Health Education Research, Vol. 18, No. 6, 770-779,
December 2003
© 2003 Oxford University Press
Social participation and health in a community rich in stock of social capital
Research Department, Social Insurance Institution of Finland, 20720 Turku, Finland
e-mail: markku.hyyppa{at}kela.fi
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Abstract |
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In Finland, members of the Swedish-speaking minority, many of whom live in the province of Ostrobothnia, intermingle with the Finnish-speaking majority. Although the two language communities are quite similar to each other in most societal respects, including socioeconomic status, education and use of health services, significant disparities have been reported in the morbidity, disability and mortality between the Swedish-speaking minority and the Finnish-speaking majority. Since the population genetic, ecological and socioeconomic circumstances are equal, Swedish speakers’ longer active life is difficult to explain by conventional health-related risk factors. A great deal of health inequality (between the language groups) seems to derive from uneven distribution of social capital, i.e. the Swedish-speaking community holds a higher amount of social capital that is associated with their well-being and health. Factor analysis revealed four patterns of social capital measures, i.e. voluntary associational activity, friendship network, religious involvement and hobby club activity, of which associational activity, friendship network and religious involvement were significantly associated with good self-rated health. Also, trustful friendship network, hobby club activity and religious involvement as well as avoidance of intoxication-prone drinking behavior were significantly more frequent among the individuals of the Swedish-speaking community. We suggest that health promotion should seek ways of working which would encourage social participation.
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Introduction |
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The concept of social capital was defined by Pierre Bourdieu in the 1970s [e.g. (Bourdieu, 1980
)]. According to James Coleman (Coleman, 1988, 1990), Robert Putnam (Putnam, 1993) and Francis Fukuyama (Fukuyama, 1999), social capital is tightly bound with social engagement, mutual trust and community. In his influential work Making Democracy Work, Putnam (Putnam, 1993) showed that the gain of social capital explains inequalities in democracy and welfare between Southern (‘Mezzogiorno’) and Northern Italy. Social capital is defined by the World Bank (http://worldbank. org/poverty/scapital/index.htm) as the norms and social relations embedded in the social structures of societies that enable people to coordinate action to achieve desired goals.
There are several theoretical and methodological limitations of using a social capital model to explain health inequalities (Hawe and Shiell, 2000; Forbes and Wainwright, 2001). Social capital is a collective construct of a community, not of the individuals within the community. However, its effects can be assessed at the individual level. Berkman et al. have presented a conceptual model for the impact of social integration, participation and engagement on health in community. To identify the conditions influencing the development and structure of social networks, they sought for
...more cross-cultural work comparing countries with different values regarding social relationships, community, sense of obligation. The same might be true of specific areas within countries or specific cultural or ethnic groups with clearly defined values. [(Berkman et al., 2000
Participation in voluntary associations is a key factor of social capital and, in his later works, Putnam has proposed that it is declining in the US (Putnam, 1995, 2000). He has not empirically proved the association of the decline of social capital and the changes of well-being and health status (in America), even if he implicitly associates the decline of social capital with deterioration of health (Putnam, 2000). A recent study by Cattell (Cattell, 2001) showed that, in two poor neighborhoods in East London, social participation produced clear benefits in well-being, although declining social engagement was not the main source of social capital for the majority of residents. Runyan et al. (Runyan et al., 1998) showed that church affiliation, perception of personal social support, and support within the neighborhood and in families were the most direct measures of social capital, which discriminated between levels of functioning in children. In their individual-level study, the addition of any one indicator of social capital (presence of two parents, social support, less than three siblings, neighborhood support or church services) increased the odds of doing better by one-third.
Scandinavian surveys have shown that social participation, either in terms of attendance at meetings and the possibility to influence decisions in organized groups and associations (Dalgard and Håheim, 1998) or in terms of attendance at (some) cultural events (Bygren et al., 1996; Konlaan et al., 2000), predicts longer life. Relationships between women’s network activities and the perceived health among network participants have recently been analyzed in Sweden, and the results suggest that networks could have an important role in health promotion (Gustafsson-Larsson and Hammarström, 2000). The most important factors of improved health among the network participants were an increased sense of belonging, participation in a process where an idea is put into practice, the work per se and increased mutual trust. Low social participation is associated with an increased risk of low leisure-time physical activity (Lindström et al., 2001), which means that social participation can modify health-related behavior. In Saskatchewan, Canada, individual-level studies on social capital and health showed that social engagement in clubs and associations correlated with self-rated health only among the elderly (Veenstra, 2000). These studies cannot solve the problem of causal direction, since active participation needs socially connected individuals.
