ABSTRACT
❿ Individuals tend to be healthier the higher they are on
the income ladder. But nations with a higher GDP/capita are not
necessarily healthier nations. A relationship has been found,
however, between income inequality and population health status.
Some of the literature that seeks to interpret these findings is
reviewed. Some suggest equality may affect health through its
impact on social cohesion or social capital. There are various
mechanisms or dynamics through which different types of social
capital might have an impact on health. Social capital may
contribute directly to health or may result in policies that are more
supportive of healthy outcomes.
I
f there is one canonical fact in
population health research it is
that social status and health are
strongly related: in virtually every
Western nation there is a relationship
between the social status of individuals,
variously measured, and a wide
variety of health indicators. Epidemiological
studies have generally measured
socio-economic status (ses) in
terms of income, educational attainment
and occupational prestige scores.
They have found relationships between
ses and such health indicators
as the incidence of cancer, heart or
cardiovascular disease, hypertension,
degree of obesity and morbidity and
mortality in general.
1
Income and health
The simplest explanations for the relationships
generally describe purchasing
power (from income),
knowledge power (from education)
and employment power (from prestige
and control) as resources that elevate
or sustain health status. Unfortunately,
however, ses has been incorporated
into many empirical epidemiological
studies with little explicit theorizing
about society and the social hierarchies
within it to which ses may correspond.
Is ses an indicator of where
an individual stands on a single static
social hierarchy or is it instead a rough
indicator of membership in a sociologically
defined social class engaged
in relations with other classes? Adler
et al. conclude that “[s]ocial class is
among the strongest known predictors
of illness and health and yet is, paradoxically,
a variable about which very
little is known.”
2 A growing interest
in the concept “social capital” coincides
with serious attention being paid
to theoretical conceptions of the nature
of social relations and society by
population health researchers.
At the individual level, the relationship
between income and health
within Western nations seems to be
curvilinear, almost logarithmic in
shape, such that we cannot determine
a poverty threshold below which
health is threatened and above which
health is randomly distributed or
solely influenced by factors unrelated
to income. Instead, the relationship
seems to produce a smooth (but
weakening) gradient wherein people
are healthier the higher they are on
the income ladder. The income and
health relationship is not recreated
across countries, however. Richard
Wilkinson has demonstrated that,
among oecd countries and given a
certain degree of societal wealth, nations
with a higher gdp/capita are not
necessarily healthier nations.
3 If the
purchasing power of income explains
the relationship between income and
health among individuals then this
finding across countries is not intuitively
obvious, since presumably the
average citizen of a wealthier society
has greater purchasing power, and
thence better health, than does the average
citizen of a poorer one.
A relationship among communities
(or societies) that focuses on community-
level attributes rather than on
characteristics of individuals, as
Wilkinson’s does among oecd countries,
is called an ecological relationship.
We would predict that the
individual-level relationship between
income and health would translate
naturally into an ecological relationship
between societal wealth and the
health of populations. This may not
be the case.
In the “relative hypothesis” psychosocial
mechanisms have been proffered
to explain why an individual’s
income affects his/her health and may
serve to elucidate the (non) relationship
described by Wilkinson. A psycho-
social interpretation might argue
that the material resources procured
by income are not the primary mechanisms
by which income affects
health: what matters are peoples’ perceptions
of themselves and their
standing relative to others. If people
compare themselves to their in-country
peers, and suffer poorer health
when they fall short in the comparison,
then it does indeed make sense
that income and health are related
within but not between nations. What
counts are comparisons among peers,
and one’s peers reside in one’s own
country. This form of an individuallevel
relationship between income and
health would not necessarily translate
into an ecological relationship between
wealth and population health
because of its focus on relative rather
than absolute income.
Another explanation focuses on
risky behaviour. We might argue that
cultures of “acceptable” activities congregate
within income classes. If smoking,
sedentary activities and poor diet
choices, for example, are more prevalent
within poorer classes than within
wealthier ones, then the individuallevel,
income-health relationship may
reflect the influences of these activities
on health status. A distribution of
(non-) healthful behaviours may contribute
to health inequalities, and if
such behaviours manifest themselves
similarly within countries, an ecological
relationship between societal wealth
and health need not surface.
