Essays on Social Capital, Health and Socioeconomic Inequalities in Health A Health Economic Study

Abstract: The thesis comprises four independent research papers and a summary that focus on two related dimensions. The first dimension focuses on the understanding of the production of health. Particularly, the question is asked whether community's stock of social capital influence individual's health. The second dimension focuses on an attempt to understand the causes of socioeconomic health inequality (SHI). The research questions are asked whether individual and contextual area factors explain SHI, how SHI change over time and whether population aging may impact on SHI. The first paper of the thesis critically reviews the notion of social capital and systematically reviews empirical literature on the association between social capital and health across countries. The study also explores some analytical and interpretational issues that may be pertinent when assessing health impact of contextual or area-level social capital. The paper concludes that there is a robust association between social capital and health at the individual-level with respect to the degree of egalitarianism within a country. Area-level social capital may be less salient when used to explain health differences across places in egalitarian countries. The second paper tests whether individual health status is related to area-level social capital, controlling for personal characteristics. The analysis is based on unbalanced panel data from Statistic Sweden's Survey of Living Conditions (the ULF survey) and a 3-level multilevel regression analysis, where level-1 consists of a total of 31,585 observations of 24,419 individuals at level-2 nested within 275 Swedish municipalities at level-3. The results show that the health status increases significantly with area-level social capital; however, almost all variation in health status exists across individuals. The third paper explores a conceptual model whereby the study suggests mechanisms by which community social capital (CSC) may act as an aggregate factor that may increase the efficiency of the long-run production function of an individual with respect to health production. The study explores the effects of CSC externalities on individual all-cause and cause-specific mortality risks. Two municipality-level variables? election participation rate and crime rate- are used to be a proxy for CSC. The study uses pooled ULF survey data from the annual interviews conducted in 1980-1997 for all the subjects aged 20-84 years who were followed up for 4-21 years. Using the extended Cox model (considering both flexible baseline hazard and time varying covariates), the study estimates the effects of CSC externalities controlling for the initial health status and a number of individual characteristics. The results indicate that CSC influence individual risk from all-cause mortality only for the males but not for females. The impacts are higher for the elderly males than for the entire population. A higher CSC decrease the mortality risk from cancer for the elderly males and may also have exerted protective effects for cardiovascular mortality and deaths due to ?suicide? or ?other external causes?. The fourth paper attempts to explain how population aging affects socioeconomic health inequality (SHI) and how SHI changes over time. Using a Swedish long panel data of 3,310 individuals and concentration index (CI) as a measure of SHI, the changes in SHI over time have been estimated. The CIs for health-related quality of life (HRQoL) scores are calculated and decomposed on its sources based on an estimation of the determinants of health using a panel data fixed-effect model. Results show that CIs increase over time when individuals are ranked by current income and demonstrates that one of the channels behind this upward trend in CIs is the fact that retired people dropped in relative income ranking as the cohorts aged. This trend in standardized indices is found to remain stable when people are instead ranked according to lifetime (mean) income. List of Papers The thesis is based on the following original papers I. Islam M. K., Merlo J., Kawachi I., Lindström M., Gerdtham U-G (2006). Social capital and health: Does egalitarianism matter? A literature review, International Journal for Equity in Health, 5 (3). II. Islam M. K., Merlo J., Kawachi I., Lindström M., Burström K., Gerdtham U-G. (2006). Does it really matter where you live? A panel data multilevel analysis of Swedish municipality level social capital on individual health-related quality of life, Health Economics Policy and Law, 1(3): 209-235. III. Islam M. K., Gerdtham U-G., Gullberg B., Lindström M., Merlo J. (2007). Social capital externalities and mortality in Sweden. Accepted for publication in Economics and Human Biology. IV. Islam M. K., Gerdtham U-G., Cleark, P., Burström K. (2006). Does socioeconomic health inequality change as the population ages? Evidence from Swedish panel data. Manuscript submitted for publication.