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A sign of the times: To have or to be? Social capital or social cohesion?
Accepted Manuscript A sign of the times: To have or to be? Social capital or social cohesion? Maria A. Carrasco, Usama Bilal PII:
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DOI:
10.1016/j.socscimed.2016.05.012
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To appear in:
Social Science & Medicine
Received Date: 18 November 2015 Revised Date:
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Accepted Date: 5 May 2016
Please cite this article as: Carrasco, M.A., Bilal, U., A sign of the times: To have or to be? Social capital or social cohesion?, Social Science & Medicine (2016), doi: 10.1016/j.socscimed.2016.05.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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A Sign of the Times: To Have or To Be? Social Capital or Social Cohesion?
Authors: Maria A. Carrasco1, Usama Bilal2
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Corresponding Author: Maria A. Carrasco, MPP, MPH, PhD Department of Health, Behavior and Society Johns Hopkins Bloomberg School of Public Health 624 N. Broadway Street [email protected]
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Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health. Baltimore, Maryland, USA 2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health. Baltimore, Maryland, USA
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A Sign of the Times: To Have or To Be? Social Capital or Social Cohesion?
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Abstract
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Among various social factors associated with health behavior and disease, social cohesion has
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not captured the imagination of public health researchers as much as social capital as evidenced
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by the subsuming of social cohesion into social capital and the numerous studies analyzing social
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capital and the comparatively fewer articles analyzing social cohesion and health. In this paper
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we provide a brief overview of the evolution of the conceptualization of social capital and social
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cohesion and we use philosopher Erich Fromm’s distinction between “having” and “being” to
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understand the current research focus on capital over cohesion. We argue that social capital is
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related to having while social cohesion is related to being and that an emphasis on social capital
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leads to individualizing tendencies that are antithetical to cohesion. We provide examples drawn
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from the literature where this conflation of social capital and cohesion results in non-concordant
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definitions and subsequent operationalization of these constructs. Beyond semantics, the
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practical implication of focusing on “having” vs. “being” include an emphasis on understanding
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how to normalize groups and populations rather than providing those groups space for
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empowerment and agency leading to health.
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Key words: social capital; social cohesion; social factors; empowerment
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Introduction
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Twenty one years have passed since Link & Phelan (1995) published their seminal article about
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social factors as fundamental causes of disease arguing that public health researchers should pay
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greater attention to distal factors, particularly societal factors (Link & Phelan, 1995). While
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Link & Phelan were not the first authors to highlight the influence of social factors on disease 1
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(Glass & McAtee, 2006), their article marked a point of renewed interest in understanding the
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mechanisms through which social factors influence health. Social capital and social cohesion are
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two such factors, which have become prominent in the public health literature. Interestingly,
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social cohesion has not captured the imagination of public health researchers as much as social
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capital as evidenced by the numerous studies analyzing social capital and its association with
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various health behaviors and outcomes and the comparatively fewer articles analyzing social
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cohesion and health. Indeed, two separate searches in PubMed with key words “social capital”
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and “social cohesion” yielded 5,485 and 2,024 articles respectively. Furthermore, many studies
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often subsume social cohesion into social capital, with some researchers proposing that social
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cohesion and network represent two valid views on social capital (Lindstrom, 2014). Given the
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close connection between social cohesion and social capital (both include trust as a defining
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characteristic), our objective is to provide insights into the question of why has social capital
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been more appealing than social cohesion. While answers to this question may seem impractical
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or, worse, inconsequential, they may help us to become aware of the predominant lens currently
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used to conceptualize social factors of disease. Additionally, answers may guide future work
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investigating how social factors are associated with health behaviors and disease.
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To be clear, our objective is not to dispute the usefulness of social capital and social
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cohesion as meaningful subjects of scientific inquiry. A rich body of literature focuses on such
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critiques using several frameworks, from Marxist approaches (Coburn, 2000; Muntaner &
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Lynch, 1999; Navarro, 2004) to a deeper analysis of Durkheim’s ideas and data (Kushner &
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Sterk, 2005). Here we assume the scientific usefulness of both social capital and cohesion and
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proceed to inquire whether their existence as separate categories is useful for public health.
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Additionally, our intent is not to analyze the original intent of the scientists who coined these 2
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social constructs but to present an overview of how these constructs have evolved through time
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and some of the ways in which they are measured. This information provides a background to
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understand the philosophical and practical implications of analyzing the influence of social
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capital or social cohesion on health.
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Social Cohesion
The concept of social cohesion and its application in public health originated with the
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work of Emile Durkheim, one of the fathers of modern sociology (Collins, 1994). In his book
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Suicide Durkheim analyzed differences in suicide rates between Protestants and Catholics in
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various countries in Europe. He found that suicide is more prevalent in Protestant than Catholic
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societies, which, according to Durkheim, exhibited weaker integration or cohesion (Durkheim,
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1951). Durkheim argued that “social facts” (attributes of societies that transcend individuals) can
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explain societal patterns related to suicide, something that had been understood primarily as the
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ultimate expression of an individual act. Durkheim’s work has served as the foundation on which
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to explore the effect of group dynamics and cohesion on health(L. Berkman et al., 2000). The
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Durkheimian perspective on social integration has become very relevant in public health since
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the 1990s when researchers started focusing on “upstream” or sociological determinants of
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health(L. Berkman et al., 2000).
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The concept of social cohesion has been thoroughly explored in the sociology and social
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psychology literature with different authors providing slightly different definitions (Bruhn, 2009;
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Chan et al., 2006). Sociologists tend to focus their analysis of social cohesion on the presence or
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absence of social bonds, which constitute the very fabric of society, Durkheim’s glue that holds
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society together (Durkheim, 1951). They typically incorporate notions of solidarity, reciprocity,
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and trust –as well as notions of equity and social inclusion – into conceptualization of social 3
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cohesion (Chan et al., 2006). Social psychologists, on the other hand, tend to consider social
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cohesion as a “characteristic and a process operating among small groups” (pp. 31) (Bruhn,
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2009), rather than a framework that holds society together. Social psychologists typically
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analyze social cohesion as an objective and perceived attribute of a group that is based on each
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member’s self-reported closeness to others and their perceptions of their own standing in the
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group. The latter depends on the individual’s sense of belonging and morale, which are based on
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their group membership (Chan et al., 2006).
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In the public health field, social epidemiologists Ichiro Kawachi and Lisa Berkman
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define social cohesion as the “extent of connectedness and solidarity among groups in a society”
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(Ichiro Kawachi & Berkman, 2000). It has been defined as a group characteristic that influences
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health at the individual and group levels and that is evidenced by the level of trust, reciprocity
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and solidarity in society (Wilkinson, 1996). Some studies have analyzed social cohesion as an
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element of social capital and hypothesized it to be protective against disease. Kawachi and
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colleagues (1997), for example, analyzed the relationship between social cohesion (defined there
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as an element of social capital) and all-cause and cause-specific age adjusted mortality using data
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from 39 states in the USA and found that income inequality was strongly correlated to per capita
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group membership and lack of social trust (cohesion), and that both were associated with total
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mortality and mortality from coronary heart disease, malignant neoplasms, and infant mortality
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(Ichiro Kawachi et al., 1997).
