Accepted for publication in J Epidemiology and Community Health

Social Capital and Collective Efficacy in Hungary: Cross-sectional Associations with Middle-Aged Female and Male Mortality Rates

Árpád Skrabski,¹Ph.D., Maria Kopp, M.D., Ph.D.,² Ichiro Kawachi, M.D., Ph.D.³

¹Apor Vilmos College

H-2072 Zsámbék, Zichy tér 3

Tel: +36 23 565-531 Fax: +36 23 565-555

E-mail: hfmf@axelero.hu

²Institute of Behavioural Sciences, Semmelweis University of Medicine

H-1089 Budapest, Nagyvárad tér 4., Hungary

Tel: +36 1 210-2953, Fax: +36 1 210-2955

E-mail: kopmar@net.sote.hu

³Center for Society and Health, Harvard School of Public Health,

Boston, USA.

Running head: Social capital and mortality in Hungary

Funding sources: This study was supported by the United Nation Development Program (UNDP) project no HUN/00/002, the National Research Fund (OTKA) projects no T-29067 (1999) and T-32974 (2000) and NKFP-01/002/2001 grant.

Conflicts of interest: None

Keywords: social capital, collective efficacy, competition, middle aged mortality, gender differences

What Is Already Known About This Topic

· Social capital – defined as the assets and resources available to individuals through civic participation – appears to be a potential determinant of population health status.

· Indicators of social capital – perceived trust, reciprocity, and membership in civic and religious organisations – correlate with mid-aged (45-64 years) male and female mortality across the 20 counties of Hungary.

· However, there are gender differences in the relationship of social capital to mortality rates.

What This Study Adds

· Indicators of social capital (perceived trust of others, reciprocity, and membership in civic organisations), collective efficacy, religious involvement and competitive attitude are associated with mid-aged (45-64 years) male and female mortality across the 150 sub-regions of Hungary.

· There are gender differences in the relationships of competitive attitude and religious involvement with mortality rates. Competitive attitude was a significant predictor of mortality only among men, while religious involvement was a significant protective factor only in women.

· Socio-economic status (educational attainment and taxable income), social capital and collective efficacy explained 67.6 % of the sub-regional variance in middle aged male mortality rates, while cigarette smoking and spirit consumption added only 0.4 % of explained variance.

· Among women, socio-economic status, social capital and collective efficacy explained only 27.3 % of the variance in mortality rates, while cigarette smoking and spirit consumption added a further 2.0%.

Abstract

Objectives: Social capital, collective efficacy, and religious involvement have each been linked to lower mortality rates. We examined the relationships between measures of social capital, collective efficacy, religious involvement and male/female mortality rates across 150 sub-regions in Hungary.

Design: Cross-sectional, ecological study.

Setting: 150 sub-regions of Hungary.

Participants and methods: 12,643 people were interviewed in 2002 (the "Hungarostudy 2002" survey), representing the Hungarian population at the sub-regional level. Social capital was measured with three indicators: lack of social trust, reciprocity between citizens, and membership in civil organisations. Additionally attitudes towards competition and rivalry was measured by the question: " If I hear about the success of a friend of mine, I feel frustrated". Collective efficacy was measured by 10 items from the Project on Human Development in Chicago Neighborhoods Community Survey. Religious involvement was measured by church attendance. Socio-economic status was measured by educational attainment and taxable income. Daily cigarette smoking and spirit consumption were included as covariates.

Main outcome measure: Gender-specific mortality rates were calculated for the middle-aged population (45-64 years) in the 150 sub-regions of Hungary from data provided by the Central Statistical Office (CSO).

Results: The social capital, collective efficacy, and competitiveness variables as well as religious involvement were each significantly associated with middle age mortality. Collective efficacy showed the strongest association in both men and women. Among men, socio-economic status, collective efficacy, social distrust, competitive attitude, reciprocity, and membership in civic organisations explained 67.6 % of the sub-regional variations in mortality rates, while smoking and spirit consumption added only a further 0.4 %. Among women the same variables explained only 29% of the variance in mortality rates. Religious involvement was found to be protective among women, while competitiveness emerged as a significant risk factor for mortality among men.

