Social capital and mental health: An interdisciplinary review of primary evidence

Abstract

An interdisciplinary interrogation of primary evidence linking social capital and mental health sought to establish: (1) ‘quality of evidence’ (assessed in terms of study design, methods used to address stated questions, rigor of data analysis, and logic and clarity of interpretation of results), and (2) applicability of the evidence to public health policy and practice with respect to mental health. It is found that social capital, a complex and compound construct, can be both an asset and a liability with respect to mental health of those in receipt of and those providing services and other interventions. The most meaningful assessment of social capital or components thereof may examine individual access to rather than possession of social capital, a property of groups, and therefore an ecological variable. Theoretical advances in research on social capital serve to identify mainly two types of social capital: bonding (between individuals in a group) and bridging (between groups). Each type of social capital has cognitive and/or structural component(s) and may operate at micro and/or macro level(s). Effective mental health policy and service provision may build or strengthen bridging social capital and benefit from both bonding and bridging social capital where either or both exist. Established indicators of social capital are amenable to quantitative and qualitative assessment, preferably in tandem. However studies that employ combined research design are rare or non-existent. Interdisciplinary multi-method investigations and analyses are called for in order to unravel mechanisms whereby social capital and mental health might be meaningfully associated.

Introduction

Leading academic public health journal editorials, commentaries, and special issues continue to draw their readers’ attention to “social capital” and “mental health” or psychosocial variables (Muntaner, 2004; Kelleher, 2003; Greenberg & Rosenheck, 2003; Sartorius, 2003; Dannenberg, Jackson, & Frumkin, 2003; Saegert & Evans, 2003; Jackson, 2003; McKenzie, Whitley, & Weich, 2002; Henderson & Whiteford, 2003). A compound and complex construct, social capital continues to appeal to the intellect and imagination of public health scholars, policy makers and practitioners alike, all of whom are immersed in the wider debate on poverty, health inequalities and social exclusion (Carlson & Chamberlain, 2003; Pearce & Davey Smith, 2003; Krishna, 2002; Moss, 2002; Pilkington, 2002; Muntaner, Lynch, & Davey Smith, 2001; Hawe & Shiell, 2000; Lynch, Due, & Muntaner, 2000; Baum (1999), Baum (2000); Kawachi & Kennedy, 1999; Leeder & Dominello, 1999; Lomas, 1998; Edwards & Foley, 1998; Edwards, Foley, & Diani, 2001; Wilkinson, 1996). The afore-mentioned authors constitute a representative sample of protagonist and antagonist theoretical and empirical stances on “social capital”, often used as an umbrella term embracing social cohesion, social support, social integration and/or participation, among several other social determinants of health in general and mental health in particular. The substance of debate has been marked by polarized political overtones and mixed philosophical undertones. Scarcity of primary data purposely gathered to investigate associations between social capital and health and/or mental/emotional wellbeing has been a major constraint. However, this situation is rapidly improving, witness the steady rise in the number of papers on social capital indexed in MEDLINE and elsewhere between 1992 and 2002; and there are hints of reconciliation between hitherto polarized camps with opposing theories and interpretations of research evidence—See Putnam, 2004; Kawachi, Kim, Coutts, & Subramanian, 2004. Social capital is now integral to global discussions of sustainability and collective management of (common) resources, as exemplified by the recent special issue of Science which revisited (and reprinted) Hardin's “Tragedy of the Commons”—See Pretty, 2003; Hardin, 1968, 2003.

Limitations in understanding of the multifaceted concepts of ‘health’, ‘community’ and ‘participation’ remain. These are all central to the social capital discourse, and by definition difficult to assess solely by means of quantitative methods of investigation and analysis (Cowley (1995), Cowley (1997)). They are all dynamic and process-oriented and not static or linear outcome-oriented phenomena, hence the need for researchers to carefully consider meanings already assigned to these terms and define their own use of them in any given context. Previous studies have highlighted common pitfalls in the use/misuse of “community” and “community participation” in health and social research (McDowell, Spasoff, & Kristjansson, 2004; Drevdahl, 2002; Bryson & Mowbray, 1981; Jewkes & Murcott, 1996; Hawe, 1996; Hawe, 1994; Fowler, 1991; Tumwine, 1989). Participatory and qualitative research evidence may shed light on otherwise intractable associations (see Cattell, 2001; Morrow (1999), Morrow (2001); Wilson, 1997), but these have not featured prominently in the social capital and mental health debate.

