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research-article2015
PED0010.1177/1757975915572382Original ArticleA. Baheiraei et al.
Original Article Association between social capital and health in women of reproductive age: a population-based study Azam Baheiraei1, Fatemeh Bakouei2, Eesa Mohammadi3, Reza Majdzadeh4 and Mostafa Hosseni4
Abstract: Women’s health is a public health priority. The origins of health inequalities are very complex. The present study was conducted to determine the association between social capital and health status in reproductive-age women in Tehran, Iran. In this population-based, cross-sectional study, the Social Capital Integrated Questionnaire, the SF-36 and socio-demographic questionnaires were used. Analysis of data by one-way ANOVA test and stepwise multiple linear regression showed that the manifestation dimensions of social capital (groups and networks, trust and solidarity, collective action and cooperation) can potentially lead to the outcome dimensions of social capital (social cohesion and inclusion, and empowerment and political action), which in turn affect health inequities after controlling for socio-demographic differences. Keywords: social capital, health status, population-based study, reproductive age women, Iran
Introduction The maintenance and promotion of women’s health is not only a human right but is also necessary for population health at a national level. (1). Women’s health in low and middle income countries is rather complex because of demographic changes. Therefore, policies and programs should generally address women’s health and focus on its effective determinants (2). The origins of health inequalities are very complicated and operate at several levels. Apart from genetic and biological factors, some other factors are associated with health inequality (3).
Some evidence indicates that social structure plays a key role in the formation of people’s health. In this regard, the researchers have focused their research mainly on social capital (4). Putnam defined social capital as ‘features of social organization such as networks, norms and social trust that facilitate coordination and cooperation for mutual benefit’ (5). Coleman suggests that there are three assets for every individual: financial capital, human capital and social capital (6). High level social and civil participation of the citizens, high general trust among people toward each other, high trust of organizations, and mutual action can
1. Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran. 2. Department of Midwifery, Babol University of Medical Sciences, Babol, Iran. 3. Department of Nursing, Tarbiat Modares University, Tehran, Iran. 4. Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. Correspondence to: Fatemeh Bakouei, Department of Midwifery, Babol University of Medical Sciences, Babol, Iran. Email: [email protected] (This manuscript was submitted on 16 April 2014. Following blind peer review, it was accepted on 28 November 2014)
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all contribute to a high level of social capital within a society (7). Social capital has been proposed as a factor that impacts positively on health. It may influence health through such mechanisms as more convenient access to information of society members, contribution to promote decision making related to health, affecting social norms, enhancing use of health services, better access to health services in society, and offering mental support (7,8). Studies have shown that various health-related outcomes such as self-reported health (9), mental health (10) and health behaviors (4,11) are associated with social capital. However, the association between social capital and health is not always consistent. It varies according to the sample, the type of health outcome (12) and the context in which it is studied (13). Because of the available inconsistent findings, there is no consensus among researchers about the relationship between social capital and health. Such inconsistency in results may originate from conceptualization and measurement instruments of social capital. In addition to the wide variety of definitions proposed for social capital, its measurement is also differs among various disciplines and fields of study. The World Bank introduced an instrument for measuring social capital through which a set of key and central questions are extracted from previous studies conducted on social capital, and this is the instrument that is used in this study (14). According to the statistics published by the Statistical Center of Iran in 2011, the highest percentage of the entire female population (about 60%) is reproductive-age women (15–49 years old) (15). Given the priority of women’s health in national reproductive health programs and the lack of such a study concerning this relationship, the present study was conducted to determine social capital status and its association with health in reproductive-age women in Tehran (capital city of Iran) with its specific social-cultural characteristics. It must be noted that about 16.2% of Iranian reproductive-age women live in Tehran (15).
Methods This study is a population-based, cross-sectional survey on reproductive-age women (15–49 years
old), residing in any one of the 22 municipality areas across Tehran. This study is a part of a mixedmethod study using a sequential explanatory design, the protocol of which has been previously published (16). The sample size in the current study was 770 people with p = 50%, d = 4%, and considered design effects (degree of freedom (df) = 1.2%). The sampling technique was multi-stage in municipality areas of Tehran so that each area is divided into a number of blocks with an unequal population. In each area, the required number of blocks was randomly selected from the list of blocks. Next, using the systematic sampling method, the reproductive-age women in the households were interviewed. In case a woman declined to take part, the next-door household was invited to participate in the study to complete the questionnaire. When invited, all potential participants were assured of the confidentiality of their information. All participants were interviewed face to face in their own house by the team of interviewers. Interviewers were trained by the research team for conducting standard interviews. To ensure reliability of the collected data, interviewers were closely controlled and monitored. The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences. Following a detailed explanation, informed consent was obtained from all participating women.
