Social capital, SES and health: an individual-level …faculty.arts.ubc.ca/veenstra/Paper9.pdf · Social capital, SES and health: an ... University of British Columbia, Vancouver,

Social capital, SES and health: an individual-level analysis

Gerry Veenstra*

Centre for Health Services and Policy Research, Institute of Health Promotion Research and Department of Anthropology and

Sociology, University of British Columbia, Vancouver, Canada

Abstract

Stimulated by the ®nding (Kawachi et al., 1997) that social capital in communities may mediate the relationshipbetween income inequality and health status, this article describes relationships between individual-level elements of

social capital Ð trust, commitment and identity in the social-psychological dimension; participation in clubs andassociations and civic participation in the action dimension Ð and self-rated health status, before and aftercontrolling for human capital (socioeconomic status measured by income and education), using survey data

collected in Saskatchewan, Canada (n = 534, 40% response rate). Income (P = 0.001) and education (P < 0.001)were related to health in the expected directions. Both income (P = 0.002) and education (P = 0.004) were relatedto health among the elderly; education (P = 0.035) to health among the middle-aged; and neither among the

youthful respondents. Frequency of socialization with work-mates (P = 0.019) and attendance at religious services(P= 0.034) had the strongest (and positive) relationships with health of the social engagement questions, even aftercontrolling for human capital, and participation in clubs and associations was positively related to health among the

elderly (P = 0.009). But for commitment to one's own personal happiness (P = 0.039), trust, commitment andidenti®cation of various kinds were not signi®cantly related to health. Civic participation was also unrelated tohealth. The main conclusion is that little evidence was found for compositional e�ects of social capital on health.Secondary ®ndings are that the relationship between SES and health was the same for men and women and

strongest among the elderly; that socialization with colleagues from work is relevant and that attendance at religiousservices and participation in clubs are related to health for the elderly. # 2000 Elsevier Science Ltd. All rightsreserved.

Keywords: Social capital; Trust; Participation; SES; Self-rated health

Introduction

Social capital has become a popular topic in thepast decade and research linking it with health has

come fast and furious. Social capital has been thoughtof as the web of cooperative relationships between citi-

zens that facilitates resolution of collective action pro-blems (Coleman, 1988) and those features of socialstructure, such as levels of interpersonal trust, norms

of reciprocity and mutual aid, that act as resources forsuch collective action (Coleman, 1988; Putnam et al.,1993). It is generally thought to be a characteristic ofsocial relationships rather than of individuals

(Coleman, 1988), although the issue is a contentious

Social Science & Medicine 50 (2000) 619±629

0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(99 )00307-X

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* Corresponding author. Department of Health Care and

Epidemiology, University of British Columbia, Mather

Building, 5804 Fairview Ave., Vancouver, BC, V6T 1Z3,

Canada. Tel.: +1-604-822-8042; fax: +1-604-822-4994.

one (Brehm and Rahn, 1997). Recently Woolcock(1998) provided social capital researchers with a com-

prehensive survey of social capital research and theori-zation that appears to encompass most of theemphases put on social capital by researchers from a

wide variety of disciplines. Tracing in¯uences back toDurkheim and Weber, among others, he identi®es fourmain dichotomies that characterize social capital rich

(or poor) `communities.' According to Woolcock, then,we should be concerned with intra-community ties (in-tegration within communities), inter-community ties

(linkages between communities), embeddedness ofstate-society relations at the macro level (synergy) andinstitutional coherence, competence and capacity, alsoat the macro level (organizational integrity) (p. 168).

For example, referring to intra-community ties, ``[t]hemore intensive the social ties and generalized trustwithin a given community, the higher its èndowment'

of (this form of) social capital'' (Woolcock, 1998, p.171).A number of studies have linked the presence of

social capital in communities, or states or even nations,with some interesting correlates. For example, Putnamet al. (1993), measuring social capital with an index

composed of participation in clubs and associations,voting turnouts and newspaper readership, concludedthat it was positively correlated with socioeconomicmodernity and political performance in Italian regions

and that it predates chronologically and thereforelikely causally, both òutcomes'. Knack and Keefer(1997) used the World Values Survey to ®nd, at the

level of nation, that group memberships may be unre-lated to trust and civic norms but that both trust andcivic norms have signi®cant impacts upon economic

activity. Kennedy et al. (1998) concluded that, amongthe US states, social capital is related to the incidenceof violent crime, as is income inequality and that socialcapital e�ectively mediates the relationship between

income inequality and crime.Similarly, Kawachi et al. (1997) found that, among

US states, social capital mediates the relationship

between income inequality and health status. Theymeasured social capital using three trust questions andone indicator of participation in clubs and associ-