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The concept is often included in ecological models as part of the community or macro-
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level context influencing health. These models present the individual nested within levels
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(interpersonal, organizational, community, government) that influence the individual’s health. In
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these models social cohesion is considered an upstream or distal factor at the outer levels of the
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ecology(L. Berkman et al., 2000; Busza et al., 2012). More recently, social cohesion has also been conceptualized as a social process related to
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changes in the power structure, particularly in the context of empowerment-based community
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mobilization strategies implemented by marginalized groups (Kerrigan et al., 2015). From this
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perspective, social cohesion is understood as a core element of community empowerment that
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brings community members together to analyze, articulate and demand their human rights and
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entitlements including access to quality HIV services (Kerrigan et al., 2015). Hence, social
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cohesion is seen as necessary for community mobilization and engagement. Finally, also
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relating it to power, social cohesion has been conceptualized as a social process that provides the
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psychosocial space for group resistance and subversion against oppressive social norms
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(Carrasco, 2015).
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Social Capital
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In the current public health literature social cohesion is tightly linked to the concept of social capital. Ichiro Kawachi posits that there are primarily two conceptualizations of social
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capital in public health: a social cohesion and a networks conceptualization (Ichiro Kawachi,
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2006). Social capital, however, was not originally conceptualized as including social cohesion.
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Bourdieu, a philosopher, anthropologist, and sociologist , originally defined social
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capital as group resources available to group members through membership in a network of
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mutual acquaintance (Bourdieu, 1986). Bourdieu considered that social capital was another form
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of capital, together with economic and cultural capital, and defined social classes and therefore
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distribution of goods and resources in society. According to Bourdieu, elites held most of these 5
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forms of capital, and this distribution was one of the sources of inequality in society. Bourdieu’s
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conceptualization of social capital emphasized its function as a resource for the dominant class
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and as a source of power since the availability of social capital enabled the dominant class to
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advance its interests (Bourdieu, 1986). Social capital was then, for Bourdieu, a form of capital
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that ought to be acquired, owned and invested. This ownership (and investments) shaped class
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relations in society and allowed for further acquisition of more social capital, reproducing the
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exiting class structure (Bourdieu, 1986).
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James Coleman, a sociologist who analyzed social capital, differed from Bourdieu’s
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views of social capital as a resource for the dominant class. Coleman linked social capital to
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human capital indicating that social capital is a resource for action for all individuals, and he
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emphasized the importance of community ties (Coleman, 1988). According to Coleman, social
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capital is facilitated by: 1) trust, expectations and reciprocity; 2) information channels; and 3)
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norms and sanctions that promote the common good (Coleman, 1988). Here lies a second
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important difference between the views of Coleman and Bourdieu: Coleman does not clearly
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distinguish the resource (social capital) from the ability to obtain it (factors that facilitate
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obtaining social capital) (Portes, 1988). This is the great point of departure from the previous
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forms of social capital (Bourdieu) and more modern ones (theorized by Coleman and refined
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later by Putnam). The inclusion of Coleman’s trust, information and norms led to a conflation
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with Durkheim’s social cohesion.
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Sociologist Alejandro Portes indicates that when social capital was exported to other
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sciences it was transformed from an individual resource into “an attribute of the community
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itself” (pp. 3) (Portes, 2000). Under this new perspective, the “benefits of social capital accrued
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not so much to individuals as to the collectivity as a whole in the form of reduced crime rates, 6
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lower official corruption, and better governance” (pp. 3) (Portes, 2000). Portes indicates that this
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conceptual stretch was initiated by political scientist Robert Putnam (Portes, 2000), who has
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become one of the most influential proponents of social capital. Putnam posits that social capital
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includes trust, norms, and networks (Robert D Putnam, 1995; Robert D Putnam et al., 1994). He
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proposes that individuals and the wider community stand to benefit from social capital since
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social capital can improve societal functioning by improving societal actions (L. F. Berkman &
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Kawachi, 2000). Putnam defined social capital as the “features of social organizations such as
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trust, norms, and networks that can improve the efficiency of society facilitating coordinated
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actions” (pp. 167) (Robert D Putnam et al., 1994). Importantly, Putnam explicitly differentiates
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between social capital and social cohesion indicating that “social capital is a narrower, more
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tightly defined concept that calls attention to one crucial ingredient in social cohesion, in the
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sense of a just, equitable, tolerant, and well-integrated society” (pp. 3) (Robert D. Putnam,
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2004)).
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While extending social capital from individuals to communities does not seem farfetched, Portes argues that this is problematic because the transition was not properly theorized
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and social capital has become a synonym for all that is good in societal structures (Portes, 2000).
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Indeed, this is one of the main criticisms about social capital and its usefulness as a social
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construct (Inaba, 2013). Furthermore, this may be one of the reasons why social cohesion, which
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was conceived by Durkheim as a societal characteristic, has been subsumed into the concept of
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social capital . Thus, characteristics of society underwent a process of transformation into
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capital, which is traditionally characterized by ownership.
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In the public health literature social capital is defined as “the resources available to individuals through their affiliative behaviors and membership in community networks” (pp. 7
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121) (Ichiro Kawachi, 1999). Social capital resides in the structure and quality of relationships
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among members of a community (Ichiro Kawachi, 2006). More recently, social capital has also
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been described as an “investment that people make in society” through their membership and
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active participation in civic institutions (pp.181) (Cockerham, 2007). An individual’s investment
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in society increases that person’s social capital, makes that person more integrated and improves
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her health and well-being (Cockerham, 2007).
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The definitions provided above reveal the transition that social capital has undergone since it made an appearance as a construct focusing on the reproduction of current class
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structures (Bourdieu, 1986). The concept was “democratized” and made available to all as a
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potential community resource or possession (Coleman, 1988). Most recently, there has been an
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emphasis on social capital accruing to the individual based on her investments. As the concept
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has evolved, it has become more individualized and it has turn into objects of possession various
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social characteristics that were not previously conceptualized as objects of ownership: namely
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trust, norms, and networks (Ichiro Kawachi & Berkman, 2000; Robert D Putnam, 1995).
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Social Capital and Social Cohesion?
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The original conceptualization of social capital followed the meaning of capital itself (in its
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Marxist sense), as something to be owned and then invested to obtain a surplus (in this case not
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exclusively monetary profit) (Bourdieu, 1986). Further developments removed this necessity for
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ownership and collectivized social capital, bringing characteristics inherent to social cohesion
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along with it (Coleman, 1988). The latest development of the concept (Robert D Putnam, 1995)
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brought back to the individual both social capital (that can be owned) and social cohesion (that
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cannot be owned). The further development of social capital has deeply influenced social
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cohesion, causing a conflation of both concepts. However, unlike social capital, whose first
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articulations focused on individual attributes, social cohesion started as a social fact in
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Durkheim’s work (Kushner & Sterk, 2005).
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In order to better understand the reasons behind these developments and differentiate between social capital and social cohesion we propose a new approach, based on Erich Fromm’s
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ideas about the difference between having and being.
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Social Capital or Social Cohesion?
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Erich Fromm’s ideas about the emphasis on having vs. being may help to answer our original
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question: Why does social capital appears to be more popular than social cohesion? According to
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Fromm, in a capitalist society geared to consumption to sustain the economic apparatus
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distinguishing between having and being may seem impossible as the “very essence of being is
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having” (pp. 3) (Fromm, 1976). In such societies, he argues, having becomes the central
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preoccupation given the generalized notion that “if one has nothing, one is nothing” (pp. 3)
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(Fromm, 1976). Fromm proceeds to indicate that the emphasis of having over being has become
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an affliction of our time, the product of a voracious industrialist machinery where human beings
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and their world become objectified in the name of production and where appropriation (i.e.
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having) becomes the main goal in life (Fromm, 1976). The current emphasis on having
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objectifies our reality. For example, in the case of knowledge, he explains the difference
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between having knowledge and knowing. Having knowledge, he says, is taking and keeping
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possession of available information, while knowing is part of the process of productive and
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critical thinking. Knowing entails awareness and to see reality in its nakedness. Having refers to
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things while being refers to experiences.