Scales and data collection In this study the following three questionnaires were used: 1. The Social Capital Integrated Questionnaire (SC-IQ) was designed by the World Bank in 2000 to measure the social capital of developing countries. The questionnaire contains six dimensions: groups and networks, trust and solidarity, collective action and cooperation, information and communication, social cohesion and inclusion, and empowerment and political action (14). The validity and reliability of the questionnaire was measured by Nedjat et al. in Iran through the forward-backward translation method. A few questions have been added to it. Mean scores for the five dimensions, except the dimension of information and communication
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(which was only for more detailed reviewing of obtained information from the general public), ranged from 0 to 100, with a higher score indicating higher social capital. The intra-class correlation coefficient (ICC) was higher than 0.7 in all the dimensions (ICC range: 0.75–0.89) (17). According to the recommendations of instrument designers of the World Bank, the researchers of this study assumed groups and networks, trust, and cooperation as manifestations of social capital. Social cohesion, empowerment, and political action were assumed to be outcomes of social capital. The scores were calculated for all aspects in a range of 0–100. (14). 2. The SF-36 questionnaire (Short Form Health Survey) was first designed by Ware et al. to evaluate the health of the community, determine health policies, and assess the efficacy of the designed treatment. The SF-36 questionnaire consists of eight health-related concepts/domains: physical functioning, role limitations due to physical problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health (18). The SF-36 questionnaire was translated in Iran by Montazeri et al. using the forward-backward translation method; it has also been culturally adapted and its validity and reliability determined. Reliability was found using internal consistency, validity was determined using known groups comparison, and convergent validity was also measured. Cronbach’s coefficient of all dimensions of the questionnaire, except vitality (0.65), ranged from 0.77 to 0.90. The mean score for the eight indicators of this test based on the protocol of the questionnaire ranged from 0 (worst status) to 100 (best status) (19). 3. The socio-demographic variable questionnaire was designed by a research team to include age, ethnicity, educational level, educational years, marital status, family size, employment status, sufficiency of income for expenses, and crowding index.
Data analysis Data were analyzed using SPSS-16. At first, the dimensions of social capital were assessed descriptively with frequency and percentage for socio-demographic factors. Then, to investigate the
relationship between dimensions of social capital and socio-demographic factors, a one-way analysis of variance (ANOVA) test was used. To avoid the effects of confounding factors, and to predict the effects of independent variables (social capital and sociodemographic factors) on dependent ones (dimensions of health), variables with significant associations in the test were entered into a stepwise multiple linear regression. The threshold of type-one error was considered to be 0.05.
Results In total, 770 reproductive-age women (15–49 years old) with a mean age of 33.9±9.3 years were interviewed. A majority of them were married (72.3%) housewives (62.2%), of Persian ethnicity (64.3%), and educated to high school level (43.8%) (Table 1). The obtained mean score and standard deviation of all the dimensions of social capital in reproductiveage women are shown in Table 1. The largest mean score (55.72±11.94) was related to the social cohesion and inclusion dimension and the lowest mean score (31.78 ±19.43) related to the groups and networks dimension. In relation to the information and communication dimension, when the respondents were asked ‘To what extent do you follow the country’s events and news?’ 46.6% of the women followed it every day and 11.1% did not follow it at all. With regards to the request to ‘Identify the three main sources of keeping up with the government’s activities’, TV (62.8%), newspapers and magazines (24%), and relatives, friends and neighbors (20.1%) were identified. The relationship between social capital in reproductive-age women and socio-demographic factors through one-way ANOVA is also shown in Table 1. According to the results, there was a significant association between some dimensions of social capital and the following variables: age, ethnicity, marital status, education level, occupation status, crowding index and sufficiency of income for expenses. To respond to the main objective of this study, the ‘relationship between social capital and health status of reproductive-age women’, the linear regression models considered all dimensions of social capital and socio-demographic factors as independent variables and all dimensions of health as dependent variables. The results of the linear IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Age groups 15–25 years 26–35 years 36–45 years 46–49 years ANOVA p Marital status Married Divorced/Widowed Single ANOVA p Ethnicity Fars Azari Others ANOVA p Educational level Illiterate/Primary (years 1–5) Intermediate (years 6–8) High school (years 9–12) University ANOVA p Occupation status Housewife Employed Student ANOVA p
Independent variables
36.31 (18.51) 31.69 (18.90) 30.02 (19.59) 28.89 (20.67) 0.004 30.62 (19.13) 21.32 (20.06) 37.06 (19.01) 0.000 30.80 (19.24) 32.50 (19.40) 35.09 (20.11) 0.105 22.84 (20.40) 26.24 (20.29) 31.02 (18.74) 35.64 (18.90) 0.000 28.97 (19.08) 35.21 (19.93) 38.62 (17.40) 0.000
556 (72.2) 31 (4) 183 (23.8)
487 (64.3) 179 (23.2) 91 (13.5)
50 (6.5) 83 (10.8) 337 (43.8) 300 (38.9)
479 (62.2) 190 (24.7) 101 (13.1)
Groups and networks
165 (21.5) 266 (34.5) 224 (29.1) 115 (14.9)
Number (%)
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54.64 (17.89) 54.55 (17.23) 53.62 (15.36) 0.865
53.80 (17.40) 55.17 (18.53) 53.83 (17.65) 55.15 (16.83) 0.771
54.39 (16.73) 54.51 (18.54) 54.91 (18.60) 0.962
55.04 (17.30) 51.65 (19.99) 53.29 (17.22) 0.325
52.72 (16.38) 55.31 (17.12) 55.21 (17.46) 53.72 (19.24) 0.409
Trust and solidarity
Social capital dimensions: mean (SD)
46.15 (26.49) 48.26 (24.05) 42.36 (23.84) 0.174
48.21 (26.07) 43.52 (28.09) 45.91 (25.90) 46.87 (24.51) 0.693
45.19 (25.35) 47.27 (26.22) 48.91 (25.65) 0.326
47.08 (26.20) 36.29 (22.10) 45.10 (23.97) 0.059
44.11 (25.18) 46.86 (25.05) 48.36 (25.67) 43.27 (27.12) 0.225
Collective action and cooperation
56.53 (11.84) 53.99 (11.81) 55.15 (12.38) 0.040
56.72 (14.03) 57.38 (11.15) 55.06 (12.44) 55.84 (11.17) 0.391
55.88 (12.00) 54.93 (12.45) 56.32 (10.74) 0.565
56.47 (11.58) 52.78 (12.12) 53.94 (12.76) 0.017
54.20 (13.15) 56.52 (11.28) 55.97 (11.32) 55.55 (12.70) 0.263
Social cohesion and inclusion
(Continued)
45.08 (15.59) 47.31 (15.62) 46.73 (15.58) 48.62 (17.38) 0.296 48.17 (15.45) 42.62 (14.17) 43.59 (16.90) 0.001 45.80 (15.61) 47.68 (16.03) 50.38 (16.45) 0.021 53.48 (15.62) 51.84 (15.35) 46.47 (16.03) 44.81 (15.39) 0.000 48.18 (16.00) 44.84 (14.87) 44.38 (16.57) 0.012
Empowerment and political action
Table 1. Respondents’ socio-demographic characteristics in association with the mean scores of social capital dimensions through ANOVA.
