Communities and hospitals: social capital, community accountability, and service provision in U.S. community hospitals

Health Services Research, Oct, 2004 by Shoou-Yih D. Lee, Wendy L. Chen, Bryan J. Weiner

Despite its brief existence, the Clinton administration's health care reform gave rise to a renewed interest in containing the self-serving interests of health care organizations and in promoting those organizations' accountability toward serving the health needs of local populations (Bogue et al. 1997). Community hospitals have been the target of local communities' demand for accountability, in part because of the central role they play in health care delivery (Harshberger 1997). The demand is amplified by the trend of mergers and conversions from nonprofit to for-profit status in the 1990s (Pittman 2003), and the concern that control of many community hospitals by national or regional corporations may sever the ties of those hospitals to local communities and reduce their response to the health needs of local populations (Proenca 1998; Spitz 1997; Steinberg and Baxter 1998).

Whether community hospitals are accountable to local communities has been a political debate and has attracted research attention. Studies have investigated the variation of community accountability in hospitals, focusing on how such variation is related to hospitals' organizational attributes (Alexander, Weiner, and Succi 2000; Lee, Alexander, and Bazzoli 2003; Proenca, Rosko, and Zinn 2000). However, little attention has been paid to community-wide structures and the role of local communities in ensuring hospitals' accountability. It is as though all the efforts to promote or maintain a satisfactory level of community accountability are assumed to originate in the hospital sector; local communities--while their welfare is immediately concerned-are implicitly viewed as an irrelevant or a silent partner in the quest to promote greater responsibility among hospitals for local community health.

In contrast to this assumption, evidence has appeared to suggest a potentially active role of communities in influencing hospital behavior and a strong link between community structures and hospitals' response to local health needs. Steinberg and Baxter (1998), as part of the Community Tracking Study, reported that in places such as Lansing, Michigan; Syracuse, New York; and Boston, Massachusetts, the community's coordinated efforts to promote hospital accountability had influenced individual hospitals' decision making, resulting in better access to care for vulnerable populations and greater responsiveness of hospitals to community standards of performance in cost and quality. Using data from the 1996 Household Survey of the Community Tracking Study conducted in 22 metropolitan areas, Hendryx et al. (2002) found a strong association between reported access to health care and the level of social capital in those areas. The researchers suggested that a high degree of social capital in the community might increase residents' access to care, possibly through improved accountability mechanisms (i.e., involvement in the generation, dissemination, and utilization of community health information) in community hospitals.

Despite these findings, several questions remain. First, the results were observed in urban areas. Whether they are applicable to rural communities is unclear. Second, Hendryx et al.'s (2002) speculation that hospitals in communities with greater social capital would be more likely to implement accountability mechanisms remains unexamined. Third, if community social capital is positively associated with hospitals' community accountability, does the relationship vary by hospitals' organizational attributes? For example, governing boards are often considered the locus of community control on hospitals. Thus, hospitals with greater community representation on the board may be more responsive to community social capital and more involved in activities that promote community health.

These questions were addressed in this study. The study sample included community hospitals operating in urban as well as rural areas, ensuring greater generality in our results than studies focusing on urban communities. Building on Hendryx et al. (2002), we examined the relationship between social capital and the accountability mechanisms in community hospitals. To shed light on how social capital might enhance community health through its influence on community hospitals, we included in our dependent variables the actual provision of community-oriented health services in hospitals. Finally, examining the variant effects of community social capital by hospital attributes would help identify opportunities and barriers to improving hospitals' contribution to community health.

THEORETICAL BACKGROUND AND HYPOTHESES

Social Capital and Hospital Community Accountability

The concept of social capital was popularized in the 1980s by Bourdieu (1983) and Coleman (1988, 1990), and more recently by Putnam's (2000) seminal book, Bowling Alone, that analyzed the transformation of America's civic society. Despite its short history, the concept has been deployed in many fields to examine a wide range of issues such as education, economic development, social mobility, civic engagement, health, community stability, public housing, and organizational competitiveness, and innovation (Baron, Field, and Schuller 2000).