Trudy Harpham

Social capital and mental illness: a systematic review

Study objective: The concept of social capital has influenced mental health policies of nations and international organisations despite its limited evidence base. This papers aims to systematically review quantitative studies examining the association between social capital and mental illness. Design and setting: Twenty electronic databases and the reference sections of papers were searched to identify published studies. Authors of papers were contacted for unpublished work. Anonymised papers were reviewed by the authors of this paper. Papers with a validated mental illness outcome and an exposure variable agreed as measuring social capital were included. No limitations were put on date or language of publication. Main results: Twenty one studies met the inclusion criteria for the review. Fourteen measured social capital at the individual level and seven at an ecological level. The former offered evidence for an inverse relation between cognitive social capital and common mental disorders. There was moderate evidence for an inverse relation between cognitive social capital and child mental illness, and combined measures of social capital and common mental disorders. The seven ecological studies were diverse in methodology, populations investigated, and mental illness outcomes, making them difficult to summarise. Conclusions: Individual and ecological social capital may measure different aspects of the social environment. Current evidence is inadequate to inform the development of specific social capital interventions to combat mental illness.

Child malaria treatment practices among mothers in Kenya.

A study of 883 mothers with children aged 0-9 years was undertaken in Kilifi district on the Kenyan coast in order to examine child malaria treatment practices. Quantitative and qualitative methods were used to investigate: whether complications of childhood malaria were recognized; decision-making dynamics in treatment-seeking; and the extent and reasons for the use of proprietary treatment. Childhood malaria was perceived as a mild, everyday illness, not preventable but treatable. The link between malaria and mosquitoes was not recognized. Mothers recognized convulsions, anaemia and splenomegaly but did not link them to malaria. Antimalarial drugs were not given or were withdrawn from children suffering from these conditions. Ill children were treated promptly by purchase of over-the-counter drugs at retail outlets. The health education implications of these findings are discussed.

Maternal mental health and child nutritional status in four developing countries

Objective: To test the hypothesis that maternal common mental disorders (CMD) are associated with poorer child nutritional status in four developing countries (Ethiopia, India, Vietnam, and Peru). Design: Community based cross sectional survey in 20 sites in each of the four countries. Maternal CMD measured by the self reporting questionnaire 20 items (SRQ20). Potential confounding factors include: household poverty, household composition, maternal characteristics such as age and education, child characteristics such as birth weight, age, and sex. Possible mediating factors included the child’s physical health and breast feeding status. Setting: Urban and rural, poor and middle income areas in each country. Participants: 2000 mothers and their children aged 6–18 months in each country. Main outcome measures: Child stunting and underweight measured using standard anthropometric techniques. Results: Levels of maternal CMD and child malnutrition are high in each study setting. After adjusting for confounding factors, the odds ratios (OR) for the association of maternal CMD with child stunting are: India 1.4 (95%CI 1.2 to 1.6), Peru 1.1 (0.9 to 1.4), Vietnam 1.3 (0.9 to 1.7), and Ethiopia 0.9 (0.7 to 1.2). For child underweight, the confounder adjusted ORs are: India 1.1 (0.9 to 1.4), Peru 0.9 (0.6 to 1.2), Vietnam 1.4 (1.1 to 1.8), and Ethiopia 1.1 (0.9 to 1.4). No clear evidence for effect modification by the child’s age or sex was found. Possible mediating factors for the effect of maternal CMD on child malnutrition did not provide strong suggestions for potential mechanisms. Conclusions: There was a relation between high maternal CMD and poor child nutritional status in India and Vietnam. However, the findings from Peru and Ethiopia do not provide clear evidence for a similar association being present in non-Asian countries. Regardless of the direction of the relation, child nutrition programmes in Asia should consider incorporating promotion of maternal mental health.

Can social capital be intentionally generated? A randomized trial from rural South Africa

While much descriptive research has documented positive associations between social capital and a range of economic, social and health outcomes, there have been few intervention studies to assess whether social capital can be intentionally generated. We conducted an intervention in rural South Africa that combined group-based microfinance with participatory gender and HIV training in an attempt to catalyze changes in solidarity, reciprocity and social group membership as a means to reduce womens vulnerability to intimate partner violence and HIV. A cluster randomized trial was used to assess intervention effects among eight study villages. In this paper, we examined effects on structural and cognitive social capital among 845 participants and age and wealth matched women from households in comparison villages. This was supported by a diverse portfolio of qualitative research. After two years, adjusted effect estimates indicated higher levels of structural and cognitive social capital in the intervention group than the comparison group, although confidence intervals were wide. Qualitative research illustrated the ways in which economic and social gains enhanced participation in social groups, and the positive and negative dynamics that emerged within the program. There were numerous instances where individuals and village loan centres worked to address community concerns, both working through existing social networks, and through the establishment of new partnerships with local leadership structures, police, the health sector and NGOs. This is among the first experimental trials suggesting that social capital can be exogenously strengthened. The implications for community interventions in public health are further explored.

