Social Capital and Health

2002:177). Therefore, this supports the argument that the destabilization impact of HIV/AIDS on governance as well as state capacity.

respects the medium that other aspects of social and economic life require to thrive.

(Barnett et al. 2000:50) Recent studies indicate that social capital, average levels of civil participation and trust are associated with improvements in the individuals’

health status. (Mellor et al. 2005) Considerable evidence has been found that social support is beneficial to health and that social isolation leads to ill health. According to Putnam, the more individuals are integrated with community the less they suffer from colds, heart attacks, strokes, cancer, depression and premature death of all sorts. Such protective effects are directly related to close family ties, friendship networks, participation in social events, and even simple Affiliation with religious and other civic association (Putnam 2000: 326). Therefore, studies conducted so far confirm that social support has a positive effect on many different aspects of both physical and mental health. Jennifer and Milyo also indicate that a higher level of social capital is positively associated with health over time. (2005:1123)

Social support has been defined as "resources provided by other persons" (Cohen et al. 1985:4). It has been seen as "information leading the subject to believe that he is cared for and loved, is esteemed and valued and belongs to social network of communication and mutual obligation." (Cobb 1976:300)

Table 2.1 shows the most important distinctions between social networks and the functional aspects of support, and the quality and type of support that are provided by the network members. Social networks are defined as the social contacts of a group of individuals. These contacts can be measured in terms of number and frequency. These measures can be further refined by separating them into the number of contacts from the primary group, or group of persons to whom the subject is most attached. (Marmot et al. 2001:155) Other measures include the density of the network, where it is estimated how much each network member is in contact with each other this gives some idea of how integrated network members are.

Table 2.1. Measure of Social Support and Social Networks

Social Networks Contacts

Number of contacts frequency of Contacts

Density of network

Social support Types of Social support

Emotional Informational Self-appraisal Instrumental or practical

Marmot, Michael/Richard, G, Wilkinson (2001): Social Determinants of Health. Oxford: University press Oxford: 156

A much greater richness of analysis may be achieved by examining the quality of support as well as the social network. In general, types of support may be divided into "emotional", "practical", or "instrumental" support. In some studies, other aspects of support have been identified which may be linked to emotional support.

These include “informational” support, measuring the information given for problem solving. A further important component of emotional support is related to self-appraisal⁵, providing support that boosts self-esteem and encourages positive self-appraisal. Practical support manifests itself in many forms, including practical help and financial support. (Marmot et al. 2001:156)

Social support involves both interaction and transactions between people. Hence, what a person invests in a relationship may also be important for their health, as well as what they receive from someone else. This reciprocity is a “cognitive” element of social capital, refers to the provision of resources by an individual or group to another individual or group, and the repayment of resources of equivalent value by these recipients to the original provider. It is argued that high levels of social capital give rise to a higher level of reciprocal relationships and thus lead to more cooperative and well-functioning societies. (Baum et al.2003.321)

Reciprocity is important for the maintenance of good social relations. Relations with a balance of giving and taking may be easier to sustain than imbalanced ones. (ibid)

5 “Self-appraisal process is one way of initiating a programme of professional development.

Individuals define criteria of competence for their work, monitor their daily professional activities, review their performance and make plans for modifying their practice in the light of their appraisal.” (Boud 1995:118)

Social support may not only have a protective effect in the prevention of or a decrease in the risk of illness, but may also be helpful for people who have to adjust to, or cope with, the stress of a chronic illness. (Marmot et al. 2001:164) These support the argument that social connection helps to reduce mortality and morbidity rate. (ibid: 161)

Social support operates at both an individual and a societal level. Social cohesion⁶ denotes strong community ties with intense participation in communal activities and public affairs and high levels of membership community group. The existence of mutual trust and respect between different sections of society contributes to self-esteem of people and their health. According to Baum et al. there are three types of trust. The first type of trust is that which exists within established relationships and social networks. The second type is a generalized trust or "social trust”, which relates to the trust extended to strangers. The third form is institutional trust, which relates to the basic forms of trust in the formal institutions of governances (Baum et al. 2003.321).

