Home is where the governing is: social capital and regional health governance

Social media links with social capital to trust in healthcare facilities: empirical evidence from Bangladesh

Purpose

The paper aims to investigate the most influential social media information sources to trust in healthcare facilities. The article shows a valuable point of reference for understanding how social media becomes the casting of social capital.

Design/methodology/approach

This paper has taken 660 responses from the people who used social media for healthcare information in the mid of 2020 during the pandemic. The people were approached through different social media groups. The paper conducted structural equation modelling (SEM). The result has shown that with the instigating power of social capital where people put trust in social media information during pandemics.

Findings

The findings demonstrated that personal sources, government organisations and healthcare professionals are the most influential sources of social media. In order to effectively ensure the encompassing provision of COVID-19 health services, this article argues that social capital considerations establish trust between healthcare facilities seeking community to healthcare information providers.

Research limitations/implications

This research has signified that social cohesion and concern for community welfare instigated people to engage in social media communication. The inherent social capital belongings influence people to trust the sources of health information from selected sources that appear on social media.

Practical implications

Healthcare policymakers may utilise this intense feeling of belongingness and cohesion of social capital and use social media platforms to spread health-related information.

Originality/value

The study shows social capital has the strength to entice people into healthcare-seeking behaviour. In this era, social capital is reformulated to digital social capital through social media and strongly affects people's trust.

Trust in the healthcare system and mortality: A population-based prospective cohort study in southern Sweden

Aims

To investigate associations between trust in the healthcare system and all-cause, cardiovascular, cancer and other causes mortality.

Study design

Prospective cohort study.

Methods

A public health questionnaire was conducted in 2008 in Scania, the southernmost part of Sweden, with a 54.1% participation rate with a postal questionnaire and three reminders. In this study 24,833 respondents were included. The baseline questionnaire study was linked to prospective 8.3-year follow-up cause-specific mortality register data. Survival (Cox) regression analyses were conducted.

Results

A 15.2% proportion of respondents reported very high, 59.1% rather high, and 21.7% not particularly high trust in the healthcare system, while 3.2% reported no trust at all and 0.9% did not know. The groups with rather high and not particularly high trust in the healthcare system had significantly lower all-cause mortality than the reference group with very high trust in the healthcare system. These statistically significant results remained throughout the multiple analyses, and were explained by lower cancer mortality in both the rather high and not particularly high trust respondent groups, and lower cardiovascular mortality in the not particularly high trust respondent group. No significant results were observed in the adjusted models for other causes mortality. No significant results were observed for the no trust and don't know categories in the multiple adjusted models, but these groups are small.

Conclusions

The results suggest a comparative advantage of moderate trust compared to very high trust in this setting of long waiting times for cancer and CVD treatment.

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Trust in the healthcare system and mortality was investigated.

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Rather high and not particularly high trust groups had lower all-cause mortality than the very high trust group.

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The lower mortality was mainly explained by lower cancer mortality.

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The lower mortality was partly explained by lower CVD mortality.

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The findings are associated with long-term queueing for particularly cancer treatment.

COVID-19 Amplifiers on Health Inequity Among the Older Populations

The coronavirus disease 2019 (COVID-19) is affecting the population disproportionately and is continuously widening the health gap among the population. Based on some recent studies on COVID-19 and the older population, the various cascades toward health inequity have been projected. This study highlights how the COVID-19 is met by health inequity triggers, such as global trade inequality, ageist social regulations, and the existing social inequity. While those triggers are applicable to all the populations, there seems to be specific amplifiers for health inequity among the older populations. In particular, six types of amplifiers have been identified: (1) expansion of riskscape, (2) reduction of social ties, (3) uncertainty of future, (4) losing trust in institutions, (5) coping with new knowledge, and (6) straining on public spending. While the fundamental mitigating responses to health inequity among the older population is tackling existing inequalities, this study may help to shed light on emerging vulnerabilities among the older population to alleviate far-reaching consequences of COVID-19 of the identified inequity amplifiers.