Conclusion: Collective efficacy and social capital are significant predictors of mortality rates in both among men and women across sub-regions of Hungary. Gender differences in the relative influences of social factors (SES and competitiveness versus religious involvement) may help to explain the differential impact of economic transformation on mortality rates for men and women in Central-Eastern European countries.

Introduction

On the heels of economic and societal transformation in the late 1980s, mortality rates among middle aged (45-64 year) men in Hungary rose to higher levels than they were in the 1930s. According to the latest statistics (1), mortality rates in 2001 were still higher than in the 1930s. In other countries of the Central-European region, similar patterns of mortality have been reported (2-6). The stagnation or deterioration of life expectancies in the region occurred despite improvements in the efficiency and delivery of the health care throughout the 1980s, as well as rising average living standards. This phenomenon has been referred to as the Central East-European health paradox (7).

There are also considerable variations across the Hungarian counties and sub-regions in mid-aged mortality rates. Regional differences in social cohesion and “social capital” have been put forward as a potential explanation of the variations in mortality experience across areas of Hungary. Social capital has been defined as the assets and resources available to individuals through their connections to their communities and to society at large (8-10). It is hypothesized that more socially cohesive communities (i.e., communities richer in stocks of social capital) are better able to buffer the stresses and uncertainties associated with economic transformation. Social capital - as assessed by indicators such as the level of trust between citizens, the existence of norms of reciprocity, as well as citizen participation in civic and voluntary organizations – may be a marker of the extent to which communities can effectively cope with the vagaries of social change. For example, patterns of social capital at the regional level (measured by trust of local institutions and the extent of civic engagement in politics) were inversely correlated with the severity of the mortality crisis following the transformation of Soviet Russia to a market economy (11)

In Hungary, we have previously reported cross-sectional associations of social capital with middle-aged female and male mortality rates across the 20 counties, based on the Hungarostudy 1995 (7), a national cross sectional survey representing the Hungarian population over the age of 16. In 1995 12,640 persons were interviewed in their homes. Each of the social capital variables (trust, perceptions of reciprocity, civic engagement) were significantly inversely associated with middle age mortality, with levels of mistrust showing the strongest associations. Some gender differences were also noted, with social mistrust (the proportion of people in a county who agreed that “People are generally dishonest and selfish and they want to take advantage of others”) being more strongly correlated with male than with the female mortality rates. By contrast, perceived reciprocity (assessed by the question: “If I help someone, I can anticipate that they will respect me and treat me just as well as I treat them”) showed a stronger correlation with female mortality rates. Close instrumental bonds among women also appear to be protective for men’s health, as judged by the association of perceived reciprocity among women to male mortality rates (7).

One of the striking observations about the pattern of mortality in Hungary (indeed throughout the Central-European region) is the high male/female mortality gap. In Hungary, the male/female differences in life expectancy is 8.3years, which is considerably higher than the average difference found in countries of Western Europe, for example 5,8 years in the neighbouring Austria, 4.8 years in Denmark and Great Britain.

The aim of the present study was therefore to investigate the determinants of male and female mortality patterns using new data from Hungary, based on the 2002 Hungarostudy, a nationally and regionally representative interview survey of the Hungarian population. In contrast to the 1995 Hungarostudy, the 2002 survey was designed to be representative of the 150 sub-regions of the country. The 2002 survey also included a more detailed battery of scales assessing social capital constructs. The survey also included a new variable assessing attitudes toward competition.

In the 1970s, significant ownership of private property was still uncommon in Hungarian society, with the state regime employing all citizens, and salaries being determined in a way that not even persons in high status could accumulate wealth. The governing socialist party primarily provided privileges to party members, which was expressed as differences in salaries only to a minor degree.

Beginning in the 1970s, however, the ruling socialist elite began a process of loosening the rules to enable certain influential people to transform public property for private gain.(12,13) The ideology of meritocracy, that is winners acquiring more economical resources under competitive circumstances, began to be introduced. In many cases the competitive opportunities consisted of seizing public property for personal enrichment. A typical attitude emerged from this period, which can be expressed by the opinion "If I hear about the success of a friend of mine, I feel frustrated ".

