The Associations Between Social Capital And Health Equity

Recent years, with the acceleration of reforming state-owned enterprises and urbanizing, the urban poor population has increased rapidly. By the end of 2003, there were 30 million urban residents living below the absolute poverty line, 30 to 40 percent of whom got into poverty because of illnesses. Thereinto, the urban poor population in the middle and western China accounted 82.19% of the whole urban poor. They have no or low income, living in a bad settlement environment, being badly undernourished, with high psychological pressure, so they have higher chances to catch illnesses than the non-poor. Although they have high health care demands, most of them are not covered by the medical insurance system, having to ignore minor health problems and treat serious diseases in a halfway.Although quite a few studies can identify that, in less egalitarian societies, those at the bottom of the social order are more likely to experience ill-health, they explain little about why or how this happens nor do they expose any underpinning dynamics which may determine health inequalities. Later, social capital variables were introduced into some health studies, combining with psychosocial theories, and a new approach came into being to explain the health inequalities.In the early 1990s, social capital theory was formally introduced into health studies. A series of studies on the associations between social capital and health have been done in such developed countries as the U.S.A., Canada, Australia and Sweden, and a few studies also explored the associations between social capital and health care utilization, and social capital and health financing. Owing to the unique social, economic, and cultural context, there are big differences between social capital in Chinese society and that in Western countries; however, up to now, there have been very few health studies touching this field in China, which didn't analyze the associations between social capital and health equity in detail.The general objective of this study is: based on the theoretical study and the evidence-based analysis, establish a theoretical model which explains how social capital influences health equity in Urban areas, and put forward some suggestions of improving health equity via social capital approach. The specific objectives include: establishing a theoretical model which explains how social capital influences health equity; comparing and analyzing the difference of social capital between the poor urban residents and the non-poor, and identifying the factors influencing social capital of urban residents; exploring the associations between social capital and health equity (including health status, health care utilization and the occurrence of catastrophic health care payments).Data and MethodsThe data sources of this study include all kinds of published or unpublished literature, household survey and key informant interview. Using purposive sampling, this study selected two UHPP project cities- Xining and Yinchuan-as the study sites. The sample covered four districts (Chengbei, Chengdong, Chengxi, Chengzhong) in Xining and three districts (Xixia, Jinfeng, Xingqing) in Yinchuan respectively. The household survey in the July of 2006 involved 801 poor households and 804 non-poor households. The key informant interview in the June of 2007 involved 16 community residents (8 poor and 8 non-poor) in Xining and Yinchuan. Considering the survey costs and the local dialect, we trained the undergraduates from the health vocational and technical college in Xining and the Nixia Medical University to complete the household survey (about 25 students in each city). The content analysis was used to analyze the qualitative data. For the quantitative data, we first showed some descriptive statistic results about the social-demographic characteristics, family economic status and the original social capital indicators, then we extracted social capital factors through factor analysis, and then we aggregated the individual-level social capital into community-level. After that, we used both one-factor and multi-factor analyses to explore the associations between social capital and health equity. The analysis of quantitative data was done by SPSS11.5 software.Main results(1) Description of social capital: except religious groups, the proportions of non-poor responders who particpate in the political, cultural and voluntary groups are all higher than those of poor responders. The mean of group memberships of non-poor responders is 1.86 times as many as that of poor responders. The proportions of "often visiting neighbors", "often inviting neibors to home" , "often chatting with neighbors" and "asking neighbors to watch one's home when one is away" among the non-poor responders are all higher than those among the poor responders. The proportions of non-poor responders, who agree that the majority of community residents are trustable and evaluate the public safety of local community as good, are respectively 1.15 and 1.11 times as big as those of poor responders. As for "when you are ill or feel uncomfortable, someone will care for you?", "if you are ill your neighbors will help you?" and "if you have private problems, close friends or relatives will discuss them with you?", the proportions of poor responders whose answers are "seldom" or "never" are all higher than those of non-poor responders. The analysis of qualitative data shows that, the poor interviewees have very few close relatives or friends, who have similar social positions to them, and the poor won't resort to them until they have to do something. The reciprocity between neighbors is mainly felt by borrowing things from each other. The interviewees agree that, through helping others, one can feel happy and useful, harmonize the interpersonal relationships, and expect to get some returns in the future.