The debate on the nature and
strength of the wealth and health relationship
has not neared resolution
within population health discourse.
For those pursuing a neo-materialist
interpretation of the structure of society
and pathways to health, the purchasing
power of wealth and/or the
distribution of risk behaviours matter.
In support of the neo-materialist position,
John Lynch and his colleagues
have presented further evidence that
wealth is related to health among an
expanded data-set of 33 Western countries.
4
In return, has argued
that the choice of countries for inclusion
in analysis matters: among the 21
richest countries in 1995 the relationship
between wealth and health is actually
negative; among the 23 countries
with the highest life expectancy the relationship
is non-existent.
5
Income inequality and health
Societal wealth does not predict
much, if any, mortality among the
wealthy nations of the industrialized
Western world. noted,
however, among the nine nations of
the Luxembourg Income Study, that
income inequality, measured by determining
the percentage of overall
wealth owned by the poorest 70 percent
of the populace, is strongly related
to population health status.
6
Several studies have found that this
and other measures of income inequality
are related to various health
indicators within nations as well. For
example, the relationship between income
inequality and health is strong
among the American states,
7 and
among American metropolitan areas.
8
In Canada, by contrast, Ross et al.
failed to find statistically significant
relationships between income inequality
and health among Canadian
provinces and again among Canadian
metropolitan areas.
9 This may be because
Canada does not have enough
variability in inequality among
provinces or cities for a relationship
to manifest itself at these levels. There
may be a threshold effect as well: the
Canadian provinces/cities are more
equal than nearly every American
state/city and may have maximized
the health benefits accrued from income
equality. On the other hand,
while I did not find a relationship between
average household income and
mortality rates among 30 health districts
in Saskatchewan, I did find a
nearly significant relationship between
a crude measure of income inequality
and the mortality rate.
10 This is somewhat
surprising since we would expect
income inequality to be less
relevant for health, and less variable,
at smaller levels of geopolitical aggregation,
yet the populations of these
health districts are quite small (ranging
in size from about 11,000 to
220,000 people).
Why would a place with a relatively
equal distribution of incomes
have healthier people?
proffer several types of explanations.
11
First, the individual-level relationship
between income and health
may “create” this ecological relationship
(even though it may not contribute
to the ecological relationship
between wealth and health).
note that because the
individual-level relationship between
income and health is curvilinear,
should a given society with a given income
distribution be transformed into
a more equal one the poorer peoples’
health would improve more than the
richer peoples’ health would deteriorate.
12
As a result the average level of
population health would improve.
modelled this possibility
among the American states and
found that the individual-level relationship
between income and health
mathematically predicts a weaker ecological
relationship between income
inequality and health than has been
noted empirically.
13 A multilevel exercise
by among
American communities determined
that the ecological relationship was
non-significant after controlling for individual
household income.
14 In contrast,
found a modest
empirical relationship between income
inequality and self-rated health status
among American states after controlling
for individual income.
15 There is
some, but not incontrovertible, evidence,
therefore, that the ecological relationship
between income inequality
and health is more than simply a reflection
of the relationship between income
and health among individuals.
Second, “an inequitable income distribution
may have direct consequences
on peoples’ perceptions of
their social environment that influence
their health.”
16 Wilkinson in particular
has advocated explanations of this
sort.
17 This argument, similar to the
relative hypothesis delineated above,
might go as follows. A society with a
wide distribution in incomes is one
with a pronounced status order.
People in all levels of the order are
cognizant of one another (e.g., via direct
interaction or communications
media). Those falling short in psychosocial
comparisons with others will
feel this shortcoming quite strongly,
given the width of the gap, and consequently
will suffer poorer health
than will the “losers” of comparisons
in more equal places. Ill health might
develop through the damaging emotions
caused by such relative deprivation,
emotions such as anxiety and
arousal, feelings of inferiority and low
self-esteem, shame and embarrassment,
and recognition of the need to
compete to acquire resources that cannot
be gained by any other means.