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ANOVA: analysis of variance.
Sufficiency of income for expenses Absolutely not To some extent Completely ANOVA p Crowding index Low Average High ANOVA p Family size Less than four Four to five More than five ANOVA p Total
Independent variables
Table 1. (continued)
34.27 (18.70) 30.98 (19.30) 31.35 (20.57) 0.148 32.11 (19.17) 31.45 (19.36) 33.42 (22.03) 0.754 31.78 (19.43)
195 (27.5) 365 (51.6) 148 (20.9)
321 (42.3) 384 (50.7) 53 (7.0) 770 (100)
29.70 (19.71) 31.32 (19.01) 36.30 (18.72) 0.001
Groups and networks
337 (44.1) 240 (31.4) 188 (24.5)
Number (%)
53.98 (17.47) 54.82 (17.59) 55.64 (14.86) 0.726 54.48 (17.40)
54.78 (18.26) 55.09 (16.63) 54.67 (17.70) 0.960
51.66 (17.06) 54.08 (17.30) 60.53 (16.58) 0.000
Trust and solidarity
Social capital dimensions: mean (SD)
46.31 (26.73) 46.08 (24.65) 47.72 (25.49) 0.909 46.18 (25.60)
46.79 (24.72) 47.46 (26.08) 46.99 (25.67) 0.953
45.42 (27.01) 44.07 (23.79) 50.95 (24.64) 0.015
Collective action and cooperation
55.93 (12.76) 55.50 (11.14) 57.06 (12.44) 0.648 55.72 (11.94)
54.65 (13.03) 55.65 (11.05) 57.91 (12.89) 0.042
54.16 (12.21) 56.41 (11.61) 57.89 (11.54) 0.002
Social cohesion and inclusion
46.16 (15.77) 46.68 (15.73) 48.69 (16.11) 0.205 46.77 (17.27) 47.35 (15.70) 47.50 (14.93) 0.894 47.57 (16.44) 46.61 (15.58) 46.01 (14.53) 0.655 46.86 (15.88)
Empowerment and political action
Original Article 5
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regression analysis in regression models 1 to 8 are shown in Table 2. Each of the regression models takes one health dimensions as the dependent variable. The table only shows those variables that remained statistically significant after adjusting for other variables in the regression test with dimensions of health. This table shows that both of the outcome dimensions of social capital (social cohesion and inclusion, and empowerment and political action) after adjustment are significantly related to the majority of the dimensions of health. The linear regression analysis (Table 3) indicated that the three manifestation dimensions of social capital (groups and networks, trust and solidarity, and collective action and cooperation) are significantly related to two outcome dimensions of social capital (social cohesion and inclusion, and empowerment and political action). Additionally, only the outcome dimensions remained in the regression models after importing all dimensions of social capital into the linear regression models and considering the dimensions of health as dependent variables (Table 2). The total conclusion in this study is shown in Figure 1.
Discussion In the present study, the individual social capital in reproductive-age women was measured and investigated. The scores of social capital dimensions were separately formatted and reported for different social and demographic groups. It was found that that the highest mean scores related to the social cohesion and inclusion dimension and the lowest mean scores to the groups and networks dimension. Because of the relative lack of studies related to the sociodemographic distribution of social capital and similarly, the lack of use of a stable instrument for measuring social capital in previous studies, a very strong basis for comparison does not exist. However, in the study by Nedjat et al. that was carried out on 2484 men and women 18 years and over in 2008, using the same questionnaire, the lowest score was related to the groups and networks dimension (18.9±12.9), whereas the highest score belonged to the trust and solidarity dimension (53.7±14.4) (19). In a British study of adults (16 and over), social trust received 41% and civic participation 45.2% (20).
