In conducting this study, we set out to apply the WHO framework of social determinants (Figure ) of health to a cross-national sample of 34 countries from Europe, North and South America, and the South Caucasus for which we had mental and physical health outcome data. The full sample of 34 countries, for which social capital data were unavailable, indicated significant positive effects of rights and freedoms on mental and physical health. We replicated the same models on a subsample of 23 countries for which we also had social capital data. Both samples contained developed countries and countries in transition. We anticipated that our results would be congruent with the WHO framework of social determinants (Figure ). The WHO framework (Figure ) associates increased rights and freedoms with increased wealth and social equality, which in turn promotes better health. Based on the WHO framework (Figure ), we also anticipated that social capital and civil society would moderate the effect of SES. As earlier noted, this WHO framework (Figure ) encapsulates the “social inequality,” “civil society and social capital,” and “rights and liberties” arguments. Therefore, similar to previous studies, we found that SES and social capital played important roles in the determination of health. However, we were surprised to discover that rights and freedoms mediated these effects. Our findings showed that the effects of SES and social capital on physical health were fully mediated through democratic rights and freedoms. However, the mental health model indicated that rights and freedoms completely mediated the effects of SES and only partially mediated the effects of social capital. The models suggest different origins for mental and physical health outcomes. We named the models, the “rights and freedoms gradient of health” to acknowledge this latter construct’s crucial role in determining health outcomes. To this end, “rights and freedoms” denotes political rights, civil liberties, and freedom from corruption. It is likely that our findings may have come to light because, as far as we know, this is the first study to simultaneously examine the effects of SES, social capital, and rights and freedoms on health outcomes using pathways models.
The mediating role of rights and freedoms has significant implications that deserve further discussion. Most previous studies investigating the effects of rights and freedoms focused on one or two physical health variables – usually life expectancy or infant mortality rates (Dasgupta, 1990
; Altman and Castiglioni, 2009
). The present study, instead, incorporated three variables of mental health and three of physical health outcomes. Our results are also consistent with previous findings that suggest that SES (Wilkinson and Picket, 2009
), social capital (Elgar, 2010
), and democratic rights and freedoms (Dasgupta, 1990
; Altman and Castiglioni, 2009
) are all independently associated with better health outcomes. First, a large body of evidence in support of the “social inequality argument
” contends that increasing a nation’s SES, in terms of overall wealth (Wickrama and Mulford, 1996
) with an equitable distribution of wealth, is associated with better health outcomes (Wilkinson and Picket, 2009
). Second, many previous studies support the “rights and liberties argument
” in that democratic rights and freedoms positively affect physical health, such as decreasing infant mortality rates and increasing life expectancies (Dasgupta, 1990
; Franco et al., 2004
; Altman and Castiglioni, 2009
). However, few studies have examined the effects of rights and freedoms on mental health. One study, though, has shown that when civil liberties increase, suicide rates decrease (Jungeilges and Kirchgässner, 2002
). Third, cross-national evidence from the “civil society and social capital argument
” suggests that social capital is positively related to better health outcomes (Elgar, 2010
). Therefore, our findings are consistent with past studies that independently associate SES, rights and freedoms, and social capital with increased health performance. Unique to the present study is that our findings place these latter constructs into relative context to one another.
Over two decades ago, Dasgupta (1990
) refuted the argument that poorer countries cannot afford the “luxury” (p.4) of rights and freedoms. Dasgupta further argued that when individuals have greater rights and freedoms, they also perform better regarding health. In this context, rights and freedoms are thought to permit citizens to exert pressure for beneficial social policy (Korpi, 1989
). An implication of this study is that its results support the notion that rights and freedoms may be essential social conditions to support not only child survival, but also child and youth development, as rights and freedoms are reflected in population indicators of mental and physical health outcomes over the life-course.
Our findings suggest that to improve population health, countries must strive to integrate efforts addressing all of these three critical factors, concurrently: socioeconomic conditions, civil society and social capital, and rights and freedoms. This concept has been recognized by the United Nations Development Program (UNDP) in developing their Human Development Index, a composite score that measures life expectancy, education and national wealth, “to emphasize that people and their capabilities should be the ultimate criteria for assessing the development of a country, not economic growth alone” [United Nations Development Programme (UNDP), 2011
]. Specifically, the democracy theme of the 2002 UNDP report [United Nations Development Programme (UNDP), 2002
] recognized the importance of linking democratic rights and freedoms, human development, and health. Yet, the UNDP does not include a measure of these rights and freedoms in their human development index as their 2002 report notes that these concepts “are difficult to measure appropriately” (p. 53).