(2) Inflencing factors of social capital: through factor analysis, we got five social capital factors- neighborhood cohesion, social participation, reciprocity and social support, interpersonal relationship network, and perception of trust and safety. The one-factor and multi-factor analyses show that, the interpersonal relationship networks of males are better than those of females, while their neighborhood cohesion is worse than females. With the increasement of age, the interpersonal relationship networks shrink, while the perception of trust and saftey is strengthened little by little. With the improvement of education level, there are increasing trends for social participation, reciprocity and social support, and interpersonal relationship network, while a decending trend for the perception of trust and safety. Compared with the employed people, the unemployed people are more inactive in social participation and have smaller interpersonal relationship networks. The multi-factor analysis shows that family economic status (poor and non-poor) and residence locality are two common determinants of the five social capital factors. Poverty is positively associated with lack of individual social capital in each dimension, with partial correlation coefficients ranging from 0.06 to 0.15. The qualitative analysis shows that some interviewees regard that it's poverty that blocks the development of their social capital.(3) Social capital and self-rated health status: standardized by age and sex, the proportions of poor self-rated health (SRH) among the poor responders in Xining and Yinchuan are 2.01 and 2.31 times as big as those among the non-poor responders respectively. The multi-factor analysis shows that, for the total sample, the higher one's education level is, the lower probability of poor self-rated health will be; catching chronic illnesses are highly positively associated with poor SRH (OR=12.29); the probability of poor SRH among the poor responders is 2.2 times as high as that among the non-poor responders; the probabilities of poor SRH among the groups with low community-level neighborhood cohesion and individual-level reciprocity and social support are 1.30 and 1.52 times as high as those among the groups with high community-level neighborhood cohesion and individual-level reciprocity and social support. The synergy indexes between poverty and low community-level neighborhood cohesion, and poverty and low individual-level reciprocity and social support, are 3.05 and 1.25 respectively, indicating a strong synergistic effect. The qualitative analysis shows that active social participation, especially community participation, can promote both physical and psychological health to some extent.(4) Social capital and health care utilization: the one-month not-visiting rates among the poor in Xining and Yinchuan are 1.10 and 1.11 times as high as those among the non-poor; the one-year not-hospitalization rates among the poor in Xining and the non-poor in Yinchuan are 1.22 and 1.33 times as high as those among the non-poor in Xining and the poor in Yinchuan. For the poor, "financial difficulty" is the most important reason of not visiting (36.83%) and not being hospitalized (93.75%). The multi-factor analysis shows that, the responders with poor SRH have the highest probability (OR=0.63) of not visiting doctors within one month, and the responders living in the communities with high neighborhood cohesion have lower probability(OR=0.65) not visiting doctors within one month than those in the communities with low neighborhood cohesion. The qualitative analysis shows that, for those interviewees catching illnesses, the supports from family members and lineal kins have important effects on their health care utilization.(5) Social capital and catastrophic health care payment: the rates of catastrophic health care payment among the poor households in Xining and Yinchuan are both a little higher than those among the non-poor households. The multi-factor analysis shows that, with the number of family members with chronic illnesses increasing, the probability of catastrophic health care payment also increases; those households, whose householders belong to the groups with high-score community-level neighborhood cohesion (OR=0.77) and low-score individual-level interpersonal relationship network (OR=0.74) , have lower probabilities of catastrophic health care payment. The qualitative analysis shows that, in the case of catastrophic health care payment, the majority of poor interviewees mainly receive some weak financial supports from their lineal kins. Many of them often give up treatments.Conclusions and policy implicationsThe low community-level neighborhood cohesion and individual-level reciprocity and social support are both closely associated with poor self-rated health, and have strong interactive effects with poverty. In the communities with high neighborhood cohesion, the residents have higher rates of health care utilization, and lower probability of catastrophic health care payment. Therefore, improving social capital of the poor may be helpful in reducing health inequity to some extent; however, owing to the spiral effect of social capital and poverty, this relief effect would be very transitory if poverty-reduction measures were not simultaneously implemented. In a context without completed social, medical and old-age security systems, the supplement function of micro-level social capital is of important significance; however, strengthening the macro-level constructions of social systems and norms to promote social equity, and establishing complete social, medical and old-age security systems are the best measures to ensure health equity.We put forward the followed suggestions for the improvement of social capital and health equity: (1) through all kinds of approaches, help urban poor residents get employed and break away from poverty; (2) take proper measures to relieve the economic burdens of urban poor households, including helping urban poor residents join medical insurance system, giving them necessary medical aids and derating education costs of their children; (3) pay more attention to the prevention and treatment of chronic illnesses among the poor residents; (4) develop more social groups and activities aiming at poor people, encourage and lead them to join more social groups and activities, and make efforts to eliminate the obstacles that limit poor people's participation; (5) strengthen the construction of community social capital, improve the cohesion among community residents, and create a community atmosphere full of mutual trust and reciprocity, and pay especial attention to the vulnerable groups within the communities; (6) the community health centers (or stations) should strengthen the exchange and communication with the poor residents and get adequate trust from them, to grasp their health information and facilitate their health care utilization.