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Social Determinants of Health: Social Capital

“Blood pressure up high. You know, didn’t have anybody to talk to so I stayed sick. Chest – always had a pain in my chest. When you get upset, you know, when something didn’t go right – when you ain’t got anybody to call, you hold that stuff on the inside, it eats you up. It eats you up.”

Homeless, Chronically Ill Patient from San Francisco General Hospital

Many essential hospital patients are low-income or homeless, minorities, chronically ill, have low English proficiency (LEP), and/or substance abuse issues. These factors often render them socially isolated. What’s more, the degree of connection with friends and family can alleviate, or exacerbate, these circumstances.

Social connections impact patients’ health outcomes and may influence overutilization of health care services. Essential hospitals, which care predominantly for marginalized groups who may experience social isolation regularly, can alleviate this burden by implementing certain care practices and building relationships with patients.

To investigate this topic further, we conducted a review of relevant literature. The following key findings emerged:

Social Relationships Are a Determinant of Health

Much like our external environments and day-to-day encounters, our social interactions and support systems play an important role in our overall health. Embedded in the theory of the social determinants of health is the concept of social and community networks – also referred to as social capital.

The overarching theory of social capital is extremely broad and has found a place in public policy, economics, and more recently, public health. Individual concepts within the theory – such as social cohesion, network theory, bonding, and bridging – have caused a lack of consensus around a master definition and measurement construct. However, researchers agree that social relationships at any level can be “invested in and form ‘capital’ that may harvest returns in the future,” especially regarding health outcomes.

Poor Social Capital Causes Physical and Mental Distress

Many years of research have proven that higher degrees of social connection lead to improved all-cause mortality rates. Additionally, social connections can lower health care utilization, benefit mental health, and support self-management behaviors.

A lack of social connection and support can negatively impact health outcomes and disease management. Social isolation, whether perceived or actual, induces a stress response within the body. Poor social connection can elicit negative physical responses e.g., high blood pressure, insomnia) and mental distress (e.g., anxiety, depression).

The emotional burden of feeling alone or not being understood by peers takes a heavy toll on patients. Chronically ill patients may often experience social isolation because their symptoms or pain may not be apparent to others. Thus, even when social support is present, patients may still feel isolated if they are unable to connect about their health condition.

Social Isolation Motivates Overutilization

The role of social capital and its ability to enforce or reinforce social norms for health behaviors, such as alcohol use, cigarette smoking, and physical activity, is well understood. What is less understood is how social capital influences utilization patterns. Existing literature explores this idea more often within geriatric patients. However, additional literature indicates that the same ideas may apply to all ages, as discussed below.

Personal relationships with clinicians may be the sole source of social connection for many patients. For example, in a landscape review conducted in fall 2013 by Essential Hospitals Institute, providers recounted that many of their complex patients had little social support and received most of their interpersonal interactions when they came in for appointments.

This issue works in tandem with the other drawbacks of poor social capital. Researchers from the University of Sydney Australia discuss how three socially isolating circumstances may result in increased health care utilization: (1) living alone, (2) not socializing, and (3) isolation from family or lack of family support. Furthermore, these social factors play into a cycle of depression, disease management, and unplanned admissions.

Essential Hospitals Build Relationships, Improve Health Outcomes

Essential hospitals are taking the lead when it comes to addressing social capital for many of their patients. Providers may not always be able to form community links for patients, but certain care practices, such as case management and team-based care, can play a substantial role in relieving feelings of isolation.

Case management is an opportunity to form caring social relationships with patients. This practice is facilitated by patient navigators, social workers, and community health workers, and it addresses a breadth of other health determinants (e.g., housing, employment). Patients are able to form a close bond with their case manager, who cares about their well-being. For example a study conducted at San Francisco General Hospital revealed just how important this social connection is to patients. As one patient said, “One person I’ve got to talk to is [name of case manager]. She is a caring person. You think nobody cares for you, but somebody still does.”

Team-based care is another opportunity for social connection, as patients build relationships with their care team. Rather than receiving care from any available clinician, patients receive care from clinicians who know them and care about them.

Such relationship building may be an indispensable tool for health promotion among patients who are in need of social support. Providers should seek opportunities to address this issue in order to improve patient care and focus on additional social determinants that are often linked with social interactions.


About the Author

Janelle Schrag is a senior program analyst with America's Essential Hospitals.

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