This line of explanation, like the
relative hypothesis, is attractive because
it moves directly from income
inequality, a characteristic of a collective,
to emotion, meaning or perception
and thence to physical health,
dramatically illustrating how income
inequality can “get under the skin,”
as would say. It is not
certain that this form of explanation
necessarily represents an alternative
explanation, however. If ill health-inducing
emotions are distributed along
a status order that corresponds with
the hierarchy of incomes then the argument
proffered by and
may apply here as well. If
such emotions are distributed
throughout an unequal society in a
less predictable or different fashion,
then this form of explanation provides
additional insight into the income inequality
and health relationship.
Third, it has been noted that income
inequality can only be applied
to populations and not to individuals
and can only be defined in relational
terms.
18 This ecological aspect of social
structure might influence health
indirectly through other ecological
processes, e.g., “an inequitable income
distribution may be associated
with a set of social processes and policies
that systematically underinvest in
human, physical, health and social infrastructure,
and this underinvestment
may have health consequences.”
19
suggest that “areas
that tolerate high income inequality
are also less likely to support the
human, physical, cultural, civic and
health resources in that area.” Unequal
places may have more violent
crime.
20 These background factors
may “create a context of community
infrastructure through policies that affect
education, public health services,
transportation, occupational health
regulations, availability of healthy
food, zoning laws, pollution, housing,
etc.”
21 Such contextual explanations
look to collective or ecological aspects
of societies that are associated with income
inequality: individual-level “outcomes”
such as health status and their
ecological counterparts such as population
health status are much further
down the explanatory line. Enter social
cohesion, posited as one particularly
important contextual means by
which income inequality adversely affects
population health.
Social cohesion, social capital
and health: preliminary work
propose that societies with a high degree
of income inequality are also
ones with low social cohesion, and
that one of the ways in which income
inequality affects health is through the
presence or absence of this social resource.
describes social
cohesion as the social nature of public
life, “dominated by peoples” involvement
in the social, ethical and human
life of the society, rather than being
abandoned to market values and
transactions. People come together to
pursue and contribute to broader,
shared social purposes.”
describe social capital, a concept
often linked with social cohesion
in population health discourse, as
“the stock of investments, resources
and networks that produce social cohesion,
trust and a willingness to engage
in community activities.”
Supposedly, then, something about
social spaces with some kinds of participation
and trust facilitates or produces
good health.
Wilkinson notes that it is particularly
difficult to determine causality in
this instance. “Although a narrower
income distribution leads to a more
egalitarian social ethic … [i]f a more
egalitarian social ethos were to develop
exogenously, for reasons unrelated
to income distribution, it is
implausible that such a society would
tolerate great material inequalities
without making efforts to reduce
them.” A cohesive community should
be understood in direct relation to its
degree of social inequality, according
to , such that cohesion and
inequality are opposite principles of
social organization. Increased social
equality corresponds with co-operative
and supportive social relations,
and such relations, about “mutuality,
reciprocity, sharing, and a recognition
that the needs of others are needs for
us”23 are hypothesized to have a profound
effect on health.
Ichiro Kawachi, Bruce Kennedy and
their colleagues have done empirical
tests of the income inequality, social
cohesion and health hypothesis among
the American states. Social capital,
measured via three trust questions and
one “participation in secondary asso-
ciations” question, aggregated to the
level of the state, was strongly related
to both income inequality and mortality.
24
They conclude that social capital
does indeed mediate the
relationship between the other two:
greater inequality leads to decreased
participation in the public space and
to greater mistrust, both of which then
influence health. They have since
shown that the same measure of social
capital is also related to aggregated
self-rated health status, even
after controlling for individual-level
proximal causes of health.
found a similar result
among post code sectors in western
Scotland
26 while I found a nearly significant
relationship between a crude
measure of social capital, incorporating
measures of participation in secondary
associations and voting
activity, and mortality rates among
Saskatchewan’s health districts.
27 In
contrast with the finding
among the American states, however,
my measures for social capital
and income inequality were not significantly
related to one another.
Although the interpretation
of “what causes what” may be
(and has been) contested, the empirical
results are stimulating, especially given
the simplicity of the sometimes crude
and opportunistic measures of social
capital. What are they measuring?