Impact of Trust and Technology on Interprofessional Collaboration in Healthcare Settings

The increases in complexity of patient care, healthcare costs, and technological advancements shifted the healthcare delivery to interprofessional collaborative care. The study aims for identifying the factors influencing the quality of team collaboration. The study examines the impact of trust and technology orientation on collaboration with the mediating effects of communication, coordination and cooperation. A questionnaire survey was conducted to gather data from healthcare professionals (N=216). Statistical analysis conducted for this study include correlations, factor analysis with reliability and validity tests and Partial Least Squares (PLS) method. The results of the study validate that (i) collaboration has positive and significant relationship with coordination, and cooperation; (ii) trust has positive and significant relationship with communication, coordination, and cooperation; and (iii) technology orientation has positive and significant relationship with cooperation but not with communication and coordination. The research and managerial implications of these factors are given in discussion. As with most empirical studies, the subjectivity of the opinion of respondents present some limitations to generalization. Other limitations include the lack of availability and use of standard measures for various constructs in the research model. The results can be used by healthcare professionals and managers to advance their understanding on the impact of trust and technology on collaboration mediating communication, coordination and cooperation practices. The significant value of this study is the identification of the factors influencing the quality of team collaboration in healthcare industry.

Whose social capital matters? The case of U.S. urban public hospital closures and conversions to private ownership

Prior literature on social capital and health has predominantly focused on health outcomes and individual access to healthcare services. It is not known to what degree, if any, community social capital influences the performance or behaviors of public hospitals, a key source of healthcare for disadvantaged communities in the United States. In this study we developed measures of community bridging social capital - horizontal social networks between heterogeneous groups of similar social position - and linking social capital - vertical networks across the status hierarchy - relevant to public hospitals. We examined associations between social capital, and U.S. urban public hospital closures and conversions to private ownership from 1987 to 2007. We found that higher voting participation was associated with a greater hazard of public hospital closure over time (p < 0.01), whereas the number of business, professional and political organizations per 10,000 residents was associated a greater hazard of conversion (p < 0.05). Additional measures of bridging and linking social capital were not associated with either outcome. Taken together, our findings suggest that, at least historically, horizontal forms of social capital among more privileged groups (e.g., business, professional, and political associations) bear influence on public hospital outcomes. Specific efforts to increase engagement of disadvantaged groups and connect them with decision-makers may be needed to fully realize the potential of linking social capital to influence local healthcare policy promoting social protection.

Good governance and budget reform in Lesotho Public Hospitals: performance, root causes and reality

Lesotho has been implementing financial management reforms, including performance-based budgeting (PBB) since 2005 in an effort to increase accountability, transparency and effectiveness in governance, yet little is known about how these efforts are affecting the health sector. Supported by several development partners and $24 million in external resources, the PBB reform is intended to strengthen government capacity to manage aid funds directly and to target assistance to pressing social priorities. This study designed and tested a methodology for measuring implementation progress for PBB reform in the hospital sector in Lesotho. We found that despite some efforts on the national level to promote and support reform implementation, staff at the hospital level were largely unaware of the purpose of the reform and had made almost no progress in transforming institutions and systems to fully realize reform goals. Problems can be traced to a complex reform design, inadequate personnel and capacity to implement, professional boundaries between financial and clinical personnel and weak leadership. The Lesotho reform experience suggests that less complex designs for budget reform, better adapted to the context and realities of health sectors in developing countries, may be needed to improve governance. It also highlights the importance of measuring reform implementation at the sectoral level.

Theoretical insights into interprofessional education: AMEE Guide No. 62

In this Guide, we support the need for theory in the practice of interprofessional education and highlight a range of theories that can be applied to interprofessional education. We specifically discuss the application of theories that support the social dimensions of interprofessional learning and teaching, choosing by way of illustration the theory of social capital, adult learning theory and a sociological perspective of interprofessional education. We introduce some of the key ideas behind each theory and then apply these to a case study about the development and delivery of interprofessional education for pre-registration healthcare sciences students. We suggest a model that assists with the management of the numerous theories potentially available to the interprofessional educator. In this model, context is central and a range of dimensions are presented for the reader to decide which, when, why and how to use a theory. We also present some practical guidelines of how theories may be translated into tangible curriculum opportunities. Using social capital theory, we show how theory can be used to defend and present the benefits of learning in an interprofessional group. We also show how this theory can guide thinking as to how interprofessional learning networks can best be constructed to achieve these benefits. Using adult learning theories, we explore the rationale and importance of problem solving, facilitation and scaffolding in the design of interprofessional curricula. Finally, from a sociological perspective, using Bernstein's concepts of regions and terrains, we explore the concepts of socialisation as a means of understanding the resistance to interprofessional education sometimes experienced by curriculum developers. We advocate for new, parallel ways of viewing professional knowledge and the development of an interprofessional knowledge terrain that is understood and is contributed to by all practitioners and, importantly, is centred on the needs of the patient or client. Through practical application of theory, we anticipate that our readers will be able to reflect and inform their current habitual practices and develop new and innovative ways of perceiving and developing their interprofessional education practice.

