness coincide to a high extent. People usually go to the doctor when they experience some kind of health problem, which is then diagnosed by a physician. This book will primarily focus on social capital and how it relates to self-assessed health problems and therefore, to a large extent, it will examine sickness instead of disease among both individuals and societies. It will study how social capital relates to health outcomes such as overall self-assessed health problems and self-perceived indicators of psychological health and circulatory health problems. It will further examine whether social capital also contributes to inequalities in these health outcomes between social groups such as social classes, educational groups, and groups based on country of birth. Mortality could be considered an unproblematic dimension of health – people live or die. However, many health problems and diseases do not necessarily lead to premature death. Yet, some of the analyses of this book will examine the associations between social capital and life expectancy in European countries.

1.2 Health inequalities

This book will also examine whether social capital contributes to health inequalities both between and within welfare states. This makes it important to specify what is meant by health inequalities and how health inequalities differ from other types of differences in health.

Health might be considered an individual phenomenon – individuals fall ill and die. This is reinforced by the medical practice, as medical treatment is focused on the individual. Most of us accept that health varies between individuals and during different points in life. Some differences in health between larger groups within society are not even necessary health inequalities (Graham, 2007). Poor health among older adults when compared to young adults is a biological fact rather than a health inequality. Yet, there are large and systematic differences in health and longevity within society that may be considered unequal. These differences indicate that social structures and the processes that cause inequalities are more important for health inequalities than inherited or acquired individual risk factors. Consequently, poor health is not an individual problem alone but also a social problem. Health differences between social groups arise through systematic differences in living conditions, health behaviours, and/or vulnerability to disease between these groups, which ultimately lead to health inequalities between them. In order to separate unfair differences in health from acceptable and expected differences we might separate between the concepts of “health inequality” and “health inequity” (Graham, 2007). Health inequality basically just refers to patterns of health differences within a population, while health inequity is a normative concept that refers to health differences that are politically, socially, and economically unacceptable. When health inequalities are mentioned within this volume, it refers to those types of inequalities that are unfair and unjust (e.g. health inequities). However, this book will not only examine unacceptable health inequities between social groups within countries. Health inequalities between countries could also be considered unfair and unjust, and might also be influenced by social determinants of health including social capital.

1.3 Social capital and health inequalities

Different models explaining health inequalities between groups in society have been proposed and social capital may play an important role in these models. The psychosocial (Wilkinson, 1996; Marmot, 2004; Wilkinson and Pickett, 2009) and neo-material explanations (Muntaner and Lynch, 1999) are probably the most prominent ones and are often suggested as two contradictory explanations for health inequalities. The neo-material explanation suggests that health inequalities originate from differences in material circumstances such as income, living conditions, working conditions, place of residence, et cetera. Hence it is primary differences in such material circumstances that cause health inequalities between social groups. The psychosocial explanation acknowledges the unequal distribution of material resources. However, according to this notion differences in material circumstances between social groups cause stress and frustration among individuals in lower social positions, which, in turn, lead to ill health. Accordingly, it is the psychological experience of inequal...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Figures and Tables
• Foreword
• 1. Introduction
• 2. Theoretical Foundations of Social Capital in Health Research
• 3. Social Capital and Welfare: Do Universal Welfare States “Crowd Out” or Stimulate Social Capital?
• 4. Social Capital and Health: Mechanisms and Empirical Findings
• 5. Health Inequalities by Education in European Welfare Regimes: The Contribution of Individual Social Capital
• 6. Health Inequalities Between European Welfare Regimes: The Contribution of Collective Social Capital
• 7. Social Capital and Health Inequality in the Social-Democratic Swedish Welfare State
• 8. The Dark Sides of Social Capital: Homophily and Closure of Immigrants’ Social Networks in the Swedish Welfare State
• 9. Concluding Discussion
• Appendix 1: Methodological Concerns and Limitations
• Notes
• References
• Index