The cycle of poor health and poverty is difficult to break [1], and social factors have been identified to be at the root of this challenge. Marmot [2] explains that health is often beyond an individual’s physical state, but rather, a product of public policies that shape the social environments people are exposed to. As the significance of social determinants of health was promoted, the mechanisms through which relationships between people are translated into physical outcomes emerged as a key area for further research [3]. This is of particular importance in the analysis of resource-poor settings, especially with research claiming that the lack of human and financial capital in developing countries magnifies the influence of social capital on physical health [4].
Social capital is a concept that is based strongly on social relations, and a range of studies confirm that the strengthening of such is crucial to achieving desired development and poverty reduction outcomes [5,6,7]. Kawachi, Subramanian and Kim [8] echo this, stating that “a relationship between social capital and physical health have been more consistently found in societies with high levels of economic inequality, whereas the links are much weaker or non-existent in more egalitarian societies” [p.22]. This study aims to contribute to the growing research base that examines the intermediary effect of social capital on health as a key component in development interventions.
ICM’s Transform program in the Philippines
The Philippines has seen robust economic growth in the last decade [9], and its economy continues to expand in the face of slowing global trade and investment flows [10]. Although it is one of the fastest-growing economies in Southeast Asia [10], poverty remains widespread with almost a quarter of the Philippine population living under the poverty line [11].
International Care Ministries (ICM) is an NGO that runs a 16-week poverty-alleviation program called Transform for populations in the Philippines living in ‘ultrapoverty’. Households that report to have a daily income of less than US$0.50 per person are classified as in ultrapoverty ([12]: p.2]). Among the participants ICM provided programs to in 2016, the average daily income per person was approximately US$0.28 ([13]: p.3]). Transform is carried out in numerous communities across the southern two-thirds of the Philippines, meaning that ICM serves a wide range of people living in diverse geographical landscapes with distinct cultures, who work in different trades and experience a variety of difficulties in the face of poverty. ICM has identified three key areas as the primary barriers to escaping poverty: a lack of relational skills, health knowledge and livelihood experience ([13]: p.5]), and a core aim of Transform is to foster social connectedness and to create a network of support within communities. Weekly Health and Livelihood training sessions are undertaken in large group settings, and the curriculum is designed to encourage participation in community-led small group work (of five or six) to discuss topics that were taught during the larger group sessions. There is also a Values curriculum dedicated to “fostering attitudes and behaviours that build strong relationships” ([13]: p.6]). To facilitate this, Transform is designed with four layers of support with different but complementary roles [13]:
- 1.
The pastor, a known leader in the community, invites participants to join the program and runs the Values training;
- 2.
Six volunteer counsellors from the local community help implement the program and provide encouragement;
- 3.
Two ICM staff members from outside the community lead the Health and Livelihood training;
- 4.
The 30 participants themselves learn and grow together.
Uphoff and Wijayartna [14] argue that all cultures have underlying norms, values, attitudes and beliefs that predispose cooperative behaviours, but its expression can be inhibited if appropriate forms of structural social capital are lacking in the communities. Through Transform’s weekly training sessions, community members had access to a new platform of social contact for 16 weeks through which relationships could be built. By investigating the outcomes of an intervention program with explicit aims to create social capital, our intention was to better understand its relationship with health in resource-poor settings as well as to evaluate the place for social capital in the design of health promotion interventions.
Social capital
Modern developments of social capital that instigated widespread academic interest are credited to the seminal works of Pierre Bourdieu [15], James Coleman [16], and Robert Putnam [17]. Bourdieu and Coleman described social capital as another form of productive ‘capital’, while Putnam, in contrast, saw social capital less as a resource but shifted the definition to focus on qualities of social cohesion that may underlie these networks. If social cohesion refers to the extent of solidarity and connectedness in a society [18], Putnam’s social capital looked closer into these “features of social organisation, such as networks, norms, and trust, that facilitate coordination and cooperation for mutual benefit” ([17]: p. 167]). Given the context of ICM’s Transform program and its focus on fostering social connectedness, Putnam’s definition of social capital, being rooted in notions of social cohesion, was the most appropriate.