There is increasing evidence that communities with high levels of social cohesion have better health than those with low levels of social cohesion. This is often accompanied by an egalitarian ethos in local politics. Various pieces of evidence support the link between social cohesion and health (Wilkinson 1996 cited in Paul 2002:12) and democracy is associated with health at the national level .(Dardet et al.

2006:670) Cities with strong civic communities have lower infant mortality (Marmot et al. 2001:169)

Social support has a wide spectrum of effects on health that ranges from an influence on mortality at the one end and on physical and psychological morbidity at the other. The decision whether or not to grant social support is a very personal matter, yet research shows that certain social structural imperatives positively influence the decision. Thus, the network’s social cohesion can go well beyond that of the sum of the individual links of its members. At a societal level, social cohesion

6 Social cohesion is defined as “the willingness of members of a society to cooperate with each other in order to survive and prosper. Willingness to cooperate means they freely choose to form partnerships and have a reasonable chance of realizing goals, because others are willing to cooperate and share the fruits of their endeavors equitably”. (Stanley 2003)

can have a powerful effect on health, which transcends that available from individual social relationships. This has implications for the improvement of the health of communities (Marmot et al. 2001:174). In General, there is substantial evidence documenting the effect of strong social networks on community health as well as the contribution of health to the active participation of society in civic matters.

2.2.4.1.2. Social Capital and HIV/AIDS

Social networks and social capital provide an analytical perspective for understanding the behavioral determinants of HIV transmission at the population level. (Mann et al. 1996 cited in Paul 2002: 13) HIV/AIDS cannot be yet cured, but the spread of the disease can be contained by adopting an integrated socio-behavioral communication approach. (Ellis et al. 2003:13) Therefore, behavioural change has been recognized as the only possible way to contain the spread of the disease. (Cohen 1993)

People are not always rational. Even when they act on a seemingly rational basis that depends upon their reasoning skills, knowledge and information they are likely to make faulty judgments. Inadequate information or false considerations about the consequences of their actions lead to even more irrational decisions. Moreover, they often misread events in ways that give rise to erroneous conceptions about themselves and the world around them. In order to protect oneself from HIV/AIDS, the appropriate skills, knowledge and perceptions regarding the prevention and transmission of the epidemic must be acquired. In the absence of knowledge and skills, people are most likely to expose themselves to HIV/AIDS. People’s behaviour is mostly motivated and regulated by their internal standards and self-evaluative reactions of their own actions. The capability for self-reflection enables people to analyze their experiences to derive generic knowledge about themselves and the world around them. People not only gain understanding through reflection, they evaluate and alter their own thinking. In verifying their thoughts by self-reflective means, they monitor their ideas, act on them or predict occurrences, judge the adequacy of their thoughts, form the results, and change them accordingly (Bandura 1986: 20-21). Based on the above, understanding and influencing social networks and social capital may have potential to influence determinants of HIV transmission.

Cross-sectional data from a large-scale, population-based survey in rural eastern Zimbabwe describes just this relationship when it analyzes the correlation between membership in different forms of community groupings and young women's chances of avoiding HIV. The results show that participation in local community groups is often positively associated with successful avoidance of HIV, which in turn is positively associated with psycho-social determinants of safer behavior.

(Gregson 2004)

Research has also revealed the links between social capital and the biological progression of AIDS. In a five-year study from Sweden, HIV infected individuals with lower "availability of attachments", i.e. meaningful social and emotional connections to others, experienced a more rapid decline in their CD4⁷ cell count than those with higher levels of support (Theorell et al. 1995:35). Another study, conducted in South Africa, indicates that strong social networks, the flow of social and material resources between communities, can provide economic stability and opportunities to households that are able deter high-risk sexual activity, particularly in a time of crisis. In addition to providing avenues for the exchange of information, strong social networks shape community norms around gender relations, sexual negotiation and communication. They provide important role models for health-promotive behavior, such as the use of condoms or clinical services such as HIV testing. Individuals within cohesive communities have a stronger sense of self-confidence, self esteem and are stronger decision makers. The emotional support generated around these networks reduces discrimination around HIV and creates a more acceptable environment for those living with the disease. Communities with large social capital stocks are more likely to take collective action to pursue common priority issues including HIV/AIDS. (Paul 2002:13)

Civil society organizations have played a more significant role in HIV/AIDS prevention, care, treatment and mitigation. (Rau 2006: 294) Civil society also offers powerful ways of ensuring inclusion. In many countries, society’s poorest, weakest and most stigmatized are disproportionally affected by HIV/AIDS. It also creates further stigma and discrimination for those who have been affected by the epidemic.