Institutional trust in the national social security and municipal healthcare systems for the elderly in Japan

Japanese social security systems and institutions for the elderly, as well as the general attitude toward elderly care services among the Japanese population, have been undergoing a dramatic change. By examining the association between institutional trust, which is a representative element of social capital, and anxiety regarding receiving elderly care, we can uncover clues toward building a more robust social security system for the elderly. This study examines the relationship between institutional trust, in the national social security and municipal healthcare systems for the elderly, and anxiety with respect to receiving elderly care among the general Japanese population. A cross-sectional survey was conducted using a self-administered questionnaire that was returned by mail in January and February 2005. The target population was 4735 community residents aged 20-75 years, who lived in the city of Koka, Shiga, Japan. A total of 2264 questionnaires were included in the analysis. A binominal logistic regression analysis showed that responses of 'trust' [odds ratio (OR): 2.09, 95% confidence interval (95% CI): 1.01-4.30] and 'strongly trust' (OR: 3.80, 95% CI: 1.55-9.31) for the national system were associated with not having anxiety regarding elderly care, compared with the reference category of feeling strongly distrust. However, trust in the municipal system showed no association with this anxiety. These results indicate the importance of developing strategies to increase a common trust in the national care services for the elderly to reduce the anxiety people feel regarding whether they will be able to receive elderly care when required.

The Importance of Social Capital in the Promotion of Community Development and the Enhancement of Local Health System

Despite the interest in social capital, the value of this concept for health promotion and inequality reduction has yet to be firmly established. Although it has been suggested that the concept of social capital may be useful for exploring factors within individual and social health and for identifying different approaches to community-based healthcare, the interlinkages between primary healthcare, social capital and community development have yet to be considered in much detail.

The purpose of this article is to analyse, through the examination of a case study from southern India (Tamil Nadu), how far social capital can trigger community participation and an effective process of enhancement of basic health system in rural areas, while conserving local medicinal knowledge. The case study is represented by Gram Mooligai Limited Company (GMLC), an innovative female community enterprise of tribal herb gatherers which commercialises medicinal plants and produces phytomedicines, using their traditional knowledge in ethnomedicine.

Exploring the hypothesis of ethnic practice as social capital: violence among Asian/Pacific Islander youth in Hawaii

BACKGROUND

Studies of youth violence have usually examined social capital using qualitative methods, but remain limited by small sample sizes. In addition, few studies examine violence among Asian/Pacific Islander (API) youth, even though they are one of the fastest-growing youth populations in the USA.

AIMS

To contribute to a better understanding of culture and ethnicity in youth violence among Asian Americans and Pacific Islanders by quantifying ethnic forms of social capital.

METHODS

We use an n = 326 sample of three API groups from Oahu, Hawaii. Defining social capital as ethnic practice, we test Filipino, Hawaiian and Samoan forms of youth social capital on intimate and non-intimate violence.

RESULTS

Bivariate findings associate lower violence with language ability among Filipinos, coming-of-age practices among Hawaiians, and community leader engagement among Samoans. Multivariate tests showed language to be the strongest correlation. Bivariate tests also suggested potentially risky forms of social capital.

CONCLUSIONS

results lead us to hypothesize that social capital that deliberately places individuals within their respective ethnic communities are risk-reducing, as are those that promote formal ethnic community structures. Those that formalize ethnic practice and social capital into commercial activities may be associated with higher risk of violence. Given the relatively small sample size and the exploratory approach for the present investigation, further research is needed to determine whether the findings can be replicated and to extend the findings of the present preliminary study.