In addition, the 2002 UNDP report states that civil society development is instrumental in building democracy. Yet, the report does not integrate civil society into their concept of mutually reinforcing capabilities (p. 53) which included links between rights and freedoms, SES, and health-education. A similar sentiment was echoed in the WHO’s framework on the social determinants of health [World Health Organization (WHO), 2010
] which noted that “social capital occupy a conspicuous (and contested) place in discussions of SDH (social determinants of health)” (p. 7) because “focus on social capital, depending on interpretation, risks reinforcing depoliticized approaches to public health” (p. 7). Our results suggest that civil society (term used by UNDP), or by extension social capital (term used by WHO), must also be integrated into frameworks and concepts that advance health outcomes. In the context of the UNDP and WHO reports, social capital and civil society are similar concepts. As previously noted, social capital can be defined as the associations or networks that generate the cooperation and trust necessary for the realization of common goals (Putnam, 2000
). Civil society can be described as the interactions of citizens “which has a life of its own, which is distinctively different from the state and largely autonomous from it” to promote the collective interest (Shils, 1991
). From these perspectives, the terms social capital and civil society can both be construed as reflecting power that originates with citizens and strengthens democratic rights and freedoms.
The relationship between social capital and SES was more difficult to interpret. We chose to denote SES as leading to social capital. This decision was somewhat arbitrary as reversing the relation in enlisting social capital leading to SES in the pathway model is equally statistically equivalent. Future research is warranted in uncovering the path. In any event, our findings suggest that social capital and SES are both necessary for the development of rights and freedoms, and consequently health. In this respect, past research has shown that increasing only SES (in terms of GDP per capita) does not lead to better health outcomes (Altman and Castiglioni, 2009
Interestingly, our findings also suggest that despite their levels of rights and freedoms, some nations are more resilient than others, in terms of countries falling significantly above or below the regression line. For example, when comparing rights and freedoms versus physical health outcomes, Estonia, Ukraine, and Brazil are significantly below the regression line, while Italy and Greece fall significantly above the regression line. Comparatively for mental health, Argentina falls above the regression line and Hungary falls below. These findings raise a wide range of questions as to what might be at play in those resilient and vulnerable countries. Pertaining to resilience, possibilities might include regional variations that exist within a given country (e.g., differences between the north/south, east/west, rural/urban) or decentralization of health care administration and service provision as may be the case in Italy. Pertaining to vulnerability, ethnic fragmentation (Aghion et al., 2004
), authoritarian regimes with an abundance of natural resources in poorer countries (Ross, 2001
), and past histories of colonialization (Diamond et al., 1987
) can impede democratization. Any such hindrance could plausibly have important health implications, given the results of this study. For example, Ukraine was under colonial rule for centuries (Subtelny, 2009
) and suffered from a Soviet-orchestrated genocide in 1932–1933 that claimed the lives of several million Ukrainians (Naimark, 2010
). The genocide resulted in a decades-long, decreased life expectancy for survivors and their offspring after the genocidal period (Meslé et al., 2012
Concerning approaches to improve health performance, our model is also consistent with past research on development aid. Specifically, Kosack (2003
) concluded that development aid better effects improvements in health (i.e., life expectancy) when combined with increases in rights and freedoms. Kosack further noted that when rights and freedoms are minimal, as in autocracies, aid is ineffective. These latter aid findings are consistent with our model that suggests rights and freedoms provide the core that successively impacts health. Further, our research also contends that improvements in SES and social capital are foundational prerequisites for the growth of rights and freedoms. By extension, our results suggest that development aid targeting improvements in SES and social capital would also benefit growth in rights and freedom. The latter would, then, improve mental and physical health outcomes.
Our results also have implication concerning current thought on mental health trends. For example, Thachuk (2011
) wrote a critical analysis of the recent trend to label mental illness as being exclusively biological in origin. Our findings suggest that mental health (such as suicide, alcohol and tobacco dependencies), to a large extent, also has strong social determinants.
Lastly, our models hold for the variables and countries used in this study. As our sample contained countries located in Europe, North and South America, and the South Caucasus, further study of nations from other regions of the world and other indicators of mental and physical health is necessary. Determining if an additional step, like good governance, exists between rights-freedoms and health outcomes is also warranted. As our findings are cross-sectional, they do not imply causation. However, our results are consistent with studies that have demonstrated causation (Dasgupta and Weale, 1992
) in rights and freedoms leading to better health outcomes.