The Measurement of Community Social Capital Through Surveys

This chapter is about quantitative surveys of social capital within general community-based health surveys. It assumes that the investigation of social capital is only part of a larger survey that includes, at the least, additional questions on health-related outcomes, attitudes or behaviour. It therefore focuses on key issues that should be addressed when designing social capital measures but acknowledges that such measures need to be limited in order to be kept in proportion to the overall survey. It aims for a minimalist but theoretically strong approach.

Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists.

Urbanization in developing countries involves changes in social support and life events which have been shown to affect mental health; mainly depression and anxiety, particularly among low income women. Although depressive and anxiety disorders have a high prevalence and account for a large proportion of visits to primary health services there is little international health research in this field. The determinants, extent and outcome of the association between urbanization and mental health requires multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods is required before effective research can begin. Other issues such as the avoidance of environmental determinism; the separation of macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of research, all need consideration in the development of research into this rapidly emerging, but relatively neglected problem.

Is social capital associated with HIV risk in rural South Africa

The role of social capital in promoting health is now widely debated within international public health. In relation to HIV, the results of previous observational and cross-sectional studies have been mixed. In some settings it has been suggested that high levels of social capital and community cohesion might be protective and facilitate more effective collective responses to the epidemic. In others, group membership has been a risk factor for HIV infection. There have been few attempts to strengthen social capital, particularly in developing countries, and examine its effect on vulnerability to HIV. Employing data from an intervention study, we examined associations between social capital and HIV risk among 1063 14 to 35-year-old male and female residents of 750 poor households from 8 villages in rural Limpopo province, South Africa. We assessed cognitive social capital (CSC) and structural social capital (SSC) separately, and examined associations with numerous aspects of HIV-related psycho-social attributes, risk behavior, prevalence and incidence. Among males, after adjusting for potential confounders, residing in households with greater levels of CSC was linked to lower HIV prevalence and higher levels of condom use. Among females, similar patterns of relationships with CSC were observed. However, while greater SSC was associated with protective psychosocial attributes and risk behavior, it was also associated with higher rates of HIV infection. This work underscores the complex and nuanced relationship between social capital and HIV risk in a rural African context. We suggest that not all social capital is protective or health promotive, and that getting the balance right is critical to informing HIV prevention efforts.

Maternal social capital and child health in Vietnam

Study objective: To explore the association between maternal social capital and child physical and mental health in Vietnam. Design: Cross sectional survey. Measures of maternal structural social capital comprised group membership, citizenship, and social support. Measures of cognitive social capital comprised trust, social harmony, sense of fairness, and belonging. Child health was measured by anthropometrics and mothers’ reports of acute and chronic physical health problems and child mental health. Participants: 2907 mothers and their 1 year old or 8 year old children from five provinces in Vietnam. Main results: The study found low levels of group membership and citizenship and high levels of cognitive social capital and support, and generally higher levels of social capital among the mothers of 8 year old compared with 1 year old children. All but one association was in the hypothesised direction (that is, higher levels of social capital associated with reduced risk of child health problems). There were more statistically significant relations between maternal social capital and the health of 1 year olds compared with 8 year old children, and between measures of social support and cognitive social capital and child health, than with group membership and involvement in citizenship activities. Conclusion: This study is the first to explore the association between multiple dimensions of social capital and a range of different child health outcomes in the developing world. These results now need to be tested using longitudinal data.

Private practitioners in the slums of Karachi : what quality of care do they offer?

Private health services have expanded in many developing countries over the last 10 yr. Qualified private practitioners provide basic health care for poorer groups in urban areas, although health care planners frequently criticize them for providing poor quality of care, charging high fees and failing to provide preventive health advice. In Karachi, a large city with more than 400 slums, private practitioners are important providers of care to the poor. This study assessed the nature and quality of care provided by 201 practitioners selected from four districts of the city. Vignettes of specific medical problems were used to assess their knowledge and their practice was measured by observing 658 doctor-patient contacts. The results show that knowledge was closer to accepted medical management than was their actual prescribing practice. On the other hand, their manners and interpersonal behaviour were good. Thus poor prescribing practice, which might equally stem from market influences as lack of knowledge, is the cause of low standards of care. In these circumstances, didactic in-service training to improve prescribing practice is unlikely to be successful.

Perceptions of symptoms of severe childhood malaria among Mijikenda and Luo residents of coastal Kenya.

Effective community based malaria control programmes require an understanding of current perceptions of malaria as a disease and its severe manifestations. Quantitative and qualitative surveys of mothers on the Kenyan Coast suggest that fever is conceptualised in biomedical terms whereas the aetiology of severe malaria is perceived to be of more complex cultural origin. This is reflected in the treatments sought for convulsions. The results are discussed in the context of ethnographic factors. To be effective, future health information programmes must take cultural beliefs into account.