Types of social capital
There are many different types of social capital, but one notable distinction is between structural and cognitive forms of social capital. Structural social capital refers to externally observable aspects of social organisation, such as roles, rules, procedures and precedents [14], for example, civic participation or group membership. Cognitive social capital is more internal and subjective, referring to shared norms, values, attitudes and beliefs [14]. Although they have been presented as mutually reinforcing components [14], it is nevertheless important to differentiate between these categories of social capital, as they can have different effects depending on both the individual’s characteristics and that of the community’s [19].
Another important conceptual development was the distinction between bonding and bridging social capital [20,21,22]. Bonding capital is accessed from relations between people in groups who share a social identity, for example, gender, class or ethnicity [8]. Bridging capital is accessed from relations that traverse boundaries of social identity [8], such as between people from different ethnic or occupational backgrounds. In Paxton’s [12] work on connected and isolated associational memberships, she categorised the connectedness of associations according to whether members have multiple memberships. Having associational networks that are linked to other voluntary associations, thus connected to the larger community, is reflective of bridging characteristics. Isolated memberships, in contrast, are “more dependent on close associates” ([12]: p.54]), reflecting bonding characteristics of fostering strong, in-group ties. Poortinga [23] proposed that they are characterised by different advantages: bonding relations are essential for social cohesion and support, whereas bridging relations build solidarity and respect amongst the wider community. Distinguishing between these two categories can, therefore, also help explain the occasionally inconsistent outcomes of social capital [8].
Critics have challenged the prevailing portrayal of social capital as inherently constructive. Putnam [18] warned that social inequalities may be embedded in social capital, as the ties that link members of a group together can also exclude other community members who do not share their social identity. Several studies have found that respondents who were less attached to their immediate community or who reported ties with people outside their social milieu displayed comparatively better health outcomes ([Mitchell and LaGory, 2002 and Caughy et al., 2003, as cited in [8]). The reliance of health improvement on the ability to access resources beyond the social boundaries of homogeneous circles suggest that community development efforts require both bonding and bridging social capital.
Social capital interventions for health promotion
There is a general consensus that social capital cannot be easily created [24, 25]. In fact, Gugerty and Kremer [26] found that a project explicitly designed to strengthen social capital had no such effect. Building social capital requires a significant investment of time and resources, and dramatic results cannot be expected in the short-run. Murayama et al. [25] highlighted that social capital is heavily shaped by broad, structural forces, such as historical patterns of residential mobility or municipal investment in local infrastructure. As a result, the cultivation of social capital is often a complement to, rather than the chief end of, health promotion interventions.
There is also surprising unity about the various mechanisms through which higher social capital can affect health: increased diffusion of information, provision of social and psychological support, ability to advocate for increased access to resources and enforcement of health-related behavioural norms through informal social control [19, 27,28,29]. De Silva and Harpham [30] phrased these pathways more simply: communities with greater social connectedness enable people to know more, feel, and act differently. In combination with a structured intervention program, this can instigate effects that further health promotion goals. In Fig. 1, we conceptualise the potential pathways by which the various types of social capital may impact self-related health.
The Medical Research Council’s guidelines, Developing and Evaluating Complex Interventions [31], highlights that a key question when evaluating complex interventions is to look at the “active ingredients” [p.7] within it and how they are exerting their effect. The aim is to “build a cumulative understanding of casual mechanisms, [to] design more effective interventions and apply them appropriately across group and setting” [p.7]. Our intention is to deepen our understanding of the context in which these mechanisms operate in with a view of informing future research in the design of complex interventions and subsequent evaluation approaches.
To guide our investigation, our primary research question was: What were the relationships between the different types of social capital and self-rated health before and after Transform, and how did those relationships change? As a sub-analysis, we also examined how the effects may be varied between communities. Although De Silva [32] claimed that the distinction between individual and ecological social capital is artificial, as “individuals’ social capital is influenced by what is available to them in the community, and the level of social capital in a community is determined by the social capital of its residents” [p.33], using a multilevel framework for analyses creates the “potential to account for group-level influences on individual health” ([8]: p.683]), and health determinants can be explored in acknowledgement of the reciprocal interactions between an individual and their contextual environment.