Institutional trust and alcohol consumption in Sweden: the Swedish National Public Health Survey 2006

BACKGROUND

Trust as a measure of social capital has been documented to be associated with health. Mediating factors for this association are not well investigated. Harmful alcohol consumption is believed to be one of the mediating factors. We hypothesized that low social capital defined as low institutional trust is associated with harmful alcohol consumption.

METHODS

Data from the 2006 Swedish National Survey of Public Health were used for analyses. The total study population comprised a randomly selected representative sample of 26.305 men and 30.584 women aged 16-84 years. Harmful alcohol consumption was measured using a short version the Alcohol Use Disorders Identification Test (AUDIT), developed and recommended by the World Health Organisation. Low institutional trust was defined based on trust in ten main welfare institutions in Sweden.

RESULTS

Independent of age, country of birth and socioeconomic circumstances, low institutional trust was associated with increased likelihood of harmful alcohol consumption (OR (men) = 1.52, 95% CI 1.34-1.70) and (OR (women) = 1.50, 95% CI 1.35-1.66). This association was marginally altered after adjustment for interpersonal trust.

CONCLUSION

Findings of the present study show that lack of trust in institutions is associated with increased likelihood of harmful alcohol consumption. We hope that findings in the present study will inspire similar studies in other contexts and contribute to more knowledge on the association between institutional trust and lifestyle patterns. This evidence may contribute to policies and strategies related to alcohol consumption.

Understanding place and health: A heuristic for using administrative data

The increasing availability, use and limitations of administrative data for place-based population health research, and a lack of theory development, created the context for the current paper. We developed a heuristic to interrogate administrative data sets and to help us develop explanatory pathways for linking place and health. Guided by a worked example, we argue that some items in administrative data sets lend themselves to multiple theories, creating problems of inference owing to the implications of using inductive versus deductive reasoning during the research process, and that certain types of theories are privileged when used administrative data bases.

Lost in translation: a genealogy of the "social capital" concept in public health

STUDY OBJECTIVE

To examine the genealogy of the social capital concept in public health, with attention to the epistemological concerns and academic practices that shaped the way in which this concept was translated into public health.

DESIGN

A citation-network path analysis of the public health literature on social capital was used to generate a genealogy of the social capital concept in public health. The analysis identifies the intellectual sources, influential texts, and developments in the conceptualisation of social capital in public health.

PARTICIPANTS

The population of 227 texts (articles, books, reports) was selected in two phases. Phase 1 texts were articles in the PubMed database with "social capital" in their title published before 2003 (n = 65). Phase 2 texts are those texts cited more than once by phase 1 articles (n = 165).

MAIN RESULTS

The analysis shows how the scholarship of Robert Putnam has been absorbed into public health research, how three seminal texts appearing in 1996 and 1997 helped shape the communitarian form that the social capital concept has assumed in public health, and how both were influenced by the epistemological context of social epidemiology at the time.

CONCLUSIONS

Originally viewed in public health research as an ecological level, psychosocial mechanism that might mediate the income inequality-health pathway, the dominance of the communitarian approach to social capital has given disproportionate attention to normative and associational properties of places. Network approaches to social capital were lost in this translation. Recovering them is key to a full translation and conceptualisation of social capital in public health.

Social capital, trust in the health-care system and self-rated health: the role of access to health care in a population-based study

This paper investigates the relationship between institutional trust in the health-care system, i.e. an institutional aspect of social capital, and self-rated health, and whether the strength of this association is affected by access to health-care services. The 2004 public health survey in the Scania region of Sweden is a cross-sectional study; a total of 27,963 respondents aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. Logistic regression model was used to investigate the association between institutional trust and self-rated health. Multivariate analyses of self-rated health were performed in order to investigate the importance of possible confounders (age, country of origin, education, economic stress, generalized trust in other people, and care-seeking behaviour) on this association. A 28.7% proportion of the men and 33.2% of the women reported poor self-rated health. A total of 15.0% and 58.3% of the respondents reported "very high" and "rather high" trust in the health-care system, respectively. Almost one-third of all respondents reported low institutional trust. Respondents born outside Sweden, with low/medium education, low generalized trust and low institutional trust had significantly higher odds ratios of poor self-rated health. Multiple adjustments for age, country of origin, education, economic stress, and horizontal trust had some effect on the significant relationship between institutional trust and poor self-rated health, for both men and women, but the additional introduction of care-seeking behaviour in the model substantially reduced the odds ratios. In conclusion, low trust in the health-care system is associated with poor self-rated health. This association may be partly mediated by "not seeking health care when needed". However, this is a cross-sectional exploratory study and the causality may go in both directions.

