Is social capital associated with HIV risk in rural South Africa?☆
Introduction
Over the past decade, South Africa has witnessed one of the fastest growing HIV epidemics in the world. Between 1992 and 2005, HIV prevalence among antenatal clinic attenders has increased by more than 10-fold, from 2.4 to 30.2% (Department of Health, 2005). Since 2002, death from AIDS has outstripped all other causes of adult mortality combined (Dorrington, Bourne, Bradshaw, Laubscher, & Timaeus, 2001).
There is an evolving literature that attempts to explain why some countries or communities have more HIV than others. The ‘risk environment’ defines aspects of social situations that are largely outside individuals' control yet have a major effect on the level of disease in populations (Rhodes et al., 2005, Rose, 1985). In South Africa, major elements of the risk environment thought to fuel vulnerability to HIV include poverty and underdevelopment in the setting of extreme social and economic inequality; the high rates of labour migration; and entrenched gender inequalities where physical and sexual violence against women and girls are commonplace (Fenton, 2004, Garcia-Moreno and Watts, 2000, Gilbert and Walker, 2002, Mane et al., 1994, Parker et al., 2000, Rao Gupta, 2002, UNAIDS, 1999, UNAIDS, 2002). Taken together, these factors interact to underpin the severity and scale of the HIV epidemic.
Social capital has been put forth as a conceptual framework to link the risk environment to a host of individual health outcomes including HIV (Berkman and Kawachi, 2001, Szreter and Woolcock, 2004). It has been defined as the “features of social organization, such as trust, norms and networks that can improve the efficiency of society by facilitating coordinated action” (Putnam et al., 1993).
There are a number of mechanisms through which social capital might affect the prevalence and distribution of HIV in populations (Berkman and Kawachi, 2001, Campbell and MacPhail, 2002, Campbell et al., 2002, Gregson et al., 2004, Veenstra, 2000). At a very basic level, non-random mixing within high-risk ‘core-groups’ – such as intravenous drug users or sex workers, contributed to much of HIV transmission early on in the epidemic (Mann & Tarantola, 1996). However, well-functioning community networks and the social and material resources that flow between them may also carry protective effects. Strong social networks may exert social or cultural pressure in ways that deter high-risk sexual activity. In addition to providing avenues for the exchange of information, these networks may shape community norms around gender relations, communication and sexual negotiation. They may provide role modelling for health-promotive behavior – such as condom use or access to HIV testing. Individuals with wider networks and deeper trust relationships may have a stronger sense of self-confidence, self esteem and may be better able to take control over decision making. The emotional support generated around these networks may reduce discrimination around HIV and create a more accepting environment for those living with the disease. Finally, more cohesive social and geographic communities may be better able to take collective action and respond to common priority issues such as HIV/AIDS.
Better understanding the relationship between social capital and HIV risk thus has potential to influence and inform prevention activities (Poundstone, Strathdee, & Celentano, 2004). Perhaps, the most compelling observational work to date in this regard comes from two very diverse contexts where epidemic control has been remarkably successful. There was an eight-fold reduction in new HIV infection rates among gay men in San Francisco over a 4-year period relatively early in the epidemic. Wohlfeiler notes that “most of the behavior change took place very quickly, and to a large degree was simultaneous with the establishment of AIDS prevention agencies, rather than a result of those efforts” (Wohlfeiler, 2002). He attributes much of this decline to effective mobilization efforts, notably, among an educated, socially active and well-resourced community facing a direct and immediate threat. Furthermore, public health initiatives were formulated through substantial consultation and involvement of the gay community itself.
The second example comes from Uganda where reductions in antenatal HIV prevalence from 30 to under 10% were observed between 1990 and 2005 – reductions that were not witnessed in neighbouring countries such as Kenya where the epidemic was of similar severity (Green, 2003). It has been suggested that effective social mobilization, particularly through peer-to-peer networks, critically underpinned the dramatic reductions in prevalence (Epstein, 2007). The effect of these dynamics was felt to be ‘equivalent to a highly effective vaccine’ (Stoneburner & Low-Beer, 2004). Again, such efforts largely preceded widespread implementation of conventional prevention measures such as condom distribution, voluntary counselling and testing services, and the syndromic management of sexually transmitted infections (STI).