Describing social capital
defined social capital
as “the aggregate of the actual or potential
resources which are linked to
possession of a durable network of
more or less institutionalized relationships
of mutual acquaintance and
recognition—or in other words to
membership of a group.”
28 Membership
in a social group provides personal
resources that may be currently
active (actual) or appropriable at a
later time or in a new circumstance
(potential). “Trust between members
of a network ‘oils the wheels’ of social
and economic exchange, reducing
transaction costs, allowing group
members to draw on favours, circulate
privileged information, and gain better
access to opportunities.”
29 Measures
of the amount of participation in
and/or number of clubs and secondary
associations
30 can be interpreted as attempts
to evaluate the prevalence of
such networks of mutual acquaintance
in a given community.
description of social
capital has been particularly influential.
[S]ocial capital is defined by its
function. It is not a single entity but
a variety of different entities, with
two elements in common: they all
consist of some aspect of social
structures, and they facilitate certain
actions of actors—whether
persons or corporate actors—
within the structure. Like other
forms of capital, social capital is
productive, making possible the
achievement of certain ends that in
its absence would not be possible…
[S]ocial capital is not completely
fungible but may be specific to certain
activities… [It] inheres in the
structure of relations between actors
and among actors.
31
Thus social capital achieves; it facilitates
ends. While definition
implicitly describes social
capital as a resource that facilitates
ends for an individual, definition
remains open to ends benefiting
a social group. This variety of
ends appears somewhat analogous to
Putnam’s distinction (in this volume)
between private and public returns.
Both definitions imply that social capital
is not a single “something.” A full
description of a social
capital should identify the relevant social
structure and the attributes of this
structure that, through simple or complicated
means that may incorporate
social action, facilitate specified ends
for specified individuals or groups.
Such a description of social capital
does not distinguish what social capital
is from what social capital does,
a distinction that (in this
volume) deems essential, but subsequent
empirical and theoretical work
may find that certain attributes of social
structure do indeed work to
achieve a multitude of ends, thereby
allowing us to separate analytically
these attributes from their effects.
There are multiple forms of social
capital. A given network of mutual
acquaintance with long-term obligations
and trust is not necessarily one
with deeply held norms pertaining to
a common good, nor need it be a network
that facilitates the flow of certain
kinds of information. (These are
three forms of social capital described
.) It follows, then, that
such multiple social capitals can work
to achieve various ends. Thus, for example,
social capital has been thought
to promote economic growth and development
32
and the performance of
political institutions,
33 as well as the
health of populations.
Figure 1 is a visual rendering of a
society’s social structure that may help
to clarify various social capitals and
their “effects.” This rendering of social
structure, a network of social relations
and the attendant ideas/beliefs
articulated by and within such rela-
tions, distinguishes deep structure
from the interconnected political, economic
and civil spheres and distinguishes
these from shallow social
structure. Social structure transcends
any one person’s conception of it but
is constantly reproduced in every-day
interaction, i.e., reconstituted and
reaffirmed in mind, action, communication
and interaction. Each object in
the picture is intrinsically social, therefore,
a pattern of social actions, relations
and meanings, both the
condition and outcome of action.
I am concerned here with the influence
of social relations in one sphere
upon social relations within another,
certainly, but also with arguing that
social relations in general are multifaceted,
enact multiple dimensions of
social structure simultaneously and,
ultimately, are all pertinent for population
health. Those aspects of social
relations pertaining to deep structure
and to the economic and political
spheres that produce (ill-) health have
received substantial attention from
medical sociologists; social relations
in the civil space pertain to the social
capital and health discourse in particular
and represent a relatively untapped
arena of inquiry. The
definition of a given social structure
will also determine the range of possible
reasons why such attributes of
social structure produce health inequalities:
neighbourhoods may vary
from one another in only a few dimensions
while entire societies likely
vary along many of the dimensions
depicted in Figure 1.
