Is social capital associated with HIV risk in rural South Africa?

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Abstract

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.

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)

  • R. Jewkes et al.

    Risk factors for domestic violence: findings from a South African cross-sectional study

    Social Science & Medicine

    (2002)
  • J.Z. Killewo et al.

    Socio-geographical patterns of HIV-1 transmission in Kagera Region, Tanzania

    Social Science & Medicine

    (1994)
  • K. Lochner et al.

    Social capital: a guide to its measurement

    Social Science & Medicine

    (1999)
  • P.M. Pronyk et al.

    Effect of a structural intervention for the prevention of intimate partner violence and HIV in rural South Africa: a cluster randomized trial

    Lancet

    (2006)
  • T. Rhodes et al.

    The social structural production of HIV risk among injecting drug users

    Social Science & Medicine

    (2005)
  • G. Veenstra

    Social capital, SES and health: an individual level analysis

    Social Science & Medicine

    (2000)
  • S. Wakefield et al.

    Family, friend or foe? Critical reflections on the role of social capital in health promotion and community development

    Social Science & Medicine

    (2005)
  • L.R. Barongo et al.

    The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages in the Mwanza Region, Tanzania

    AIDS

    (1992)
  • L.F. Berkman et al.

    Social integration, social networks, social support and health

  • L.F. Berkman et al.

    Social epidemiology

    (2001)
  • J.M. Bland et al.

    Cronbach's alpha

    British Medical Journal

    (1997)
  • K.M. Blankenship et al.

    Structural interventions: concepts, challenges and opportunities for research

    Journal of Urban Health

    (2006)
  • S.S. Bloom et al.

    Community effects on the risk of HIV infection in rural Tanzania

    Sexually Transmitted Infections

    (2002)
  • J.T. Boerma et al.

    Spread of HIV infection in a rural area of Tanzania

    AIDS

    (1999)
  • C. Campbell

    Letting them die: How HIV/AIDS prevention programs often fail

    (2003)
  • C. Campbell et al.

    Is social capital a useful conceptual tool for exploring community level influences on HIV infection? An exploratory case study from South Africa

    AIDS Care

    (2002)
  • CDC

    Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS community demonstration projects

    American Journal of Public Health

    (1999)
  • D. Cohen et al.

    “Broken windows” and the risk of gonorrhoea

    American Journal of Public Health

    (2000)
  • M.A. Collinson et al.

    Highly prevalent circular migration: households, mobility and economic status in rural South Africa

  • M. De Silva et al.

    Maternal social capital and child nutrition in four developing countries

    Journal of Health and Place

    (2007)
  • M.J. De Silva et al.

    Social capital and mental illness: a systematic review

    Journal of Epidemiology and Community Health

    (2004)
  • Department of Health

    National HIV and syphilis prevalence survey: South Africa 2005

    (2005)
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    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.

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