In contrast, a lack of social capital may serve to exacerbate HIV infection and limit the effectiveness of control efforts. In her post-mortem of an intensive program to reduce HIV transmission in and around a mining community in South Africa, Campbell noted how the absence of community cohesion and the transformation of social and sexual norms associated with chronic poverty and dislocation played a major role in limiting the impact of an ambitious and well-conceived intervention program (Campbell, 2003).
Despite its promise, the application of social capital discourse to framing and responding to public health challenges such as HIV/AIDS remains at a very early stage. Few studies have empirically examined social capital as an explicit component of the HIV risk environment. Cross-sectional research from the US drawing upon state-wide social capital measures have noted inverse associations with STI rates, including AIDS (Holtgrave & Crosby, 2003). Others have demonstrated associations between social capital proxies, such as the density of broken windows in a neighbourhood, and rates of gonorrhoea (Cohen et al., 2000). In Southern Africa, cross-sectional research from Zimbabwe and South Africa suggests that while membership in some social groups is associated with lower rates of HIV, membership in others seems to exacerbate the risk of infection (Campbell et al., 2002, Gregson et al., 2004).
While these studies are exploratory, they raise intriguing questions regarding the temporal and causal nature of such relationships and the potential mechanisms through which social capital might affect HIV risk. In reflecting on the need to advance the rigour of this emerging evidence base, a number of authors have highlighted common limitations to previous research, suggesting critical directions for future work (De Silva et al., 2004, Harpham et al., 2002, Macinko and Starfield, 2001, Szreter and Woolcock, 2004).
- •
Despite over a decade's experience, there is no universally accepted way to measure social capital. Social capital assessments have often relied upon indicators from surveys designed for a different purpose. To address these concerns, there is emerging consensus that social capital assessments should capture both structural (aspects of social group membership) and cognitive dimensions (perceptions of trust, solidarity, and reciprocity in one's community), and should attempt to ensure these measures are locally appropriate and valid.
- •
Research questions should be underpinned by a clear theoretical and conceptual base
- •
Few longitudinal studies exist, to allow for a more definitive exploration of causal relationships and mechanisms of action.
- •
The effects of mediating and confounding variables have been poorly addressed.
- •
Finally, few intervention studies exist, alongside a paucity of research from developing counties.
In this study, we attempt to address a number of these shortcomings in examining the relationship between social capital and HIV/AIDS in a rural South African context. The research took place within the Intervention with Microfinance for AIDS and Gender Equity (IMAGE Study), a randomized trial that explored the effect of a combined microfinance and training program on HIV risk and levels of intimate partner violence (IPV) (Pronyk et al., 2006). The intervention was offered to groups of women and aimed to generate social capital through stimulating participation in social networks, enhancing solidarity, and mobilizing communities around priority concerns including HIV/AIDS. The dataset allows for a detailed assessment of both cognitive and structural dimensions of social capital alongside numerous psychosocial, behavioral and biological aspects of HIV risk. The paper examines the nature and strength of these associations, and explores wider implications for policy and practice.
Section snippets
Setting and sampling frame
This study was set among eight villages in South Africa's rural Limpopo Province. The area was densely settled with a total population of approximately 60,000, and is adjacent to a platinum mining belt. Study villages were between 2 and 20 km from a main trading centre. Poverty was widespread (Rose & Charlton, 2003) with high levels of circular labour migration (Collinson, Tollman, Kahn, Clark, & Garenne, 2006). Forty percent of households were female headed and the average household size was
Results
Response rates in this study were above 90%. Numbers vary for some associations due to missing data for some indicators, reflecting individuals without a non-spousal partner in the previous 12 months, those who refused HIV testing, or who were HIV positive at baseline and thus not included in the assessment of HIV incidence.
Discussion
This study suggests that in a rural South African context, social capital has important bearing on HIV risk in ways that are both complex and nuanced. Among males, residing in households with greater levels of cognitive social capital (CSC) were largely HIV protective. These men felt more open to discuss sex in the home, reported more protective patterns of condom use, and HIV prevalence was reduced compared to their counterparts from households with lower levels of CSC. Household levels of
Acknowledgment
We would like to thank the managing director of Small Enterprise Foundation, John de Wit, and the many staff who have made this work possible.
References (65)
- et al.
Investments in social capital – implications for the production of health
Social Science & Medicine
(2003) - et al.
Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth
Social Science & Medicine
(2002) Poor people, poor places, and poor health: the mediating role of social networks and social capital
Social Science & Medicine
(2001)- et al.
Social capital and young adolescents' perceived health in different sociocultural settings
Social Science & Medicine
(2005) - et al.
Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection
Social Science & Medicine
(2004) Preventing HIV/AIDS through poverty reduction: the only sustainable solution
The Lancet
(2004)- et al.
Treading the path of least resistance: HIV/AIDS and social inequalities – a South African case study
Social Science & Medicine
(2002) - et al.
Community group participation: can it help young women to avoid HIV? An exploratory study of social capital and school education in rural Zimbabwe
Social Science & Medicine
(2004) - et al.
‘‘Hearing the Voices of the Poor”: assigning poverty lines on the basis of local perceptions of poverty. A quantitative analysis of qualitative data from participatory wealth ranking in rural South Africa
World Development
(2007) - et al.
Social capital and health promotion: a review
Social Science & Medicine
(2000)
Risk factors for domestic violence: findings from a South African cross-sectional study
Social Science & Medicine
Socio-geographical patterns of HIV-1 transmission in Kagera Region, Tanzania
Social Science & Medicine
Social capital: a guide to its measurement
Social Science & Medicine
Effect of a structural intervention for the prevention of intimate partner violence and HIV in rural South Africa: a cluster randomized trial
Lancet
The social structural production of HIV risk among injecting drug users
Social Science & Medicine
Social capital, SES and health: an individual level analysis
Social Science & Medicine
Family, friend or foe? Critical reflections on the role of social capital in health promotion and community development
Social Science & Medicine
The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages in the Mwanza Region, Tanzania
AIDS
Social integration, social networks, social support and health
Social epidemiology
Cronbach's alpha
British Medical Journal
Structural interventions: concepts, challenges and opportunities for research
Journal of Urban Health
Community effects on the risk of HIV infection in rural Tanzania
Sexually Transmitted Infections
Spread of HIV infection in a rural area of Tanzania
AIDS
Letting them die: How HIV/AIDS prevention programs often fail
Is social capital a useful conceptual tool for exploring community level influences on HIV infection? An exploratory case study from South Africa
AIDS Care
Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS community demonstration projects
American Journal of Public Health
“Broken windows” and the risk of gonorrhoea
American Journal of Public Health
Highly prevalent circular migration: households, mobility and economic status in rural South Africa
Maternal social capital and child nutrition in four developing countries
Journal of Health and Place
Social capital and mental illness: a systematic review
Journal of Epidemiology and Community Health
National HIV and syphilis prevalence survey: South Africa 2005
Cited by (108)
Racial and ethnic differences in the association of social cohesion and social capital with HIV testing
2023, SSM - Population HealthCitation Excerpt :On a positive note, social organization and community participation has long been a common route through which marginalized groups have used to fight for equality and health resources (James, Schulz et al., 2001, pp. 165–188). Empirical studies showed that both social capital and social cohesion aspects have been associated with lower HIV risk through HIV testing (Karim et al., 2008; Pronyk et al., 2008; Fonner, Kerrigan et al. 2014). As we have shown, the mechanisms relating to health and HIV are complex, and thus producing both positive and negative associations.
Association between social capital and suicide ideation, plan and attempt among men living with HIV in China
2021, Journal of Affective DisordersCitation Excerpt :For Durkheim, social cohesion, especially traditional family life, provided the best protection against suicide. Several other studies have also identified the role of social capital in improving mental health and reduce risk for suicide by increasing an individual's access to social resources and encouraging social support and care-seeking behavior (Pronyk et al., 2008; Vogel et al., 2007). Therefore, focusing on promotion of social capital would be an evidence-based strategy for suicide prevention and control if the findings of our study can be confirmed with longitudinal data to rule out potential reverse impact of suicidal ideation on social capital.
The role of microfinance in improving living standards: Evidence from Tunisia
2024, Poverty and Public Policy
- ☆
The study has received financial support from AngloAmerican Chairman's Fund Educational Trust, AngloPlatinum, Department for International Development (UK), the Ford Foundation, the Henry J. Kaiser Family Foundation, HIVOS, South African Department of Health and Welfare, and the Swedish International Development Agency.