Somewhere to Live, Something to Do, Someone to Love: Examining Levels and Sources of Social Capital Among People with Disabilities
Social capital has emerged as an important ingredient in the maintenance of physical and mental wellbeing. Although this construct has been studied within the disability community, a comparative analysis of social capital among individuals with disabilities and the general population is missing from the literature. Also sparse is an investigation into the sources from which people with disabilities draw their social capital. Building on the seminal work of political scientist Robert Putnam, a modified version of the Harvard Kennedy School’s Social Capital Community Benchmark Survey was administered to 218 adults with high support needs living with a broad range of disabilities and currently receiving support from one of six disability organizations across the United States and Canada. Chi-squared analyses were conducted to test for differences between observed frequencies and expected frequencies obtained from general population surveys on six key measures of social capital. Results indicate that, in most areas, social capital levels among individuals with disabilities were lower when compared with those of general population respondents. In cases where social capital levels were higher than or comparable to general population respondents, an incongruity between subjective evaluations and quantitative reports, and/or support received from non-normative sources such as parents and professionals are likely explanations. Our findings support continued efforts by rehabilitation professionals to facilitate community integration for people with disabilities through the promotion of friendships and other social relationships in a variety of contexts.
integration for adults with intellectual disabilities resettling into community provision. Journal of Applied Research in Intellectual Disabilities, 14(4), 392-400. doi: 10.1046/j.1468-3148.2001.00082.x
Antaki, C., Finlay, W.M.L., & Walton, C. (2007). The staff are your friends:
Intellectually disabled identities in official discourse and interactional practice. British Journal of Social Psychology, 46(1), 1-18. doi:10.1348/014466606X94437
Appel, L., Dadlani, P., Dwyer, M., Hampton, K., Kitzie, V., et al. (2014). Testing the validity of social capital measures in the study of information and communication technologies. Information, Communication & Society, 17(4), 398-416.
Ashman, A.F., Hulme, P., & Suttie, J. (1990). The life circumstances of aged people
with an intellectual disability. Australia & New Zealand Journal of Developmental Disabilities, 16(4), 335-347.
Atkin, K., & Tozer, R. (2014). Personalization, family relationships and autism: Conceptualising the role of adult siblings. Journal of Social Work, 14(3), 225-242.
Barnes, C., & Sheldon, A. (2010). Disability, politics and poverty in a majority world context. Disability & Society, 25(7), 771-782.
Beart, S., Hardy, G., & Buchan, L. (2004). Changing selves: A grounded theory account of belonging to a self-advocacy group for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 17, 91-101.
Beber, E., & Biswas, A.B. (2009). Marriage and family life in people with developmental
disability. International Journal of Culture and Mental Health, 2(2), 102-108.
Bell, D.M., McKay, C., & Phillips, K.J. (2001). Overcoming the barriers to voting
experienced by people with learning disabilities. British Journal of Learning Disabilities, 29(4), 122-127. doi: 10.1046/j.1468-3156.2001.00127.x
Benedet, J., & Grant, I. (2014). Sexual assault and the meaning of power and authority for women with mental disabilities. Feminist Legal Studies, 22, 131- 154.
Benoit, C., Jansson, M., Jansenberger, M., & Phillips, R. (2013). Disability stigmatization as a barrier to employment equity for legally-blind Canadians. Disability & Society, 28(7), 970-983.
Bourdieu, P. (1986). The forms of capital. In J. G. Richardson (Ed.), Handbook of Theory and Research for the Sociology of Education. New York: Greenwood.
Bramston, P., Bruggerman, K., & Pretty, G. (2002). Community perspectives and subjective quality of life. International Journal of Disability, Development and Education, 49, 385-397.
Bricher, G. (2000). Disabled people, health professionals and the social model of
disability: Can there be a research relationship? Disability & Society 15(5), 781-793. doi: 10.1080/713662004
Brill, J. (2008). Likert scale. In P. Lavrakas (Ed.), Encyclopedia of survey research methods (pp. 428-430). Thousand Oaks, CA: Sage Publications, Inc.