Area variation in mortality in Tasmania (Australia): the contributions of socioeconomic disadvantage, social capital and geographic remoteness

This study investigated the association between socioeconomic disadvantage, social capital, geographic remoteness and mortality in the Australian state of Tasmania. The analysis is based on death rates among persons aged 25-74 years in 41 statistical local areas (SLA) for the period 1998-2000. Multilevel binomial regression indicated that death rates were significantly higher in disadvantaged areas. There was little support for an association between social capital and mortality, thereby contesting the often held notion that social capital is universally important for explaining variations in population health. Similarly, we found little evidence of a link between geographic remoteness and mortality, which contrasts with that found in other Australian states; this probably reflects the small size of Tasmania, and limited variation in the degree of remoteness amongst its SLA.

The role of the media in public participation: framing and leading

This article focuses on the framing of women's health services in the context of restructuring dictated by health system regionalization. By examining the archives of a local newspaper and the minutes and documents of one of the key organizations involved in restructuring after regionalization, it was possible to examine the public discourse of the time and subsequently the journalists' and the readerships' understandings of women's health. The evidence suggests that the Salvation Army was instrumental in setting the tone that was taken by the media in framing the issues around the closure and move of its Grace Women's Health Centre. While the Calgary Health Region was successful in bringing the Grace under its mandate and organizational control, it was the Salvation Army, with its highly visible and powerful fundraising arm and its advocacy for holistic women's health that caught the public's attention. The internal discourse tracked some of the emerging issues, known only to those involved at managerial levels within the health system, but the public discourse kept women centered in decisions regarding the partnership. Women from many constituencies must continue to participate in the public policy realm to ensure that women's health remains an issue in health reform.

Representation strategies in public participation in health policy: The Aboriginal Community Health Council

Within Canada's Aboriginal population, an ongoing health promotion strategy has been the facilitation of community participation in the development and application of health policy. The Calgary Health Region's Aboriginal Community Health Council has provided a setting for involving the local Aboriginal population in health policy and program development for over a decade. This paper represents the results of a case study to identify the Council's strategies for this work. Data sources included documents, such as meeting minutes and other reports; key informant interviews with past and present Council members and health region representatives; and participant observation of Council functions. Although direct membership in the Council provided a core approach for representing the community, other strategies were actively utilized to involve the public. These included building links and partnerships with community organizations, networking, consultation activities and the identification of special needs groups.

Public participation for women's health: strange bedfellows or partners in a cause?

A major focus of health system reform in Canada has been the regionalization of health services administration. With a goal of bringing decision-making closer to the community, there has been a commitment to public participation in planning by some health authorities. Women, however, often feel that their participation is minimal or their needs are not addressed. During regionalization of the Alberta health system, the Calgary Health Region (CHR) negotiated an agreement with the Salvation Army to provide women's health services through the Grace Women's Health Centre, a major part of the region's women's health program. We present a case study exploring the process and final agreement and the impact of this agreement on women's participation in health policy development. The historical context and the nature and impact of the agreement are described and several participation strategies that occurred within the partnership are discussed. The development of a formal partnership agreement, a governance model, was a success for public participation in this case; however, the greatest success for women was maintenance of a political space in which women's health as a priority could be discussed in a context where the forces against gender equity talk are strong.

The privileging of communitarian ideas: citation practices and the translation of social capital into public health research

The growing use of social science constructs in public health invites reflection on how public health researchers translate, that is, appropriate and reshape, constructs from the social sciences. To assess how 1 recently popular construct has been translated into public health research, we conducted a citation network and content analysis of public health articles on the topic of social capital. The analyses document empirically how public health researchers have privileged communitarian definitions of social capital and marginalized network definitions in their citation practices. Such practices limit the way public health researchers measure social capital's effects on health. The application of social science constructs requires that public health scholars be sensitive to how their own citation habits shape research and knowledge.

