Social capital and life satisfaction: a cross-sectional study on persons with musculoskeletal impairments in Hanoi, Vietnam

In Vietnam, the number of persons with disabilities was estimated approximate 5,333,000 which was equivalent to 6.4% of the total population [4]. We targeted persons with disabilities who belonged to disabled people's groups in Hanoi, the capital city of Vietnam. The Ordinance on Disabled Persons in Vietnam defines persons with disabilities as those having 'defective of one or many parts of the body or functions which are shown in different forms of disability, and which reduce the capability of activity and cause many difficulties to work, life and studies [4].' The distribution of general types of disability in Vietnam was reported as follows: mobility 42%, learning 23%, hearing 22% and visual 7% in 2006 [22]. We particularly focused on musculoskeletal impairment, which could cause mobility disability and physically limit social participation.

Inclusion criteria included having one or more musculoskeletal impairments, belonging to a disabled people's group under DP Hanoi, and being over 18 years old. We excluded those with other kinds of disabilities such as visual, hearing, and intellectual disabilities.

Among 22 disabled people's groups under DP Hanoi, nine groups were run by and for persons with musculoskeletal impairments. Two hundred and thirty-two members were registered in the nine groups. We tried to contact all of them in the regular or special meetings of each group from June to July 2008. After the meetings, the group leaders contacted those who did not attend the meetings and recruited them individually. In the end, we contacted 152 members (65.5%) and 136 of them (58.6%) agreed to participate in this study and met the criteria.

We obtained ethical approval from the ethical committee of the University of Tokyo. We explained the study objectives to all participants, and obtained their informed consent. Two authors (KT and NTMT) supervised all aspects of the data collection.

We developed a self-administered questionnaire and had it translated from English into Vietnamese. The questionnaire was developed to measure social capital, life satisfaction, socio-economic factors, and disability-related factors. In February 2008, we pre-tested the questionnaire among 21 persons with musculoskeletal impairments in targeted disabled people's groups to enhance its validity and reliability. For those who could not write, we allowed them to be physically supported by personal assistants with their verbal responses.

Table 2 shows the characteristics of the 136 participants by gender. The mean age was 36 (SD 13.3) years old. All study participants were literate and 31 (22.8%) had graduated from a university. One hundred and seven (78.7%) had a job such as bicycle repair and shop assistant, and 80 (58.8%) had a regular job or lived on a pension, which provides regular income. The causes of participants' impairments varied such as polio, angiopathy, and injury by traffic accidents or war; accordingly, types of impairment varied such as deformation, amputation, and paralysis. Of the total, 43 (31.6%) were disabled at birth, and 70 (51.5%) had two or more disabled parts. Ninety (66.2%) who had the maximum score of the Barthel Index did not need any help with ADL.

In the binary analysis, we found significant associations between several variables and life satisfaction. As shown in Table 3, educational level (p = .009) was significantly associated with life satisfaction. Those with high education, especially the university graduates, were more likely to have higher life satisfaction. Regarding disability-related factors, ADL (p = .013) and indoor moving status (p = .015) were significantly associated with life satisfaction. Those who were physically independent were inclined to have higher life satisfaction.

Table 4 demonstrates the association between social capital and life satisfaction. Out of the five items of structural social capital, 'group membership' (p < .001) and 'support from groups' (p = .048) were significantly associated with life satisfaction. Those who were active members of two or more groups had higher life satisfaction than those who actively participated in only one group or who did not actively participate in any groups. Similarly, those who received support from two or more groups were inclined to have higher life satisfaction. Regarding the four items of cognitive social capital, 'sense of belonging' (p = .017) to their community was observed as a significant contributor to high life satisfaction. The one hundred and seven participants (78.7%) who felt themselves to be a part of their community were more likely to have higher life satisfaction.

Table 5 shows the result of the multiple regression analysis. Since multicolinearity was found between 'group membership' and 'support from groups' (Pearson's correlation = .728), we excluded 'support from groups' from the regression model. The model's R² was .233, and the significance of the model was confirmed with ANOVA (p = .012). As a result, only 'group membership' was significantly associated with life satisfaction (Standardized Beta = .26, t = 2.01, p = .041). The effect of other variables was considerably weakened although 'educational level (university)' remained close to the significant level (Standardized Beta = .24, t = 1.82, p = .073).

