The authors have declared that no competing interests exist.
Conceived and designed the experiments: YM XQ ZH. Performed the experiments: YM NL RC. Analyzed the data: YM NL RC. Contributed reagents/materials/analysis tools: YM RC XQ. Wrote the paper: YM. Reviewed and revised manuscript: YM RC ZH.
With growing recognition of the social determinants of health, social capital is an increasingly important construct in international health. However, the application of social capital discourse in response to HIV infection remains preliminary. The aim of this study was to assess the impact of social capital on quality of life (QoL) among adult patients with acquired immune deficiency syndrome (AIDS).
A convenient sample of 283 patients receiving antiretroviral treatment (ART) was investigated in Anhui province, China. QoL data were collected using the Medical Outcomes Study HIV Survey (MOS-HIV) questionnaire. Social capital was measured using a self-developed questionnaire. Logistic regression models were used to explore associations between social capital and QoL.
The study sample had a mean physical health summary (PHS) score of 50.13±9.90 and a mean mental health summary (MHS) score of 41.64±11.68. Cronbach's α coefficients of the five multi-item scales of social capital ranged from 0.44 to 0.79. When other variables were controlled for, lower individual levels of reciprocity and trust were associated with a greater likelihood of having a poor PHS score (odds ratio [OR] = 2.02) or PHS score (OR = 6.90). Additionally, the factors of social support and social networks and ties were associated positively with MHS score (OR = 2.30, OR = 4.17, respectively).
This is the first report to explore the effects of social capital on QoL of AIDS patients in China. The results indicate that social capital is a promising avenue for developing strategies to improve the QoL of AIDS patients in China, suggesting that the contribution of social capital should be fully exploited, especially with enhancement of QoL through social participation. Social capital development policy may be worthy of consideration.
Social capital has become a popular topic in public health research in recent years, though there has been a lack of consensus concerning its definition
Social capital can also be defined at different levels, specifically at individual and collective levels
The construct of social capital used within health fields in China may differ from that in the West owing to cultural differences
Although people generally have an intuitive understanding of quality of life (QoL) as a concept, it is still difficult to define it. The World Health Organization (WHO) has defined QoL as individuals' perceptions of their positions in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. This definition focuses upon respondents' perceived QoL
Despite the rapid accumulation of general population social capital studies, little attention has been paid to the utility of social capital by AIDS patients
In China, there were estimated 780,000 people living with HIV/AIDS and 133,524 AIDS patients, cumulatively, who received antiretroviral treatment (ART) by the end of 2011
Ethical approval for the study was obtained from the Biomedical Ethics Committee, Anhui Medical University.
Anhui province, which is located in the southeast region of China, has a relatively low HIV/AIDS prevalence among Chinese provinces. In the 1990s, the primary cause of the AIDS epidemic in Anhui Province was illegal blood-collection, while in recent years sexual intercourse has become the main means of HIV transmission
This study examined a convenient selected sample, with the inclusion and exclusion criteria outlined below. Since 2003, the “Four free and One Care” policy has been enacted in response to the HIV epidemic in China
Trained investigators from the Anhui Medical University conducted face-to-face interviews with the patients with the support of staff at the local Center for Disease Control and Prevention (CDC). All of the eligible respondents were identified from the AIDS patient database of the local CDC. They were informed verbally via telephone of the purpose and procedure of the study, the confidentiality parameters, and the compensation for travelling expenses ahead of time. Study participants expressed a verbal understanding of these issues and signed consent forms. Most of the data collection was undertaken either in the local CDC or in the respondents' homes. Other information, such as CD4 count and the duration each individual has been living with HIV, was obtained from the patients' medical files in the local CDC. With an overall response rate of 90.52%, we conducted full interviews with a total of 283 participants: 23 in Maanshan city, 24 in Benbu city, 31 in Fuyang city, 32 in Langxi city, 47 in Luan city, 39 in Anqing city, 47 in Chuzhou city, and 40 in Wuhu city.
Social capital assessment was a small part of our survey and thus we did not administer an extensive social capital questionnaire. Based on our operational definition of social capital explained in the introductory text of this paper and in consideration of existing comprehensive instruments (e.g., the Word Bank′s Social Capital Assessment Tool) and the related literature
Four dimensions of social capital were considered: social networks and ties; social support; social participation; and reciprocity and trust. Social networks and ties included the number of close relatives, the number of close friends, the relationship within one's neighborhood, and frequency of contact with the relatives, friends and neighbors. Social support mainly addressed moral and material support. Social participation involved the frequency of group and community participation. Reciprocity and trust was measured in terms of vertical trust (trust in hospitals, municipal authorities, etc.), horizontal trust (generalized trust in other people), and mutual support. This information is reported in
Individual-level social capital was measured by producing a component score of each dimension using factor analysis which was grouped into a binary variable. The mean component score was used as the cutoff point: high individual-level social capital (component score ≥0) and low individual-level social capital (component score <0)
The general risk factors record contained: (1) socio-demographic information, including education level, main occupation, gender, family monthly income, current smoking and alcohol intake etc.; as well as (2) AIDS related information, including mode of transmission, duration of living with HIV, and CD4 cell count.