ations. Their conclusion was that greater incomeinequality decreases a state's store of social capitalwhich in turn leads to poorer health of citizens. In par-

ticular, higher levels of trust and greater associationalparticipation were related to lower levels of mortalityfrom most of the major causes of death. Kawachi etal. (1999) found that individuals living in states with

low social capital were at increased risk of poor self-rated health, even after controlling for individual riskfactors (e.g. low income, low education, smoking,

obesity, lack of access to health care).So why might social capital have an in¯uence upon

health? Kawachi and Berkman (1998) distinguishbetween compositional and contextual e�ects and hy-

pothesize attributes of these e�ects. It could be thatmore socially isolated individuals live in social capitalpoor areas and, since the relationship between social

isolation and health is well documented, social capitalpoor areas might then have poorer aggregate health. Itcould also be true that trust held by individuals, or

civic participation, for example, are directly related tohealth. There is evidence that psycho-social processesare sometimes related to health by providing a�ective

support and a source of self-esteem (Wilkinson, 1996).However, although social support and social involve-ment in networks, both at the individual level, havebeen linked to a number of health status measures, the

contextual nature of social capital leads one to suspectthat social capital rich communities may have in¯u-ences upon individual's health through pathways other

than networking and receiving support from familymembers and friends.The challenge, therefore, of social capital research

is to identify contextual in¯uences upon health Ðe�ects that are, unfortunately, less easily discernedempirically. According to Kawachi and Berkman

(1998) (see also the World Bank's web-page on socialcapital) and considering the neighbourhood level inparticular, social capital may in¯uence (1) health re-lated behaviours by promoting di�usion of health-re-

lated information and thus increasing the likelihoodthat healthy norms of behaviour are adopted and byexerting social control over deviant health-related

behaviour and (2) access to services and amenities,since socially cohesive communities may be more suc-cessful at uniting to ensure that budget cuts do not

a�ect local services. Referring to the state level ``morecohesive states produce more egalitarian patterns ofpolitical participation that result in the passage ofpolicies which ensure the security of all its members''

(Kawachi and Berkman, 1998, p. 22) which then in-¯uence health. The performance of political insti-tutions may also be related to levels of social capital,

as described theoretically and demonstrated empiri-cally by Putnam et al. (1993). `ÙS data demonstratethat states with low levels of interpersonal trust are

less likely to invest in human security and to be gen-erous with their provisions for safety nets'' (Kawachiand Berkman, 1998, p. 22). Veenstra and Lomas

(1999) have detailed mechanisms through which socialcapital may a�ect the performance of governing insti-tutions in health care speci®cally.Is social capital entirely the property of social struc-

ture and social relationships or does it exist, at least inpart, in individuals? Presumably individuals are therepository of societal norms and values, although they

may not be aware of such. Social capital theory ada-mantly adheres to the perspective that social capital is

G. Veenstra / Social Science & Medicine 50 (2000) 619±629620

more than aggregated characteristics of individuals,

but certainly the individuals living in social capital richcommunities re¯ect that fact by their personal partici-pation patterns and their personal attitudes toward

one another. If there is a relationship between socialcapital and the health of populations, as new researchhas indicated (Kawachi et al., 1997), then perhapssome of the variance in health status is explained by

trust, civic norms, civic participation and socialengagement professed and engaged in by individuals.The more complex task is to discover why social capi-

tal rich communities promote health in addition to thecharacteristics of individuals, certainly, but cross-sec-tional individual-level analysis can still shed some light

on the relationship between social capital and health.This article attempts to explore relationships among

trust, social engagement and civic participation and

health using cross-sectional data from a survey of ran-domly selected individuals in Saskatchewan, Canada,as another small step toward uncovering the complex-ities of the relationship between social capital and

health. First, it highlights relationships between humancapital (socioeconomic status measured by educationand income, in particular) and self-rated health status

among gender and age groups. Second, it explores re-lationships between some human parts of social capital(social and civic participation and the social-psycho-

logical constructs of trust, identity and commitment, inparticular) and self-rated health status before and aftercontrolling for socio-demographic and human capitale�ects. If a relationship exists between the human

parts of social capital and health than we have evi-dence of a compositional e�ect of social capital uponhealth, especially if the relationship holds after control-

ling for human capital as well. If there are few re-lationships of this kind then the challenge is renewedto ®nd the more intricate pathways through which

trust in communities, for example, has an in¯uenceupon peoples' health.