In this study, one of the structural social capital components, 'group membership,' was significantly associated with life satisfaction even after controlling for confounding factors. Specifically, being an active member of two or more groups was associated with higher life satisfaction. This finding indicates that the number of groups to which an individual actively belongs could differentiate the life satisfaction. Those who had higher life satisfaction were active members of not only disabled people's groups but also other types of groups, such as religious groups and sports groups. Being an active member of these groups in addition to disabled people's groups could lead to higher life satisfaction. In contrast, those who thought they were not active members of any group and those who thought they were active members of only one group were more likely to have lower life satisfaction. Furthermore, this finding can be interpreted as showing a positive effect of social participation on life satisfaction. Persons with musculoskeletal impairments are more likely to be socially isolated because of their impairments and a potentially unfriendly environment around them, such as physical barriers to access or personal prejudice [30]. Whether persons with musculoskeletal impairments can participate in society through group activities, therefore, can significantly affect their life satisfaction.

Other components of structural social capital such as 'support from individuals' and 'citizenship activities' were not significantly associated with life satisfaction. Although direct evidence is lacking, we interpret these results as follows. Regarding 'support from individuals,' the term 'support' might have been understood narrowly by persons with musculoskeletal impairments. Our participants received physical support from others to the extent that they needed it. That situation might have caused them to think that 'support' meant just physical support. As for 'citizenship activities,' the inaccessibility to citizenship activities in Vietnam should be reconsidered [31]. In Vietnam, it is essential for citizens to have a connection with authorities such as head members of the Communist Party to make any action in their community. The participants who did not have any personal connection with authorities could have an opportunity to meet with authorities in certain official meetings which attached great importance to formality. However, they might know that the discussion in those meetings meant a little compared to personal connection with authorities. Similarly, distinct administrative division of community builds a barrier between communities. De Silva et al. [32] have pointed out the low level of 'citizenship activities' in Vietnam, especially related to talking to the authorities. Persons with musculoskeletal impairments could unilaterally make a decision related to 'group membership;' however, participation in 'citizenship activities' requires the willingness of others to collaborate. This difference may explain why 'citizenship activities' did not affect life satisfaction.

Cognitive social capital plays a crucial role in mental health [33]; however, none of the cognitive social capital components were significant in our multiple regression analysis. Since cognitive social capital is related to one's subjective perception of the community, the term 'community' should be carefully defined. While we defined the term 'community' as the official commune in Vietnam, the perception of the official commune might be different from the 'community' especially in persons with musculoskeletal impairments. For example, we measured a sense of belonging to the community with the question 'Do you feel as though you are really a part of this community?'. However, persons with musculoskeletal impairments could feel a sense of belonging not only to the official commune but also to various types of informal communities. For instance, the virtual community of the Internet might be important because of its greater ease of access for some persons with musculoskeletal impairments [34]. To assess the actual impact of cognitive social capital on the life satisfaction of persons with musculoskeletal impairments, the appropriate definition of the term 'community' should be carefully considered.

Persons with musculoskeletal impairments may face difficulties in continuing their education due to inaccessibility and discrimination [30]. The literacy rate has reached over 90% in Vietnam [22, 35]; however, it is still not known how many persons with or without musculoskeletal impairments do not go to university and for what reasons. In Vietnam, universities provide useful opportunities for social participation. For example, two out of nine disabled people's groups that we targeted in this study were university-based, and the majority of members of those two groups were talked into joining the groups by peers in the same university. Although we did not find a significant association between educational level and life satisfaction in our multiple regression analysis probably because people with high education were likely to have more opportunities to participate in various groups such as sports group in university, equal access to higher education for persons with musculoskeletal impairments remains an important factor in their social participation.

The findings of this study, however, should be interpreted carefully. First, this study did not consider whether a participant could recover from the musculoskeletal impairment. Most participants were living with musculoskeletal impairments that were medically stable but likely permanent. Social factors may play a different role among persons with recoverable musculoskeletal impairments because they tend to focus more on medical factors. Second, this study was conducted only with the members of disabled people's groups in the capital city. Therefore, caution is needed to generalize our findings to the other populations such as persons without musculoskeletal impairments, persons with musculoskeletal impairments who do not belong to any group, and persons with musculoskeletal impairments in rural area. Third, our analysis does not show the relationship between specific combinations of groups and life satisfaction since it included data on the actual number of groups each participant actively participate in without making any combinations of groups. Fourth, this study was a cross-sectional study which cannot clarify the actual causality. Although we found a significant association between particular variables and life satisfaction, we must use additional research methods such as case studies and in-depth interviews, and further longitudinal studies are necessary to clarify the impact of social capital on life satisfaction.