The risk of death was lower among elderly Americans if they participated in social (or productive) activities (Glass et al., 1999). Volunteer activity has been suggested to promote social integration at older age. This activity may have dual benefits in terms of the contributions that the volunteers are making and the potential health benefits they may derive from the experienced social engagement (Seeman, 2000).
Since membership in voluntary associations makes a significant positive contribution to reducing distress (Rietschlin, 1998) and further to community health, as the Swedish study showed (Gustafsson-Larsson and Hammarström, 2000), it is reasonable to elucidate the individual-level relationships between associational participation and health, and to scrutinize community participation in culturally deviant communities (Berkman et al., 2000; Forbes and Wainwright, 2001).
Kawachi et al. (Kawachi et al., 1999) counted group memberships and civic associations in their study, but they were unable to identify in detail which were important for health. Clubs and cultural participatory activities seem to be associated with individuals’ health in different ways in culturally dissimilar communities, e.g. singing in a choir is typical among Swedish-speaking women, while attendance at volunteer community meetings is typical among Swedish-speaking men in Finland (Hyyppä and Mäki, 2001b). We observed that a single membership in fraternal, social, humanitarian or cooperative associations does not necessarily correlate with self-rated health.
Swedish-speaking minority in bilingual Ostrobothian municipalities
Finland has generally been regarded as an example of a monocultural and egalitarian society. However, Finland has a Swedish-speaking minority that meets the four major criteria of ethnicity, i.e. self-identification of ethnicity, language, social structure and ancestry (Allardt and Starck, 1981; Bhopal, 1997). The current 5.7% (n = 285 000) Swedish-speaking ethnic minority is backed up by constitutionally guaranteed rights, as well as an extensive network of (Swedish) institutions and organizations, including a comprehensive Swedish educational system, Swedish TV and radio channels, newspapers and magazines, and a Swedish episcopate in the Lutheran Church of Finland. Swedish speakers live mainly in Finland’s southern coast areas along the Gulf of Finland, in the Aland Islands and in the western coast along the Gulf of Bothnia, so-called Ostrobothnia (Figure 1). The Swedish-speaking residents intermingle with Finnish speakers and 100 000 of them live in the Ostrobothnian municipalities. At the time of this study, 50.8% of Ostrobothnian residents had Swedish as their mother tongue. It is most important for the following series of studies on inequalities in social capital and health to point out that the two language groups in Ostrobothnia are quite similar to each other in many societal respects, including socioeconomic status, education and use of health services (MacRae, 1997).
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Ever since epidemiological health surveys have been published in Finland, the total mortality rates have favored the Swedish-speaking minority. (The earliest reports date back to the 1930s.) Significant disparities have been established in the annual suicide rates, violent and accidental death rates, and especially in cardiovascular mortality [for references, see (Hyyppä and Mäki, 2001a
)]. These findings are internationally exceptional since the reported mortality rates do not often favor ethnic minorities. The fact that Swedish speakers live longer than the Finnish-speaking majority is very interesting from the health promotion point of view, especially if the disparity is culture rather than place related (Mcintyre et al., 1993).
Independent of age cohort and diagnostic category, the Finnish-speaking men and women are much more frequently on a disability pension than their Swedish-speaking compatriots in Finland. Both the average age of retirement on disability pension and the average age at death were significantly higher among the Swedish-speaking than the Finnish-speaking individuals living in the same region, e.g. in Ostrobothnia (Hyyppä and Mäki, 2001a). Recently, an extensive longitudinal study confirmed that the rate of very early retirement as an indicator for poor health is lower among Swedish speakers than among Finnish speakers, and, more important, this cannot be attributed to regional and sociodemographic factors (Saarela and Finnäs, 2002). These register-based results opened new perspectives on the issues of social capital and on its relationships with the individuals’ health (Hyyppä and Mäki, 2001a,b).