Methods

I selected eight (of 30) health districts inSaskatchewan, Canada, as part of a larger project

(described in Veenstra and Lomas, 1999; Table 1),within which to conduct a survey of randomly selectedcitizens 18 yr of age and older. In the larger project Irequired at least two urban districts, two mid-sized

ones and two rural ones. The limited number ofchoices in the ®rst two categories restricted my selec-tion for the ®rst two groups and led me to include

four rural districts instead of just two; I chose the dis-tricts judiciously, therefore, rather than randomly. Asurvey was administered to randomly selected citizens

within randomly selected households from these eighthealth districts in the summer of 1997.Using a CD-ROM from the company Pro-CD with

phone numbers, names, addresses and postal codes ofthe households in Saskatchewan with a listed tele-phone, I took a random sample of households fromeach district Ð 220 from the larger ones and 180 from

the smaller ones. The survey was mailed and the recipi-ent asked to give the questionnaire to a member of thehousehold selected randomly. They were asked to

select the random respondent by listing the membersof the household, 18 yr of age or older, in order ofbirthday within the year and selecting the person

whose birthday falls earliest in the year. After a weekreminder postcards were sent to all recipients, followedby a re-mailing of the survey six weeks later and a®nal reminder postcard one week after that. To

attempt to ascertain how non-representative thesamples were I compared aggregated age, gender andincome characteristics of the samples to known charac-

teristics of the districts. Most of my samples werebiased toward high income, female and older respon-dents. More speci®cally, it appears that I under-

sampled the lowest income group, often over-sampledthe highest income group, under-sampled the youngest

Table 1

Response rates for the survey of randomly selected citizens in eight health districtsa

Total

Health District

A B C D E F G H

Respondents (no.) 534 73 73 86 54 61 54 73 60

Surveys mailed (no.) 1599 220 220 220 220 179 180 180 180

RTS (no.) 274 33 17 27 57 23 70 15 32

Response rate 1 (%) 33.4 33.2 33.2 39.1 24.5 34.1 30.0 40.6 33.3

Response rate 2 (%) 40.3 39.0 36.0 44.6 33.1 39.1 49.1 44.2 40.5

a RTS=mail returned to sender (i.e. undeliverable). Response rate 1 is the number of respondents divided by the number of sur-

veys mailed. Response rate 2 is the number of respondents divided by the number of surveys assumed delivered (i.e. eliminating

RTS from the denominator).

G. Veenstra / Social Science & Medicine 50 (2000) 619±629 621

age category and over-sampled the middle-aged agecategories.

Indices

Overall civic participation

This index was a collection of responses to all items

in the survey that address civic participation; that is,actions that demonstrate a desire to serve the greatergood, an interest in a�airs in the public realm and ex-perience participating in political life. The items were

``Have you ever belonged to a neighbourhoodimprovement association?'', ``Have you volunteeredregularly in the past year?'', ``Did you donate blood in

the past year?'', ``Do you read the local newspaper reg-ularly?'', ``Have you ever written a letter to the editorof a newspaper?'', ``Do you watch the TV news regu-

larly, almost every day?'', ``Have you ever been on theboard of a community organization?'', ``Did you votein the District Health Board (DHB) election in Oct.1995?'', ``Did you vote in the last provincial election?''

and ``Have you ever contacted a local government o�-cial about an issue that concerned you?'' I did nothave a priori reason to assume that civic participation

is a cohesive concept and thus did not conduct re-liability analysis upon this index.

Trust in government (political trust)

This index used the items ``Rate the performance of

the federal government in solving problems inCanada,'' ``Rate the performance of the provincialgovernment in solving problems in Saskatchewan,''``Rate the performance of your DHB in solving pro-

blems in your district,'' ``Rate the performance of thelocal government in solving problems in your commu-nity,'' ``The DHB pays attention to what the general

public thinks when making decisions,'' ``The local gov-ernment does not waste taxpayers' money,'' `ÀlthoughI have complaints, I trust the federal government's de-

cisions,'' ``The provincial government has the public's'best interests at heart,'' `Àlthough I have complaints,I trust the DHB to make good decisions'' and ``Thelocal government tells the public all it needs to know

about relevant issues in the community.'' When eachitem was correlated with the remainder of the index,minus that item, the correlations ranged from lows of

r= 0.364 (the local government does not waste tax-payers' money) and r= 0.520 (rate the performance ofthe federal government in solving problems in Canada)

to highs of r = 0.709 (although I have complaints, Itrust the DHB to make good decisions) and r = 0.712(the provincial government has the publics' best inter-

est at heart). The mean of the inter-item correlationswas r = 0.402 and Cronbach's alpha was 0.871.