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A parallel could be drawn with social capital, which is related to possession or ownership
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(having), and social cohesion, which is a characteristic of a group or society (being). Associating
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capital with societal characteristics and dynamics (trust, norm, and networks) turns these into
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elements that can be harnessed and possessed. As such, it is impingent on individuals to ensure
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that they appropriate themselves of capital to advance their goals, including supporting and
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maintaining health. On the other hand, from a being perspective, social cohesion is a
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characteristic that can be fostered but that ultimately is vested in a group rather than in the
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individuals as an individual cannot have social cohesion by herself. Fromm's description of the
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current emphasis on having (instead of being) could be a potential reason for the predominance
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of social capital over social cohesion.
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Levels, Inference, and Measurement
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The distinction between social capital and social cohesion is not trivial and refers precisely to the
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ability of individuals (or communities) to own (have) capital or of communities to be cohesive.
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While this distinction is not explicitly drawn at the levels of inference (individual vs collective),
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different inferences will result from the perspective taken . In addition, it is also important to
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ensure that the measurements used match the level of inference. As Kawachi stated, an
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important challenge researchers face is “better integrating theory and measurement across
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different levels of social interaction, from individuals interacting with others within their own
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groups to interactions between groups within a broader social context.”(I. Kawachi & Berkman,
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2014). That is, it should be explicit from one’s theoretical framework whether the concept of
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social capital or the concept of social cohesion is being studied, at what level is it studied and
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how the measurement operationalization fits into this theory.
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Below are examples of the measurement of social capital and social cohesion at both the
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individual and collective levels. The examples illustrate that Kawachi’s call for better
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integration of theory and measurement (I. Kawachi & Berkman, 2014) needs to be clearly heard.
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For each example we specify the level at which each construct is conceptualized (theoretical
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perspective) and operationalized (measurement and analytical point of view).
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First, in a classic study, Kawachi and colleagues (Ichiro Kawachi et al., 1997) measured social
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capital by looking at indicators of civic engagement (number of groups and associations per
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capita) and trust (individual responses to a questionnaire about trust in others, aggregated to the
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state level). This study conceptualizes social capital as a collective level (“ecologic”) variable
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whose counterpart at the individual level is measured by an individual person’s social networks.
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This study focuses on the former (collective level social capital) and operationalizes it by using
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an exclusively collective variable (civic engagement, measured at the state level) and individual
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responses about trust aggregated to the collective level (in this case, state).
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Second, a study by Muennig and colleagues (Muennig et al., 2013) explicitly lays out a
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theorization of social capital following Bain and Hicks (1998). This includes what they label as
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cognitive social capital (“internal states such as trust”) and structural social capital (“availability
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and use of social organizations or connections such as organizational membership or connection
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to others”) (Bain & Hicks, 1998). The authors are interested in structural social capital and
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measure it using indicators of human interaction (responses to a questionnaire on frequency of
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social contacts) and social participation (responses to a questionnaire on frequency of attendance
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to meetings). The study seems to conceptualize and operationalize social capital at the individual
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level. They measure it using individual-level responses to questionnaires that then confer a social
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capital measurement for each individual.
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Third, a study by Jennings and colleagues (Jennings et al., 2014) conceptualizes social cohesion
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following Sampson (Sampson et al., 1997) as a structural (collective) attribute of neighborhoods.
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They measure social cohesion using a 5-item questionnaire (at the individual level) and then
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aggregate individual scores to generate neighborhood level averages. The study conceptualizes
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social cohesion as a collective (structural) factor and operationalizes it at the collective level (in
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this case, neighborhood).
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Fourth and last, a study by Fonner and colleagues (Fonner et al., 2014), defines social cohesion
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as part of social capital, labeling it “bonding social capital”. They measure social cohesion with
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an 11-item scale with questions about individual perceptions of group processes. The resulting
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score is then assigned to each individual participant. This study recognizes the collective nature
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of social cohesion (as something that is originated through social interaction), and
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operationalizes it using an individual-level scale about individual perceptions of group processes.
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Practical Implications
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While the distinction between having and being as a perspective to analyze social capital and
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social cohesion may be intellectually interesting, it is important to analyze the practical
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implications in public health. According to Fromm, the major difference between these two
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modes is that the having mode leads to the objectification of human beings and their
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characteristics, leading to their alienation or separation from others. Thus, here lies an important
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conflict whereby social capital and its individualizing and fragmenting nature may be antithetical
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to social cohesion. By emphasizing research on social capital researchers may be indirectly
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feeding into individualization tendencies that fragment communities into more easily moldable,
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malleable, and manipulable units, leading to a more effective deployment of power and its
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normalizing tendencies. Indeed, one of the major concerns of institutions, groups, and
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individuals in modern western societies “revolves around the regulation of bodies in space, the
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monitoring of the surfaces of bodies and the relationship between bodies” (pp.11) (Lupton,
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1995). From this perspective, social capital offers more opportunity for regulation as
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individuals can possess it and use it. Social cohesion, on the other hand, cannot be possessed or
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used and it is less readily amenable to manipulation for population normalization as groups that
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come together may do so to resist and subvert social norms or the prevailing power structure.
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Thus, the practical implication of focusing on having vs. being and subsuming social
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cohesion into social capital entails having an emphasis on understanding how to normalize
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groups and populations rather than having an emphasis on providing those groups space for
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empowerment and agency leading to health. While it could be argued that having more social
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capital can lead to agency (empowerment), as discussed above, this poses an inherent
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contradiction that, beyond semantics, has practical implication on public health practice and
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research. Public health researchers and practitioners interested in empowerment-for-health
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approaches should be aware of the difference between social capital and social cohesion when
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designing public health interventions to ensure posing appropriate research questions and using
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the most conducive frameworks and approaches.
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Social constructs created by social scientists to understand social processes not only
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inform, expand, and constrain our view of reality but also shape it. This constructionist view is
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informed by the concept of the double hermeneutic coined by sociologist Anthony Giddens
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(Giddens, 1990). In his book, the Consequences of Modernity (1990), Giddens argues that there
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is an important difference between the natural and social sciences, referring to this difference as
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the single and double hermeneutic. In the natural sciences, scientists try to understand and 13
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theorize about the way the natural world is structured. The understanding is one-way; since the
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natural world does not seek to develop an understanding of scientists. Giddens calls this the
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‘single hermeneutic’. In contrast, social sciences study people and society. Some social sciences
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such as sociology study what people do, how they understand their world, and how this
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understanding shapes their actions. Unlike items studied by natural sciences, people can use the
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knowledge and insights of social science to change their actions, hence Gidden’s ‘double
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hermeneutic’ for the social sciences. Thus, social scientists frame, inform, and affect reality in
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ways that need to be apparent to them. Defaulting to use a construct because it is widely used or
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because there is perceived consensus on its meaning may not be the most useful way to advance
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social sciences. Worse, this approach may shape reality in unintended ways that have important
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implications (as detailed in this manuscript).
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Limitation
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Dichotomization is an oversimplification of our complex reality. A limitation of this paper is that we relied on a dichotomization (social capital vs. social cohesion) to make our case.
