Social capital and the utilization of maternal and child health services in India: A multilevel analysis
Introduction
Social capital has become one of the most popular sociological concepts to be studied in public health. Although the body of evidence linking social capital to lower levels of mortality, better self-rated health and healthy behaviors continues to grow (Islam et al., 2006, Kim et al., 2008), little is known about the relationship between social capital and health care utilization, especially in low- and middle-income countries. In order to better understand the relationship between social capital and health care use, there has been an effort in the public health literature to dichotomize the various conceptualizations of social capital into “structural” and “cognitive” forms (Bain and Hicks, 1998). Structural social capital primarily reflects Bourdieu׳s (1986) conceptualization of social capital as resources available through social networks. This form of social capital tends to be objectively verified by measuring individuals׳ actions and behaviors. Cognitive social capital aligns more closely with Coleman׳s (1988) and Putnam׳s (1993) concepts of social trust, reciprocity, and effective norms. This form of social capital tends be subjectively verified by measuring individuals׳ attitudes and perceptions. These two forms of social capital should not be seen as mutually exclusive, but as complementary because they assess different aspects of social capital.
While the majority of public health research conceptualizes social capital as structural or cognitive, others make the distinction between “bonding”, “bridging”, and “linking” social capital (Szreter and Woolcock, 2004). Bonding capital refers to strong ties to family and friends resulting in a densely knit social network where individuals are alike in terms of their social identity (e.g., age, caste, religion, place of residence). Bridging capital, by contrast, refers to weak ties to acquaintances where there is little social involvement between people who are typically not alike in terms of their social identity (Granovetter, 1983). Linking capital is a form of bridging capital that refers to social ties among people interacting across hierarchical power gradients in society (Szreter and Woolcock, 2004). Since these three forms of social capital reflect the nature of social ties, they align more closely with the conceptualization of structural social capital.
Potential mechanisms through which social capital affects health care utilization are related to components of structural social capital—such as civic participation, political participation, and social networks—and cognitive social capital—such as social cohesion and collective efficacy (Fig. 1). Civic participation, which is often measured by membership in community groups, can affect health care use through formally organized activities that address community issues (Carpiano, 2006) or through the informal provision of instrumental and psychosocial support to overcome barriers to care (Perry et al., 2008). Certain types of group membership can also lead to negative outcomes by establishing strong intragroup ties, or bonding social capital, which leads to conformity to traditional norms and restricts individual freedom to make appropriate health care decisions (Portes, 1998). Political participation has the potential to lead to linking ties with people of influence (Poortinga, 2012), which can give rise to opportunities to influence local health policies or lead to social pressure to comply with existing policies. Social capital can also influence health service utilization through social networks between communities (or community members) and representatives of formal institutions such as health care providers, teachers and government officers. These networks are a form of linking social capital and are important for leveraging resources, ideas, and information, especially for poor communities (Woolcock, 2001).
Social cohesion, a component of cognitive social capital, evokes a sense of mutual trust and solidarity among neighbors. This can lead to the ability of a group to enforce and maintain social norms (i.e., informal social control), which can have a positive or negative impact on health care utilization. If group norms promote the use of health services, health care utilization will increase; if group norms discourage the use of health services, health care utilization will decrease. Collective efficacy can also have positive and negative effects on health care use by encouraging individuals to forgo their own self-interest and act in the interest of the group (Coleman, 1988).
In order to elucidate the mechanisms through which social capital affects health care utilization in India, we must first address three important gaps in the existing social capital and health literature: (1) it is unclear whether social capital operates as an individual or collective attribute in relation to health care utilization; (2) few studies empirically differentiate between various components of structural and cognitive social capital; and (3) the majority of studies focus on the positive effects of social capital, ignoring the equally important potential negative aspects of social capital.
First, there is disagreement about whether social capital is an individual or collective attribute. There are many researchers who state that social capital is a collective characteristic that should be measured at the group level (Harpham et al., 2002, Lochner et al., 1999). Other studies report that social capital operates at the individual level through interpersonal trust and civic participation; however, they acknowledge complex interactions between group-level social capital and individual-level social capital (Poortinga, 2006a, Subramanian et al., 2002). In order to understand how social capital operates as a collective attribute, it is important to consider the size of the geographic area. Studies show that social capital can be better understood at the level of the local community, where it depends on day-to-day interactions between neighbors, compared to the state or country level, where social capital reflects more distal social policies (De Clercq et al., 2012, Eriksson et al., 2011, Hamano et al., 2010, Mohnen et al., 2011).
Second, there is a need to differentiate between various components of cognitive and structural social capital. If different components of social capital are used in a single measure, then it is difficult to assess what specific factors are influencing health outcomes (Carpiano, 2006). In a review of the association between social capital and access to health care, Derose and Varda (2009) found that studies reported a differential effect of various forms of social capital on health service use, which calls into question the practice of combining these different types of variables (i.e., cognitive and structural or bonding and bridging) into summary social capital scales. Moreover, studies that distinguish between various components of social capital rarely validate the measures used, making it difficult to determine which components of social capital are actually being measured.