Trust in neighbours

This index used the items ``Do any of your closefriends live in your neighbourhood?'', ``Do you knowthe names of most of the adults living in the nearby

homes?'', `Ìs there a neighbour whom you wouldallow to help you when you were sick?'', `Ìs there aneighbour whom you would allow to keep an eye on

your home while you were away?'', `Ìs there a neigh-bour whom you would allow to lend you $50?'', `Ìsthere a neighbour to whom you would lend $50?'', `Ìs

there a neighbour to whom you would help when he/she was sick?'' and `Ìs there a neighbour to whom youwould lend your car for an hour?'' Scale reliabilityanalysis using dichotomous questions is less valid than

when the questions are continuous, but when eachitem was correlated with the remainder of the index,minus that item, the correlations ranged from lows of

r = 0.295 (do you know the names of most of theadults living in the nearby homes) to a high ofr = 0.681 (is there a neighbour whom you would allow

to help you when you were sick). The mean of theinter-item correlations was r= 0.359 and Cronbach'salpha was 0.805.

Trust in people from respondents' communities

This index used the items ``Most people in my com-

munity can be trusted,'' ``People from my communityare willing to help if you need assistance'' and ``Mycommunity is a pretty safe place.'' When each item

was correlated with the remainder of the index, minusthat item, the correlations ranged from a low ofr = 0.589 (my community is a pretty safe place) to a

high of r = 0.683 (people from my community arewilling to help if you need assistance). The mean ofthe inter-item correlations was r= 0.568 and

Cronbach's alpha was 0.795.

Trust in people from respondents' parts of Saskatchewan

This index used the items ``When it comes down toit, you can always trust the people in my part ofSaskatchewan'' and ``Most of the people who live in

my part of Saskatchewan are honourable.'' The inter-item correlation was r = 0.695 and Cronbach's alphawas 0.817.

Trust people in general

This index used the aforementioned indices of ``trustin people from respondents' parts of Saskatchewan''and ``trust in people from respondents' communities''


with the items ``Most people in my neighbourhood canbe trusted,'' ``Most people can be trusted,'' ``Most

people in my religious group can be trusted'' and``Most people in my ethnic group can be trusted.''When each item was correlated with the remainder of

the index, minus that item, the correlations rangedfrom a low of r= 0.696 (index of trust in people fromrespondents' communities) to a high of r = 0.805

(most people can be trusted). The mean of the inter-item correlations was r = 0.620 and Cronbach's alphawas 0.906.

Analysis

Human capital (SES) and health

The dependent variable in this analysis, self-rated

health status, was assessed by asking ``How would youdescribe your state of health compared to other per-sons your age?'' with èxcellent,' `good,' `fair' and`poor' as eligible responses. Table 2 shows that both

income and education are signi®cantly related tohealth, overall, in the expected directions. Breakingdown the population by age groups note that, for per-

sons younger than 39 years of age, neither income noreducation are signi®cantly related to health, that forthe middle aged (39±65) only education is signi®cantly

related to health (Table 3) and that for the elderly(over 65) both income and education are signi®cantlyrelated to health (Table 3). Thus the relationship

between income and health is strongest among theelderly (CV=0.341) and non-signi®cant among the

remainder of the populace. Education is signi®cantlyrelated to health among the middle aged and among

the elderly, but more strongly so among the latter.Finally, the relationship between SES and health holdsin the male and female sub-populations equally (Table

4).Among the other socio-demographic variables, reli-

gious a�liation (P = 0.528, CV=0.080), gender

(P = 0.368, CV=0.077), marital status (P = 0.163,CV=0.090), number of children (P = 0.188,eta=0.097), employment status as farmer (P = 0.158,CV=0.099) or student (P = 0.527, CV=0.049), home-

maker status (P = 0.531, CV=0.064), self- (P = 0.119,CV=0.105) or part-time (P = 0.067, CV=0.116)employment status and owning or renting one's home

(P = 0.122, CV=0.105) were not signi®cantly relatedto health. Age, being employed full-time and beingretired were related to health, however (Table 5). Thus

income, education, age, full-time employment statusand retirement status are the only socio-demographicvariables meaningfully and statistically signi®cantly re-lated to self-perceived health status in this data set. In

subsequent analyses, to control for human capital, Iperformed logistic regressions upon two self-ratedhealth status dependent variables Ð one that separated

excellent/good from fair/poor and another that separ-ated excellent from good/fair/poor. In these logistic re-gressions I included income as a four-part set of

dummy variables that separated household incomesless than $20,000 from those between $20,000 and$39,999, those between $40,000 and $59,999 and those

greater than $60,000. Education was a tripartite set ofdummy variables separating those with university, col-

Table 2

SES predictors of self-reported health status, overall

Self-reported health status (% (n ))

excellent good fair/poor P

Household income < $20,000 20.4 (21) 49.5 (51) 30.1 (31) P = 0.001 CV=0.199

20±29 26.3 (21) 66.3 (53) 7.5 (6)

30±39 18.2 (10) 61.8 (34) 20.0 (11)

40±49 25.4 (18) 56.3 (40) 18.3 (13)

50±59 38.3 (18) 55.3 (26) 6.4 (3)

