Social capital, trust in institutions, discrimination and self-rated health. An epidemiological study in southern Sweden.

Abstract: The rational for studying health consequences of social determinants is to enable understanding of factors that affect population patterns of health, disease and well-being in order to produce knowledge useful for guiding policies and actions to reduce social inequalities in health and promote social well-being. The aims of this study have been to investigate the association between aspects of social capital, discrimination and health. The first article is a prospective study which investigates the impact of self-rated health with five alternatives on the incidence of first-ever acute myocardial infarction (AMI). Papers II-IV are cross-sectional studies and concern the associations between institutional trust in the health care system, political trust in the Riksdag (the Swedish parliament) and anticipation of discrimination, on the one hand, and self-rated health, on the other, adjusting for generalized (horizontal) trust in other people as a confounder. The 2000 public-health survey in Skåne is a cross sectional study based on self-reported information from a postal questionnaire survey sent to randomly selected persons born in 1919-1981 during the period November 1999 to February 2000. A total of 13,715 (59%) persons answered the questionnaire. Paper I is a prospective cohort study using the 2000 survey as baseline, linked to AMI morbidity/mortality data from January 2000-December 2002. Data from the 2004 public health survey in Skåne in southern Sweden are used for papers II-IV. A postal questionnaire was sent out to a random sample of 47,621 persons aged 18-80 years during the autumn of 2004. A total of 27,963 (59%) respondents returned complete answers. In paper I the three-year first-ever acute myocardial infarction incidence rate was significantly higher among people who were daily smokers, and had higher age, low education, and poor self-rated health. The five-alternative item on self-rated health, both dichotomized and the not dichotomized alternatives, predicts first-ever AMI, even after multiple adjustments in Cox-regression models. In the second cross-sectional study low (institutional) trust in the health care system was associated with poor self-rated health (paper II). Adjustment for “care-seeking behaviour” in the multivariate model had a decreasing effect on the vertical trust differences in poor self-rated health. Low “political trust” in the Riksdag was significantly associated with poor self-rated health, even after adjustments for plausible confounders including generalised (horizontal) trust in other people (paper III). Individuals with higher “anticipation of discrimination by employers” had a higher risk of having poor health status (paper IV). The inclusion of generalised trust in other people in the multivariate model had a decreasing effect on the “anticipation of discrimination by employers” differences in poor self-rated health. The positive association between poor self-rated health and the risk of first-ever acute myocardial infarction, as well as between the institutional trust variables/discrimination and self-rated health seem to represent causal pathways which might be at least partly independent of socioecIn conclusion, the results show that self-rated health with five alternatives predicts incidence of first-ever acute myocardial infarction. Furthermore, we found that low trust (institutional) in the health care system and in the Riksdag, and anticipation of discrimination by employers are associated with poor (self-rated) health. The association between trust in the health care system and self-rated health seem to be partly mediated by care-seeking behaviour. After adjustments for confounders including generalised (horizontal) trust in other people the significant association remains.