Third, more attention needs to be placed on the importance of negative aspects of social capital in relation to health outcomes. Portes (1998) describes the negative consequences of social capital that are often overlooked in the current literature on social capital and health. For example, tight-knit communities with strong bonding ties can demand conformity and restrict individual freedom and initiative. In addition, communities with high levels of social cohesion can put pressure on individuals to oppose contemporary ideas and innovative thinking for the sake of solidarity.
This study will address all three gaps in the existing literature on social capital and health by examining: (1) whether social capital is associated with maternal and child health care utilization at the community level, beyond the characteristics of individuals belonging to a community; (2) the differential association between various forms of social capital and three different types of health service utilization (antenatal care, professional delivery care, and complete childhood immunization); and (3) the potential negative effects of social capital on health care utilization. Before describing the specific hypotheses about social capital in this context, it is important to understand why social capital is relevant to maternal and child health care use in India.
India has seen significant progress towards reducing maternal and child mortality in the past half century, but this progress has slowed in recent years despite the availability of cost-effective health service interventions (Hazarika, 2012). Studies on the use of maternal and child health services in India have primarily focused on the influence of individual and household characteristics, while largely ignoring the influence of the social environment (Stephenson and Tsui, 2002). This is an important limitation because the sociocultural context is of particular importance to health service utilization in India due to the substantial differences in health policy and expenditures at the state level as well as the salience of village and neighborhood characteristics at the community level. For example, Sunil et al. (2006) reported that the percentage of rural women in India who had “excellent” utilization of maternal health services, including antenatal care and delivery care, varied from 6% in the state of Uttar Pradesh to 92% in the state of Kerala. The percentage of children reported to have received all recommended immunizations varied from 27% in Uttar Pradesh to 91% in Kerala (Ministry of Health and Family Welfare, 2005). Variations across states in utilization rates are attributable to a combination of factors such as distance, availability and quality of skilled providers, and adequacy of infrastructure (Desai and Wu, 2010, Navaneetham and Dharmalingam, 2002, Ministry of Health and Family Welfare, 2005).
Community characteristics have also been shown to have an influence on maternal health care use and immunization coverage in India. Stephenson and Tsui (2002) used a multilevel model to examine the association between the use of maternal and reproductive health services and community factors, such as economic development, the strength of the health infrastructure, the presence of health services, and population size. Although population size was the only community-level predictor variable shown to be associated with antenatal care or professional delivery care, there was still unexplained variation at the community level for both service types. These results suggest that influential unobserved community-level factors were omitted from their models. Similarly, Sunil et al. (2006) used a multilevel model to show that the use of maternal health services in India was associated with various programmatic variables measured at the community level, including the presence of women׳s groups (mahila mandal), visits by health workers during pregnancy, and access to public and private health facilities.
The current study posits that social capital is an important community-level factor omitted from previous studies on the utilization of maternal and child health care in India. There are two primary reasons why community-level social capital has the potential to influence the use of maternal and child health services in India. First, disparities in health service coverage continue to persist throughout India (Hazarika, 2012). Therefore, women who have unequal access to health services due to financial constraints may benefit from living in communities with social connections to diverse groups of people. The resources embedded in these social relationships have the potential to help women access the care they need. Second, religious or caste organizations in India may reinforce traditional attitudes about the use of preventive care (Vikram et al., 2012). Therefore, women who live in communities with stronger social ties to religious and caste groups may feel pressure to forgo preventive care. To date, only one known study has examined the association between social capital and health care utilization in India (Vikram et al., 2012).
Section snippets
Study hypotheses
The study hypotheses are based on the conceptual framework presented in Fig. 1, which depicts the potential mechanisms through which social capital affects the use of antenatal care, professional delivery care and childhood immunizations. In addition to the hypotheses mentioned below, this study explores the complex interaction between individual- and community-level components of social capital. H1 Intergroup bridging ties at the community level are positively associated with all three types of
Study population
This study used the 2005 India Human Development Survey (IHDS), a nationally representative, multi-topic survey of 41,554 households in 2474 villages or urban neighborhoods across 33 states and union territories of India (Desai et al., 2005). The 2005 IHDS was designed to broaden the understanding of human development across India. Detailed information about data collection procedures, funding, quality assurance, and availability of the data has been previously documented (Desai et al., 2010).
Results
Social capital was associated with the use of all three types of maternal and child health services at the community level, beyond the characteristics of individuals belonging to a community. Three of the six components of community-level social capital were significantly associated with antenatal care use after controlling for potential confounding factors at the individual and community level, individual-level social capital, and cross-level interactions between individual and community
Discussion
The results from this study showed that social capital operated at the community level in association with all three care-seeking behaviors, after adjusting for characteristics of individuals within each community (compositional characteristics), characteristics of communities (contextual characteristics), and state-level variations in health service utilization. These findings are in line with other studies that have found a contextual effect of social capital on other health outcomes,
Acknowledgments
This manuscript was developed as part of the author׳s dissertation at the University of Michigan School of Public health. During the development of this manuscript, the author received financial support from the University of Michigan Rackham Predoctoral Fellowship. The author is grateful to the Carolina Population Center for training support (T32 HD007168) and for general support (R24 HD050924) during the writing of this manuscript. The author would like to thank Sonalde Desai and Reeve
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