An alternative approach to social capital: exploring the linkage between health consciousness and community participation

In recent years, social capital has received a great deal of attention in health communication. The fundamental premise behind the increased attention to social capital is the positive health outcome of social capital. Social capital is treated as an antecedent to health. Building on recent research that points out the role of trait-level variables in the production of social capital, this article examines the role of health consciousness in the production of social capital. The central idea here is that health conscious individuals choose to participate in their communities because of the positive health benefits of such participation.

Deliberations about deliberative methods: issues in the design and evaluation of public participation processes

A common thread weaving through the current public participation debate is the need for new approaches that emphasize two-way interaction between decision makers and the public as well as deliberation among participants. Increasingly complex decision making processes require a more informed citizenry that has weighed the evidence on the issue, discussed and debated potential decision options and arrived at a mutually agreed upon decision or at least one by which all parties can abide. We explore the recent fascination with deliberative methods for public involvement first by examining their origins within democratic theory, and then by focusing on the experiences with deliberative methods within the health sector. In doing so, we answer the following questions "What are deliberative methods and why have they become so popular? What are their potential contributions to the health sector?" We use this critical review of the literature as the basis for developing general principles that can be used to guide the design and evaluation of public involvement processes for the health-care sector in particular.

Trust and the development of health care as a social institution

Health systems are inherently relational and so many of the most critical challenges for health systems are relationship and behaviour problems. Yet the disciplinary perspectives that underlie traditional health policy analysis offer only limited and partial insights into human behaviour and relationships. The health sector, therefore, has much to learn from the wider literature on behaviour and the factors that influence it. A central feature of recent debates, particularly, but not only, in relation to social capital, is trust and its role in facilitating collective action, that is co-operation among people to achieve common goals. The particular significance of trust is that it offers an alternative approach to the economic individualism that has driven public policy analysis in recent decades. This paper considers what the debates on trust have to offer health policy analysis by exploring the meaning, bases and outcomes of trust, and its relevance to health systems. It, first, presents a synthesis of theoretical perspectives on the notion of trust. Second, it argues both that trust underpins the co-operation within health systems that is necessary to health production, and that a trust-based health system can make an important contribution to building value in society. Finally, five conclusions are drawn for an approach to health policy analysis that takes trust seriously.

The M-C-M' cycle and social capital

Social capital has become a popular term over the past two decades amongst researchers, policy makers and practitioners from varied disciplines. This popularity, however, has resulted in a great deal of confusion over the nature and application of social capital in different contexts. This confusion has made it difficult to identify and measure social capital within the evaluation of specific social and health programmes, one of the aims of which may be to stimulate social capital. This paper identifies a theoretical model that seeks to capture the dynamic nature of social capital to assist in the development of research methods that will facilitate its measurement and exploration within such programmes. The model reported in the paper identifies the key components of social capital and expresses the relationship between those components in a dynamic system based on Marx's description of the process of capital (economic) exchanges expressed in the M-C-M' cycle. The M-C-M' cycle is the transformation of money (M) into commodities (C), and the change of commodities back again into money (M') of altered value. The emphasis within the paper is on the capital element of the concept and its transactional nature with the aim of avoiding the pitfall of attributing social capital in relation to social behaviours in isolation of context and interaction. Importantly, the paper seeks to distinguish the central elements of social capital from some of the antecedent factors and outcomes often attributed to and confused with social capital adding to the problem of providing valid measurement. The model is presented as the basis for the measurement of social capital within a transactional process involving the investment of social resources in a cyclical process, which may result in net gains or losses. This process is described as the R-C-R' cycle following Marx's model of economic capital, with the focus being on the transfer of social resources (R) rather than money (M). R represents an internal resource held by individuals, C the external resource or commodity they obtain from the network and the R' the internal resource of altered value. The possibilities of the model in assisting in the measurement of social capital specifically in assessing formal networks are explored.

