Árpád Skrabski,¹ Ph.D., Maria Kopp, M.D., Ph.D.,² Ichiro Kawachi, M.D., Ph.D.³
Social Capital and Collective Efficacy in Hungary: Cross-sectional Associations with Middle-Aged Female and Male Mortality Rates

Accepted for publication in J Epidemiology and Community Health

Running head: Social capital and mortality in Hungary

Conflicts of interest: None

Keywords: collective efficacy, gender differences, Hungary, mortality, social capital

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 all cause 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 68.0 % of the sub-regional variance in middle aged male mortality rates.
• Among women, socio-economic status, social capital and collective efficacy explained only 29.3 % of the variance in mortality rates.

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 also measured. 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 all-cause 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 68.0 % of the sub-regional variations in mortality rates. Among women the same variables explained only 29.3 % 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. [1,3] 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. [4] Social capital has been defined as the assets and resources available to individuals through their connections to their communities and to society at large [5-7]). 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. [8]
   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 significant wealth. The governing communist 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 communist elite began a process of loosening the rules to enable certain influential people to transform public property for private gain. [9] ) The ideology of meritocracy, that is winners acquiring more economic resources under competitive circumstances, began to be introduced. In many cases the competitive opportunities consisted of seizing public property for personal enrichment.
   The theory of relative deprivation, introduced by Runciman [10]), 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 [11]):

"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).

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 8.3 years, which is considerably higher than the average difference found in countries of Western Europe, for example 5.8 years in neighbouring Austria, and 4.8 years in Denmark and Great Britain. An other interesting finding was that in Hungary the middle aged mortality ratio comparing the lowest to highest educational stratum is 1.8 for men, compared to 1.2 for females [12].
   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 , a national cross sectional survey representing the Hungarian population. In 1995 12,640 persons were interviewed in their homes. Each of the social capital variables (trust, perceptions of reciprocity, civic engagement) were significantly associated with middle age mortality, with levels of mistrust showing the strongest associations with elevated mortality rates. [4]
   The aim of the present study was 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. Because of the relative homogenity of the subregions compared to the 20 counties studied earlier these data are more adequate for ecological analyses.
   Social capital is a multidimensional concept, each dimension contributing to the meaning although each alone is nor able to capture fully the concept in its entirety. [13]) In the 2002 survey we included a more detailed battery of scales assessing social capital constructs, such as collective efficacy [14] ), religiosity [15] and competitiveness. Our hypothesis was that religiosity and collective efficacy, defined as social cohesion among neighbours combined with their willingness to intervene on behalf of the common good will be more characteristic of the less developed regions of Hungary.
   The quality of social interactions is the core concept in social capital construct. Therefore our hypothesis was that the attitude of rivalry might be closely connected to social distrust and it is the opposite of the attitude when a group of individuals work together co-operatively towards a common goal. 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 [4,16] .

Sampling methods

A clustered, stratified sampling procedure was implemented. The sample represented 0.16 % of the population above age 18 according to age and sex. The sampling frame was the National Population Register updated in 2001 according to the Census including the total population of Hungary. Communities with population more than 10 000 were included in the sample, as well as a random sample of smaller villages. We got two 14.000 persons random samples, the second for substituting the refusals. 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 second sample of 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. [4,16].

Definitions

Outcome variables

Male and female all-cause mortality rates in the 45-64 year age group for 1996-2000 were obtained for each sub-region from the CSO sub-region data base. [17])

Social capital variables

Following Putnam [18] and Kawachi [7], individual components of social capital were assessed by three items concerning levels of social trust, perceptions of reciprocity, and membership in civic organisations. [4] 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. [7] 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 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) This question is part of the shortened Hostility Questionnaire measuring the competitive attitude. [16]
   Religious involvement was measured by the question: "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) 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 [14,19] Collective efficacy is defined as the collective belief in undertaking coordinated action. [20] 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 version 7.5 was used for multivariate analyses, stepwise regression analyses were used to explain mortality differences among sub-regions and ANOVA for comparing means according to gender. [21] )

Results

The Cronbach alpha for the 10-tem collective efficacy scale was 0.83, indicating a high level of internal consistency reliability.
Table 1. shows the characteristics of the study population.
Table 2. shows besides the unadjusted correlation coefficients the partial correlation coefficients of social capital, competitive attitude, collective efficacy and religious involvement variables after controlling for education and income.
   Higher income and educational attainment were significantly negatively correlated with social distrust (r=-196**,-.172**), competitive attitude (r= -408**,-.420**), and positively correlated with membership in civic organisations (r=.141**,.159**). However, higher income and educational attainment were also negatively correlated with collective efficacy (r=-.667**, -.707** ), with reciprocity (r=-554**, -.552), and with religious involvement (r=-.224**, -.262**). These patterns appeared to be consistent with collective efficacy, reciprocity, and religious involvement being higher in less economically developed sub-regions of Hungary.
   Because of this opposite influence of socio-economic situation on different subgroups of social capital variables, we adjusted the correlation according to education and income.The social capital variables (trust, reciprocity, and membership in civic organisations) were moderately, and significantly, correlated with each other. As hypothetied, competitive attitude was significantly inversely correlated with indicators of social cohesion (social capital variables and collective efficacy). Religious involvement was positively correlated with perceptions of reciprocity, collective efficacy, and membership of civic organizations. However, it was not significantly correlated with mistrust, and it was positively correlated with competitive attitude.