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However, dichotomizations are useful analytical tools as they allow us to uncover extremes that
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may be so intertwined that they are perceived as one. Indeed, dichotomization allows social
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scientists to peel two extreme layers of reality. This is what Erich Fromm masterfully did in his
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book To Have or To Be?. He contraposed “Having” and “Being”, illustrating them in various
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realms (i.e. learning, remembering, reading, faith, and loving) (Fromm, 1976). We bring
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Fromm’s insights into the realm of public health research and draw a parallel with the
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intertwining of two constructs that were originally conceived separately: social capital and social
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cohesion. By dichotomizing these constructs we are able to bring to the collective consciousness
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the fact that they were not always intertwined and to explain the philosophical reasons for this
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intertwining and its practical implications. If we are to move toward a more humanistic
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approach to public health it is important to raise consciousness on the implications of the
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theorization, definition, measurement and operationalization of social constructs to understand
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our social world and its effect on the people’s health.
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References Bain, K., & Hicks, N. (1998). Building social capital and reaching out to excluded groups: the challenge of partnerships. World Bank.
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Berkman, L., Glass, T., Brissette, I., & Seeman, T. (2000). From social integration to health: Durkheim in the new millennium. Social Science & Medicine, 51, 843-857.
Berkman, L.F., & Kawachi, I. (2000). Social Epidemiology: Oxford University Press, USA.
SC
Bourdieu, P. (1986). The forms of capital Handbook of theory and research for the sociology of education In J. Richardson (Ed.), Handbook of Theory and Research for the Sociology of
M AN U
Education pp. 241-258). New York: Greenwood.
Bruhn, J. (2009). The Group Effect: Social Cohesion and Health Outcomes. New York: Springer. Busza, J., Walker, D., Hairston, A., Gable, A., Pitter, C., Lee, S., et al. (2012). Community-based approaches for prevention of mother to child transmission in resource-poor settings: a
TE D
social ecological review. Journal of the International AIDS Society, 15. Carrasco, M.A. (2015). No estas sola: Social cohesion, HIV stigma, and HIV/STI prevention among female sex workers living with HIV in Santo Domingo. Department of Health,
Health.
EP
Behavior and Society. Baltimore, MD, USA: Johns Hopkins Bloomberg School of Public
AC C
Chan, J., To, H.-P., & Chan, E. (2006). Reconsidering social cohesion: Developing a definition and analytical framework for empirical research. Social indicators research, 75, 273-302.
Coburn, D. (2000). Income inequality, social cohesion and the health status of populations: the role of neo-liberalism. Social Science & Medicine, 51, 135-146.
Cockerham, W. (2007). Social Causes of Health and Disease. London: Polity Press.
16
ACCEPTED MANUSCRIPT
Coleman, J. (1988). Social capital in the creation of human capital. American journal of sociology, S95-S120. Collins, R. (1994). Four sociological traditions: Selected readings: Oxford University Press
RI PT
Oxford.
Durkheim, E. (1951). Suicide : a study in sociology. New York: Free Press.
Fonner, V.A., Kerrigan, D., Mnisi, Z., Ketende, S., Kennedy, C.E., & Baral, S. (2014). Social
Swaziland. PLoS ONE, 9, e87527.
SC
Cohesion, Social Participation, and HIV Related Risk among Female Sex Workers in
M AN U
Fromm, E. (1976). To have or to be? . New York: Harper & Row Publishers. Giddens, A. (1990). The consequences of modernity. Cambridge: Polity Press. Glass, T., & McAtee, M. (2006). Behavioral sciences at the crossroads in public health: Extending horizons, envisioning the future. Social Science & Medicine, 1650-1671.
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Inaba, Y. (2013). What’s wrong with social capital? Critiques from social science. In I. Kawachi (Ed.), Global Perspectives on Social Capital and Health pp. 323-342): Springer. Jennings, J.M., Hensel, D.J., Tanner, A.E., Reilly, M.L., & Ellen, J.M. (2014). Are social
EP
organizational factors independently associated with a current bacterial sexually transmitted infection among urban adolescents and young adults? Social Science &
AC C
Medicine, 118, 52-60.
Kawachi, I. (1999). Social capital and community effects on population and individual health. Annals of the New York Academy of Sciences, 896, 120-130.
Kawachi, I. (2006). Commentary: social capital and health: making the connections one step at a time. International Journal of Epidemiology, 35, 989-993.
17
ACCEPTED MANUSCRIPT
Kawachi, I., & Berkman, L. (2000). Social cohesion, social capital, and health. In I. Kawachi, & L. Berkman (Eds.), Social epidemiology pp. 174-190). New York: Oxford University Press.
RI PT
Kawachi, I., & Berkman, L.F. (2014). Social Capital, Social Cohesion and Health. In L.F.
Berkman, I. Kawachi, & M. Glymour (Eds.), Social epidemiology: Oxford University Press.
SC
Kawachi, I., Kennedy, B.P., Lochner, K., & Prothrow-Stith, D. (1997). Social capital, income inequality, and mortality. American Journal of Public Health, 87, 1491-1498.
M AN U
Kerrigan, D., Kennedy, C.E., Morgan-Thomas, R., Reza-Paul, S., Mwangi, P., Win, K.T., et al. (2015). A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. The Lancet, 385, 172-185.
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Kushner, H.I., & Sterk, C.E. (2005). The Limits of Social Capital: Durkheim, Suicide, and Social Cohesion. American Journal of Public Health, 95, 1139-1143. Lindstrom, M. (2014). Does social capital include trust? Commentary on Carpiano and Fitterer
EP
(2014). Social Sciences & Medicine, 235-236. Link, B.G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of
AC C
health and social behavior, 80-94.
Lupton, D. (1995). The imperative of health: Public health and the regulated body: Taylor & Francis.
Muennig, P., Cohen, A.K., Palmer, A., & Zhu, W. (2013). The relationship between five different measures of structural social capital, medical examination outcomes, and mortality. Social Science & Medicine, 85, 18-26.
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Muntaner, C., & Lynch, J. (1999). Income Inequality, Social Cohesion, and Class Relations: A Critique of Wilkinson's Neo-Durkheimian Research Program. International journal of health services, 29, 59-81.
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Navarro, V. (2004). Commentary: Is capital the solution or the problem? International Journal of Epidemiology, 33, 672-674.
Portes, A. (1988). Social Capital: Its Origins and Applications in Modern Sociology. Annual
SC
Review of Sociology, 24, 1-24.
Portes, A. (2000). The two meanings of social capital. Sociological forum pp. 1-12): Springer.
M AN U
Putnam, R.D. (1995). Tuning in, tuning out: The strange disappearance of social capital in America. PS: Political science & politics, 28, 664-683.
Putnam, R.D. (2004). Education, Diversity, Social Cohesion and ‘Social Capital’. Dublin, Ireland: OECD Education Ministers.
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Putnam, R.D., Leonardi, R., & Nanetti, R.Y. (1994). Making democracy work: Civic traditions in modern Italy: Princeton university press. Sampson, R.J., Raudenbush, S.W., & Earls, F. (1997). Neighborhoods and Violent Crime: A
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Multilevel Study of Collective Efficacy. Science, 277, 918-924.
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Wilkinson, R.G. (1996). Unhealthy societies: the afflictions of inequality. New York: Routledge.
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Acknowledgements The authors are grateful to Dr. Lori Leonard and Dr. Deanna Kerrigan for providing comments
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on earlier drafts. M. Carrasco was partially supported by the National Institute of Allergy and Infectious Disease (T32 AI050056-12). U. Bilal was supported by the Johns Hopkins Center for a Livable Future – Lerner Fellowship and a Postgraduate Fellowship from the Obra Social La
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Highlights
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Social cohesion is often studied as part of social capital A theoretical articulation of the consequences of this conflation is lacking Fromm’s distinction of “having” and “being” may explain emphasis on social capital Subsuming cohesion into capital discourages empowerment strategies leading to health Examples of measurement of both concepts show how this conflation is problematic
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• • • • •
S0277-9536(16)30224-6
DOI:
10.1016/j.socscimed.2016.05.012
Reference:
SSM 10642
To appear in:
Social Science & Medicine
Received Date: 18 November 2015 Revised Date:
4 May 2016
Accepted Date: 5 May 2016
Please cite this article as: Carrasco, M.A., Bilal, U., A sign of the times: To have or to be? Social capital or social cohesion?, Social Science & Medicine (2016), doi: 10.1016/j.socscimed.2016.05.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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A Sign of the Times: To Have or To Be? Social Capital or Social Cohesion?
