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Health Care That Capitalizes on Social Ties

Portland-area researchers find that investing in social capital improves health among the disadvantaged.

Bringing people together has long been the goal of labor organizers, politicians and all manner of charities focused on America’s urban poor. But the results of a pilot program suggest that strengthening trust and connectedness actually makes people healthier.

In Poder es Salud/Power for Health, low-income African-American and Latino residents of Oregon’s Multnomah County (which contains Portland) organized projects ranging from an Aztec dance class to a homework club. The activities bolstered feelings of social support and improved physical and mental health. Such programs might provide some aid to other immigrant and minority communities that suffer from high rates of conditions like heart disease and have limited access to preventive care.

That the program worked as intended comes as little surprise to many who study “social capital.” That’s the idea, popularized during the mid-1990s by Harvard sociologist Robert Putnam, that shared norms and values help socially connected groups work together.

Researchers ranging from epidemiologists to economists have crunched numbers and conducted interviews to demonstrate links between social indicators, like civic participation, and health outcomes, such as infant mortality — in short, more powerful communities do a better job of addressing members’ health. Yet the team led by Oregon Health & Science University’s Yvonne Michael is one of only a handful that have attempted to convert such conclusions into intervention.

“These authors not only test whether there’s an association (between health and social capital), but they manage to increase social capital and see vast effects on health. That’s new to me — and really interesting,” said Oakland University economist Sherman Folland.

While many programs have been shown to increase social capital, Power for Health was among the first to emphasize connectedness and relationships above all. It’s a different approach from most public health programs, which focus on diseases or the health behavior of individuals in the community, and it stemmed from the idea that poor health in communities of color often results from interconnected social problems, such as job insecurity or inadequate housing.

“We didn’t identify a health problem like heart disease, asthma or diabetes,” Michael said. “By addressing this general idea of ‘let’s enhance community social capital,’ in the long term we’ll address a whole range of health issues.”

Developed by Michael, Noelle Wiggins of the Multnomah County Health Department and Portland State University professor Stephanie Farquhar, Power for Health employed a method called community-based participatory research. It functions the way it sounds — instead of a top-down approach, researchers partner with locals to plan and conduct the program. While the participatory method may be less controlled than traditional experiments, it helps researchers involve community members directly, drawing in people who might otherwise be wary of working with “experts.”

They trained part-time community health workers, found via church groups, community organizations and an apartment complex, to guide the 170 participants. These facilitators helped locals brainstorm about important issues and social problems, along with ideas to combat them.

The projects they developed varied widely: a diabetes support and information group; a citizen trash pickup inspired by photographs of the local garbage scourge; a youth peace campaign to tackle an increase in gang violence and lethal force by police.

The low-budget implementations didn’t eliminate these afflictions outright, but they did make small differences and engendered feelings among residents that they could influence their community. Researchers surveyed locals just before Power for Health, as well as eight months later, and recorded a marked positive change in both connectedness and health. Several social capital indicators rose — for instance, they had more people available to support them than before the program. Their self-rated physical health also rose, and depressive symptoms decreased.

“It was really exciting, especially given that the people we interviewed were selected randomly form the list of the community members. These weren’t necessarily people who were involved in any of the intervention pieces,” Michael said.

She can only hypothesize as to how their work translated into trust and better health, though residents did describe for interviewers how activities like providing job assistance or food helped. And other studies have shown that social ties help people transmit important information about health and well-being.

“Most of our health information is from social connections, not reading health magazines or attending classes,” said Harvard epidemiologist Ichiro Kawachi.

With such a small sample and no control group, it would be difficult to identify which projects worked best. Michael also noted that the people who participated may have started out with high social capital, and she acknowledged that one of the African-American community groups initially involved dropped out.

Nevertheless, she and others are encouraged by the results and believe other groups might replicate the model, employing trained community health workers to develop entirely different local projects in other social-capital-starved communities — even if they struggle to explain the wonky concept to adults who lack even a high school diploma.

“What we’re looking for are more ways to practically intervene,” Kawachi said. “I think it’s a robust, increasingly promising way of improving health.”

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