The theory of relative deprivation, introduced by Runciman (14), hypothesizes that stress and frustration can arise out of situations in which there is rapid improvement in living standards (at least for some). As summarized by Coleman ( 15) “As long as there is no visible change in objective conditions, all persons feel that they are “in the same boat”. However, when there is rapid improvement in conditions, those of some improve more rapidly than those of others. Those for whom conditions are not improving very rapidly see other, perhaps no more qualified, doing much better than they are. It is from this perspective that they perceive a widening gap, which leads them to feel frustration” (Coleman, 1990, pp. 475-6).

Besides fostering a sense of anomie, relative deprivation may be deleterious to both psychological and physical health, through stress-related coping responses (e.g., more smoking, heavier drinking), as well as invidious social comparisons. Conversely, social cohesion may help to dampen certain habits and practices (such as conspicuous displays of new wealth) that signal a widening gap in material circumstances.

In the present study, we sought to examine the community-level associations between competitive attitudes and male/female mortality rates, as well as the potential mitigating forces of social cohesion, civic engagement, and religious involvement.

Methods

The Hungarostudy 2002 is a national cross sectional survey representing the Hungarian population at the level of the 150 sub-regions of Hungary. In 2002 12,643 persons were interviewed in their homes [7,16] .

Sampling methods

A clustered, stratified sampling procedure was implemented. The sample represented 0.25 % of the population above age 18 according to age and sex. The sampling frame was the National Population Register. Sub-regions with population more than 10 000 were included in the sample, as well as a random sample of smaller sub-regions. The overall refusal rate was 17.7 % for the full sample, although there were significant differences depending on urban/rural residence. In large cities the refusal rate tended to be higher than in small villages. For each refusal, we selected another person from the same community with similar sampling characteristics defined by age and sex. The replacement sampling procedure was found not to result in significant selection bias. The interviewers of this study were district nurses, and the duration of the home interviews was about one hour long. [7,16].

Middle aged (45-64 years) male and female morality rates, years of educational attainment and taxable income per capita data were obtained from the Central Statistical Office sub-regional data base for each sub-region. (17)

Definitions

Outcome variables

Male and female mortality rates in the 45-64 year age group were obtained for each county from the CSO sub-region data base.

Social capital variables

Following Putnam [18] and Kawachi [10], individual components of social capital were assessed by three items concerning levels of social trust, perceptions of reciprocity, and membership in civic organisations. [7] The level of trust was assessed from responses to the item that asked whether the interviewed person agreed that “People are generally dishonest and selfish and they want to take advantage of others.” (Responses 0-3, Totally disagree to totally agree). This item is very similar to the item from the US General Social Survey, used by Kawachi et al. [10] as an indicator of lack of social trust.

Citizens’ perceptions of reciprocity were assessed from the responses to the item “If I help someone, I can anticipate that they will respect me and treat me just as well as I treat them.” (Responses 0-3, Totally disagree to totally agree).

Membership in civic organisations was measured by yes/no responses to a question about belonging to civic group or groups. Civic organisations were defined as non-profit, voluntary organisations, societies, self-help groups, and clubs. Political parties, unions and churches were not included.

Competitive attitude was assessed by the question "If I hear about the success of a friend of mine, I feel frustrated " (Responses: 0-3, Totally disagree to totally agree)

Religious involvement was measured by two questions: "Are you religious? If yes, what is the form of your worship?" (Responses 0-4, I am not religious, No worship, Worship in my own way, Rarely in my church, Regularly in my church) and "How important is the religion for you?" (Responses 0-3, Not at all, Slightly, Very important, It influences my every action).In the present study, we analyzed only the first variable.

We included ten items of the collective efficacy scale from the 1995 Community Survey of the Project on Human Development in Chicago Neighborhoods, a seminal study of social capital in the USA [19-21] Collective efficacy is defined as the collective belief in undertaking coordinated action. It is situational, not universal. The questionnaire assesses the differential ability of neighbourhoods to realise the common values of residents, which is referred to as “social cohesion”. The other component assesses " informal social control", which concerns the belief in the likelihood that neighbours will intervene in risky situations.