60±74 39.5 (17) 44.2 (19) 16.3 (7)

75±99 31.6 (12) 55.3 (21) 13.2 (5)

> $100,000 48.4 (15) 35.5 (11) 16.1 (5)

Highest level of education completed university 36.8 (39) 50.9 (54) 12.3 (13) P < 0.001 CV=0.214

community college 40.5 (17) 50.0 (21) 9.5 (4)

technical/vocational program 32.6 (31) 54.7 (52) 12.6 (12)

high school 24.9 (49) 58.9 (116) 16.2 (32)

elementary school 8.6 (6) 50.0 (35) 41.4 (29)

none 25.0 (2) 75.0 (6) 0 (0)


lege or technical-vocational training from those whocompleted high school and those who completed el-ementary school or less.

Social engagement and health

Many studies have documented relationshipsbetween engagement in social networks and health sta-tus (e.g. Hanson and Ostergen, 1987; Orth-Gomer and

Johnson, 1987; House et al., 1988; Hirdes and Forbes,1992). Generally the literature di�erentiates betweensocial support (from close friends and family, in par-

ticular) and social involvement in larger networks (for-mal and informal voluntary associations, inparticular). What has not been explored to any greatextent is the type of social involvement and the nature

of the associations. Does it make a di�erence, withrespect to predicting health, whether the clubs onebelongs to (1) are formally constituted (with an execu-

tive and formal decision-making rules, for example),(2) allow anyone to join or have strongly de®nedboundaries, (3) do things for others or serve their own

needs only, (4) are con¯ictual or cooperative withinthe group and (5) are homogenous ethnically, reli-giously or with respect to age? Does it make a di�er-ence if members also meet with one another in other

settings, compared to groups where members meet to

share one common interest only? Does the amount oftime one spends in the group matter, or how manypeople belong to it?

Among the social support questions asked, the fre-quency of socialization with family members and withfriends and belonging to a small group that provides

support and caring for its members were not signi®-cantly related to health. Casting the net of social invol-vement wider frequency of socialization with

neighbours, volunteering, communicating on the inter-net and the number of clubs and associations thatrespondents currently belong to were also unrelated to

health, as were planning to live in the neighbourhoodin ®ve years and experience belonging to a neighbour-hood improvement association.Frequency of socialization with work-mates was

positively related to health overall (P= 0.019;Z=0.145; Table 6). After controlling for income andeducation in two logistic regressions (upon the two

health status dichotomous dependent variables) itbecame insigni®cant in one but remained almost sig-ni®cant in the other (P = 0.051). Thus there is some

indication that socializing with work-mates is relatedto health, maybe even after controlling for humancapital.Willingness to turn to a work colleague in a time of

trouble was related to health overall as well

Table 3

SES predictors of self-reported health status

Self-reported health status

(% (n ))


Between the ages of 39 and 66


20±39 23.7 (14) 59.3 (35) 16.9 (10)

40±59 29.7 (22) 55.4 (41) 14.9 (11)

> $60,000 40.0 (30) 44.0 (33) 16.0 (12)

Highest education achieved university, college or

technical-vocational program

36.4 (52) 49.7 (71) 14.0 (20) P = 0.035 CV=0.142

high school 26.9 (25) 53.8 (50) 19.4 (18)

elementary school or less 4.8 (1) 66.7 (14) 28.6 (6)

excellent/good fair/poor

66 and older

Household income < $20,000 58.7 (27) 41.3 (19) P = 0.002 CV=0.341

20±39 92.1 (35) 7.9 (3)

> $40,000 76.2 (16) 23.8 (5)

excellent good fair/poor



25.9 (7) 63.0 (17) 11.1 (3) P = 0.004 CV=0.256

high school 4.7 (2) 72.1 (31) 23.3 (10)



(P= 0.024; Z=0.143; Table 6). Willingness to turn toa work colleague was most important for predicting

health status among the youngest age group but eventhen was non-signi®cant (P = 0.098). After controllingfor income and education in two logistic regressions, inthe full sample, such willingness became non-signi®cant

in both (P = 0.750; P = 0.089).Finally, attendance at religious services was related

to health overall (P = 0.034; Z=0.136; Table 6),

although the relationship did not appear to be linear.Respondents who rated their health as fair or poorwere less likely to attend religious services, but the

healthiest were less likely than those who rated theirhealth as `good'. This suggests that age might be rel-evant. Attending religious services was more important

for predicting health status in the elderly population(P= 0.051, Z=0.235) than in the others and followeda linear pattern in this age group. After controlling forincome and education in two logistic regressions,

among the elderly, it became signi®cant in one(P= 0.038) but was non-signi®cant in the other(P= 0.333). This could be because few elderly rated