This study identified that women’s access to social capital was different in terms of some sociodemographic factors. One especially interesting aspect of this study is the lack of relationship found between dimensions of trust and solidarity, collective action and cooperation, empowerment and political action, and social cohesion and inclusion with variables such as higher education and employment (determinants of social status). This may signify a unique historical and cultural conception relevant to women in Iranian society in relation to different dimensions of social capital. In other studies, education and employment had a significant association with social capital (7,21). The findings of this study have also supported the relationship between the dimensions of manifestation and outcome as it is conceptualized in the social capital-integrated questionnaire used in the present study. It means that people with higher scores in groups and networks, trust, and participation achieved higher scores in social cohesion and inclusion, and empowerment and political action. This finding is similar to other studies (22,23). This suggests that the elements in the manifestation and outcome dimensions must be viewed separately in conceptual and empirical terms. As a result, focus is required not only on communications and groups of people, but also on the value of these communications as capital resources. Along with the main goal of this study, which is to explore the relationship between social capital and health status of reproductive-age women, the findings revealed that after controlling for other variables, both of the dimensions of social capital outcome (social cohesion and inclusion, and empowerment and political action) are significantly related to dimensions of health: general health, social functioning, role limitations due to emotional problems, and mental health. Social cohesion and vitality were significantly associated with physical functioning and bodily pain. Likewise, empowerment and political action were found to be related to role limitations due to physical problems. These finding generally confirm the importance of social capital for the various components of self-rated health. In other words, health dimension scores significantly increased as social capital outcome dimension scores increased, indicating a positive relationship between social capital and health. This is confirmed in other
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Table 2. Linear regression analysis for the prediction of variance in health dimension score by socio-demographic factors and social capital dimensions. Variables Model 1: Physical functioning Age Educational years Social cohesion and inclusion Model 2: Role physical Age Empowerment and political action Model 3: Bodily pain Educational years Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Model 4: General health Age Educational years Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action Model 5: Vitality Educational years Sufficiency of income for expenses Completely Absolutely not Empowerment and political action Model 6: Social functioning Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action Model 7: Role emotional Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action Model 8: Mental health Educational years Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action
B
Confidence interval
−0.50 1.14 0.19
−0.74 to −0.26 0.65–1.63 0.03–0.36
−0.54 0.23
−0.84 to −0.23 0.05–0.41
0.62
0.01–1.23
Reference −9.76 0.23
– −14.31 to −5.20 0.03–0.42
−0.27 0.94
−0.48 to −0.05 0.47–1.41
Reference −4.26 0.21 0.21
– −7.70 to −0.81 0.06–0.36 0.10–0.32
0.72
0.24–1.19
Reference −5.94 0.32
– −9.56 to −2.33 0.20–0.44
Reference −7.15 0.23 0.23
– −10.88 to −3.42 0.07–0.38 0.11–0.34
Reference −9.05 0.33 0.23
– −15.25 to −2.84 0.07–0.59 0.04–0.43
0.76 Reference −4.58 0.31 0.31
0.26–1.25 – −8.31 to −0.84 0.15–0.47 0.18–0.43
PV 0.000 0.000 0.021 0.001 0.009 0.04 – 0.000 0.01 0.01 0.000 – 0.01 0.004 0.000 0.003 – 0.001 0.000 – 0.000 0.004 0.000 – 0.004 0.01 0.01 0.002 – 0.01 0.000 0.000
PV: prediction of variance. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Table 3. Linear regression analysis of manifestation dimensions on outcome dimensions of social capital. Manifestation dimensions of social capital
Groups and networks Trust and solidarity Collective action and cooperation
Outcome dimensions of social capital Social cohesion and inclusion
Empowerment and political action
B (confidence interval)
PV
B (confidence interval)
PV
0.05 (0.01–0.09) 0.15 (0.10–0.20) 0.04 (0.01–0.07 )
0.011 0.001 0.020
0.06 (0.02–0.10) 0.18 (0.12–0.25) 0.07 (0.03–0.12)
0.002 0.001 0.001
PV: prediction of variance.
Social capital • Groups & networks • Trust & solidarity • Collective action
• Social cohesion • Empowerment
Health
Figure 1. Proposed relationship between the two components of social capital (manifestation and outcome) and health.
studies, wherein people with a higher level of social capital indicated a better sense of physical and mental health (4,24). Another study reported that some indices of social capital such as civic participation are inversely related to health. Civic participation, in particular communication networks, can motivate unhealthy behaviors such as alcohol use and smoking (25). Some studies have also reported that social capital resources have an indirect positive relationship with mental health (26). One study showed that structural social capital (communication networks) has a negative relationship with mental disorder (27). Moreover, some researchers have found a lack of a relationship between health and social capital after considering demographic variables (4,28). Through a meta-analysis conducted in 2012 showing that the majority of reviewed
papers were in Western countries and rarely in Asian countries, it was found that social capital does not have a consistently positive effect on health outcomes: the effect of social capital may be beneficial for one particular population while it is detrimental for another. Thus, researchers will need to determine which dimensions of social capital have negative or positive influences on health for their population (29). As shown in Table 2, based on the findings of this study, years of education and income are significantly related to the majority of the dimensions of health. In other words, each year of education and the sufficiency of family income for life expenses lead to a better health score. Other studies have also confirmed this finding and emphasized the companionship of human capital, financial capital, and social capital with regard to health (4,26).
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Limitations of the study
References
The study’s limitation is that the ways in which these variables affect health status was not studied. The causal pathways underlying these associations need to be elucidated in order to better determine the right interventions and effective strategies needed to prevent health inequalities.
Conclusion/Recommendation Generally, the findings of this cross-sectional study showed that the dimensions of social capital manifestations (groups and networks, trust and solidarity, collective action and cooperation) can potentially lead to the dimensions of social capital outcomes (social cohesion and inclusion, and empowerment and political action), which in turn affect health inequities, after controlling for socio-demographic differences. Therefore, a greater focus on social capital’s role on health promotion and health policies is required. Moreover, the findings showed that women with higher financial or human capital (e.g. through education) experience better health. Thus, considering the social capital inequities in health issues, the required interventions must involve multiple strategies minimizing the socioeconomic inequities as well as making greater use of the social capital and empowerment approaches. Each society has its own type of social capital; therefore, a program’s effect on health depends not only on the program itself and its participants but also on the social capital of the given society. The next step of this crosssectional research is to conduct longitudinal and interventional studies for confirming the causal nature and mechanisms of these relationships. Acknowledgements The authors would like to thank all the women who participated in the present study.
Conflict of interest None declared
Funding This work was supported and funded by Tehran University of Medical Sciences (TUMS) grant no. 91-04-62-20184.
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PED0010.1177/1757975915572382Original ArticleA. Baheiraei et al.