Brisson, D., Roll, S., & East, J. (2009). Race and ethnicity as moderators of neighbor- hood bonding social capital: Effects on employment outcomes for families living in low-income neighborhoods. Families in Society, 90(4), 368–74.
Brown, C. L., & Emery, J. C. H. (2010). The impact of disability on earnings and labour force participation in Canada: Evidence from the 2001 PALS and from Canadian case law. Journal of Legal Economics, 16(2), 19-59.
Burkhauser, R.V., & Stapleton, D.C. (2004). The decline in the employment rate for
people with disabilities: Bad data, bad health, or bad policy? Journal of Vocational Rehabilitation, 20(3),185-201.
Cohen, S. (2004). Social relationships and health. American Psychologist, 59(8), 676-
684. doi: 10.1037/0003-066X.59.8.676
Coleman, J. (1988). Social capital in the creation of human capital. American Journal of Sociology, 94(1), 95–120.
Condeluci, A., Ledbetter, M.G., Ortman, D., Fromknecht, J., DeFries, M. (2008). Social
capital: A view from the field. Journal of Vocational Rehabilitation, 29(3), 133-
Davys, D., Mitchell, D., & Haigh, C. (2011). Adult sibling experiences, roles, relationships and future concerns – A review of the literature in learning disabilities. Journal of Clinical Nursing, 20(19-20), 2837-2852.
d’Hombres, B., Rocco, L., Suhrcke, M., & McKee, M. (2011). Does social capital
determine health? Evidence from eight transition countries. Health Economics, 19(1), 56-74. doi: 10.1002/hec.1445
DeGeorge, K.L. (1998). Friendships and stories: Using children’s literature to teach
friendship skills to children with learning disabilities. Intervention in School and Clinic, 33(3), 157-162. doi: 10.1177/105345129803300304
Donoghue, C. (2003). Challenging the authority of the medical definition of disability:
An analysis of the resistance to the social constructionist paradigm. Disability & Society, 18(2), 199-208. doi: 10.1080/0968759032000052833
Drum, C. E., Horner-Johnson, W., & Krahn, G. L. (2008). Self-rated health and healthy days: Examining the “disability paradox.” Disability and Health Journal, 1(2), 71-78.
Dyda, D. (2008). Jobs change lives: Social capital and shared value exchange. Journal
of Vocational Rehabilitation, 29(3), 147-56.
Egan, J., & Walsh, P. N. (2001). Sources of stress among adult siblings of Irish people with intellectual disability. The Irish Journal of Psychology, 22(1), 28-38.
Emerson, E., McVilly, K. (2004). Friendship activities of adults with intellectual
disabilities in supported accommodation in northern England. Journal of Applied Research in Intellectual Disabilities, 17(3), 191-197. doi: 10.1111/j.1468-3148.2004.00198.x
Epstein, S., & Meier, P. (1989). Constructive thinking: A broad coping variable with
specific components. Journal of Personality and Social Psychology, 57(2), 332–350. doi: 10.1037/0022-35188.8.131.522
Finlay, W. M., & Lyons, E. (2002). Acquiescence in interviews with people who have mental retardation. Mental Retardation, 40, 14-29.
Flaherty, Patti. (2008). Social capital and its relevance in brain injury rehabilitation
services. Journal of Vocational Rehabilitation, 29(3), 141-146.
Folland, S. (2007). Does “community social capital” contribute to population health?
Social Science & Medicine 64(11), 2342-2354. doi:10.1016/j.socscimed.2007.03.003
Fowler, K., Wareham-Fowler, S., & Barnes, C. (2013). Social context and depression severity and duration in Canadian men and women: Exploring the influence of social support and sense of community belongingness. Journal of Applied Social Psychology, 43, E85- E96.
Gambrill, E., & Paquin, G. (1992). Neighbours: A neglected resource. Children and
Youth Services Review, 14(3-4), 253-272. doi: 10.1016/0190-7409(92)90030-Y
Galer, D. (2014). “A place to work like any other?” Sheltered workshops in Canada, 1970-1985. Canadian Journal of Disability Studies, 3(2), 1-30.