Authors: Maria A. Carrasco1, Usama Bilal2
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Corresponding Author: Maria A. Carrasco, MPP, MPH, PhD Department of Health, Behavior and Society Johns Hopkins Bloomberg School of Public Health 624 N. Broadway Street [email protected]
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Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health. Baltimore, Maryland, USA 2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health. Baltimore, Maryland, USA
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A Sign of the Times: To Have or To Be? Social Capital or Social Cohesion?
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Abstract
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Among various social factors associated with health behavior and disease, social cohesion has
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not captured the imagination of public health researchers as much as social capital as evidenced
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by the subsuming of social cohesion into social capital and the numerous studies analyzing social
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capital and the comparatively fewer articles analyzing social cohesion and health. In this paper
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we provide a brief overview of the evolution of the conceptualization of social capital and social
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cohesion and we use philosopher Erich Fromm’s distinction between “having” and “being” to
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understand the current research focus on capital over cohesion. We argue that social capital is
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related to having while social cohesion is related to being and that an emphasis on social capital
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leads to individualizing tendencies that are antithetical to cohesion. We provide examples drawn
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from the literature where this conflation of social capital and cohesion results in non-concordant
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definitions and subsequent operationalization of these constructs. Beyond semantics, the
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practical implication of focusing on “having” vs. “being” include an emphasis on understanding
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how to normalize groups and populations rather than providing those groups space for
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empowerment and agency leading to health.
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Key words: social capital; social cohesion; social factors; empowerment
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Introduction
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Twenty one years have passed since Link & Phelan (1995) published their seminal article about
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social factors as fundamental causes of disease arguing that public health researchers should pay
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greater attention to distal factors, particularly societal factors (Link & Phelan, 1995). While
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Link & Phelan were not the first authors to highlight the influence of social factors on disease 1
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(Glass & McAtee, 2006), their article marked a point of renewed interest in understanding the
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mechanisms through which social factors influence health. Social capital and social cohesion are
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two such factors, which have become prominent in the public health literature. Interestingly,
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social cohesion has not captured the imagination of public health researchers as much as social
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capital as evidenced by the numerous studies analyzing social capital and its association with
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various health behaviors and outcomes and the comparatively fewer articles analyzing social
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cohesion and health. Indeed, two separate searches in PubMed with key words “social capital”
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and “social cohesion” yielded 5,485 and 2,024 articles respectively. Furthermore, many studies
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often subsume social cohesion into social capital, with some researchers proposing that social
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cohesion and network represent two valid views on social capital (Lindstrom, 2014). Given the
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close connection between social cohesion and social capital (both include trust as a defining
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characteristic), our objective is to provide insights into the question of why has social capital
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been more appealing than social cohesion. While answers to this question may seem impractical
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or, worse, inconsequential, they may help us to become aware of the predominant lens currently
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used to conceptualize social factors of disease. Additionally, answers may guide future work
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investigating how social factors are associated with health behaviors and disease.
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To be clear, our objective is not to dispute the usefulness of social capital and social
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cohesion as meaningful subjects of scientific inquiry. A rich body of literature focuses on such
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critiques using several frameworks, from Marxist approaches (Coburn, 2000; Muntaner &
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Lynch, 1999; Navarro, 2004) to a deeper analysis of Durkheim’s ideas and data (Kushner &
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Sterk, 2005). Here we assume the scientific usefulness of both social capital and cohesion and
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proceed to inquire whether their existence as separate categories is useful for public health.
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Additionally, our intent is not to analyze the original intent of the scientists who coined these 2
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social constructs but to present an overview of how these constructs have evolved through time
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and some of the ways in which they are measured. This information provides a background to
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understand the philosophical and practical implications of analyzing the influence of social
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capital or social cohesion on health.
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Social Cohesion
The concept of social cohesion and its application in public health originated with the
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work of Emile Durkheim, one of the fathers of modern sociology (Collins, 1994). In his book
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Suicide Durkheim analyzed differences in suicide rates between Protestants and Catholics in
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various countries in Europe. He found that suicide is more prevalent in Protestant than Catholic
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societies, which, according to Durkheim, exhibited weaker integration or cohesion (Durkheim,
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1951). Durkheim argued that “social facts” (attributes of societies that transcend individuals) can
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explain societal patterns related to suicide, something that had been understood primarily as the
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ultimate expression of an individual act. Durkheim’s work has served as the foundation on which
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to explore the effect of group dynamics and cohesion on health(L. Berkman et al., 2000). The
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Durkheimian perspective on social integration has become very relevant in public health since
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the 1990s when researchers started focusing on “upstream” or sociological determinants of
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health(L. Berkman et al., 2000).
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The concept of social cohesion has been thoroughly explored in the sociology and social
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psychology literature with different authors providing slightly different definitions (Bruhn, 2009;
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Chan et al., 2006). Sociologists tend to focus their analysis of social cohesion on the presence or
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absence of social bonds, which constitute the very fabric of society, Durkheim’s glue that holds
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society together (Durkheim, 1951). They typically incorporate notions of solidarity, reciprocity,
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and trust –as well as notions of equity and social inclusion – into conceptualization of social 3
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cohesion (Chan et al., 2006). Social psychologists, on the other hand, tend to consider social
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cohesion as a “characteristic and a process operating among small groups” (pp. 31) (Bruhn,
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2009), rather than a framework that holds society together. Social psychologists typically
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analyze social cohesion as an objective and perceived attribute of a group that is based on each
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member’s self-reported closeness to others and their perceptions of their own standing in the
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group. The latter depends on the individual’s sense of belonging and morale, which are based on
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their group membership (Chan et al., 2006).
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In the public health field, social epidemiologists Ichiro Kawachi and Lisa Berkman
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define social cohesion as the “extent of connectedness and solidarity among groups in a society”
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(Ichiro Kawachi & Berkman, 2000). It has been defined as a group characteristic that influences
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health at the individual and group levels and that is evidenced by the level of trust, reciprocity
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and solidarity in society (Wilkinson, 1996). Some studies have analyzed social cohesion as an
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element of social capital and hypothesized it to be protective against disease. Kawachi and
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colleagues (1997), for example, analyzed the relationship between social cohesion (defined there
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as an element of social capital) and all-cause and cause-specific age adjusted mortality using data
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from 39 states in the USA and found that income inequality was strongly correlated to per capita
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group membership and lack of social trust (cohesion), and that both were associated with total
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mortality and mortality from coronary heart disease, malignant neoplasms, and infant mortality
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(Ichiro Kawachi et al., 1997).
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The concept is often included in ecological models as part of the community or macro-
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level context influencing health. These models present the individual nested within levels
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(interpersonal, organizational, community, government) that influence the individual’s health. In
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these models social cohesion is considered an upstream or distal factor at the outer levels of the
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ecology(L. Berkman et al., 2000; Busza et al., 2012). More recently, social cohesion has also been conceptualized as a social process related to
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changes in the power structure, particularly in the context of empowerment-based community
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mobilization strategies implemented by marginalized groups (Kerrigan et al., 2015). From this
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perspective, social cohesion is understood as a core element of community empowerment that
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brings community members together to analyze, articulate and demand their human rights and
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entitlements including access to quality HIV services (Kerrigan et al., 2015). Hence, social
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cohesion is seen as necessary for community mobilization and engagement. Finally, also
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relating it to power, social cohesion has been conceptualized as a social process that provides the
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psychosocial space for group resistance and subversion against oppressive social norms
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(Carrasco, 2015).