Original Article Association between social capital and health in women of reproductive age: a population-based study Azam Baheiraei1, Fatemeh Bakouei2, Eesa Mohammadi3, Reza Majdzadeh4 and Mostafa Hosseni4
Abstract: Women’s health is a public health priority. The origins of health inequalities are very complex. The present study was conducted to determine the association between social capital and health status in reproductive-age women in Tehran, Iran. In this population-based, cross-sectional study, the Social Capital Integrated Questionnaire, the SF-36 and socio-demographic questionnaires were used. Analysis of data by one-way ANOVA test and stepwise multiple linear regression showed that the manifestation dimensions of social capital (groups and networks, trust and solidarity, collective action and cooperation) can potentially lead to the outcome dimensions of social capital (social cohesion and inclusion, and empowerment and political action), which in turn affect health inequities after controlling for socio-demographic differences. Keywords: social capital, health status, population-based study, reproductive age women, Iran
Introduction The maintenance and promotion of women’s health is not only a human right but is also necessary for population health at a national level. (1). Women’s health in low and middle income countries is rather complex because of demographic changes. Therefore, policies and programs should generally address women’s health and focus on its effective determinants (2). The origins of health inequalities are very complicated and operate at several levels. Apart from genetic and biological factors, some other factors are associated with health inequality (3).
Some evidence indicates that social structure plays a key role in the formation of people’s health. In this regard, the researchers have focused their research mainly on social capital (4). Putnam defined social capital as ‘features of social organization such as networks, norms and social trust that facilitate coordination and cooperation for mutual benefit’ (5). Coleman suggests that there are three assets for every individual: financial capital, human capital and social capital (6). High level social and civil participation of the citizens, high general trust among people toward each other, high trust of organizations, and mutual action can
1. Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran. 2. Department of Midwifery, Babol University of Medical Sciences, Babol, Iran. 3. Department of Nursing, Tarbiat Modares University, Tehran, Iran. 4. Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. Correspondence to: Fatemeh Bakouei, Department of Midwifery, Babol University of Medical Sciences, Babol, Iran. Email: [email protected] (This manuscript was submitted on 16 April 2014. Following blind peer review, it was accepted on 28 November 2014)
Global Health Promotion 1757-9759; Vol 0(0): 1 –10; 572382 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975915572382 http://ghp.sagepub.com Downloaded from ped.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 18, 2015
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all contribute to a high level of social capital within a society (7). Social capital has been proposed as a factor that impacts positively on health. It may influence health through such mechanisms as more convenient access to information of society members, contribution to promote decision making related to health, affecting social norms, enhancing use of health services, better access to health services in society, and offering mental support (7,8). Studies have shown that various health-related outcomes such as self-reported health (9), mental health (10) and health behaviors (4,11) are associated with social capital. However, the association between social capital and health is not always consistent. It varies according to the sample, the type of health outcome (12) and the context in which it is studied (13). Because of the available inconsistent findings, there is no consensus among researchers about the relationship between social capital and health. Such inconsistency in results may originate from conceptualization and measurement instruments of social capital. In addition to the wide variety of definitions proposed for social capital, its measurement is also differs among various disciplines and fields of study. The World Bank introduced an instrument for measuring social capital through which a set of key and central questions are extracted from previous studies conducted on social capital, and this is the instrument that is used in this study (14). According to the statistics published by the Statistical Center of Iran in 2011, the highest percentage of the entire female population (about 60%) is reproductive-age women (15–49 years old) (15). Given the priority of women’s health in national reproductive health programs and the lack of such a study concerning this relationship, the present study was conducted to determine social capital status and its association with health in reproductive-age women in Tehran (capital city of Iran) with its specific social-cultural characteristics. It must be noted that about 16.2% of Iranian reproductive-age women live in Tehran (15).
Methods This study is a population-based, cross-sectional survey on reproductive-age women (15–49 years
old), residing in any one of the 22 municipality areas across Tehran. This study is a part of a mixedmethod study using a sequential explanatory design, the protocol of which has been previously published (16). The sample size in the current study was 770 people with p = 50%, d = 4%, and considered design effects (degree of freedom (df) = 1.2%). The sampling technique was multi-stage in municipality areas of Tehran so that each area is divided into a number of blocks with an unequal population. In each area, the required number of blocks was randomly selected from the list of blocks. Next, using the systematic sampling method, the reproductive-age women in the households were interviewed. In case a woman declined to take part, the next-door household was invited to participate in the study to complete the questionnaire. When invited, all potential participants were assured of the confidentiality of their information. All participants were interviewed face to face in their own house by the team of interviewers. Interviewers were trained by the research team for conducting standard interviews. To ensure reliability of the collected data, interviewers were closely controlled and monitored. The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences. Following a detailed explanation, informed consent was obtained from all participating women.
