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Does greater individual social capital improve the management of hypertension? Cross-national analysis of 61 229 individuals in 21 countries
  1. Benjamin Palafox1,
  2. Yevgeniy Goryakin2,
  3. David Stuckler3,
  4. Marc Suhrcke4,
  5. Dina Balabanova1,
  6. Khalid F Alhabib5,
  7. Alvaro Avezum6,
  8. Ahmad Bahonar7,
  9. Xiulin Bai8,
  10. Jephat Chifamba9,
  11. Antonio L Dans10,
  12. Rafael Diaz11,
  13. Rajeev Gupta12,
  14. Romaina Iqbal13,
  15. Noorhassim Ismail14,
  16. Manmeet Kaur15,
  17. Mirac V Keskinler16,
  18. Rasha Khatib17,
  19. Annamarie Kruger18,
  20. Iolanthe M Kruger18,
  21. Fernando Lanas19,
  22. Scott A Lear20,
  23. Wei Li8,
  24. Jia Liu8,
  25. Patricio Lopez-Jaramillo21,
  26. Nasheeta Peer22,
  27. Paul Poirier23,
  28. Omar Rahman24,
  29. Rajamohanan K Pillai25,
  30. Sumathy Rangarajan26,
  31. Annika Rosengren27,
  32. Sumathi Swaminathan28,
  33. Andrzej Szuba29,
  34. Koon Teo26,
  35. Yang Wang8,
  36. Andreas Wielgosz30,
  37. Karen E Yeates31,
  38. Afzalhussein Yusufali32,
  39. Salim Yusuf26,
  40. Martin McKee1
  1. 1 The Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
  2. 2 Organization for Economic Cooperation and Development, Paris, France
  3. 3 Department of Policy Analysis and Public Management and Dondena Research Centre, University of Bocconi, Milan, Italy
  4. 4 Centre for Health Economics, University of York, York, UK
  5. 5 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  6. 6 Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
  7. 7 Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, The Islamic Republic of Iran
  8. 8 National Center for Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
  9. 9 College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
  10. 10 UP College of Medicine, University of the Philippines Manila, Manila, Philippines
  11. 11 Estudios Clinicos Latino America, Rosario, Argentina
  12. 12 Eternal Heart Care Centre and Research Institute, Jaipur, India
  13. 13 Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  14. 14 Department of Community Health, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
  15. 15 School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  16. 16 Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
  17. 17 Department of Public Health Sciences, Loyola University Medical Center, Maywood, Illinois, USA
  18. 18 Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
  19. 19 Universidad de La Frontera, Temuco, Chile
  20. 20 Simon Fraser University, Burnaby, British Columbia, Canada
  21. 21 Research Institute FOSCAL, Santander, Colombia
  22. 22 South African Medical Research Council, Durban, South Africa
  23. 23 Institut universitaire de cardiologie et de pneumologie de Quebec, Quebec, Canada
  24. 24 Independent University, Dhaka, Bangladesh
  25. 25 Department of Pediatrics, Dr SMCSI Medical College Karakonam, Trivandrum, India
  26. 26 Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
  27. 27 Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
  28. 28 St John’s Research Institute, Bangalore, Karnataka, India
  29. 29 Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
  30. 30 University of Ottawa, Ottawa, Ontario, Canada
  31. 31 Department of Medicine, Queen’s University, Kingston, Ontario, Canada
  32. 32 Hatta Hospital, Dubai Health Authority/Dubai Medical University, Dubai, United Arab Emirates
  1. Correspondence to Mr Benjamin Palafox; Benjamin.Palafox{at}


Introduction Social capital, characterised by trust, reciprocity and cooperation, is positively associated with a number of health outcomes. We test the hypothesis that among hypertensive individuals, those with greater social capital are more likely to have their hypertension detected, treated and controlled.

Methods Cross-sectional data from 21 countries in the Prospective Urban and Rural Epidemiology study were collected covering 61 229 hypertensive individuals aged 35–70 years, their households and the 656 communities in which they live. Outcomes include whether hypertensive participants have their condition detected, treated and/or controlled. Multivariate statistical models adjusting for community fixed effects were used to assess the associations of three social capital measures: (1) membership of any social organisation, (2) trust in other people and (3) trust in organisations, stratified into high-income and low-income country samples.

Results In low-income countries, membership of any social organisation was associated with a 3% greater likelihood of having one’s hypertension detected and controlled, while greater trust in organisations significantly increased the likelihood of detection by 4%. These associations were not observed among participants in high-income countries.

Conclusion Although the observed associations are modest, some aspects of social capital are associated with better management of hypertension in low-income countries where health systems are often weak. Given that hypertension affects millions in these countries, even modest gains at all points along the treatment pathway could improve management for many, and translate into the prevention of thousands of cardiovascular events each year.

  • hypertension
  • health economics
  • epidemiology
  • control strategies
  • health systems

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Handling editor Seye Abimbola

  • Contributors BP, YG, DS, MS, DB and MM wrote the analysis plan and had the primary responsibility of writing this paper. SY conceived and initiated the PURE study, supervised its conduct and data analysis, reviewed and revised all drafts of this manuscript. All other authors coordinated the worldwide study and reviewed and commented on drafts. All authors approved the final draft.

  • Funding The UK Economic and Social Research Council funded MM, DB and BP for these analyses through a grant (number ES/L014696/1) under its Secondary Data Analysis Initiative scheme. SY is supported by the Mary W Burke endowed chair of the Heart and Stroke Foundation of Ontario. The PURE Study is an investigator-initiated study that is funded by the Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario and through unrestricted grants from several pharmaceutical companies (with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier and GSK), and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries. These include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, Grant number: 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia Grant Nbr 100 - IRDC/BIOTEK 16/6/21 (13/2007), Grant Number 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia Grant Nbr 600 - RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), occupied Palestinian territory; International Development Research Centre (IDRC), Canada; Philippines: Philippine Council for Health Research & Development (PCHRD); Poland: Polish Ministry of Science and Higher Education Grant Nr 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: Saudi Heart Association. The Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (Research group number: RG -1436-013); South Africa: The North-West University, SANPAD (SA and The Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: AFA insurance, grants from the Swedish state under the ALF agreement, Västra Götaland Region (FOUU), the Swedish Heart and Lung Foundation, the Swedish Research Council, the Swedish Council for Health, Working Life and Welfare and the King Gustaf V:s and Queen Victorias Freemasons’Foundation; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi-Aventis, Turkey; UAE: Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

  • Disclaimer The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries.

  • Competing interests None declared.

  • Ethics approval Ethics committees in each of the 21 participating countries approved the protocol.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data for this study and related studies from the PURE and EPOCH studies are stored at the Population Health Research Institute (PHRI), McMaster University. Requests for PURE and EPOCH data are assessed by the study steering committee and applications can be made to the study project manager, Sumathy Rangarajan (

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