7 CD4 is the name of a special receptor protein found on the surface of CD4 cells. CD4 cells are a type of T cell that HIV infects and destroys. CD4 counts, or levels, measure the number of CD4 cells in the blood. (Canadian AIDS Treatment Information Exchange 2010)

In this respect mutual support groups set up by members and peers within a community are often most successful ways of providing services to that community and in challenging stigma in empowering ways (The Alliance 2006).

The CSO’s innovative and creative approaches to HIV/AIDS prevention and care offer models for action that could slow and control the epidemic. (Rau 2006: 289) CSOs have already had a number of successes by demanding inactive governments take action against HIV/AIDS. By taking the lead in initiating, developing and delivering innovative responses to HIV/AIDS, the CSOs set the HIV/AIDS agenda at the international level and call the pharmaceutical companies to account. (UN 2005:28-29)

Communities’ contributions to the struggle against HIV/AIDS are enormous. As a result, NGO responded disproportionately fast and decisive. NGOs have different operational structures to governments and can respond quickly on a small scale, are close to their constituents, and are aware of power relations and influences at the local level. Many governments, on the other hand, were responding only reluctantly and slowly to the epidemic in its early stages. This was partly due to denial, and partly because the problem is strongly associated with sex, death (areas that are seen as private rather than public concerns), and socially unacceptable or illegal behaviour that governments do not wish to condone. In comparison, NGOs are well placed to support stigmatised groups and can find paths to reach marginalised groups (DeJong 2003 cited in Slater 2004:27).

The reverse may also be true that CSOs themselves will be affected by the impact of HIV/AIDS, (Rau 2006: 288) and social networks can contribute to the active transmission of HIV/AIDS. (Liljeros et al. 2003, Rothenberg et al 1998, Morris et al.2004).

Seropositive and AIDS patients go through a course of disruptive events. On top of their infection or disease, some will experience minor or more severe psychological imbalances, isolate themselves or be excluded from their social networks. Their family structure or stable sexual relations are likely to be ruined. AIDS reduces of life expectancy and quality of life to those suffering from the disease. Due to stigma and discrimination associated with the disease, unlike other diseases the psychological and social consequences of AIDS, pain and stress affect not only for the patients but also for their relatives and friends. (Schwefel et al. 1990:47)

According to the CIA, AIDS is contributing to poverty, crime, and instability.

AIDS, other diseases, and health problems will hurt prospects for transition to democratic regimes as they undermine civil society, hamper the evolution of sound political and economic institutions, and intensify the struggle for power and resources (CIA 2000).

In the course of the epidemic, people will have to face additional hardships – for themselves and for their families. Because of this, people will change their social and political behaviours to accommodate these new circumstances (Matlosa et al.

2003:75). Therefore this situation makes the people respond to scarcity by hardening the already existing religious, class, ethnic or linguistic divisions that separate them.

Competition among these increasingly distinct groups worsens, which reduces both their interactions with each other and with the state. These create fragile bonds which make it hard for groups to articulate their needs nonviolently through established networks. This can bring about a threat of ethnocentrism, or the increase in in-group solidarity and out-group hostility, which in turn leads to greater mistrust.

(Green 2002:6)As was already mentioned, HIV/AIDS create enormous impact on state capacity and as a result the state is no longer able to guarantee the security of its people. (Green 2002:4). This indicates how epidemics create impact on civil society development by altering the rationale for political and social action by individuals and communities.