The turn of century has seen official designation of mental health as a “global burden of disease”, with widespread depression accounting for most of the “burden” (WHO, 2001). A renewed shift of focus from curative to preventive measures has come about through multi-disciplinary enquiry into the mechanisms whereby social support and effective and efficient health care delivery may promote health in general and mental health in particular (Sartorius, 2002; Harpham, Grant, & Thomas, 2002; McKenzie et al., 2002; Kawachi & Berkman, 2001; Berkman, Glass, Brissette, & Seeman, 2000). This paper sets out to investigate what is known so far about the associations between social capital and mental health, what remains unknown (if not unknowable), and what possible policy and practice implications might be gleaned from available primary evidence.

Social capital and mental health are both compound and complex terms which require multidimensional definitions and corresponding multi-method means of investigation and analysis. Concerning social capital, two distinct schools of thought are currently prominent in the published literature: Robert Putnam's communitarian line of political thinking (Putnam, 1995) and Pierre Bordieu's social theory of forms of capital (Bourdieu, 1986) amplified by James Coleman's exposition of “family social capital”(Coleman, 1988). These have both been subjects of critical discussion in the behavioral and social sciences (see Edwards & Foley, 1998; Edwards et al., 2001). Within social epidemiology/psychiatry, definitions of social capital are intertwined with the measurement scales used to quantify it, and there is little consistency in the literature. However, it is clear that social capital is not synonymous with (although it may well embrace and indeed be manifested by) social participation, social integration, social cohesion, and/or social support individuals can access or be barred from on account of their membership in groups and/or formal and informal institutions. Both theoretical and empirical analyses of social capital in a broad array of disciplines and sub-disciplines (including sociology, social epidemiology, and political sciences) identify two types of social capital: bonding and bridging. Each of these has two components (some authors call them “forms” of social capital): structural and cognitive operating at micro (individual—person or family/household) and/or macro (ecological—i.e. neighborhood, community, formal or informal group) levels—see Table 1 for a sketchy outline; and Macinko & Starfield, 2001; Hawe & Shiell, 2000 for substantive reviews. As these authors have pointed out, the language of social capital spans the realms of economic metaphor and political rhetoric. Definitions are usually extracted from the key protagonists (Putnam, Bourdieu, and/or Coleman) in précis form. Brief definitions capture little of the meaning with which constructs such as social capital are imbued. Researchers have taken the definition of their choice and run with it in different directions to extend the original meaning of this compound and complex construct; generating more questions than answers in the process. For the purposes of this review, a brief consideration of the roots of Putnam's, Bourdieu's and Coleman's expositions of social capital is outlined.

The social capital thesis of Robert Putnam and colleagues was developed around the workings of democracy at the level of local and regional government in Italy during its decentralization “experiment” which began in 1970. Devolution of power from the central government to the regions had opened up for citizens unparalleled opportunities for participation in political decision-making processes. ‘Social capital’ constituted one chapter out of six in Putnam et al.'s treatise Making Democracy Work (Putnam et al., 1993), but it was the key chapter, the anchor without which the preceding five chapters may have floated astray. Putnam et al.'s longitudinal data chart development and change in Italy's diverse local government and civic regional institutions over a 20-year period of study. Local small-scale informal institutions such as rotating credit associations built on the basis of trust and reciprocity primarily between close friends and family relations feature significantly in this classic work. Rotating credit and saving associations (ROSCA) are well known, primarily women's institutions which provide effective informal social security for their members. ROSCA exist practically in all parts of the world and they provide comprehensive social support (emotional, cognitive and material) directly to women (and thereby to their families) in ways that formal institutions normally cannot (see Ardener & Burman, 1995). However, neither Putnam nor his disciples consider carefully the workings of ROSCA, and whether or not “levels of social capital” can be adequately measured without incorporating site-specific ethnographic narrative and analysis of gender-specific informal institutions such as these in Italy or in other countries. Putnam's popularized version of social capital or lack of it in the USA (Putnam, 2000) obscures the salient points of his earlier work, and has justifiably generated rebuttals (Edwards et al., 2001; Edwards & Foley, 1998) including in mental health circles (Pevalin, 2003).