Power is the differential capacity to
command resources and gives rise to
structured, asymmetric relations of
domination and subordination among
social actors. Class relations and
other embedded power imbalances
(by gender, sexual orientation, age,
race or ethnicity, language, geographic
location and/or religion, for
example), if pronounced, probably
belong to the deepest structures of society.
They influence many aspects of
the social structure but are not explicitly
recognized by actors in most
interactions. Deeply held norms about
the “right” and “good” usually remain
unrecognised as well, examples
of which might include the nature of
God in one society or the truth of scientific
findings in another. To my
mind, then, deep structure contains
both realistic/materialistic (e.g., embedded
power relations or control
over resources) and ideational aspects
(e.g., strongly held shared norms and
beliefs) blended in some kind of synthetic
ontology. Although it is difficult
to prove that any one aspect of
social structure “causes” another, I
would argue that the shape of deep
structure strongly influences the
shapes taken by the other elements in
the image. Thus aspects of deep structure
will influence activity and the distribution
of material resources in the
economic sphere. They will influence
control of human resources and/or
people within the political sphere, including
the state and such substructures
as the judiciary, civil service, police
and military. They will also
influence activity within the civil
sphere, including relations with close
friends and neighbours, so-called
strong or bonding relationships; relations
with more distant friends, associates
and colleagues, so-called weak
or bridging relationships; civic activities
linking the individual and the
state, so-called linking relationships;
and those secondary or voluntary associations
that are not directly financed
or maintained by the state.
argue that
class relations (and politics too)
should be incorporated into the income
inequality-social cohesionhealth
discourse
argue that class should be considered
as a phenomenon in its own
right: the proper objects of study for
sociologists interested in the social determinants
of health are “beneath-thesurface
relations, in the present
context crucially including those of
class, perceivable and examinable
only through their effects.
proposition that the degree
of adherence to neo-liberal tenets in a
society will influence both the distribution
of wealth and social cohesion
(and especially trust) describes how
the deepest structures of society shape
the civil, political and economic
spheres.
36 According to Coburn, a
deeply embedded belief in the ability
of markets to allocate resources properly
will influence the nature of social
relations in the civil space and the distribution
of resources in the economic
sphere, in part via its dance with class
relations and through its influence on
the nature of the welfare state.
According to these perspectives, then,
aspects of deep structure shape social
relations in many spheres of patterned
interaction.
Most conceptions of social capital
focus on attributes of civil society.
They explore participation in networks
based within that nebulous
place between the family and the
state, excluding the economic sphere,
and focus on trust among members of
such networks and the collaborative
actions they enact. Questions asked of
individuals assessing “trust in most
people” pertain to the nature of social
relations throughout all of social
structure and may or may not serve
to measure trust in other members of
civil networks in particular. As such,
trust in “most people” is better conceived
as a product of a civil societybased
social capital than a component
of such a social capital. The work by
and his colleagues
among the regions of Italy pertains to
relationships among the civil, economic
and political spheres. Thus the
prevalence of voluntaristic activities
such as participation in soccer clubs
or church choirs and civic activities
such as voting or reading a local
newspaper (in the civil sphere) may be
related to one or all of the performance
of political institutions, socioeconomic
modernity and income
inequality. argue
that actions such as participation in
secondary associations and prescriptions
such as adherence to civic norms
and duties may influence economic
development.explicitly
incorporates the nature of the state
and state-citizen relations into his conception
of social capital and its correlates.
38
The empirical and theoretical
insights provided by these researchers
reinforce my belief, articulated by
, that “the economy, the state
and civil society are, in fact, inextricably
interrelated.
I have depicted shallow structures
as aspects of the social structure that
rest upon deep structure and the interrelated
economic, political and civil
spheres, influencing these others
somewhat but more properly reflecting
more deeply embedded social relations.