The collective efficacy scale is derived by summing the responses to the 10 items that make up the scale (see appendix)

The weighted, standardised average values for the above variables were computed for the 150 Hungarian sub-regions, separately for men and women.

Socio-economic and behavioural covariates

We included the following socio-economic variables: taxable income per capita and average years of educational attainment at the sub-regional level, obtained from the CSO data base. We also obtained cigarette smoking per day and spirit consumption per occasion for each sub-region from the HUNGAROSTUDY 2002 survey.

SPSS Base 7,5 was used for multivariate analyses. (22)

Results

The internal consistency reliability of the collective efficacy scale (the Cronbach alpha) was 0,83 for the ten items questionnaire, which means good internal consistency.

Table 1 shows the partial correlation coefficients of social capital, competitive attitude, collective efficacy and religious involvement variables after controlling for educational attainment and taxable income. Interestingly, income and education showed opposite connection with two different factors of social capital variables. Higher income and education showed negative correlation with social distrust (r=-196**,-.172**), competitive attitude (r= -408**,-.420**) and positive correlation with membership in civic organizations (r=.141**,.159**) . Contrastingly higher income and education are in highly significant negative corelation with collective efficacy (r=-.667**, -.707** with reciprocity (r=-554**, -.552) and with religious involvement (r=-.224**, -.262**) This means that collective efficacy, reciprocity and more religious involvement are characteristic of more traditional, less developed regions while trust, lower rival attitude and participation in civic organizations of the more developed regions.

According to Table 1. collective efficacy and reciprocity are very closely interrelated, and religious involvement is significantly connected only with these two variables. Membership in civic organizations is significantly connected with collective efficacy and reciprocity. On the other hand social distrust and competitive attitude are highly significantly interconnected. Collective efficacy was in significant negatíve connection with social distrust and competitive attitude as well.

Relationships between social capital constructs and male and female middle aged mortality rates

After controlling for socio-economic variables as well as stress-related coping behaviors (cigarette smoking and spirit consumption), multivariable regression analyses indicated that the social capital variables (social distrust, reciprocity, and membership in civic organisations), as well as collective efficacy, religious involvement and competitive attitude were each significantly associated with mortality rates (Table 2 and 3). Among men, the above variables explained 68.0 % of the mortality variance across sub-regions. Years of education alone explained 61.8 % of the variance in male mortality rates, but the next significant predictor was the collective efficacy. Interestingly, religious involvement among men was positively correlated with mortality. The direction of this association may reflect reverse causality, i.e., men are more likely to become involved in religion after they become ill.

Among women, the variables in the multivariable model explained only 29.3 % of the mortality differences across sub-regions. After taxable income, collective efficacy, daily cigarette smoking and religious involvement were the most important predictors of middle aged female mortality. Interestingly, among women competitive attitude was not significantly connected with mortality, although the average values of competitive attitude were not significantly different between men and women. (P = 0.07).

Discussion

As a result of correlation analysis (Table 1.) we found very similar structure of social capital variables as Hyyppa and Maki [22,23] in a Finnish- Swedish study. In our study collective efficacy and reciprocity were closely connected, in the Finnish-Swedish study this is the neighbourhood co-operation. Social distrust and rival attitude were the next variables in our study, reciprocal trust in the Finnish study. Membership in civic associations was negatively connected to rival attitude. Religious involvement was connected only with collective efficacy and reciprocity.. In the Hyyppa study church attendance was the third factor among the social capital related variables. It is a very striking phenomenon, that two separate pattern emerged in relation to education and income, while distrust, rival attitude and membership in civic organizations showed better pattern in higher socioeconomic strata, collective efficacy and reciprocity was stronger in lower socioeconomic regions. Collective efficacy might counteract the negative consecuences of lower socioeconomic situation.