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Social Capital
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In the current public health literature social cohesion is tightly linked to the concept of social capital. Ichiro Kawachi posits that there are primarily two conceptualizations of social
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capital in public health: a social cohesion and a networks conceptualization (Ichiro Kawachi,
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2006). Social capital, however, was not originally conceptualized as including social cohesion.
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Bourdieu, a philosopher, anthropologist, and sociologist , originally defined social
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capital as group resources available to group members through membership in a network of
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mutual acquaintance (Bourdieu, 1986). Bourdieu considered that social capital was another form
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of capital, together with economic and cultural capital, and defined social classes and therefore
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distribution of goods and resources in society. According to Bourdieu, elites held most of these 5
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forms of capital, and this distribution was one of the sources of inequality in society. Bourdieu’s
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conceptualization of social capital emphasized its function as a resource for the dominant class
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and as a source of power since the availability of social capital enabled the dominant class to
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advance its interests (Bourdieu, 1986). Social capital was then, for Bourdieu, a form of capital
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that ought to be acquired, owned and invested. This ownership (and investments) shaped class
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relations in society and allowed for further acquisition of more social capital, reproducing the
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exiting class structure (Bourdieu, 1986).
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James Coleman, a sociologist who analyzed social capital, differed from Bourdieu’s
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views of social capital as a resource for the dominant class. Coleman linked social capital to
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human capital indicating that social capital is a resource for action for all individuals, and he
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emphasized the importance of community ties (Coleman, 1988). According to Coleman, social
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capital is facilitated by: 1) trust, expectations and reciprocity; 2) information channels; and 3)
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norms and sanctions that promote the common good (Coleman, 1988). Here lies a second
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important difference between the views of Coleman and Bourdieu: Coleman does not clearly
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distinguish the resource (social capital) from the ability to obtain it (factors that facilitate
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obtaining social capital) (Portes, 1988). This is the great point of departure from the previous
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forms of social capital (Bourdieu) and more modern ones (theorized by Coleman and refined
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later by Putnam). The inclusion of Coleman’s trust, information and norms led to a conflation
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with Durkheim’s social cohesion.
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Sociologist Alejandro Portes indicates that when social capital was exported to other
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sciences it was transformed from an individual resource into “an attribute of the community
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itself” (pp. 3) (Portes, 2000). Under this new perspective, the “benefits of social capital accrued
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not so much to individuals as to the collectivity as a whole in the form of reduced crime rates, 6
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lower official corruption, and better governance” (pp. 3) (Portes, 2000). Portes indicates that this
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conceptual stretch was initiated by political scientist Robert Putnam (Portes, 2000), who has
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become one of the most influential proponents of social capital. Putnam posits that social capital
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includes trust, norms, and networks (Robert D Putnam, 1995; Robert D Putnam et al., 1994). He
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proposes that individuals and the wider community stand to benefit from social capital since
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social capital can improve societal functioning by improving societal actions (L. F. Berkman &
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Kawachi, 2000). Putnam defined social capital as the “features of social organizations such as
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trust, norms, and networks that can improve the efficiency of society facilitating coordinated
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actions” (pp. 167) (Robert D Putnam et al., 1994). Importantly, Putnam explicitly differentiates
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between social capital and social cohesion indicating that “social capital is a narrower, more
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tightly defined concept that calls attention to one crucial ingredient in social cohesion, in the
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sense of a just, equitable, tolerant, and well-integrated society” (pp. 3) (Robert D. Putnam,
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2004)).
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While extending social capital from individuals to communities does not seem farfetched, Portes argues that this is problematic because the transition was not properly theorized
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and social capital has become a synonym for all that is good in societal structures (Portes, 2000).
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Indeed, this is one of the main criticisms about social capital and its usefulness as a social
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construct (Inaba, 2013). Furthermore, this may be one of the reasons why social cohesion, which
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was conceived by Durkheim as a societal characteristic, has been subsumed into the concept of
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social capital . Thus, characteristics of society underwent a process of transformation into
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capital, which is traditionally characterized by ownership.
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In the public health literature social capital is defined as “the resources available to individuals through their affiliative behaviors and membership in community networks” (pp. 7
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121) (Ichiro Kawachi, 1999). Social capital resides in the structure and quality of relationships
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among members of a community (Ichiro Kawachi, 2006). More recently, social capital has also
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been described as an “investment that people make in society” through their membership and
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active participation in civic institutions (pp.181) (Cockerham, 2007). An individual’s investment
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in society increases that person’s social capital, makes that person more integrated and improves
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her health and well-being (Cockerham, 2007).
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The definitions provided above reveal the transition that social capital has undergone since it made an appearance as a construct focusing on the reproduction of current class
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structures (Bourdieu, 1986). The concept was “democratized” and made available to all as a
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potential community resource or possession (Coleman, 1988). Most recently, there has been an
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emphasis on social capital accruing to the individual based on her investments. As the concept
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has evolved, it has become more individualized and it has turn into objects of possession various
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social characteristics that were not previously conceptualized as objects of ownership: namely
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trust, norms, and networks (Ichiro Kawachi & Berkman, 2000; Robert D Putnam, 1995).
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Social Capital and Social Cohesion?
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The original conceptualization of social capital followed the meaning of capital itself (in its
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Marxist sense), as something to be owned and then invested to obtain a surplus (in this case not
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exclusively monetary profit) (Bourdieu, 1986). Further developments removed this necessity for
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ownership and collectivized social capital, bringing characteristics inherent to social cohesion
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along with it (Coleman, 1988). The latest development of the concept (Robert D Putnam, 1995)
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brought back to the individual both social capital (that can be owned) and social cohesion (that
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cannot be owned). The further development of social capital has deeply influenced social
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cohesion, causing a conflation of both concepts. However, unlike social capital, whose first
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articulations focused on individual attributes, social cohesion started as a social fact in
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Durkheim’s work (Kushner & Sterk, 2005).
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In order to better understand the reasons behind these developments and differentiate between social capital and social cohesion we propose a new approach, based on Erich Fromm’s
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ideas about the difference between having and being.
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Social Capital or Social Cohesion?
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Erich Fromm’s ideas about the emphasis on having vs. being may help to answer our original
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question: Why does social capital appears to be more popular than social cohesion? According to
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Fromm, in a capitalist society geared to consumption to sustain the economic apparatus
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distinguishing between having and being may seem impossible as the “very essence of being is
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having” (pp. 3) (Fromm, 1976). In such societies, he argues, having becomes the central
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preoccupation given the generalized notion that “if one has nothing, one is nothing” (pp. 3)
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(Fromm, 1976). Fromm proceeds to indicate that the emphasis of having over being has become
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an affliction of our time, the product of a voracious industrialist machinery where human beings
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and their world become objectified in the name of production and where appropriation (i.e.
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having) becomes the main goal in life (Fromm, 1976). The current emphasis on having
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objectifies our reality. For example, in the case of knowledge, he explains the difference
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between having knowledge and knowing. Having knowledge, he says, is taking and keeping
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possession of available information, while knowing is part of the process of productive and
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critical thinking. Knowing entails awareness and to see reality in its nakedness. Having refers to
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things while being refers to experiences.