Geisthardt, C.L., Brotherson, M.J., & Cook, C. (2002). Friendships of children with
disabilities in the home environment. Education & Training in Mental Retardation & Developmental Disabilities, 37(3), 235-252.
Green, F., & Schleien, S. (1991). Understanding friendship and recreation: A theoretical
sampling. Therapeutic Recreation Journal, 25(4), 29-40.
Hampton, K., Goulet, L.S., Her, E.J., Rainie, L. (2009). Social isolation and new technology. Retrieved from Pew Research Centre website http://www.pewinternet.org/Reports/2009/18--Social-Isolation-and-New Technology/Part-3-Network-Diversity-and-Community/2-Are-internet-users-less- likely-to-participate-in-the-local-community.aspx
Hampton, K., Goulet L.S., Rainie, L., Purcell, K. (2011). Social networking sites and our lives. Retrieved from Pew Research Centre website: http://www.pewinternet.org/Reports/2011/Technology-and-social-networks/Part- 4/Trust.aspx
Hartley, L. S., & MacLean, E. W. (2006). A review of the reliability and validity of Likert-type scales for people with intellectual disability. Journal of Intellectual Disability Research, 50(11), 813-827.
Harvard Kennedy School. (2006). Social Capital Community Benchmark Survey
[Data file]. Retrieved from http://www.hks.harvard.edu/saguaro/pdfs/2006SCCSbanner.pdf
Hawe, P., & Shiell, A. (2000). Social capital and health promotion: A review. Social
Science & Medicine, 51(6), 871-885. doi: 10.1016/S0277-9536(00)00067-8
Hawkins, R. L., & Maurer, K. (2012). Unravelling social capital: Disentangling a concept for social work. British Journal of Social Work, 42, 353-370.
Heal, L. W., & Sigelman, C. K. (1995). Response biases in interviews of individuals with limited mental ability. Journal of Intellectual Disability Research 39, 331- 40.
Heiman, T. (2000). Quality and quantity of friendship: Student and teacher perceptions.
School Psychology International, 21(3), 265-280. doi:10.1177/0143034300213004
Heller, T., & Arnold, C. K. (2010). Siblings of adults with developmental disabilities: Psychosocial outcomes, relationships, and future planning. Journal of Policy and Practice in Intellectual Disabilities, 7(1), 16-25.
Heller, T., & Kramer, J. (2009). Involvement of adult siblings of persons with developmental disabilities in future planning. Intellectual and Developmental Disabilities, 47(3), 208-219.
Hubbard, S. (2004). Disability studies and health care curriculum: The great divide.
Journal of Allied Health, 33(3),184-188.
Irvine, A.N. (2007). Social relationships from the perspective of persons with
developmental disabilities, their family members, educators, and employers (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses Database. (AAINR32981)
Isaac, R., Raja, B.W.D., & Ravanan, M. P. (2010). Integrating people with disabilities: Their right – our responsibility. Disability & Society, 25(5), 627-630.
Kampert, A. L., & Goreczny, A. J. (2007). Community involvement and socialization among individuals with mental retardation. Research in Developmental Disabilities, 28, 278-286.
Kanazawa, S., & Savage, J. (2009). Why nobody seems to know what exactly social
capital is. The Journal of Social, Evolutionary, and Cultural Psychology, 3(2), 118-132.
Karp, D.A. (1994). The dialectics of depression. Symbolic Interaction, 17(4), 341-366.
Kawachi, I., & Berkman, L. F. (2001). Social ties and mental health. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 78(3), 458-467.
Keeley, L.H., Redley, M., Holland, A.J., & Clare, I.C.H. (2008). Participation in the 2005
general election by adults with intellectual disabilities. Journal of Intellectual Disability Research, 52(3), 175-181. doi: 10.1111/j.1365-2788.2007.00991.x
Kelly, S. M. (2013). Labor force participation rates among working-age individuals with visual impairments. Journal of Visual Impairment & Blindness, 107(6), 509-513.