Scales and data collection In this study the following three questionnaires were used: 1. The Social Capital Integrated Questionnaire (SC-IQ) was designed by the World Bank in 2000 to measure the social capital of developing countries. The questionnaire contains six dimensions: groups and networks, trust and solidarity, collective action and cooperation, information and communication, social cohesion and inclusion, and empowerment and political action (14). The validity and reliability of the questionnaire was measured by Nedjat et al. in Iran through the forward-backward translation method. A few questions have been added to it. Mean scores for the five dimensions, except the dimension of information and communication
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(which was only for more detailed reviewing of obtained information from the general public), ranged from 0 to 100, with a higher score indicating higher social capital. The intra-class correlation coefficient (ICC) was higher than 0.7 in all the dimensions (ICC range: 0.75–0.89) (17). According to the recommendations of instrument designers of the World Bank, the researchers of this study assumed groups and networks, trust, and cooperation as manifestations of social capital. Social cohesion, empowerment, and political action were assumed to be outcomes of social capital. The scores were calculated for all aspects in a range of 0–100. (14). 2. The SF-36 questionnaire (Short Form Health Survey) was first designed by Ware et al. to evaluate the health of the community, determine health policies, and assess the efficacy of the designed treatment. The SF-36 questionnaire consists of eight health-related concepts/domains: physical functioning, role limitations due to physical problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health (18). The SF-36 questionnaire was translated in Iran by Montazeri et al. using the forward-backward translation method; it has also been culturally adapted and its validity and reliability determined. Reliability was found using internal consistency, validity was determined using known groups comparison, and convergent validity was also measured. Cronbach’s coefficient of all dimensions of the questionnaire, except vitality (0.65), ranged from 0.77 to 0.90. The mean score for the eight indicators of this test based on the protocol of the questionnaire ranged from 0 (worst status) to 100 (best status) (19). 3. The socio-demographic variable questionnaire was designed by a research team to include age, ethnicity, educational level, educational years, marital status, family size, employment status, sufficiency of income for expenses, and crowding index.
Data analysis Data were analyzed using SPSS-16. At first, the dimensions of social capital were assessed descriptively with frequency and percentage for socio-demographic factors. Then, to investigate the
relationship between dimensions of social capital and socio-demographic factors, a one-way analysis of variance (ANOVA) test was used. To avoid the effects of confounding factors, and to predict the effects of independent variables (social capital and sociodemographic factors) on dependent ones (dimensions of health), variables with significant associations in the test were entered into a stepwise multiple linear regression. The threshold of type-one error was considered to be 0.05.
Results In total, 770 reproductive-age women (15–49 years old) with a mean age of 33.9±9.3 years were interviewed. A majority of them were married (72.3%) housewives (62.2%), of Persian ethnicity (64.3%), and educated to high school level (43.8%) (Table 1). The obtained mean score and standard deviation of all the dimensions of social capital in reproductiveage women are shown in Table 1. The largest mean score (55.72±11.94) was related to the social cohesion and inclusion dimension and the lowest mean score (31.78 ±19.43) related to the groups and networks dimension. In relation to the information and communication dimension, when the respondents were asked ‘To what extent do you follow the country’s events and news?’ 46.6% of the women followed it every day and 11.1% did not follow it at all. With regards to the request to ‘Identify the three main sources of keeping up with the government’s activities’, TV (62.8%), newspapers and magazines (24%), and relatives, friends and neighbors (20.1%) were identified. The relationship between social capital in reproductive-age women and socio-demographic factors through one-way ANOVA is also shown in Table 1. According to the results, there was a significant association between some dimensions of social capital and the following variables: age, ethnicity, marital status, education level, occupation status, crowding index and sufficiency of income for expenses. To respond to the main objective of this study, the ‘relationship between social capital and health status of reproductive-age women’, the linear regression models considered all dimensions of social capital and socio-demographic factors as independent variables and all dimensions of health as dependent variables. The results of the linear IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Age groups 15–25 years 26–35 years 36–45 years 46–49 years ANOVA p Marital status Married Divorced/Widowed Single ANOVA p Ethnicity Fars Azari Others ANOVA p Educational level Illiterate/Primary (years 1–5) Intermediate (years 6–8) High school (years 9–12) University ANOVA p Occupation status Housewife Employed Student ANOVA p
Independent variables
36.31 (18.51) 31.69 (18.90) 30.02 (19.59) 28.89 (20.67) 0.004 30.62 (19.13) 21.32 (20.06) 37.06 (19.01) 0.000 30.80 (19.24) 32.50 (19.40) 35.09 (20.11) 0.105 22.84 (20.40) 26.24 (20.29) 31.02 (18.74) 35.64 (18.90) 0.000 28.97 (19.08) 35.21 (19.93) 38.62 (17.40) 0.000
556 (72.2) 31 (4) 183 (23.8)
487 (64.3) 179 (23.2) 91 (13.5)
50 (6.5) 83 (10.8) 337 (43.8) 300 (38.9)
479 (62.2) 190 (24.7) 101 (13.1)
Groups and networks
165 (21.5) 266 (34.5) 224 (29.1) 115 (14.9)
Number (%)
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54.64 (17.89) 54.55 (17.23) 53.62 (15.36) 0.865
53.80 (17.40) 55.17 (18.53) 53.83 (17.65) 55.15 (16.83) 0.771
54.39 (16.73) 54.51 (18.54) 54.91 (18.60) 0.962
55.04 (17.30) 51.65 (19.99) 53.29 (17.22) 0.325
52.72 (16.38) 55.31 (17.12) 55.21 (17.46) 53.72 (19.24) 0.409
Trust and solidarity
Social capital dimensions: mean (SD)
46.15 (26.49) 48.26 (24.05) 42.36 (23.84) 0.174
48.21 (26.07) 43.52 (28.09) 45.91 (25.90) 46.87 (24.51) 0.693
45.19 (25.35) 47.27 (26.22) 48.91 (25.65) 0.326
47.08 (26.20) 36.29 (22.10) 45.10 (23.97) 0.059
44.11 (25.18) 46.86 (25.05) 48.36 (25.67) 43.27 (27.12) 0.225
Collective action and cooperation
56.53 (11.84) 53.99 (11.81) 55.15 (12.38) 0.040
56.72 (14.03) 57.38 (11.15) 55.06 (12.44) 55.84 (11.17) 0.391
55.88 (12.00) 54.93 (12.45) 56.32 (10.74) 0.565
56.47 (11.58) 52.78 (12.12) 53.94 (12.76) 0.017
54.20 (13.15) 56.52 (11.28) 55.97 (11.32) 55.55 (12.70) 0.263
Social cohesion and inclusion
(Continued)
45.08 (15.59) 47.31 (15.62) 46.73 (15.58) 48.62 (17.38) 0.296 48.17 (15.45) 42.62 (14.17) 43.59 (16.90) 0.001 45.80 (15.61) 47.68 (16.03) 50.38 (16.45) 0.021 53.48 (15.62) 51.84 (15.35) 46.47 (16.03) 44.81 (15.39) 0.000 48.18 (16.00) 44.84 (14.87) 44.38 (16.57) 0.012
Empowerment and political action
Table 1. Respondents’ socio-demographic characteristics in association with the mean scores of social capital dimensions through ANOVA.