Social capital and self-rated health
To investigate the possible relationships between social capital measures and health in Finnish- and Swedish-speaking individuals, we compared demographic and social features, health status, health behavior, social ties, reciprocal trust, and social engagement in Ostrobothnia (Hyyppä and Mäki, 2001b). The results showed that the Finnish speakers were more often migrants and mistrusting, and less active in community events and in singing in a choir (women) than the Swedish speakers, when health-related variables (urban residence, migration, age, body mass index (BMI), household income, smoking, singing in a choir, membership in any voluntary association, participation in community events and long-term diseases) were controlled for. Our results suggest that the Swedish-speaking community shows more mutual trust and civic engagement than the Finnish-speaking community in the same geographic region. The excess of community spirit seems to distinguish Swedish- and Finnish-speaking communities in Ostrobothnian bilingual municipalities.
Social capital in terms of friendship network, membership in any religious association and trust/mistrust contributed significantly and independently to self-rated health in both language communities. Other important voluntary social and civic activities as well as group memberships may also be relevant to empowerment, and important for community health. However, due to the statistical modeling in our study, it was not possible to analyze the whole spectrum of voluntary civic and social engagements in relation to health (Hyyppä and Mäki, 2001b). The aims of the present study on a bilingual community were to examine which civic and social activities are important for health, and to identify possible pathways through which social engagement and participation in voluntary associations influences individuals’ health.
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Methods |
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Our study population consisted of randomly selected samples of Finnish speakers (n = 1000) and Swedish speakers (n = 1000) representing all adults (aged between 16 and 65 years) living in bilingual Ostrobothnian municipalities with some 75 000 Finnish-speaking and 78 000 Swedish-speaking adult residents (Figure 1). In Ostrobothnia, 94% of the Finnish speakers and 66% of the Swedish speakers are urban. Data on sociodemographics, health status, health behavior and social capital were collected between December 1998 and February 1999 by means of a questionnaire. The response rate was 64.2% for the total sample (65.8% for Finnish speakers and 62.6% for Swedish speakers), equaling the average response rate in recent health surveys in Finland. Non-responders were not contacted for their demographics. Finally, 284 Finnish-speaking men and 374 Finnish-speaking women (total n = 658) and 271 Swedish-speaking men and 355 Swedish-speaking women (total n = 626) participated.
In addition to language (Swedish = 1, Finnish = 0), sociodemographic items included age, gender, marital status (married or cohabiting = 1, single = 0), type of residence (urban = 1, rural 0), migration [years of residence in the study region and birth place inside versus outside study region (yes = 1, no = 0)], number of family members, education (less than high school = 0, at least high school level = 1), household income (less than 20 000 euro (circa 20 000 US$) = 0, more = 1], employment status (employed = 0, unemployed = 1) and gainful employment (yes = 1, no = 0). Measures of health status and behavior included self-reported weight (kg) and height (cm), smoking (no = 1, yes = 0), and alcohol drinking habits (drunken at least once a week = 1, less = 0). The question about perceived general health was derived from the following: ‘Would you say that in general your health at the present is good, almost good, fair, poor or bad?’. The item was binary coded (good = 1, almost good, fair, poor or bad = 0) for an outcome measure. Also, long-term diseases and handicaps associated with disability as well as chronic diseases diagnosed by physicians were investigated.