Many aspects of social
structure reproduced in interaction
are often consciously articulated: e.g.,
culture (art, music, television, movies),
education, media communications
and moral standards referring to
beauty and taste. These aspects of social
structure may also serve to promote
health-producing actions and
thence good or ill health, i.e., social
capital. It makes sense to me, however,
to limit the social capital concept
to the civil sphere since most aspects
of social structure could be otherwise
deemed a health-producing social capital
of sorts. We could argue that cooperative
class relations facilitate
co-operative relations between workers
and supervisors in the workplace
and thence better health for all of
those participating in the labour market,
or that deeply held beliefs concerning
the rightness of neo-liberal
tenets facilitate the ends of a dominant
ethnic group and thence good
health for that group (but poor health
for others). These might be called “social
capital,” aspects of social structure
that facilitate certain actions and
achieve certain ends (i.e., population
health) for certain groups. The concept
loses analytical meaning in such
instances, however, by potentially encompassing
all of social relations. The
nature of social relations in the civil
space, the extent to which they are
embedded in social relations pertaining
to other aspects of social structure
and the ends they can facilitate for
groups and individuals delimit a manageable
conception of social capital.
Why might social capital within the
civil space influence the health of people?
Like the individual- and ecological-
level relationships described
above, we can analytically distinguish
between the contextual and compositional
effects of social capital on
health. Contextual effects, or instrumental
benefits, refer to social capitalrelevant
aspects of social structure
that influence the population health
of groups through indirect means.
Compositional effects, or intrinsic
benefits that result from contributing
to social capital, refer to the direct influences
of participation in multiplex
networks, or adherence to prescriptive
norms, for example, on the health of
the participants themselves, simply by
virtue of participating or adhering.
Compositional effects: The actions
and ideals that individuals engage in
or express which serve to contribute
to the store of a given social capital
might be health-inducing in and of
themselves. This explanation is analogous
to the arguments described
above wherein the income inequality
and health or wealth and health relationships
simply or partially reflect the
individual-level income and health
one. Thus Wilkinson suggests that
friendship patterns “can reflect, on the
one hand, people’s social ease and
confidence, or, on the other, the extent
to which social contact provokes
anxiety, negative social comparisons,
feelings of inadequacy and angst.”
40
There is a broad literature on the effects
of various kinds of social support
and social relationships on health,
41
and patterns of mutual acquaintance
in a social capital context may serve
to sustain health along these lines.
Knowledge of the resources inherent
in one’s networks may promote a
sense of mastery or personal control
and reduce stress. show
evidence that participation in the civic
space is related to mental health status
(and physical health status too, but
less strongly) in Australia.
42 On the
other hand,
did not find individual-level relationships
between participation in a local
association and self-rated health status
in Scotland while I describe few relationships
between participation in
various kinds of secondary associations
and self-rated health status
among individuals in eight of
Saskatchewan’s health districts.
43
These constitute only a few of the individual-
level actions and perceptions
that might contribute to a social capital
in the civil space, however.
Contextual factors: To the degree
that large-scale bureaucratic institutions
are embedded within the non-political
and non-economic social world,
social capital within the civil space
may influence the performance of political
institutions in particular, demonstrated
theoretically and empirically by
With, I have also speculated
about means by which social capitals
may affect the governing performance
of regional health authorities specifically,
although an empirical test of the
relationship in Saskatchewan did not
support the hypothesis.
45
Other characteristics of political institutions
which might also be influenced
by social relations in the civil
space, such as adherence to welfarestate
principles, are especially pertinent
to health.
argue that American states with low
levels of interpersonal trust (a consequence
of some social capitals?) are
less likely to invest in human security
and provide generous safety nets.
46
Interpersonal trust supposedly accompanies
more egalitarian patterns
of political participation that often result
in the passage of policies which
ensure the security of all its members,
policies perhaps pertaining to education,
transportation, pollution, child
welfare and zoning laws. Social capitals
may influence access to services
and amenities, since socially cohesive
communities may be more successful
at uniting to ensure that budget cuts
do not affect health and social services.
A state that seeks to redress social
inequality in general may serve to
reduce income inequality through
welfare measures, thereby potentially
improving the population’s health by
the means, both materialistic and psycho-
social, suggested above. To my
mind this constitutes the more plausible
line of causality among social
capitals in the civil space, income inequality
and population health status:
not that income inequality threatens
the nature of social relations so much
as the distribution of income reflects,
in part, the nature of social relations
in the civil and political spheres and
the deeper parts of social structure.