QoL was evaluated using the 35-item simplified Chinese simplified version of the Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire
The MOS-HIV measures 10 domains, including 8 multi-item domains (general health, physical function, role function, cognitive function, pain, mental health, energy/fatigue, and health distress) and 2 single-item domains (social function and QoL). We applied another single-item inquiry on health transition. Raw item scores were summed for each domain and transformed into a 0–100 scale, with higher scores indicating better functioning and well-being. Two summary scores, namely the physical health summary (PHS) score and mental health summary (MHS) score, were generated from the factor analysis of the 10 scales. We considered patients to have a poor quality of life if their PHS and/or MHS were at or below the 25th percentile of the distribution
A descriptive analysis was performed on the sample, and the results were expressed as means ± standard deviations (SDs), frequencies, and percentages. Using principal component analysis factoring for factor extraction, Cronbach's α values were calculated to evaluate the validity and reliability of social capital scale. Finally, a logistic regression was conducted to explore associations between social capital and QoL.
A logistic regression model was employed to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) and thereby reveal whether there was an association between each dimension of social capital and QoL, after controlling for demographic variables including gender, ethnicity, educational level, and marital status. All analyses were performed using the SPSS statistical package (Windows version 11.5, SPSS Inc., Chicago, Illinois), and p value <0.05 was taken as statistically significant.
Our study sample of 283 respondents had a mean age of 40.76±10.23 years (range, 18–70 years) and a mean CD4 count of 414.63±194.32 cells/mm3 (range, 189–763 cells/mm3). A full descriptive summary of the respondents is provided in
Variables | No. persons | Percentage | |
Age group |
18–29 years | 38 | 14.7 |
30–39 years | 74 | 28.6 | |
≥40 years | 147 | 56.8 | |
Gender | Male | 161 | 56.9 |
Female | 122 | 43.1 | |
Marital status | Unmarried | 52 | 18.4 |
Currently married | 174 | 61.5 | |
Other (e.g. divorced, widowed) | 57 | 20.1 | |
Education level | Illiterate | 53 | 18.7 |
Primary | 75 | 26.5 | |
Junior high | 101 | 35.7 | |
Senior high+ | 54 | 19.1 | |
Occupation | Farmer | 65 | 23.0 |
Laborer/merchant | 37 | 13.1 | |
Carder/village/doctor/teacher | 21 | 7.4 | |
Non-working | 160 | 56.5 | |
Ethnicity |
Han | 253 | 97.7 |
Other | 6 | 2.3 | |
Current smoker | No | 186 | 65.7 |
Yes | 97 | 34.3 | |
Current drinker | No | 232 | 82.0 |
Yes | 51 | 18.0 | |
Family monthly income (Yuan) | <1000 | 118 | 41.7 |
≥1000 | 165 | 58.3 | |
HIV transmission mode | Sharing needles | 10 | 3.5 |
Sexual relationship | 178 | 62.9 | |
Blood | 95 | 33.6 | |
Duration living with HIV | <12 months | 58 | 20.5 |
≥12months | 225 | 79.5 |
missing = 24.
Four factors were extracted with eigenvalues above 1.0. After running a varimax orthogonal rotation, the four factors explained 64.5% of the total variance.
Items | Main Components | |||
1 | 2 | 3 | 4 | |
1. How many intimate relatives do you have? |
|
0.211 | −0.049 | 0.182 |
2. How many close friends do you have? |
|
−0.025 | 0.087 | 0.072 |
3. How often do you visit your neighbors? |
|
−0.068 | −0.137 | −0.148 |
4. How often do you invite your neighbors to your home? |
|
0.150 | 0.044 | 0.166 |
5. Can you get the care when you feel uncomfortable or are suffering from the disease flare-ups? | 0.311 |
|
0.088 | 0.018 |
6. Can you get financial assistance when you experience family life difficulties? | 0.518 |
|
0.130 | 0.034 |
7. Do you believe that if you have private problems, you can discuss them with residents in your community? | 0.386 |
|
0.024 | 0.358 |
8. Who could you turn to for support when the above situation occurs? | 0.017 |
|
0.167 | 0.083 |
9. How many groups or organizations have participated in? | 0.220 | 0.156 | 0.089 |
|
10. How many times have you taken part in the activities held by organizations you have joined? | −0.218 | 0.133 | −0.008 |
|
11. How many times have you participated in collective community activities? | 0.054 | 0.08 | 0.035 |
|
12. Do you believe that the majority of residents in your community can be trusted? | −0.025 | 0.082 |
|
0.027 |
13. Do you believe that the majority of local hospital and CDC staff can be trusted? | 0.079 | −0.008 |
|
0.026 |
14. Do you believe that the majority of residents in your community participate in activities organized by the community for the benefit of only a few residents? | 0.222 | 0.099 |
|
0.032 |
15. Would you like to provide support for residents in your community who need help? | 0.443 |
|
0.221 | 0.076 |
The overall Cronbach's α coefficient for social capital was 0.75. The Cronbach's α coefficients of the four factors ranged from 0.44 to 0.79. The social networks and ties factor had the weakest internal consistency of the four factors (α = 0.44).