Social and political factors influencing the functioning of regional health boards in British Columbia (Canada)

Health reform is associated with changes in the way the health system works and in the roles of major stakeholders, such as governments, health professionals, and the lay public. This paper reviews the immediate relevance of these social and political elements to health boards, particularly those with lay board members; source documents include peer-reviewed articles, and government documents and news releases in Canada especially. Also presented are the perceptions of 130 regional health board members in British Columbia (BC), Canada, who responded to our 1996 survey questionnaire. Two sets of social and political factors are identified and discussed in this paper. The first set deals with the composition of health board members (qualifications, representation, and selection). Our findings suggest that there is now less attention focusing on the composition of health boards in BC. This may contribute to a re-focusing of attention on the boards' effectiveness in working with stakeholders and in influencing the health system. The other set of social and political factors deals with the relations of health boards with key stakeholder groups. The responses to our questionnaire suggest that the health boards in BC may have had some success in addressing the concerns of various stakeholder groups. However, the respondents also suggested that the stakeholder groups needed to be more understanding and involved in the regionalization (decentralization) process. Health boards that have lay representatives, including regional health authorities in Canada, face similar social and political factors immediate to their operation.

Ethnic identities, social capital and health inequalities: factors shaping African-Caribbean participation in local community networks in the UK

This paper examines the impact of ethnic identity on the likelihood of peoples' participation in local community networks, in the context of recent policy emphasis on the participation of marginalised communities in such networks as a means of reducing health inequalities. Conceptually, the paper is located against the background of debates about possible links between health and social capital--defined in terms of grassroots participation in local community networks--and an interest in the way in which social exclusion impacts on social capital. The paper draws on lengthy semi-structured, open-ended interviews with 25 African-Caribbean residents of a deprived multi-ethnic area of a south England town. While African-Caribbean identity played a central role in peoples' participation in inter-personal networks, this inter-personal solidarity did not serve to unite people at the local community level beyond particular face-to-face networks. Levels of participation in voluntary organisations and community activist networks were low. Informants regarded this lack of African-Caribbean unity within the local community as a problem, saying that it placed African-Caribbean people at a distinct disadvantage--furthering their social exclusion through limiting their access to various local community resources. The paper examines the way in which the construction of ethnic identities--within a context of institutionalised racism at both the material and symbolic levels--makes it unlikely that people will view local community organisations or networks as representative of their interests or needs, or be motivated to participate in them. Our findings highlight the limitations of policies which simply call for increased community participation by socially excluded groups, in the absence of specific measures to address the obstacles that stand in the way of such participation.

Challenges of citizen participation in regional health authorities

Citizen participation has been included as part of health reform, often in the form of lay health authorities. In Canada, these authorities are variously known as regional health boards or councils. A set of challenges is associated with citizen participation in regional health authorities. These challenges relate to: differences in opinion about whether there should be citizen participation at all; differences in perception of the levels and processes of participation; differences in opinion with respect to the roles and responsibilities of health authority members; differences in opinion about the appropriate composition of the authorities; differences in opinion about the requisite skills and attributes of health authority members; having a good support base (staff, good information, board development); understanding and operationalizing various roles of the board (governance and policy setting) versus the board staff (management and administration); difficulties in ensuring the accountability of the health authorities; and measuring the results of the work and decisions of the health authorities. Despite these challenges, regional health authorities are gaining support as both theoretically sound and pragmatically based approaches to health-system reform. This review of the above challenges suggests that each of the concerns remains a significant threat to meaningful public participation.

Social capital and health (plus wealth, income inequality and regional health governance)

This article describes an empirical exploration of relationships among aspects of thirty health districts in Saskatchewan, Canada. These aspects include social capital, income inequality, wealth, governance by regional health authorities and population health, the primary dependent variable. The social capital index incorporated associational and civic participation, average and median household incomes served as proxies for wealth, the degree of skew in the distribution of household incomes assessed income inequality while the model for effective governance by District Health Boards (DHBs) focused on reflection of health needs, policy making and implementation, fiscal responsibility and the integration and co-ordination of services. I found no evidence of a relationship between social capital in health districts and the performance of DHBs. Among the determinants of health, wealth appeared unrelated to age-standardised mortality rates while income inequality was positively and social capital was negatively related to mortality. Income inequality was not as strongly related to age-standardised mortality after controlling for social capital. and vice versa, suggesting the two may be comingled somehow when it comes to population health, although they were not significantly related to one another. Of the predictors of social capital the distribution of age in districts appeared to be the most salient; of the predictors of age-standardised mortality rates the gender composition of a district was most salient.

