4 Social and community influences
Here the role of social and community influences on health are considered. The concept of social capital has become very popular within public health in recent years, although, like many similar concepts, it been used in different ways by different people. Indeed, Wall et al. (1998) and Hawe and Shiell (2000) have argued that the concept is being used so widely and diversely that its explanatory power is being weakened.
The concept of social capital can be traced to one of several sources (Bourdieu, 1986; Coleman, 1988; Putnam, 1995); however, the work of Bourdieu is probably the most relevant here. He describes social capital as: ‘the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance or recognition – or in other words to membership of a group’ (Bourdieu, 1986, p. 248).
In a synthesis of the literature on social capital, Portes (1998, p. 1) describes it as ‘the ability to secure benefits through membership in networks and other social structures’ (see also Chapter 4 and Gibson, 2007). So social capital is both a resource enabling better access to goods and services as well as a network of relationships between individuals and between individuals and institutions.
A lifecourse approach would focus on how social capital is accrued throughout life and how it can be passed on from one generation to the next. Writing about education, Bourdieu (1999) discusses the way in which extra knowledge – or cultural capital – is passed on from parents to children and, drawing on this, Sullivan (2001) argues that this is one of the ways in which middle-class families ensure educational advantages for their children. Bagnall et al. (2003) carried out a study into involvement in parent /teacher associations (PTA) in the North West of England. Drawing on their analysis of 88 in-depth interviews they found that, while middle-class parents found PTA involvement a useful way of building social capital, working-class parents were more likely to generate social capital using their own family and other local social networks. For mobile middle-class people, the PTA enabled then to connect with ‘like-minded’ people as well as establishing institutional and relational links with the school as a means of ‘getting ahead’ (see Box 3).
Box 3 Social capital and ‘getting ahead’
Interviewer: Why did you join the PTA?
Respondent (female, 40 years old): Well, partly to meet people, partly to help fundraising for the school, and it’s quite a good way of finding out what’s going on as well.
For middle-class parents, PTA involvement is represented as the norm, but for working-class parents a lack of involvement is the norm. The latter are also much more likely to be dismissive of PTA involvement and more likely to describe themselves as being ‘too busy’. Bagnall et al. suggest that working-class parents are more interested in ‘getting by’ rather than ‘getting on’, as illustrated by the following two quotes from this study in Box 4.
Box 4 Social capital and ‘getting by’
Interviewer: [...] are you involved in any PTAs, or anything like that?
Respondent (male, 33 years old): No, not at the moment, not involved at all ... I think the people who are attracted to it don’t attract me, basically.
Interviewer: Did you get involved with the school – PTAs, things like that?
Respondent (female, 39 years old): Not particularly PTAs, because having quite a lot on ourselves, because I do my husband’s paperwork as well as doing the job myself, running the house, looking after the children, because he’s so busy.
The relationship between social capital and health is disputed. Some writers have suggested that there is a direct relationship between inequalities in social capital and inequalities in health, whereas others (for example Kaplan et al., 1996) are less certain. Kawachi et al. (1997) argue that there is a clear relationship between increased morbidity and mortality and disinvestment in social capital. A study of physical activity and the social environment (i.e. culture, people and institutions with whom people interact) involving over 3,300 adults in six countries (Ståhl et al., 2001) also found that the social environment was the strongest predictor of physical activity. Those who perceived low levels of social support from their personal environment (i.e. family, friends, school and workplace) were twice as likely to be physically inactive compared to those who reported high levels of support. The study concluded that strategies to promote greater physical activity would need to focus more on social norms regarding active lifestyles, and on making activity more ‘socially acceptable’. Thus, a settings approach, which is discussed further in the next chapter, seeks to enable different social environments – such as schools, workplaces, and so on – to maximise their health-promoting potential.
Social capital is, thus, linked to both social inclusion and social exclusion because, as you have already seen, it is not equally distributed. The Social Exclusion Unit (SEU) defines social exclusion as happening:
when people or places suffer from a series of problems such as unemployment, discrimination, poor skills, low incomes, poor housing, high crime, ill health and family breakdown. When such problems combine they can create a vicious cycle.
Social exclusion can happen as a result of problems that face one person in their life. But it can also start from birth. Being born into poverty or to parents with low skills still has a major influence on future life chances.
Key groups who may suffer social exclusion include people with mental health problems, young runaways, teenage mothers and ex-prisoners, all of whom may lack membership of the networks and social structures that promote positive health and wellbeing. One of the goals of the SEU is the reintegration of people who, for one reason or another, have ‘fallen through the net’.
Psycho-social approaches emphasise the importance of relational networks in promoting good health. For example, religiosity, or spirituality, has been found to increase a sense of belonging and, through various related activities, such as volunteering, promote good health (Yeung, 2004). Social and community influences can be important determinants of health, not just because of the material resources to which individuals may or may not have access, but also because of the relational networks within which individuals find, or locate, themselves. As Link and Phelan suggest: ‘when a population develops the wherewithal to avoid disease and death, individuals’ ability to benefit from that wherewithal is shaped by resources of knowledge, money, power, prestige, and beneficial social connections’ (Link and Phelan, 2002, p. 730).