Kenneth, T. R. (2004). Old wine in a slightly cracked new bottle. American Psychologist
Kinne, S., Patrick, D. L., & Doyle, D. L. (2004). Prevalence of secondary conditions among people with disabilities. American Journal of Public Health, 94, 443-445.
Krauss, M.W., Seltzer, M.M., & Goodman, S.J. (1992). Social support networks of adults
with mental retardation who live at home. American Journal on Mental Retardation, 96(4), 432-441.
Kroll, C. (2011). Different things make different people happy: Examining social
capital and subjective well-being by gender and parental status. Social Indicators
Research, 104(1),157-177. doi: 10.1007/s11205-010-9733-1
Kropf, N.P. (1997). Older parents of adults with developmental disabilities: Practice
issues and service needs. Journal of Family Psychotherapy, 8(2), 37-54.
Kulkarni, M. (2012). Social networks and career advancement of people with
disabilities. Human Resource Development Review, 11(2), 138-155.
Lau, K., Chow, S.M.K., & Lo, S.K. (2006) Parents’ perception of the quality of life of
preschool children at risk or having developmental disabilities. Quality of Life
Research: An International Journal of Quality of Life Aspects of Treatment, Care
& Rehabilitation, 15(7), 1133-1141.
Levy, J.M., & Hernandez, B. (2009). Employment and people with disabilities. Journal
of Social Work in Disability & Rehabilitation, 8(3-4), 99-101.
Lin, N. (2001) Social capital: A theory of social structure and action. Cambridge: Cambridge University Press.
Lippold, T., & Burns, J. (2009). Social support and intellectual disabilities: A comparison
between social networks of adults with intellectual disability and those with physical disability. Journal of Intellectual Disability Research, 53(5), 463-473.
Lovell, S. A., Gray, A. R., & Boucher, S. E. (2015). Developing and validating a measure of community capacity: Why volunteers make the best neighbours. Social Science & Medicine, 133, 261-268.
McNair, J., & Smith, H.K. (1998). Community-based natural support through local
churches. Mental Retardation, 36(3), 237-241.
Merriam, S. B., & Kee, Y. (2014). Promoting community wellbeing: The case for lifelong learning for older adults. Adult Education Quarterly, 64(2), 128-144.
Mithen, J., Aitken, J., Ziersch, A., & Kavanagh, A. N. (2015). Inequalities in social capital and health between people with and without disabilities. Social Science & Medicine, 126, 26-35.
Morris, J. (2001). That kind of life? Social exclusion and young disabled people with high levels of support needs. London, England: Scope.
Murayama, H., Fujiwara, Y., & Kawachi, I. (2012). Social capital and health: A review of prospective multilevel studies. Journal of Epidemiology, 22, 179-187.
National Organization on Disability. (2010). Harris Survey of Americans with
Disabilities. New York, NY. Retrieved from
O’Brien, K. (2012). Review of the social cure: Identity health and wellbeing. The
Australian Educational and Developmental Psychologist, 29(1), 79-80.
O’Brien, J., & O’Brien, C.L. (1993). Unlikely alliances: Friendships and people with
developmental disabilities. In A.R. Novak Amado (Ed.), Friendships and community connections between people with and without developmental disabilities (pp. 9-39). Baltimore, MD: Paul H. Brookes Publishing.
Orne, M.T. (2002). On the social psychology of the psychological experiment: With
particular reference to demand characteristics and their implications. Prevention
& Treatment, 35, 1-11. doi: 10.1037/1522-37184.108.40.2065a
Pagan, R. (2013). Time allocation of disabled individuals. Social Science & Medicine, 84, 80-93.
Parris, A.N., & Granger, T.A. (2008). The power and relativity of social capital. Journal
of Vocational Rehabilitation, 29(3), 165-71.
Partington, K. (2005). What do we mean by our community? Journal of Intellectual
Disabilities, 9(3), 241-251. doi: 10.1177/1744629505056697
Pavey, B. (2003). Citizenship and special educational needs: What are you going to
do about teaching them to vote? Support for Learning, 18(2), 58-65.
People First Workers. (1996). Speaking out for equal rights workbook 2, equal people course books. Buckingham: Open University, People First & MENCAP.