their health as èxcellent,' and so the dichotomousdependent variable separating excellent/good healthfrom fair/poor health was more suitable for this popu-

lation.I asked respondents to assess the nature of the (up

to three) clubs or associations that they participate in

the most. The amount of time they spend per weekwith the group and the size of the group were not re-

lated to health. Whether the club has an executive, hasformal decision-making rules, is open to allowing any-

one to join, does things for others, is cooperativewithin the group, has members who meet in other set-tings, are from the same religious group, are from thesame ethnic group, are from the same age group, are

from the same community, share a common interest,where the respondent has been a member of the execu-tive and where the respondent feels he/she has personal

in¯uence in the group, were all unrelated to health.Exploring the non-relationship between overall par-

ticipation in clubs and health further, within age and

gender groups, I found that participation in clubs andassociations was important for predicting health statusamong the elderly (P = 0.009; Z=0.277) but not

among the other age groups. After controlling forincome and education, however, this signi®cant re-lationship ``went away''.

Social-psychological constructs and health

If social capital has strong compositional e�ects on

health than it is important to determine the e�ect ofsocial-psychological components of social capital aswell as the e�ect of its action components. Trust, in

particular, has been titled as a principal element insocial capital by numerous theorists (e.g. Putnam etal., 1993; Cox, 1995; Fukuyama, 1995; Knack and

Keefer, 1997; Woolcock, 1998). Kawachi et al. (1997)found a relationship between social capital and health

Table 4

SES predictors of self-reported health status

self-reported health status

(% (n ))


Men


20±39 21.0 (13) 66.1 (41) 12.9 (8)

40±59 28.1 (16) 52.6 (30) 19.3 (11)

> $60,000 40.0 (26) 43.1 (28) 16.9 (11)



33.7 (34) 53.5 (54) 12.9 (13) P = 0.001 CV=0.196

high school 28.4 (17) 52.6 (50) 18.9 (18)


Women


20±39 24.7 (18) 63.0 (46) 12.3 (9)

40±59 32.8 (20) 59.0 (36) 8.2 (5)

> $60,000 39.1 (18) 47.8 (22) 13.0 (6)



37.6 (53) 51.1 (72) 11.3 (16) P < 0.001 CV=0.209

high school 21.6 (22) 64.7 (66) 13.7 (14)



status among the US states. Was this because trust Ð

three of the four measures in their social capital indexwere aggregated responses to trust questions Ð has adirect relationship with health? Do the psychological

bene®ts of feeling trusting produce a greater sense ofwell-being or are the e�ects of trust on health moresubtle and indirect, or both?

The trust indices Ð trust governments, trust allpeople, trust people from respondents' parts ofSaskatchewan, trust people from respondents' commu-nities, trust neighbours, trust people from respondents'

religious and ethnic groups Ð were not signi®cantlyrelated to self-rated health status. It appears, inSaskatchewan at least, that the e�ect of trust on

health, if it exists, operates more subtly than can beaccounted for by individual-level analysis.Veenstra and Lomas (1999) hypothesized that

peoples' identi®cations with and commitments tonation, community or sub-community would in¯uencetrust, civic and associational participation ± important

individual-level components of social capital. I askedrespondents to rank a series of eight identities in orderof importance to them, allowing for omissions andties. Neither of these identities Ð Canadian, a resident

of Saskatchewan, a resident of one's part ofSaskatchewan, a member of one's religious group orethnic group, a resident of one's neighbourhood or the

identity granted by one's major occupation Ð was re-lated signi®cantly to health. Few of the commitmentquestions Ð how important is the success of one's

family, neighbourhood, ethnic or religious group, com-munity, part of Saskatchewan, Saskatchewan andCanada Ð were signi®cantly related to health either.Only commitment to one's personal happiness was

related to health (P = 0.039; Z=0.111; Table 7).Exploring this relationship further, commitment to per-sonal happiness was most relevant for predicting

health status among the middle-aged (P = 0.028;Z=0.166) and male (P = 0.011; Z=0.193) sub-popu-lations. Among the middle aged, after controlling for

income and education, the relationship ``went away.''Among men, again after controlling for income and

education, this relationship remained signi®cant

(P = 0.022) in only the second logistic regression.

Civic participation and health

I have described few direct relationships between in-dividual-level elements of social capital and health Ð

neither participation in clubs, for the most part, thenature of the clubs themselves, socializing with familyand friends, close relationships with neighbours andthe social-psychological attributes of trust, identity and

commitment were signi®cantly (P < 0.05) related toself-rated health status. Only participation in clubsamong the elderly, willingness to turn to a work col-

league in a time of trouble, frequency of socializationwith work-mates and attendance at religious serviceswere related to health. The remaining element of social

capital that may have an in¯uence is civic partici-pation; that is, participation in the public sphere withmore than a purely egotistic ¯avour to it (Putnam et

al., 1993). Civic participation may include political actssuch as voting or lobbying, altruistic acts such asdonating blood or volunteering and activities thatdemonstrate an interest in public a�airs (signalled by a

commitment to read the local newspaper or watch thenews on television, for example). The Putnam et al.(1993) social capital index included three such items Ð

the percentage of homes subscribing to the local news-paper and the percentage of eligible voters who cast avote in general and special elections.

