SOCIAL CAPITAL AND ITS RELATIONSHIP WITH HEALTH-RELATED BEHAVIORS IN RURAL UTTAR PRADESH, INDIA by Md Zabir Hasan A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland April 2019 © 2019 Md Zabir Hasan All Rights Reserved Abstract Social capital has become one of the most contested concepts in the social sciences. This multidimensional concept can be theorized both at the individual and community level. At the individual level, social capital is defined as the embedded resources available through one’s social network. And at the community level, it means the characteristics of the social relations within and among groups featured by trust and norms which can be leveraged for coordinated action for collective benefit. While in economics and political science the concept of social capital has a longer history, the role of social capital in global health became more imperative in 2010 after the World Health Organization acknowledged it as a determinant of health and inequity. It is essential to recognize the role of social capital to understand how individuals and communities adopt and sustain health-related norms, acquire information and social support to overcome barriers to health services. Considering social capital as a critical determinant of health, the three papers of this dissertation explored the nuance of measurement of social capital across gender and its relationship with health behavior in the state of Uttar Pradesh (UP), India. The analysis of these three papers was based on a cross-sectional baseline household survey for a multi-sectoral rural development initiative, known as Project Samuday. The household survey was conducted among 6,218 household heads (≥18years) and all women between 15-49 year of age (n = 6,826) from 6,218 randomly selected households in two rural districts of UP, Hardoi and Sitapur. After receiving verbal informed consent, trained data collectors implemented a multi-module questionnaire designed to collect demographic information, health behavior and social capital of the respondents. The aim of Paper 1 was to understand the performance of “Shortened Adapted Social Capital Assessment Tool in India” (SASCAT-I), while measuring social capital across gender using a measurement invariance analysis. Organizational Participation, Social Support, Trust and Social Cohesion – emerged as four uniquely identified factors of social capital. However, measurement invariance analysis demonstrated the concept of Organizational Participation and Social Support were ii similar across gender, but the perception of Trust and Social Cohesion were different for men and women. Paper 2 examined the association of individual and community-level social capital with infectious or communicable disease-related preventive care seeking behavior – receiving all three diphtheria–pertussis– tetanus (DPT3) vaccines – among 12-59 month children using multilevel logistic regressions. We found a higher community level Organizational Participation and Social Cohesion of the mothers were associated with a child’s odds of receiving all three DPT vaccines. Whereas, individual mother’s Organizational Participation was negatively associated with DPT3 vaccination status. Paper 3 explored the role of social capital and social influence on non-communicable disease (NCD) related health behavior – tobacco use – among 6,218 household heads (≥18 years). The social influence of tobacco consumption was measured by “non-self” cluster proportion of tobacco use in the community. The explanatory power of the social capital and social influence on tobacco consumption was assessed using generalized linear (logistic) models with Huber/White/sandwich robust variance estimator. The social influence had a positive and significant association with an individual’s tobacco consumption. Beyond the effect of social influence, we also found Organizational Participation of individual household heads had an independent and positive association with tobacco consumption. Contributing to the tradition of establishing measurement invariance of any psychosocial constructs, this dissertation is the first of its kind to addresses the possible measurement bias across gender of SASCAT-I. The findings suggest – the perception of social capital varied across gender specifically for Trust and Social Cohesion. We found Organizational Participation and Social Cohesion, had significant relationships with health care-seeking behavior, though they were not always positive. Furthermore, instead of calculating the raw scale score by summing or taking a mean of item scores, factor analysis should be used to analyze data collected by SASCAT-I to account the multidimensionality of social capital. Despite the nuances of definition and measurement, exploration of social capital is particularly important to understand the effectiveness of health system interventions and the capacity of individuals and communities to bring positive changes in their life. iii Committee of dissertation readers Committee Members: Krishna D. Rao, PhD, MSc (Advisor) Assistant Professor, Department of International Health Saifuddin Ahmed, PhD (Committee Chair) Professor, Department of Population, Family and Reproductive Health Shivam Gupta, MD, PhD Associate Scientist, Department of International Health Jeannie-Marie Leoutsakos, PhD Associate Professor, School of Medicine Alternate Committee Members: Marie Diener-West, PhD Professor, Department of Biostatistics Caitlin Elizabeth Kennedy, PhD Associate Professor, Department of International Health iv Acknowledgment Who not to acknowledge for the accomplishment of this dissertation? – It is an existential question for me. My journey of the doctoral program and completion of the dissertation would not be possible without the support and assistance of many. First of all, I would like to acknowledge my advisor, Dr. Krishna Rao. Your guidance has been instrumental for me to survive the long haul of the doctoral program. I am immensely grateful for your mentorship which challenged me to think beyond numbers and ground my research into reality. Apart from my advisor, I want to thank Dr. Shivam Gupta humbly. Without his support, none of this would have been possible. I have learned so much from him – either in the class or in the course of the fieldwork or during the long conversations we had about social capital and what that means. I want to acknowledge all the faculty members who contributed to my dissertation while serving in different committees. My sincerest gratitude goes to Drs. Caitlin Elizabeth Kennedy, Jeannie-Marie Leoutsakos, Lorraine T. Dean, David Peters, David M. Bishai, Saifuddin Ahmed and Marie Diener-West. Your critical insights and thoughtful input enriched my work, and I will always be grateful for your support. Apart from them, I want to thank Drs. Danielle German, Peter Winch, Diwakar Mohan, Ligia Paina and Kerry Scott for providing valuable inputs and reviewing my work in different phases of my dissertation. I would like to thank Drs. David Peters, Courtland Robinson, Abdulgafoor M. Bachani, Maria Merritt and Joanne Katz for the organizational supports and motivations which enabled me to complete my doctoral journey. And a special thanks goes to Cristina Salazar for her administrative support and inspirational words. Your smile always brightened my day!!! During my fieldwork in India, I received exceptional support from many. I will take this opportunity to express my gratitude to HCL foundation (HCLF) and Project Samuday. Their work on the economic and social development of rural areas of Uttar Pradesh, India is an inspiration for public health. I would like to thank Navpreet Kaur, Alok Varma, Akshay Ahuja, Kunal Saini, and others in the HCLF v team for being a supportive collaborator. To my colleagues whom I met during the Project Samuday – Dr. Arindam Das, Ranjan Kumar Prusty and Samresh Rai – thank you so much for supporting me in the field with your experience and prudence. I am also grateful to Kantar Public, our collaborating data collection agency, and their extraordinary team of researchers and data collectors. And I am forever indebted to all the research participants from Hardoi and Sitapur district of Uttar Pradesh. It is not possible for me to repay the men and women of rural Uttar Pradesh for their time and patience. For their warmth and hospitality, Lucknow and Uttar Pradesh will always be in my heart. I humbly acknowledge the financial contribution of Fogarty International Training Center (2D43TW007587-06) which supported my education and living during my doctoral training. I express my gratitude to the principal investigators of this grant, Dr. Robert Black and Dr. Abdullah Baqui. Their generous support and guidance cannot be measured by any means. I will also take this opportunity to thank my mentors from the James P. Grant School of Public Health – Drs. Malabika Sarker, Alayne Adams, and Sabina Faiz Rashid. You all helped me to be the researcher I am today. You are my inspirations, and it is my honor have you as my mentors. To my fellow students of health systems and international health – I thank you from the bottom of my heart to be a part of my journey. I want to thank Douglas Glandon for being a fantastic teammate especially. You are a relentless force of positivity. And a special thanks goes to Dr. Avril Kaplan, my fellow social capital aficionado. Your knowledge and determination always motivated me, and I have learned