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ANOVA: analysis of variance.
Sufficiency of income for expenses Absolutely not To some extent Completely ANOVA p Crowding index Low Average High ANOVA p Family size Less than four Four to five More than five ANOVA p Total
Independent variables
Table 1. (continued)
34.27 (18.70) 30.98 (19.30) 31.35 (20.57) 0.148 32.11 (19.17) 31.45 (19.36) 33.42 (22.03) 0.754 31.78 (19.43)
195 (27.5) 365 (51.6) 148 (20.9)
321 (42.3) 384 (50.7) 53 (7.0) 770 (100)
29.70 (19.71) 31.32 (19.01) 36.30 (18.72) 0.001
Groups and networks
337 (44.1) 240 (31.4) 188 (24.5)
Number (%)
53.98 (17.47) 54.82 (17.59) 55.64 (14.86) 0.726 54.48 (17.40)
54.78 (18.26) 55.09 (16.63) 54.67 (17.70) 0.960
51.66 (17.06) 54.08 (17.30) 60.53 (16.58) 0.000
Trust and solidarity
Social capital dimensions: mean (SD)
46.31 (26.73) 46.08 (24.65) 47.72 (25.49) 0.909 46.18 (25.60)
46.79 (24.72) 47.46 (26.08) 46.99 (25.67) 0.953
45.42 (27.01) 44.07 (23.79) 50.95 (24.64) 0.015
Collective action and cooperation
55.93 (12.76) 55.50 (11.14) 57.06 (12.44) 0.648 55.72 (11.94)
54.65 (13.03) 55.65 (11.05) 57.91 (12.89) 0.042
54.16 (12.21) 56.41 (11.61) 57.89 (11.54) 0.002
Social cohesion and inclusion
46.16 (15.77) 46.68 (15.73) 48.69 (16.11) 0.205 46.77 (17.27) 47.35 (15.70) 47.50 (14.93) 0.894 47.57 (16.44) 46.61 (15.58) 46.01 (14.53) 0.655 46.86 (15.88)
Empowerment and political action
Original Article 5
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regression analysis in regression models 1 to 8 are shown in Table 2. Each of the regression models takes one health dimensions as the dependent variable. The table only shows those variables that remained statistically significant after adjusting for other variables in the regression test with dimensions of health. This table shows that both of the outcome dimensions of social capital (social cohesion and inclusion, and empowerment and political action) after adjustment are significantly related to the majority of the dimensions of health. The linear regression analysis (Table 3) indicated that the three manifestation dimensions of social capital (groups and networks, trust and solidarity, and collective action and cooperation) are significantly related to two outcome dimensions of social capital (social cohesion and inclusion, and empowerment and political action). Additionally, only the outcome dimensions remained in the regression models after importing all dimensions of social capital into the linear regression models and considering the dimensions of health as dependent variables (Table 2). The total conclusion in this study is shown in Figure 1.
Discussion In the present study, the individual social capital in reproductive-age women was measured and investigated. The scores of social capital dimensions were separately formatted and reported for different social and demographic groups. It was found that that the highest mean scores related to the social cohesion and inclusion dimension and the lowest mean scores to the groups and networks dimension. Because of the relative lack of studies related to the sociodemographic distribution of social capital and similarly, the lack of use of a stable instrument for measuring social capital in previous studies, a very strong basis for comparison does not exist. However, in the study by Nedjat et al. that was carried out on 2484 men and women 18 years and over in 2008, using the same questionnaire, the lowest score was related to the groups and networks dimension (18.9±12.9), whereas the highest score belonged to the trust and solidarity dimension (53.7±14.4) (19). In a British study of adults (16 and over), social trust received 41% and civic participation 45.2% (20).