Social relations in the civil space
may also influence economic development
and growth, the concern of
many of the papers in this volume.
Suffice it to say that to the degree that
additional wealth aggregated to the
level of the community contributes to
health (debated above) the influence
of civil space social relations upon the
economic sphere will have implications
for population health. To the degree
that social relations within the
civil sphere affect deep structure, social
capitals may mitigate class, racial,
ethnic, gendered, religious and other
power imbalances. Networks of mutual
acquaintance spanning these potential
chasms may introduce people
to perspectives different from their
own and produce a spirit of tolerance,
thereby lessening the magnitude of influence
embedded relations have upon
social relations in general and health
inequalities along racial lines, for example,
in particular.
At any of the macro, meso and
micro levels, some forms of social capital
may influence health-related behaviours
by promoting diffusion of
health-related information (i.e., via the
information channels described by
Coleman), thus increasing the likelihood
that healthy norms of behaviour
are adopted, or by exerting social control
(i.e., via the effective sanctions
also described by Coleman) over deviant
health-related behaviour. They
may mitigate against the incidence of
crime, juvenile delinquency and access
to firearms within communities. With
respect to psycho-social determinants
of health, participation in co-operative
networks that venture far into the civil
space may produce social trust.
47 Lavis
and provide evidence from
the World Values Survey that the expression
of trust is related to self-rated
health status in Canada at the individual
level,
48 although I found that multiple
forms of social and political trust
were unrelated to self-rated health status
in Saskatchewan.
provide evidence that trust and health
may be related at the ecological level,
although this does not imply that individually
held trust necessarily produces
health for that individual
has shown (in this volume)
that community-level social capital
seems to influence degree of happiness.
Compositional aspects of a civil
space-oriented social capital may be a
determinant of health, certainly, but
do not in my opinion constitute the
most important contributions of social
capital theory to population
health research. Individual-level relationships
have been explored in depth
by social epidemiologists and others
over the years; contextual effects are
less well understood, and more difficult
to model, than are compositional
ones, and thereby represent a promising
area for exploration and conceptualization.
A final caveat: I have
described potential influences on
health of social capitals located within
the civil space but do not claim that
civil society necessarily provides the
most potent influence of the social
structure on health. The interrelatedness
of the three spheres with deep social
structure implies that population
health researchers should always set
civil society within the larger sociopolitico-
economic context. At this
time it appears that theories focusing
on consensus are popular with governments
and policy makers, perhaps
due to the rapid and overwhelming
pace of change in modern societies, as
are theories that support smaller government
by emphasizing the role of
civil society. In my opinion, theories
of the social determinants of health
that seek to be comprehensive should
additionally encompass deeply embedded
conflict and inequality and the
roles of state and economy for producing
good health for populations.
Epilogue
Social capital is the new kid on the
block when it comes to exploring the
social determinants of the health and
well-being of Canadians, evidenced by
a plethora of new research studies in
Canada that implicitly or explicitly
seek to explore social capitals and
their effects. Just to name a few, the
nre project based at Concordia University
is currently exploring processes
of inclusion and exclusion among
Canadian rural communities while the
Equality/Security/Community project,
based at ubc and concerned with describing
the distribution of well-being
in Canada, is focusing on economic,
political and social determinants of
public policies and their outcomes.
Two studies based at the University of
British Columbia, the Resilient Communities
project and the Sawmills project,
are exploring social capital and
both economic resiliency and population
health among coastal communities
in British Columbia. Similar relationships
are being investigated among
these coastal communities and among
a larger regional and national sample
of communities by researchers from
the Equality, Security and Community
project and the Georgia Basin Futures
project at ubc. The Left Out project,
based at the universities of Alberta
and Toronto, is exploring issues of
exclusion and belonging as they pertain
to social cohesion and health in
Edmonton and Toronto while the Deconstructing
the Local Determinants
of Health project at McMaster university
is exploring social capital as
one of the determinants of the health
of residents in Hamilton neighbourhoods.
Results from these and other
investigations should shed light on
many of the issues raised in this paper
and increase our understanding of the
social determinants of the health of
Canadians.
Credit:ivythesis.typepad.com
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