A study conducted in South Africa reveals how significantly a CSO can be affected by HIV/AIDS. According to this study, CSOs ability to fulfill their mission will decrease in the face of increasing HIV infections due to its internal impact on their organizations and due to shift of the community's need. As a result they are being steered towards new areas; particularly HIV/AIDS specific projects that may be outside their core purpose and certainly require new skill-sets (INTRAC 2004:6-7).

The increase in prevalence of HIV/AIDS will have a negative impact on social capital as HIV infected individuals have fewer social and emotional connections to others. In this respect, a survey of representative samples in seven southern African countries found that the countries with the highest measured levels of illness have the lowest overall levels of attendance to local community meetings and participation in local service and welfare groups. The study further indicates that

AIDS killed critical proportions of those who organize and chair community meetings or local welfare groups. (Mattes 2002:16)

A study conducted in Kenya indicates how the “Harambee” movement was affected by HIV/AIDS. The Harambee movement is an informal voluntary self-help social-economic movement that was founded after Kenya's independence. The movement provides a meeting-place for people and contributes money to support people in need or to start a self-development project. This movement enabled communities to build schools, water systems, and medical facilities. With the emergence of the HIV/AIDS pandemic, the demands for social support within the community, especially for medical bills, have increased tremendously. The declining economic resources led politicians to raise funds for medical bills. 85% of the members of parliament and councilors interviewed for the study estimated most of their fund raising engagement focusing on the medical requirements of their constituents.

(Kimotho 2005: 3)

Social interaction and social structure mediate disease transmission. (Liljeros et al.

2003:195) Several studies emphasize the important role of network configuration in the transmission of HIV. (Rothenberg et al 1998) Romantic and sexual partnerships form the dynamic network along which disease travels. Sexual network characteristics have been identified as important for the understanding of HIV transmission patterns and the spread of the disease. The spread of HIV in a particular setting depends upon the extent to which a network is connected. (Morris et al. 2004:2) Social network analysis provides the essential tool for analyzing social structures, including sexual networks. (Liljeros et al. 2003:194) Sexual networks are

“groups of persons who are connected sexually to one another”. The number of persons in a network, how central high-risk persons are within it, the percentage in monogamous relationships and the number of “links” each member has to others all determine how quickly HIV can spread within a network. Sexual networks are distinct from, but often overlap with social networks (Wohlfeiler et al.2003:1).

The different ways persons select partners affect how quickly HIV can spread.

Exclusively monogamous persons are, by definition, not part of a sexual network. If both are HIV-negative they remain as they are. Serial monogamists are persons who go from one relationship at a time to the next. If they have unprotected sex, they

have a higher risk of HIV than exclusively monogamous persons. Earlier partners’

risk may affect later partners, too (Wohlfeiler et al.2003:1).

Concurrent relationships involve having more than one sexual partner in a given period and going back and forth between them. This increases the probability for transmission, because earlier partners can be infected by later partners. The central person of such a concurrent relationship can function as a “node” that connects all sexual partners in a dense cluster, thus creating highly connected networks that facilitate transmission. Concurrent partners can connect each of their respective clusters and networks as well. Concurrency alone can fuel an epidemic even if the average number of partners is relatively low (Wohlfeiler et al. 2003:1, Morris et al.

2004:7) .

In general, social networks and contacts have a positive as well as negative impact on the spread of HIV/AIDS. Social contacts help to bring about behavioural change which can protect the community from HIV/AIDS. On the other hand, sexual networks contribute to the active transmission of HIV/AIDS within the community.

Although social capital contributes to protecting the community from the epidemic, it will be also affected by it. Studies indicate that social capital, the strength of associational life, trust, and norms of reciprocity may be undermined by HIV/AIDS in several ways. HIV/AIDS weakens the informal exchange of knowledge and causes a decline in incentives for coordinated group action. Formal institutions that contribute to social capital formation, such as church groups, sports clubs, and professional associations, will be weakened as members die. Social networks whose members are highly mobile or live in urban areas will be more susceptible to HIV/AIDS. The stigma attached to the virus weakens social capital because the existing networks ostracize those who are infected. (Andersen et al. 2002:13) The loss of lives and the resulting psychological, physical, and financial trains tamper with the social structures and the ability to produce social capital. (Were et al.

2003:12)