Items from the Finnish Survey on Living Conditions 1976–1994, the Mobile Clinic Health Examination Surveys 1966–2000 and a questionnaire in Swedish on cultural behavior among Swedish-speaking Finns, ‘Finlandssvenskarnas kulturbeteende’ (Airo, 1994), were used to cover social ties, friendship networks, integrity and voluntary participation in clubs and associations. Reciprocal trust was assessed by two items: ‘Generally speaking, would you say most people can be trusted?’ and ‘Do you think most people would try to take advantage of you, if they got a chance?’. To assess social engagement, the subjects were asked about their active participation in hobby clubs (singing in a choir, acting in a theatre group, dancing in a dancing club, playing in a music band, participating in a writers’ club, or a film or video club, or others); attendance at various cultural, religious, political, sports, recreational, work-related and community events; passive attendance at summer music festivals and art exhibitions; and memberships in a variety of voluntary associations (sports, political, social, fraternal, local, neighborhood-related, religious, education-related, school-related, recreational, work-related and community organizations). For the purpose of identifying properly the nature of clubs, voluntary associations and participation, examples of each item were named in the questionnaire. All items were translated from Finnish to Swedish independently by two Swedish speakers and back to Finnish by one bilingual Finnish speaker (Hyyppä and Mäki, 2001b). The Ethical Committee of the Social Insurance Institution approved the survey protocol.
Multicorrelation analyses were performed between the continuous (age, BMI) and binary coded demographic, socioeconomic, health behavior and social capital predictors and response variables (self-rated health, diagnosed diseases or disability). First, after reducing variables due to mutual correlations and missing responses, multiple logistic regression models were used to regress response variables on the above-mentioned single measures of health and social capital to test whether the social capital variables are independently associated with health. Second, we conducted a factor analysis on the sample with items of social capital. There were 1210 responders in this analysis after missing cases were deleted. Kaiser–Meyer–Olkin measure of sampling adequacy 0.72 demonstrated that the sample size was adequate to produce stable factor solutions. Four factors had eigenvalues above 1.0 After testing the sufficiency of four factors against the need of more factors, we accepted the four-factor model (
2 2129.7; P = 0.0001), and these four factors were extracted and promax rotated. Interfactor correlations varied from 0.10 (factors 2 and 4) to 0.23 (factors 1 and 4). Internal consistency by Cronbach’s 
were the following: factor 1, 0.73; factor 2, 0.75; factor 3, 0.62; and factor 4, 0.54. We substituted single variables of social capital with the four-factor pattern and ran the newly formed multiple logistic regression model that we had accepted as the final model. Fitting of the logistic regression model was tested with the maximum likelihood method. Adjusting for all other variables in the regression equation, odds ratios with 95% confidence intervals and significance levels were calculated on the binary response (good self-rated health or language group) by one unit change of the predicting variable. All data were analyzed with SAS 8e statistical software.
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Results |
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Health measures
Adjusted for demographic features, health-related behaviors and social networks, the multiple regression analysis showed that reciprocal trust, neighborhood network and membership in any religious association correlated highly significantly (P < 0.001), and active participation in associations almost significantly (P = 0.058), with good self-rated health. Adjusted for other health-related variables, the above-mentioned variables of social capital did not show associations with diagnosed diseases or disability. Age, BMI, tobacco smoking and household income were significantly (and in the expected direction) associated with diagnosed diseases or disability.
Significance of social participation
The first factor pattern was loaded by neighborhood cooperation, participation in a cultural hobby club or in some other group, and active participation in any volunteer organization, sports organization, school-related group, volunteer community meeting and hunting association. The number of close friends, friendship ties and reciprocal trust loaded the second factor. The third factor was loaded by regular church attendance, visiting religious summer meetings and membership in a religious association. The fourth factor was loaded by membership in cultural associations, participation in writing or drama groups, playing music and singing in a choir. In comparison with factors 1–3 (‘associational activity’, ‘friendship network’ and ‘religious involvement’), factor 4 (‘hobby group’) was less strongly loaded by its variables.
Table I shows the associations between the four principal factors and self-rated health, when language, age, migration, BMI, education, employment status, household income, disability, diagnosed diseases, tobacco smoking and alcohol drinking habits are controlled for in the final multiple logistic model. Most of the ‘confounding’ health-related risk factors behaved significantly (and independently) in the expected ways, but unemployment had no influence on self-rated health in this community sample. Together, all the ‘confounding’ variables and factor measures of social capital explained one-third of the variance in self-rated health. Social capital alone explained one-fifth of the variance in self-rated health, when the diagnosed diseases and disability were excluded, but only 5%, when they were included.