Individual respondent scores ranged from −2.00 to 2.46 for social networks and ties, from −3.38 to 1.92 for social participation, from −0.70 to 3.81 for reciprocity and trust, and from −3.22 to 2.44 for social support. The percentages of respondents with low individual-level social capital in the four dimensions were 49.5%, 78.4%, 40.6%, and 44.2%, respectively.
Multivariate-adjusted ORs (
Variables | OR (95%CI) |
|
|
|
High individual level | 1.00 | |
Low individual level |
|
|
|
Current drinker | Yes | 1.00 | |
No | 2.90 (1.09 |
0.032 | |
Family monthly income (Yuan) | ≥1000 | 1.00 | |
<1000 | 4.02 (2.07 |
<0.001 | |
Age group (years) | 18 |
1.00 | |
30 |
3.68 (1.01 |
0.049 | |
≥40 | 2.51 (1.17 |
0.018 | |
Duration living with HIV | <12 months | 1.00 | |
≥12months | 2.51 (1.23 |
0.012 |
ORs were adjusted for variables in the table, and further for gender, marital status, education level, occupation, ethnicity, current smoking status, CD4 count, and HIV transmission mode.
As shown in
Variables | OR (95%CI) |
|
|
|
High individual level | 1.00 | |
Low individual level |
|
|
|
|
High individual level | 1.00 | |
Low individual level |
|
|
|
|
High individual level | 1.00 | |
Low individual level |
|
|
|
Education level | Illiterate | 4.48 (1.50 |
0.007 |
Primary | 0.87 (0.31 |
0.797 | |
Junior high | 0.83 (0.31 |
0.715 | |
Senior high+ | 1.00 | ||
Duration living with HIV | <12 months | 1.00 | |
≥12months | 4.48 (1.55 |
0.006 |
ORs adjusted for the same factors as those in
Our study provides an initial exploration of correlations between the aspects of social capital and QoL among AIDS patients at the individual level in China. With further development, our findings can be used to develop evidence-based policy to improve the QoL of AIDS patients.
The strengths of our analysis were that careful attention was given to the design and validation of the social capital questionnaire. We obtained better internal reliability values for the social capital questionnaire used in our survey (0.44–0.79) than the values obtained by previous studies conducted in mainland China
Somewhat surprisingly, for three of the four domains (networks and ties, reciprocity and trust, and social support, but not social participation), we found that participants had high individual-level social capital. Thus, our findings suggest that AIDS patients may not be as marginalized as previously thought
Consistent with prior studies
We observed that one's level of social networks and ties was a significant predicator of one's mental health status, consistent with our expectations and previous research
Social support may provide a buffer against the adverse effects of stress caused by medical side effects, which may in turn increase individual well-being. Our finding that social support was associated with mental health but not physical health is in line with previous work by Bastardo et al.
The putative association between social participation and QoL is controversial
Our study has some limitations. First, the analysis of the links between the different social capital variables was cross-sectional and hence cannot be used to conclude causal relationships. Second, the results may not be generalized to all Chinese AIDS patients. Our data were collected in Anhui province, which has a relatively low HIV/AIDS prevalence for China, and thus may not reflect the situation in other provinces due to regional differences in the epidemic characteristics of AIDS, prevention and control measures, funding, and policy environment. Finally, because we measured social capital at the individual level only, the impact of context-level social capital on QoL, and the interactive influence of individual-level and context-level social capital on QoL are not clear. These limitations notwithstanding, our study provides a base upon which future surveys examining the impact of social capital on the QoL of AIDS patients in the Chinese context can be built.
As an exploratory study, it was not possible to obtain a truly representative sample of Chinese AIDS patients, but this limitation does not diminish the implications of our findings. Our study indicates that our self-developed social capital scale for Chinese AIDS patients has good reliability and validity, that a higher level of social capital is associated with a better QoL overall among AIDS patients in Anhui province, China, and that social capital exhibits a stronger association with mental health than physical health. China may not have fully exploited the contribution of social capital, especially social participation, in enhancing QoL. Social capital development policy warrants further consideration.
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The authors thank the participants and all who were involved in the surveys. Special thanks to the officials from the provincial and local CDC institutions in Anhui province for participating in the project and coordinating the field work.