What determines health? To where should we shift resources? Attitudes towards the determinants of health among multiple stakeholder groups in Prince Edward Island, Canada

The population health perspective has become significant in academic and policy discourse. The purpose of this paper is to assess its significance among health care practitioners and administrators as well as the general public. Respondents in Prince Edward Island, Canada were asked to rank the broad determinants of health and comment on to where resources should be shifted to improve the health of the population. Important variations are noted between the groups with family physicians and front-line staff being similar in perceptions to the general public on most determinants than other groups. The paper concludes with discussion on the relevance of the findings for population health research and health policy.

Epidemiology of participation: an Australian community study

STUDY OBJECTIVE

To determine the levels of participation in social and civic community life in a metropolitan region, and to assess differential levels of participation according to demographic, socioeconomic and health status. To contribute to policy debates on community participation, social capital and health using these empirical data.

DESIGN

Cross sectional, postal, self completed survey on health and participation.

SETTING

Random sample of the population from the western suburbs of Adelaide, the capital city of South Australia, a population of approximately 210 000.

PARTICIPANTS

2542 respondents from a sample of 4000 people aged 18 years and over who were registered on the electoral roll.

MAIN RESULTS

The response rate to the survey was 63.6% (n=2542). Six indices of participation, on range of social and civic activities, with a number of items in each, were created. Levels of participation were highest in the informal social activities index (46.7-83.7% for individual items), and lowest in the index of civic activities of a collective nature (2.4-5.9% for individual items). Low levels of involvement in social and civic activities were reported more frequently by people of low income and low education levels.

CONCLUSIONS

Levels of participation in social and civic community life in an urban setting are significantly influenced by individual socioeconomic status, health and other demographic characteristics. An understanding of the pattern of participation is important to inform social and health policy making. Increasing levels of participation will reduce social exclusion and is likely to improve the overall quality of community life.

Population health promotion: responsible sharing of future directions

Population health promotion illustrates most robustly that health is a shared responsibility. Improving our understanding of the social production of health and the purchase population health promotion has on shaping social welfare policy presents a number of challenges to the future development of this discourse. Three are briefly discussed in this paper. First is the matter of language we use to describe our understanding of processes and influences. Second is the conceptualization of the pathways that shape population health status. Finally, cultural practices both extant and required to improve health status and reduce inequalities are addressed.

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

Stimulated by the finding (Kawachi et al., 1997) that social capital in communities may mediate the relationship between income inequality and health status, this article describes relationships between individual-level elements of social capital--trust, commitment and identity in the social-psychological dimension; participation in clubs and associations and civic participation in the action dimension--and self-rated health status, before and after controlling 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 related to 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 after controlling 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 and identification of various kinds were not significantly related to health. Civic participation was also unrelated to health. The main conclusion is that little evidence was found for compositional effects of social capital on health. Secondary findings 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 religious services and participation in clubs are related to health for the elderly.

Social capital and health: implications for public health and epidemiology

Public health and its "basic science", epidemiology, have become colonised by the individualistic ethic of medicine and economics. Despite a history in public health dating back to John Snow that underlined the importance of social systems for health, an imbalance has developed in the attention given to generating "social capital" compared to such things as modification of individual's risk factors. In an illustrative analysis comparing the potential of six progressively less individualised and more community-focused interventions to prevent deaths from heart disease, social support and measures to increase social cohesion faired well against more individual medical care approaches. In the face of such evidence public health professionals and epidemiologists have an ethical and strategic decision concerning the relative effort they give to increasing social cohesion in communities vs expanding access for individuals to traditional public health programs. Practitioners' relative efforts will be influenced by the kind of research that is being produced by epidemiologists and by the political climate of acceptability for voluntary individual "treatment" approaches vs universal policies to build "social capital". For epidemiologists to further our emerging understanding of the link between social capital and health they must confront issues in measurement, study design and analysis. For public health advocates to sensitise the political environment to the potential dividend from building social capital, they must confront the values that focus on individual-level causal models rather than models of social structure (dis)integration. The evolution of explanations for inequalities in health is used to illustrate the nature of the change in values.