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Gender differences were analyzed separately, because in the final regression model gender was independently and almost significantly (P = 0.07) associated with self-rated health, i.e. women tended to have poorer self-rated health. ‘Friendship network’ and ‘religious involvement’ predicted self-rated health in all women independently of language group. ‘Religious involvement’ was the only social capital measure to predict self-rated health in the whole male population and in the Finnish-speaking men. In the Swedish-speaking men ‘friendship network’ was a significant (P = 0.004) and ‘religious involvement’ an almost significant (P = 0.074) predictor. ‘Associational activity’ was a significant (P = 0.04) and ‘religious involvement’ an almost significant (P = 0.06) predictor among the Swedish-speaking women, whereas ‘friendship network’ only was a significant predictor of good self-rated health among the Finnish-speaking women. After adjusting for all predictor variables, the following language group differences emerged: Swedish speakers were slightly older, more frequently migrated, and less frequently unemployed, disabled and intoxication-prone users of alcohol than Finnish speakers.
In order to show possible dose-responses in key variables of social capital, we reanalyzed scaled factor 2 (‘friendship network’) and factor 3 (‘religious involvement’) for self-rated good health. Within each factor scale, scale scores were transformed and converted to intervals that ranged from 0 (low) to 3 (high). Unadjusted odds ratios of dose-responses in friendship network were 0 versus 3 = 0.52 (0.38–0.73), 1 versus 3 = 0.88 (0.65–1.20) and 2 versus 3 = 0.97 (0.69–1.36). Unadjusted odds ratios of dose-responses in religious involvement 0.52 (0.34–0.79), 0.60 (0.44–0.84) and 0.82 (0.58–1.14), respectively.
Table II shows that ‘associational activity’ (P = 0.0001) was more frequent in the Finnish-speaking community, whereas ‘friendship network’ (P = 0.0001) and ‘hobby group’ activity were more frequent in the Swedish-speaking community (P = 0.03). ‘Religious involvement’ (P = 0.08) was equally frequent in the both language groups. No gender differences were either observed. Intoxication-prone alcohol drinking was much more frequent among the Finnish speakers and in both genders.
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Discussion |
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We found that the keystones of social capital, i.e. active participation in voluntary associations and friendship ties (Putnam, 1993
), are associated with self-rated good health in a bilingual community with Swedish- and Finnish-speaking residents. Although our study is cross-sectional and tells us nothing about causal relationships, it has several strengths when proving the beneficial impact of voluntary associational participation on individuals’ health. First, we have earlier shown that, living in the same geographical region, the Swedish-speaking individuals have much longer active life than the Finnish-speaking individuals (Hyyppä and Mäki, 2001a). Second, because both language groups live intermingled under similar environmental conditions, have similar socioeconomic status and use similar health services, the previously observed disparities in mortality and morbidity [for references, see (Hyyppä and Mäki, 2001a)] are difficult to explain by conventional health-related risk factors. We have shown that social capital is associated with self-rated health and that Swedish speakers have a greater stock of social capital (Hyyppä and Mäki, 2001b). Third, we could show dose–response effects on self-rated health in the key variables of social capital. Taking together these facts and the present results, we cannot refrain from suggesting the excess of social capital to be the elixir of life—at least in the Swedish-speaking community in Finland.
However, we were not the first to establish empirically the role of social capital for better health and longer life. Individual-level relationships between social capital and health have been reported during the past years. Social capital may have an impact on children’s well-being (Runyan et al., 1998) and a contextual effect of low social capital on the risk of poor self-rated health has been reported (Kawachi et al., 1999). Individual-level elements of social capital are related to health among the elderly (Veenstra, 2000) and social capital has a significant role in shaping health-related behavior (Lindström et al., 2001). Further, low social participation is associated with increased mortality (Dalgard and Håheim, 1998), while attendance at cultural events may have a positive influence on survival (Bygren et al., 1996; Konlaan et al., 2000), social network activities lead to improved health in women (Gustafsson-Larsson and Hammarström, 2000) and religious involvement (an important indicator of social capital) is associated with lower mortality (McCullough et al., 2000).