Individuals and groups with material assets would be expected to both generate and benefit from the structural and cognitive components of social capital differently from those without. The ‘haves’ would be better placed to reciprocate goods and services amongst themselves compared to the ‘have-nots’. In countries like the USA where the haves and have-nots are structurally and socially segregated, there would be increased likelihood that the have-nots will be more miserable (and thus suffer worse emotional/mental ill health) than they might in Italy where the effects of such inequality may be mitigated by strong cultural influences of communitarian (as opposed to individualistic) society. More complex and intractable issues present themselves when gender, class and/or race come into the equation. Prominent scholars and practitioners have both tackled virtually insoluble questions that revolve around health inequality and social exclusion in public health generally (Wilkinson, 1996) and mental health specifically (Sayce, 2000). This paper argues that contemporary social capital and mental health discourse would do well to be inclusive rather than exclusive of historical and socio-cultural narratives in order to avoid going round and round in circles of arguments between epidemiologists, however sociologically and/or anthropologically aware.

If the premise that the fundamental goal of research is to portray as accurate a representation of reality as possible holds, then it would behove all researchers to seek information from the best possible source(s) using the most reliable method(s). As different academic disciplines and sub-disciplines carry with them their own strengths and limitations/biases in research, it is necessary for policy makers, practitioners and other users of research findings (including the study participants themselves where power structures and other factors do not relegate them to mere passive respondents to survey questionnaires) to employ inter-disciplinary analyses of available evidence where it exists and to actively seek and/or commission it where it is lacking. Research on social capital and mental health may be particularly prone to misrepresenting study populations and distorting their realities, with possible detrimental public health and social policy consequences.

Consider a juxtaposition of the history of civic participation/democracy and social capital in Putnam et al.'s Italy with Franco Basaglia's movement of democratization of psychiatry and the process of de-institutionalization of mental health patients during the second half of the last century—Table 2. The point here is that measures of ‘social capital’ in isolation from political and economic historical context of any given society are bound to produce only partial accounts of reality; and by implication, evidence that may be inapplicable (if not outright wrong and harmful) to policy and practice.

Turning to the origins of Bourdeiu's and Coleman's notions of social capital, theory precedes empirical evidence. Pierre Bourdieu's work on the “forms of capital” (human, cultural and social) was informed by a brief spell of quasi-ethnographic fieldwork in Algeria followed by extensive analysis and theorizing back in France (Bourdieu, 1986; see also Calhoun et al., 1993; Robbins, 1991). It is beyond the scope of this paper to discuss the impact of Bourdieu's social theory upon sociologists and other researchers on both sides of the Atlantic, suffice it to say that it has had significant influence on Coleman's exposition of “family social capital” (Coleman, 1988). Although Bourdieu's ideas originated in observations of communitarian social capital (not dissimilar to Putnam's) in rural Algeria, its interpretation and uptake in the USA has been distinctly individual. There remains much confusion in the literature as to whether social capital, a common good, can meaningfully be discussed at the individual level with respect to disease causation and/or health promotion (see for instance Davey Smith & Lynch's most recent commentary, Davey Smith & Lynch, 2004). This is not unrelated to the ongoing crisis of identity and soul-searching among epidemiologists witnessed over the past decade; bringing to the fore cause-effect ambiguities around social determinants of health/ill-health; and the limitations of epidemiological training, theory, and methods (Krieger, 1994; Susser & Susser (1996), Susser & Susser (1996); Shy, 1997; Walker, 1997; Morabia, 1998; Mcpherson, 1998; Pearce, 1999; Wall, 1999; Davey Smith & Ebrahim, 2001). This paper acknowledges these ongoing conversations in social epidemiology, and seeks to contribute new perspectives grounded in bio-medical anthropology. It is proposed that while it is reasonable to assess (qualitatively and quantitatively) individual access to available stocks of social capital, it may be problematic both theoretically and empirically to ‘measure’ individual levels of social capital; or derive from individual measures aggregate quantities of social capital said to be at the disposal of groups. This paper maintains that researchers from outside looking in are bound to present very different portrayals of reality from investigators/facilitators who engage their study participants in participatory co-investigations of social capital and mental health.