Perceived reciprocity (assessed by the question: “If I do nice things for someone, I can anticipate that they will respect me and treat me just as well as I treat them”) and collective efficacy were strongly associated. As a result of partial correlation controlling for age, years in schools and basis of income tax, the reciprocity and collective efficacy showed a stronger negative correlation with middle aged female than with male mortality rates. The religious involvement and membership in civic organisations showed strong negative correlation with middle aged female mortality rate as well. This four variables and the social trust, which is the opposite of the following statement “People are generally dishonest and selfish and they want to take advantage of others” could be an effective protective factor in the case of middle aged women. According to the stepwise regression analysis (Table 3.) these five parameters explain a considerable part of mid-aged female mortality differentials among sub-regions. In the case of women these factors are practically as important to explain the mortality differences as the socio- economic factors. This means that the existing and broad socio-economic differences among Hungarian regions are less important in regards the middle aged female mortality differences. The neighbourhood cohesion, religious involvement, trust and reciprocity were not so much influenced by sudden socio-economic changes in the last decades, therefore the protective network of women remained relatively unchanged. Besides this, there was a negative correlation between collective efficacy and basis of income tax, which means, that in poorer sub-regions the network of neighbourhood community remained stronger, than in the more developed regions. This association might counterbalance the health deteriorating effect of worsening economic situation, first of all among women.

Among men the socio-economic factors, the relative differences among regions are about four times more important predictors of middle-aged mortality differences, than among women. Social distrust and the rival attitude were important predictors of middle aged mortality differences among men. These results were confirmed by partial correlation analysis (Table 4.), where social distrust and rival attitude strongly correlated with mortality, while collective efficacy showed negative correlation with the middle aged male mortality rate. That is in a suddenly changing socio-economic situation the relative economic deprivation, the rival attitude and the social distrust are all more important risk factors for men while the strong collective efficacy could be a protective factor, even in the case of men.(25) Rival attitude was in highly significant negative association with participation in civic organizations, consequently the protective effect of participation in civic associations might effect health trough lower rival, competitive attitude in members of civic networks among men.

Acknowledgements

This study was supported by the United Nation Development Program (UNDP) project no HUN/00/002/A/01/99, the National Research Fund (OTKA) projects No T-29067 (1999) and T-32974 (2000) and NKFP 1/002/2001.

The authors would like to thank to the other members of the "Hungarostudy 2002" team ( János Réthelyi, Csilla Csoboth, György Gyukits, Adrienne Stauder, János Lőke, Andrea Ódor, Katalin Hajdu, Csilla Raduch, András Székely, László Szűcs, and Sándor Rózsa), to the network of district nurses for the home interviews, for Professor András Klinger for the sampling procedure, for the National Population Register for the selection of the sample and especially to Katalin Hajdu and Csilla Raduch for valuable assistance in the study.

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Appendix:

CHICAGO SOCAL CAPITAL QUESTIONNAIRE

Community survey questionnaire, The Project on Human Development in Chicago neighborhoods, 1994.

0 strongly disagree

1. disagree

2. neither agree nor disagree

3. agree

4. strongly agree

If there is a problem around here, the neighbours get together to deal with it.

This is a close-knit neighbourhood.

When you get right down to it, no one in this neighbourhood cares much about what happens to me.

There are adults in this neighbourhood that children can look up to.

People around here are willing to help their neighbours.

People in this neighbourhood generally don’t get along with each other.

People in this neighbourhood can be trusted.

Adults in this neighbourhood know who the local children are.

Parents in this neighbourhood generally know each other.

If a group of neighbourhood children were skipping school and hanging out on a street corner, the neighbours would do something about it.

Table 1.

Partial correlation coefficients of variables of social capital, competitive attitude, collective efficacy and religious involvement

Controlling for educational attainment and taxable income (weighted by interviewed persons in sub-regions (N = 12526)

Collective efficacy

Reciprocity

Social distrust

Competitive attitude

Member-ship in civic organisa-tion

Religious involve-ment

Collective efficacy

.235**

-.141**

-.204**

.158**

.132**

Reciprocity

.235**

.148**

-.046**

.163**

.020*

Social distrust

-.141**

.148**

.270**

.141**

.003