My civic participation index was not related tohealth. Breaking the index down and exploring re-lationships between its elements and health moredirectly, neither reading the local newspaper, experi-

ence writing a letter to the editor of a newspaper,watching the local television news, experience servingon the board of a community organization, donating

blood, experience contacting a local elected o�cialabout a problem issue or voting in elections was re-lated to self-rated health status. Exploring further this

non-relationship between civic participation and healthstatus I found that the civic participation index may be

Table 5

Additional socio-demographic predictors of self-reported health status

Self-reported health status

excellent good fair poor P

Mean age (yr (N, S.D.)) 46.7 (141, 14.6) 52.3 (278, 16.9) 59.4 (65, 19.4) 57.4 (25, 14.8) P < 0.001 eta=0.237

Employed full-time (% (n )) yes 35.7 (70) 56.1 (110) 6.1 (12) 2.0 (4) P < 0.001 CV=0.206

no 23.2 (78) 53.9 (181) 16.4 (55) 6.5 (22)

Retired (% (n )) yes 16.0 (25) 53.2 (83) 24.4 (38) 6.4 (10) P < 0.001 CV=0.262

no 32.7 (123) 55.3 (208) 7.7 (29) 4.3 (16)


more strongly related to health among men(P = 0.060; Z=0.152) than women, but the relation-

ship was not quite signi®cant although it was in theexpected direction across the health categories. Aftercontrolling for income and education the relationship

disappeared entirely.

Summary

Among the 534 respondents in this study, in

Saskatchewan, income (P = 0.001; CV=0.199) andeducation (P < 0.001; CV=0.214) were signi®cantlyrelated to self-rated health status in the expected direc-tions. These relationships were not statistically signi®-

cant, however, among the youthful respondents(between 18 and 39 yr of age). For middle-agedrespondents (aged 39 to 65) only education

(P = 0.035; CV=0.142) was signi®cantly related tohealth. Among the elderly (aged 65 and over) bothincome (P = 0.002; CV=0.341) and education

(P = 0.004; CV=0.256) were related to health. The re-lationships between income and health and educationand health were similar in direction and strength for

the male and female sub-populations.Of the many social engagement questions asked in

the survey, only frequency of socialization with work-mates (P = 0.019; Z=0.145), willingness to turn to a

work-mate in a time of trouble (P = 0.024; Z=0.143)and attendance at religious services (P = 0.034,Z=0.136) were signi®cantly related to health among all

respondents. There was some indication that socializa-tion with work-mates and attendance at religious ser-vices remained signi®cant after controlling for human

capital, but willingness to turn to a work colleague didnot. The other social support questions, participationin clubs and associations, the nature of the clubs beingassociated in and relationships with neighbours were

all unrelated to health, overall. There was evidencethat participation in clubs (P = 0.009; Z=0.277) wasrelated to health for the elderly sub-population, how-

ever, as was attendance at religious services among theelderly (P= 0.051; Z=0.235).The social-psychological constructs identi®ed by

Veenstra and Lomas (1999), such as trust in variouscommunities of people and of government, identi®-cation with di�erent communities and commitment to

the common good of these communities, were not re-lated to self-rated health status. Only commitment toone's own personal happiness had any relationshipwith health, overall (P = 0.039; Z=0.111), among the

middle-aged (P = 0.028; Z=0.166) and among men(P = 0.011; Z=0.193), where higher commitment tohappiness corresponded to higher self-reported health.

Finally, the civic participation indicators, includingsuch activities as voting, writing letters to editors, pay-T

able

6

Socialnetworkspredictors

ofself-reported

healthstatus

Self-reported

healthstatus

excellent

good

fair/poor

fair

poor

P

How

often

doyoumeetsociallywithwork-m

ates?

Mean

score

on7pointscale,1=

everyday,7=

never

(n,S.D

.)

3.66(110,1.94)

4.26(212,1.89)

4.33(52,1.98)

P=

0.010eta=0.145

Ifyouneeded

assistance

inapersonalmatter,how

likely

would

youbeto

turn

toacolleagueatwork?Meanscore

on

6pointscale

1=

verylikely,6=

notlikelyatall(n,S.D

.)