Human beings thrive more in groups than in isolation (Berkman et al., 2000; Berkman, 1995). However, social ties may constrain individual freedom and sense of wellbeing; and there may be trade-offs between the safety of cohesive ties and the flexibility of weak ties (Gargiulo and Benassi, 2000; Kawachi & Berkman, 2001; Portes & Landolt, 1996; Granovetter, 1973). In Putnam's popularized language (after de Souza Briggs), bonding social capital helps people to “get by”, while bridging social capital enables them to “get ahead”. These two functions of social capital may operate at micro levels of individuals, their families and social networks; or macro levels of formal and informal institutions to which individuals and/or groups subscribe (Table 1). While structural components of social capital are relatively easy to quantify, elements of cognitive social capital may only be fully examined by means of qualitative and participatory methods of investigation and analysis.

Several researchers have grappled with questions of definition and quantitative measurement of social capital, and there are now established and adaptable scales for measuring collective efficacy in terms of informal social control, social cohesion and trust (Sampson, Raudenbush, & Earls, 1997; Saguaro Seminar, 2000; Harpham et al., 2002), as well as issue and/or site-specific scales developed for the purposes of assessing neighborhood quality (Yang, Yang, & Shih, 2002; Ross & Mirowsky, 1999). However, these do not necessarily incorporate meanings assigned to notions of “trust” (thick and thin), and “reciprocity” by their study participants/respondents themselves. Ideally, ethnographic/qualitative investigations should precede and inform the design of quantitative measurement scales; and/or coincide with and/or follow in order to help interpret statistical data. Qualitative and participatory assessments of social capital are few and far between (Morrow, 2001; Cattell, 2001; Wilson, 1997), and this presents a serious limitation on the extent to which health and social capital relationships can be properly understood.

Defining and measuring mental health is equally challenging. Mental health encompasses a wide range of categories of illness and social behavioral disorders including psychosis, anxiety, depression and substance misuse/addiction. One aspect of social capital, namely, informal social control in terms of adherence to shared norms of behavior has been shown to be positively associated with health promoting behaviors such as smoking cessation and lack of indulgence in excessive alcohol consumption (Lindström, Hanson, & Ostergren et al. (2000), Lindström, Hanson, & Oestergren (2001); Weitzman & Kawachi, 2000). However, social participation and access to common goods can also lead individuals to their early grave; if for instance, their closest emotional ties happen to be immersed in health demoting activities such as excessive smoking and alcohol consumption.

This paper adopts the holistic definition of mental health espoused by Sartorius (2001, p. 101), “the state of balance that individuals establish within themselves and between themselves and their social and physical environment”. Two fundamental assumptions are made at the outset: one, health is conceptually ambiguous and defiant of objective definition, quantification and bureaucratic appropriation (Cowley, 1997) and therefore any measurable associations between social capital and mental health can only be approximate. Qualitative assessments of social capital in terms of “resources for health” (Cowley & Billings, 1999) may complement quantitative approximations; and two, public health policy (and practice) has historically been influenced (if not driven) by contemporary socio-political discourse, the latest of which is imbued with social capital (see Szreter (2002a), Szreter (2002b)). Mental health policy and practice, critical components of this larger picture, remain central to the social capital discourse.

There are fundamental limits to building social capital through top-down social engineering, but public policy and practice may support and strengthen bottom-up processes of social action to promote health, collective efficacy and economic prosperity. This review attempts to forward an inter-disciplinary framework of analysis of primary evidence that links social capital and mental health with a view to discerning the implications for inter-sectoral policy and practice with special reference to mental health.