A novel popular construct, social capital is difficult to define (Coleman, 1988; Putnam, 1993, 2000; Fukuyama, 1999; Winter, 2000; Cattell, 2001; Forbes and Wainwright, 2001; Stone, 2001) and measure (Lochner et al., 1999; Winter, 2000; Hawe and Shiell, 2000; Stone, 2001), but most researchers agree that active participation in voluntary associations is an important component of social capital, linking it with community spirit and empowerment [see, e.g. (Berkman et al., 2000; Stone, 2001)]. However, we lack guidelines on measuring civic and social engagement for the purpose of health promotion, as stipulated by public health advocates and community health promoters (Lomas, 1998; Hawe and Shiell, 2000; Forbes and Wainwright, 2001). Hanson et al. (Hanson et al., 1997) introduced a model for measuring social networks. Their questionnaire items gave good test–retest stability for social participation. However, the 12 items covered passive visiting in various civic, cultural and social events rather than active participation, which the items of social participation in our questionnaire did. An Australian epidemiological study on civic and social participation separated some levels and patterns of questionnaire items that are associated with physical and mental health (Baum et al., 2000).
The patterns emerging in our study divide social engagement of individuals into four classes and do not follow with the previous observations. From the community health point of view, associational activity and hobby club activity are communal features, and, as such, easier to establish than the other favorable features of social capital, i.e. friendship ties, mutual trust and religious involvement, which are culture-anchored and private by nature [see also (Forbes and Wainwright, 2001)]. On the other hand, although we planned our study design with the social capital construct in mind, we had to compromise and use questionnaire items already applied in large national population studies in both official languages in Finland. By compiling the items of social engagement from all of the above-mentioned investigations and assessing their validity and reliability, we could approach the core of social capital.
Following the guidelines from social integration to health presented by Berkman et al. (Berkman et al., 2000), we place our observations in due order. First (‘macro’), the Swedish-speaking community in Finland has its own minority culture backed up by constitutionally guaranteed rights, e.g. by the Language Act. Second (‘meso’), the Swedish speakers’ civic and social networks are tight and rich in qualitative terms, at least in comparison with the networks of the Finnish-speaking community in the same region. Consequently, the inequalities in networks are not place-related but culture-related (see Mcintyre et al., 1993). Swedish speakers have close friendship ties, participate in cultural hobby clubs, and avoid destructive drinking behavior more often than their Finnish-speaking compatriots. Also, Swedish speakers’ ethnic culture is characterized by religious involvement, including attendance at church and at religious summer meetings, and membership in religious associations. Third (‘micro’), a yet unpublished study on intersubjective emotion episodes (Lehtonen and Hyyppä, unpublished) shows interesting qualitative differences in psychosocial features. Qualitative interviews were carried out among Swedish speakers and age- and gender-matched Finnish speakers in the same bilingual municipality to collect narratives of emotionally significant events. We found that, in their narratives, the Swedish speakers emphasized human relations, attachment, reciprocity and affiliation more frequently than the Finnish speakers did. Fourth, we have not (yet) investigated pathways through which the macro, meso and micro levels influence health, but all currently available statistics on health, morbidity and mortality favor the Swedish-speaking community (Hyyppä and Mäki, 2001a).
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Concluding remarks |
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TopAbstractIntroductionMethodsResultsDiscussionConcluding remarksReferences |
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We have shown that social capital is related with well-being and (good self-rated) health in a bilingual community in Finland. We have also established important health-related patterns of social capital. The observed disparities in well-being and health we attribute to the richness of a trustful friendship network, to the active social participation in hobby groups and to religious involvement, which associate with generalized trust in community (Stolle, 1998
). The quantity of these elements of social capital distinguishes the (Swedish-speaking) minority language community from the (Finnish-speaking) majority in Finland. Finally, we suggest that, even without knowing the pathways through which the positive effects of social capital are mediated from the community spirit to the individuals’ health, it is the 11th hour for public health advocates and epidemiologists to focus attention on the cultural and social systems’ impact on health. Transition from the ‘modern’ to the ‘post-modern’ strategy of community health might turn down the neoliberal economic trends testing and eviscerating current welfare systems.
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References |
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Received on April 9, 2002; accepted on September 19, 2002
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