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A parallel could be drawn with social capital, which is related to possession or ownership
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(having), and social cohesion, which is a characteristic of a group or society (being). Associating
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capital with societal characteristics and dynamics (trust, norm, and networks) turns these into
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elements that can be harnessed and possessed. As such, it is impingent on individuals to ensure
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that they appropriate themselves of capital to advance their goals, including supporting and
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maintaining health. On the other hand, from a being perspective, social cohesion is a
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characteristic that can be fostered but that ultimately is vested in a group rather than in the
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individuals as an individual cannot have social cohesion by herself. Fromm's description of the
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current emphasis on having (instead of being) could be a potential reason for the predominance
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of social capital over social cohesion.
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Levels, Inference, and Measurement
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The distinction between social capital and social cohesion is not trivial and refers precisely to the
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ability of individuals (or communities) to own (have) capital or of communities to be cohesive.
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While this distinction is not explicitly drawn at the levels of inference (individual vs collective),
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different inferences will result from the perspective taken . In addition, it is also important to
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ensure that the measurements used match the level of inference. As Kawachi stated, an
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important challenge researchers face is “better integrating theory and measurement across
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different levels of social interaction, from individuals interacting with others within their own
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groups to interactions between groups within a broader social context.”(I. Kawachi & Berkman,
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2014). That is, it should be explicit from one’s theoretical framework whether the concept of
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social capital or the concept of social cohesion is being studied, at what level is it studied and
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how the measurement operationalization fits into this theory.
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Below are examples of the measurement of social capital and social cohesion at both the
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individual and collective levels. The examples illustrate that Kawachi’s call for better
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integration of theory and measurement (I. Kawachi & Berkman, 2014) needs to be clearly heard.
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For each example we specify the level at which each construct is conceptualized (theoretical
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perspective) and operationalized (measurement and analytical point of view).
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First, in a classic study, Kawachi and colleagues (Ichiro Kawachi et al., 1997) measured social
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capital by looking at indicators of civic engagement (number of groups and associations per
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capita) and trust (individual responses to a questionnaire about trust in others, aggregated to the
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state level). This study conceptualizes social capital as a collective level (“ecologic”) variable
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whose counterpart at the individual level is measured by an individual person’s social networks.
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This study focuses on the former (collective level social capital) and operationalizes it by using
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an exclusively collective variable (civic engagement, measured at the state level) and individual
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responses about trust aggregated to the collective level (in this case, state).
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Second, a study by Muennig and colleagues (Muennig et al., 2013) explicitly lays out a
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theorization of social capital following Bain and Hicks (1998). This includes what they label as
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cognitive social capital (“internal states such as trust”) and structural social capital (“availability
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and use of social organizations or connections such as organizational membership or connection
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to others”) (Bain & Hicks, 1998). The authors are interested in structural social capital and
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measure it using indicators of human interaction (responses to a questionnaire on frequency of
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social contacts) and social participation (responses to a questionnaire on frequency of attendance
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to meetings). The study seems to conceptualize and operationalize social capital at the individual
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level. They measure it using individual-level responses to questionnaires that then confer a social
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capital measurement for each individual.
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Third, a study by Jennings and colleagues (Jennings et al., 2014) conceptualizes social cohesion
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following Sampson (Sampson et al., 1997) as a structural (collective) attribute of neighborhoods.
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They measure social cohesion using a 5-item questionnaire (at the individual level) and then
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aggregate individual scores to generate neighborhood level averages. The study conceptualizes
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social cohesion as a collective (structural) factor and operationalizes it at the collective level (in
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this case, neighborhood).
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Fourth and last, a study by Fonner and colleagues (Fonner et al., 2014), defines social cohesion
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as part of social capital, labeling it “bonding social capital”. They measure social cohesion with
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an 11-item scale with questions about individual perceptions of group processes. The resulting
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score is then assigned to each individual participant. This study recognizes the collective nature
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of social cohesion (as something that is originated through social interaction), and
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operationalizes it using an individual-level scale about individual perceptions of group processes.
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Practical Implications
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While the distinction between having and being as a perspective to analyze social capital and
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social cohesion may be intellectually interesting, it is important to analyze the practical
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implications in public health. According to Fromm, the major difference between these two
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modes is that the having mode leads to the objectification of human beings and their
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characteristics, leading to their alienation or separation from others. Thus, here lies an important
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conflict whereby social capital and its individualizing and fragmenting nature may be antithetical
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to social cohesion. By emphasizing research on social capital researchers may be indirectly
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feeding into individualization tendencies that fragment communities into more easily moldable,
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malleable, and manipulable units, leading to a more effective deployment of power and its
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normalizing tendencies. Indeed, one of the major concerns of institutions, groups, and
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individuals in modern western societies “revolves around the regulation of bodies in space, the
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monitoring of the surfaces of bodies and the relationship between bodies” (pp.11) (Lupton,
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1995). From this perspective, social capital offers more opportunity for regulation as
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individuals can possess it and use it. Social cohesion, on the other hand, cannot be possessed or
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used and it is less readily amenable to manipulation for population normalization as groups that
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come together may do so to resist and subvert social norms or the prevailing power structure.
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Thus, the practical implication of focusing on having vs. being and subsuming social
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cohesion into social capital entails having an emphasis on understanding how to normalize
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groups and populations rather than having an emphasis on providing those groups space for
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empowerment and agency leading to health. While it could be argued that having more social
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capital can lead to agency (empowerment), as discussed above, this poses an inherent
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contradiction that, beyond semantics, has practical implication on public health practice and
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research. Public health researchers and practitioners interested in empowerment-for-health
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approaches should be aware of the difference between social capital and social cohesion when
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designing public health interventions to ensure posing appropriate research questions and using
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the most conducive frameworks and approaches.
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Social constructs created by social scientists to understand social processes not only
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inform, expand, and constrain our view of reality but also shape it. This constructionist view is
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informed by the concept of the double hermeneutic coined by sociologist Anthony Giddens
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(Giddens, 1990). In his book, the Consequences of Modernity (1990), Giddens argues that there
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is an important difference between the natural and social sciences, referring to this difference as
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the single and double hermeneutic. In the natural sciences, scientists try to understand and 13
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theorize about the way the natural world is structured. The understanding is one-way; since the
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natural world does not seek to develop an understanding of scientists. Giddens calls this the
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‘single hermeneutic’. In contrast, social sciences study people and society. Some social sciences
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such as sociology study what people do, how they understand their world, and how this
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understanding shapes their actions. Unlike items studied by natural sciences, people can use the
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knowledge and insights of social science to change their actions, hence Gidden’s ‘double
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hermeneutic’ for the social sciences. Thus, social scientists frame, inform, and affect reality in
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ways that need to be apparent to them. Defaulting to use a construct because it is widely used or
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because there is perceived consensus on its meaning may not be the most useful way to advance
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social sciences. Worse, this approach may shape reality in unintended ways that have important
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implications (as detailed in this manuscript).
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Limitation
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Dichotomization is an oversimplification of our complex reality. A limitation of this paper is that we relied on a dichotomization (social capital vs. social cohesion) to make our case.
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However, dichotomizations are useful analytical tools as they allow us to uncover extremes that
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may be so intertwined that they are perceived as one. Indeed, dichotomization allows social
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scientists to peel two extreme layers of reality. This is what Erich Fromm masterfully did in his
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book To Have or To Be?. He contraposed “Having” and “Being”, illustrating them in various
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realms (i.e. learning, remembering, reading, faith, and loving) (Fromm, 1976). We bring
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Fromm’s insights into the realm of public health research and draw a parallel with the
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intertwining of two constructs that were originally conceived separately: social capital and social
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cohesion. By dichotomizing these constructs we are able to bring to the collective consciousness
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the fact that they were not always intertwined and to explain the philosophical reasons for this
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intertwining and its practical implications. If we are to move toward a more humanistic
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approach to public health it is important to raise consciousness on the implications of the
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theorization, definition, measurement and operationalization of social constructs to understand
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our social world and its effect on the people’s health.