3.41(114,1.70)

3.95(197,1.66)

3.93(54,1.95)

P=

0.024eta=0.143

How

often

doyouattendreligiousservices?Meanscore

on7

pointscale,1=

everyday,7=

never

(n,S.D

.)

4.69(127,1.33)

4.42(256,1.40)

4.83(63,1.55)

5.09(22,1.57)

P=

0.034eta=0.136


ing attention to issues in the community and volunteer-ing and an index that collected all of these together,

were all statistically unrelated to health in the entiresample. There was some indication that civic partici-pation may be more related to health among men

(P = 0.060; Z=0.152) than among women, however.

Discussion

Self-rated health status has been determined to be agood predictor of mortality in many studies (Idler andBenyamini, 1997) and, since it can easily be added to

questionnaires that are ostensibly pursuing researchquestions in realms other than in health, can be relatedto social variables far beyond the traditional measures

of SES. Such was the case in the research projectdescribed in this article, where self-rated health status,enclosed almost as an after-thought within a study of

social capital and governance, could be correlated witha number of individual-level aspects of social capital ±activities such as associational and civic participationand experience collaborating with others to solve com-

munity problems and social-psychological constructssuch as trust, identity and commitment.The potential relationships between these individual-

level aspects of social capital and health status areinteresting because of the important Kawachi et al.(1997) ®nding that social capital, aggregated to the

level of state in the US, was strongly correlated withhealth status and that social capital mediates the re-lationship between income inequality and health

(although this latter conclusion could be contested). Ifsocial capital in communities ``causes'' health, thenhow, exactly, does it do so? Other studies have shownthat social support networks in the community are re-

lated to health status, perhaps by providing a sense ofe�cacy or emotional support. This study has shown,in Saskatchewan at least, that the relationship between

social engagement in clubs and associations (extendednetworks beyond one's kin, that is) and self-ratedhealth is not strong. Neither is the relationship

between the main social-psychological components ofsocial capital theory Ð identity, commitment andmost importantly trust Ð and health, nor the relation-ship between political or civic participation and health.

The only strong relationships found in this data set arethe old standbys, income and education, which arestrong predictors of health among the elderly, in par-

ticular, but also to some degree among the middle-aged. I should stress, however, that the small samplesizes in the tests (n = 534) required fairly strong re-

lationships for the statistical tests to capture signi®-cance. The study is also limited by its cross-sectionalnature, which makes conclusions about causality pro-T

able

7

Social-psychologicalpredictors

ofself-reported

healthstatus

Self-reported

healthstatus

excellent

good

fair

poor

P

Itisveryim

portantto

methatIam

personallyhappy.Meanscore

on7

pointscale,1=

agreestrongly,7=

disagreestrongly

(n,S.D

.)

1.33(147,0.68)

1.53(288,0.83)

1.58(66,0.95)

1.32(25,0.75)

P=

0.039eta=0.111


blematic, and by the low response rate (40%), whichmakes for potential bias and non-representativeness.

The main ®nding from this project, then, is that littleevidence was found for compositional e�ects of socialcapital on health in Saskatchewan. This is probably

not a surprise for that majority of social capital theor-ists who stress the primacy of social relationships overattributes of individuals, but, unfortunately, suggests

that further research be sensitive to contextualmeasures. Such research is di�cult to conduct,demands variables that are more than merely aggregate

in nature and sometimes requires sophisticated analyti-cal tools such as hierarchical modelling, for example.The other ®ndings are, ®rst of all, that the relation-

ship between SES and health was not di�erent for men

than for women, contrary to what some researchershave found (i.e. Orth-Gomer and Johnson, 1987;House et al., 1988), although commitment to one's

happiness and political or civic participation had stron-ger relationships with health for men than for women.Perhaps men are less likely to care for their health

than are women and so the variance in commitment tohappiness is greater among men. Second, the relation-ship between SES and health was stronger among the

elderly than among the middle-aged, contradictingHouse et al. (1990) who claimed it is strongest amongthe middle-aged. Third, the amount of socializationwith colleagues from work, for those who do work,

appeared to be signi®cantly related to self-rated healthand socialization with family and friends was not.What is so special about socializing with colleagues?

Does it imply a less con¯ictual setting at work, withless stress and, hence, better health? Finally, amongthe elderly, frequency of attendance at religious ser-

vices and participation in clubs and associations ingeneral were also related to health. This could bebecause the most ill are unable to participate as they'dlike to, for physical reasons, or because social connec-

tions particularly enhance health in this population, orboth.

Acknowledgements

This research project was supported ®nancially bythe HEALNet-RHP Theme in Saskatoon,

Saskatchewan and by the Social Sciences andHumanities Research Council of Canada (SSHRCC)which provided me with doctoral fellowships in 1996/

97 and 1997/98.

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