This study identified that women’s access to social capital was different in terms of some sociodemographic factors. One especially interesting aspect of this study is the lack of relationship found between dimensions of trust and solidarity, collective action and cooperation, empowerment and political action, and social cohesion and inclusion with variables such as higher education and employment (determinants of social status). This may signify a unique historical and cultural conception relevant to women in Iranian society in relation to different dimensions of social capital. In other studies, education and employment had a significant association with social capital (7,21). The findings of this study have also supported the relationship between the dimensions of manifestation and outcome as it is conceptualized in the social capital-integrated questionnaire used in the present study. It means that people with higher scores in groups and networks, trust, and participation achieved higher scores in social cohesion and inclusion, and empowerment and political action. This finding is similar to other studies (22,23). This suggests that the elements in the manifestation and outcome dimensions must be viewed separately in conceptual and empirical terms. As a result, focus is required not only on communications and groups of people, but also on the value of these communications as capital resources. Along with the main goal of this study, which is to explore the relationship between social capital and health status of reproductive-age women, the findings revealed that after controlling for other variables, both of the dimensions of social capital outcome (social cohesion and inclusion, and empowerment and political action) are significantly related to dimensions of health: general health, social functioning, role limitations due to emotional problems, and mental health. Social cohesion and vitality were significantly associated with physical functioning and bodily pain. Likewise, empowerment and political action were found to be related to role limitations due to physical problems. These finding generally confirm the importance of social capital for the various components of self-rated health. In other words, health dimension scores significantly increased as social capital outcome dimension scores increased, indicating a positive relationship between social capital and health. This is confirmed in other
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Table 2. Linear regression analysis for the prediction of variance in health dimension score by socio-demographic factors and social capital dimensions. Variables Model 1: Physical functioning Age Educational years Social cohesion and inclusion Model 2: Role physical Age Empowerment and political action Model 3: Bodily pain Educational years Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Model 4: General health Age Educational years Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action Model 5: Vitality Educational years Sufficiency of income for expenses Completely Absolutely not Empowerment and political action Model 6: Social functioning Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action Model 7: Role emotional Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action Model 8: Mental health Educational years Sufficiency of income for expenses Completely Absolutely not Social cohesion and inclusion Empowerment and political action
B
Confidence interval
−0.50 1.14 0.19
−0.74 to −0.26 0.65–1.63 0.03–0.36
−0.54 0.23
−0.84 to −0.23 0.05–0.41
0.62
0.01–1.23
Reference −9.76 0.23
– −14.31 to −5.20 0.03–0.42
−0.27 0.94
−0.48 to −0.05 0.47–1.41
Reference −4.26 0.21 0.21
– −7.70 to −0.81 0.06–0.36 0.10–0.32
0.72
0.24–1.19
Reference −5.94 0.32
– −9.56 to −2.33 0.20–0.44
Reference −7.15 0.23 0.23
– −10.88 to −3.42 0.07–0.38 0.11–0.34
Reference −9.05 0.33 0.23
– −15.25 to −2.84 0.07–0.59 0.04–0.43
0.76 Reference −4.58 0.31 0.31
0.26–1.25 – −8.31 to −0.84 0.15–0.47 0.18–0.43
PV 0.000 0.000 0.021 0.001 0.009 0.04 – 0.000 0.01 0.01 0.000 – 0.01 0.004 0.000 0.003 – 0.001 0.000 – 0.000 0.004 0.000 – 0.004 0.01 0.01 0.002 – 0.01 0.000 0.000
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Table 3. Linear regression analysis of manifestation dimensions on outcome dimensions of social capital. Manifestation dimensions of social capital
Groups and networks Trust and solidarity Collective action and cooperation
Outcome dimensions of social capital Social cohesion and inclusion
Empowerment and political action
B (confidence interval)
PV
B (confidence interval)
PV
0.05 (0.01–0.09) 0.15 (0.10–0.20) 0.04 (0.01–0.07 )
0.011 0.001 0.020
0.06 (0.02–0.10) 0.18 (0.12–0.25) 0.07 (0.03–0.12)
0.002 0.001 0.001
PV: prediction of variance.
Social capital • Groups & networks • Trust & solidarity • Collective action
• Social cohesion • Empowerment
Health
Figure 1. Proposed relationship between the two components of social capital (manifestation and outcome) and health.
studies, wherein people with a higher level of social capital indicated a better sense of physical and mental health (4,24). Another study reported that some indices of social capital such as civic participation are inversely related to health. Civic participation, in particular communication networks, can motivate unhealthy behaviors such as alcohol use and smoking (25). Some studies have also reported that social capital resources have an indirect positive relationship with mental health (26). One study showed that structural social capital (communication networks) has a negative relationship with mental disorder (27). Moreover, some researchers have found a lack of a relationship between health and social capital after considering demographic variables (4,28). Through a meta-analysis conducted in 2012 showing that the majority of reviewed
papers were in Western countries and rarely in Asian countries, it was found that social capital does not have a consistently positive effect on health outcomes: the effect of social capital may be beneficial for one particular population while it is detrimental for another. Thus, researchers will need to determine which dimensions of social capital have negative or positive influences on health for their population (29). As shown in Table 2, based on the findings of this study, years of education and income are significantly related to the majority of the dimensions of health. In other words, each year of education and the sufficiency of family income for life expenses lead to a better health score. Other studies have also confirmed this finding and emphasized the companionship of human capital, financial capital, and social capital with regard to health (4,26).
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Limitations of the study
References
The study’s limitation is that the ways in which these variables affect health status was not studied. The causal pathways underlying these associations need to be elucidated in order to better determine the right interventions and effective strategies needed to prevent health inequalities.
Conclusion/Recommendation Generally, the findings of this cross-sectional study showed that the dimensions of social capital manifestations (groups and networks, trust and solidarity, collective action and cooperation) can potentially lead to the dimensions of social capital outcomes (social cohesion and inclusion, and empowerment and political action), which in turn affect health inequities, after controlling for socio-demographic differences. Therefore, a greater focus on social capital’s role on health promotion and health policies is required. Moreover, the findings showed that women with higher financial or human capital (e.g. through education) experience better health. Thus, considering the social capital inequities in health issues, the required interventions must involve multiple strategies minimizing the socioeconomic inequities as well as making greater use of the social capital and empowerment approaches. Each society has its own type of social capital; therefore, a program’s effect on health depends not only on the program itself and its participants but also on the social capital of the given society. The next step of this crosssectional research is to conduct longitudinal and interventional studies for confirming the causal nature and mechanisms of these relationships. Acknowledgements The authors would like to thank all the women who participated in the present study.
Conflict of interest None declared
Funding This work was supported and funded by Tehran University of Medical Sciences (TUMS) grant no. 91-04-62-20184.
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