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References Bain, K., & Hicks, N. (1998). Building social capital and reaching out to excluded groups: the challenge of partnerships. World Bank.
RI PT
Berkman, L., Glass, T., Brissette, I., & Seeman, T. (2000). From social integration to health: Durkheim in the new millennium. Social Science & Medicine, 51, 843-857.
Berkman, L.F., & Kawachi, I. (2000). Social Epidemiology: Oxford University Press, USA.
SC
Bourdieu, P. (1986). The forms of capital Handbook of theory and research for the sociology of education In J. Richardson (Ed.), Handbook of Theory and Research for the Sociology of
M AN U
Education pp. 241-258). New York: Greenwood.
Bruhn, J. (2009). The Group Effect: Social Cohesion and Health Outcomes. New York: Springer. Busza, J., Walker, D., Hairston, A., Gable, A., Pitter, C., Lee, S., et al. (2012). Community-based approaches for prevention of mother to child transmission in resource-poor settings: a
TE D
social ecological review. Journal of the International AIDS Society, 15. Carrasco, M.A. (2015). No estas sola: Social cohesion, HIV stigma, and HIV/STI prevention among female sex workers living with HIV in Santo Domingo. Department of Health,
Health.
EP
Behavior and Society. Baltimore, MD, USA: Johns Hopkins Bloomberg School of Public
AC C
Chan, J., To, H.-P., & Chan, E. (2006). Reconsidering social cohesion: Developing a definition and analytical framework for empirical research. Social indicators research, 75, 273-302.
Coburn, D. (2000). Income inequality, social cohesion and the health status of populations: the role of neo-liberalism. Social Science & Medicine, 51, 135-146.
Cockerham, W. (2007). Social Causes of Health and Disease. London: Polity Press.
16
ACCEPTED MANUSCRIPT
Coleman, J. (1988). Social capital in the creation of human capital. American journal of sociology, S95-S120. Collins, R. (1994). Four sociological traditions: Selected readings: Oxford University Press
RI PT
Oxford.
Durkheim, E. (1951). Suicide : a study in sociology. New York: Free Press.
Fonner, V.A., Kerrigan, D., Mnisi, Z., Ketende, S., Kennedy, C.E., & Baral, S. (2014). Social
Swaziland. PLoS ONE, 9, e87527.
SC
Cohesion, Social Participation, and HIV Related Risk among Female Sex Workers in
M AN U
Fromm, E. (1976). To have or to be? . New York: Harper & Row Publishers. Giddens, A. (1990). The consequences of modernity. Cambridge: Polity Press. Glass, T., & McAtee, M. (2006). Behavioral sciences at the crossroads in public health: Extending horizons, envisioning the future. Social Science & Medicine, 1650-1671.
TE D
Inaba, Y. (2013). What’s wrong with social capital? Critiques from social science. In I. Kawachi (Ed.), Global Perspectives on Social Capital and Health pp. 323-342): Springer. Jennings, J.M., Hensel, D.J., Tanner, A.E., Reilly, M.L., & Ellen, J.M. (2014). Are social
EP
organizational factors independently associated with a current bacterial sexually transmitted infection among urban adolescents and young adults? Social Science &
AC C
Medicine, 118, 52-60.
Kawachi, I. (1999). Social capital and community effects on population and individual health. Annals of the New York Academy of Sciences, 896, 120-130.
Kawachi, I. (2006). Commentary: social capital and health: making the connections one step at a time. International Journal of Epidemiology, 35, 989-993.
17
ACCEPTED MANUSCRIPT
Kawachi, I., & Berkman, L. (2000). Social cohesion, social capital, and health. In I. Kawachi, & L. Berkman (Eds.), Social epidemiology pp. 174-190). New York: Oxford University Press.
RI PT
Kawachi, I., & Berkman, L.F. (2014). Social Capital, Social Cohesion and Health. In L.F.
Berkman, I. Kawachi, & M. Glymour (Eds.), Social epidemiology: Oxford University Press.
SC
Kawachi, I., Kennedy, B.P., Lochner, K., & Prothrow-Stith, D. (1997). Social capital, income inequality, and mortality. American Journal of Public Health, 87, 1491-1498.
M AN U
Kerrigan, D., Kennedy, C.E., Morgan-Thomas, R., Reza-Paul, S., Mwangi, P., Win, K.T., et al. (2015). A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. The Lancet, 385, 172-185.
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Kushner, H.I., & Sterk, C.E. (2005). The Limits of Social Capital: Durkheim, Suicide, and Social Cohesion. American Journal of Public Health, 95, 1139-1143. Lindstrom, M. (2014). Does social capital include trust? Commentary on Carpiano and Fitterer
EP
(2014). Social Sciences & Medicine, 235-236. Link, B.G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of
AC C
health and social behavior, 80-94.
Lupton, D. (1995). The imperative of health: Public health and the regulated body: Taylor & Francis.
Muennig, P., Cohen, A.K., Palmer, A., & Zhu, W. (2013). The relationship between five different measures of structural social capital, medical examination outcomes, and mortality. Social Science & Medicine, 85, 18-26.
18
ACCEPTED MANUSCRIPT
Muntaner, C., & Lynch, J. (1999). Income Inequality, Social Cohesion, and Class Relations: A Critique of Wilkinson's Neo-Durkheimian Research Program. International journal of health services, 29, 59-81.
RI PT
Navarro, V. (2004). Commentary: Is capital the solution or the problem? International Journal of Epidemiology, 33, 672-674.
Portes, A. (1988). Social Capital: Its Origins and Applications in Modern Sociology. Annual
SC
Review of Sociology, 24, 1-24.
Portes, A. (2000). The two meanings of social capital. Sociological forum pp. 1-12): Springer.
M AN U
Putnam, R.D. (1995). Tuning in, tuning out: The strange disappearance of social capital in America. PS: Political science & politics, 28, 664-683.
Putnam, R.D. (2004). Education, Diversity, Social Cohesion and ‘Social Capital’. Dublin, Ireland: OECD Education Ministers.
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Putnam, R.D., Leonardi, R., & Nanetti, R.Y. (1994). Making democracy work: Civic traditions in modern Italy: Princeton university press. Sampson, R.J., Raudenbush, S.W., & Earls, F. (1997). Neighborhoods and Violent Crime: A
EP
Multilevel Study of Collective Efficacy. Science, 277, 918-924.
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Wilkinson, R.G. (1996). Unhealthy societies: the afflictions of inequality. New York: Routledge.
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Acknowledgements The authors are grateful to Dr. Lori Leonard and Dr. Deanna Kerrigan for providing comments
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on earlier drafts. M. Carrasco was partially supported by the National Institute of Allergy and Infectious Disease (T32 AI050056-12). U. Bilal was supported by the Johns Hopkins Center for a Livable Future – Lerner Fellowship and a Postgraduate Fellowship from the Obra Social La
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Highlights
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Social cohesion is often studied as part of social capital A theoretical articulation of the consequences of this conflation is lacking Fromm’s distinction of “having” and “being” may explain emphasis on social capital Subsuming cohesion into capital discourages empowerment strategies leading to health Examples of measurement of both concepts show how this conflation is problematic
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• • • • •