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), stepwise 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 collective efficacy. Interestingly, religious involvement among men was positively correlated with mortality. 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 = .405).(Table 1)
   Cigarette smoking, when it was entered alone into the regression analyses explained 10.5 % of variance in male and 10.0 % in the female mid aged mortality differences.

Discussion

The present study extends the previous findings of an association between social capital and area-level variations in mortality rates in Hungary. The 1995 Hungarostudy established an association between social capital and mortality rates in the 20 counties of Hungary [4] . The present study, based on the recently released Hungarostudy 2002, replicates and extends the association down to the 150 sub-regions of the country.

Given the growing literature about ways and means of measuring social capital, there are limitations of any measures that were used in our survey. (13) They are proxy measures and do not really capture the complexity of social capital.construct. On the basis of our results two different patterns appeared within social capital measures, collective efficacy, reciprocity, and religious involvement being higher in less economically developed sub-regions of Hungary while social trust, membership in civic organizations and lower competitive attitude in the more developed regions.
   As in the earlier study, noteworthy gender differences were found in the correlates of regional mortality patterns. Among males, educational attainment was the strongest determinant of mortality rates, alone accounting for 61.8% of the variance across sub-regions. Beyond educational attainment, the social cohesion variables (collective efficacy, mistrust, membership of civic organisations, and reciprocity) each made significant contributions to mortality rates. Collective efficacy was more closely connected with reciprocity. Measure of reciprocity concerns a value statement about respect rather than an act of reciprocity.
   High risk health behaviours such as cigarette smoking and spirit consumption - though frequently invoked to explain the Central and Eastern European mortality paradox - in an adjusted model together added only 0.4% to the explained variance in sub-regional male mortality rates, but in an unadjusted model cigarette smoking explained 10 % of mortality differences Risk behaviour is closely connected to socioeconomic differences and social capital variables. These results mean that social variables and health related behaviour may represent two consequtive steps in the same chain of causality.
   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.
   The theory of relative deprivation suggests that invidious social comparisons triggered during periods of rapid economic change may lead to stress and frustration, especially among those who are left behind on the socioeconomic hierarchy [11] . Although the strong inverse associations between competitive attitudes and educational attainment (-0.42) as well as income (-0.41) are consistent with the theory of relative deprivation, caution is warranted in interpreting these findings because our study was ecological in design, and hence we cannot draw individual-level inferences.
   Our findings also provide clues that community cohesion may dampen competitive attitudes among its members, as well as buffer the harmful health consequences of competition. Here also, caution is warranted in drawing causal inferences, given the cross-sectional nature of our study. To our knowledge, ours is the first study to report an association between community competitive attitude and male mortality rates. This variable, as well as the underlying theory of relative deprivation, hold potential promise for future investigations of the mortality paradox in Central and Eastern European societies. Harbouring competitive attitudes may have adverse health consequences both at the individual level and at the community level. Whether competitive attitudes in the community acts as a deleterious contextual influence on health outcomes remains to be determined in multi-level analyses.
   Among women, in contrast to men, taxable income was the most significant determinant of sub-regional mortality rates, accounting for 15% of the explained variance. Overall, the variables in our multivariable models accounted for a much smaller proportion of the variance in female mortality rates (29%). In contrast to men, competitive attitude was not a predictor of mortality rates in women, while religious involvement was significantly inversely correlated. The magnitude of the association between each unit increase in collective efficacy and mortality rates was stronger for women than for men, despite the fact that men have higher mortality rates. The apparent "immunity" of women from the effects of competitive attitudes, combined with the stronger beneficial effect of collective efficacy for women, may partly account for the wide gender gap in mortality rates observed in Hungary.
   Gender differences in responses to stress have been noted by others [22]. As a generalization, men tend to respond to stress by displaying more hostility towards others, by withdrawing socially, or by engaging in damaging coping behaviors such as substance abuse. By contrast, women tend to cope with stressful situations by actively seeking social support, and engaging in a variety of "tending and befriending" behaviors. In the absence of individual-level data, such an explanation remains highly speculative. Nonetheless, the gender differences observed in our data provide some tantalizing clues to the mystery of the gender gap in mortality observed in Hungary (and indeed much of Central and Eastern Europe) following economic and societal transformation.
   The most important limitation of the study is the cross-sectional design, which cannot allow casual explanations. Although this is true, the mortality and societal structure of the sub-regions of Hungary are relatively very stable in the last decade, there are no substantial changes in the mortality and socio-economic order of these regions. Therefore we can suppose that the present situation is the result of a long process, both in respect of social characteristics and health of a region.

Acknowledgements

Funding sources: This study was supported by the NKFP-01/002/2001, by the UNDP HUN/00/002/A/01/99, and the OTKA T-32974 (2000) and TS- 040889 (2002) projects.

The authors would like to thank to the other members of the "Hungarostudy 2002" team, to the network of district nurses for the home interviews, for Professor András Klinger for the sampling procedure.

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Table 1. Characteristics of the study population in the 150 subregions of Hungary

TABLE 2. Correlations among social capital, competitive attitude, collective efficacy and religious involvement variables
Partial correlation (Sig. 2-tailed) controlling for educational attainment and taxable income with bold letters
Pearson correlation (Sig. 2-tailed) with italicized letters (weighted by the number of interviewed persons in sub-regions (N = 12526)

** correlation is significant at the 0.001 level
* correlation is significant at the 0.05 level

TABLE 3- Multi-variable linear regression results for middle aged (45-64 years old) male mortality (weighted by the number of interviewed men in the 150 subregions)(n=5676)