Peters, T. (2008). The relationship of self-disclosure and perceived emotional support
to adult wellbeing (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses database. (AAI3333425)
Pew Research Centre. (2005). Pew Research Centre for the People & the Press.
Retrieved from: http://www.people-press.org/2005/04/19/additional-findings-and-analyses/
Pew Research Centre. (2007). Pew Research Social & Demographic Trends [Data
file]. Retrieved from: http://www.pewsocialtrends.org/2007/02/22/americans-and-social-trust-who-where-and-why/
Poortinga, W. (2006). Social relations or social capital? Individual and community health effects of bonding social capital. Social Science & Medicine, 63(1), 255-270.
Potts, B. (2005). Disability and employment: Considering the importance of social
capital. Journal of Rehabilitation, 71(3), 20-25.
Putnam, R. (1995). Tuning in, tuning out: The strange disappearance of social capital in
America. Political Science & Politics, 28(4), 664-683. Retrieved from http://dx.doi.org/10.2307/420517
Putnam, R. (2000). Bowling alone: The collapse and revival of American community.
New York, NY: Simon & Schuster.
Rocco, L., & Suhrcke, M. (2012). Is social capital good for health? A European
perspective. Copenhagen: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0005/170078/Is-Social-Capital-good-for-your-health.pdf
Roper Centre for Public Opinion Research. (2005). Taking America's Pulse III –
Intergroup Relations Survey [Data file]. Retrieved from University of Conneticut, iPOLL Databank: http://www.ropercenter.uconn.edu/data_access/ipoll/ipoll.html
Rosen, J.W., & Burchard, S.N. (1990). Community activities and social support
networks: A social comparison of adults with and adults without mental retardation. Education & Training in Mental Retardation, 25(2), 193-204.
Rosnow, R.L. (2002). The nature and role of demand characteristics in scientific
inquiry. Prevention & Treatment, 5(1), 1-7. doi: 10.1037/1522-37220.127.116.117c
Rossiter, K., & Clarkson, A. (2013). A social history of Huronia Regional Centre. Canadian Journal of Disability Studies, 2(3), 1-30.
Runnion, V.M., & Wolfer, T.A. (2004). Relationship disruption in adults with cognitive
disabilities. Families in Society, 85(2), 205-213.
Saltkjel, T., & Malmberg-Heimonen, I. (2014). Social inequalities, social trust and civic participation – the case of Norway. European Journal of Social Work, 17(1), 118- 134.
Scheffler, R.M., Brown, T.T., & Rice, J.K. (2007). The role of social capital in reducing
non-specific psychological distress: The importance of controlling for omitted variable bias. Social Science & Medicine, 65(4), 842-854.
Schleien, S.J., Heyne, L.A., Rynders, J.E., & McAvoy, L.H. (1990). Equity and
excellence: Serving all children in community recreation. Journal of Physical Education, Recreation, and Dance, 61(8), 45-48.
Schuller, T. (2007). Reflections on the use of social capital. Review of Social Economy, 65(1), 11-28.
Shalock, R. L., Brown, I., Brown, R., Cummins, R. A., Felce, D., Matikka, K. D., Keith, K. D., & Parmenter, T. (2002). Conceptualizations, measurement, and application of quality of life for persons with intellectual disabilities: Report of an international panel of experts. Mental Retardation, 40, 457-70.
Sheppard-Jones, K.H., Prout, T., Kleinert, H., & Taylor, S.J. (2005). Quality of life
dimensions for adults with developmental disabilities: A comparative study. Mental Retardation, 43(4), 281-291.
Shooshtari, S., Naghipur, S., & Zhang, J. (2012). Unmet healthcare and social services
needs of older Canadian adults with developmental disabilities. Journal of Policy and Practice in Intellectual Disabilities, 9(2), 81-91.
Simpson, M. I. (2007). From savage to citizen: Education, colonialism and idiocy. British Journal of Sociology of Education, 28(5), 561-574.
Smith, T.W., Marsden, P.V., Hout, M. (2011). General Social Survey, 1972-2010 [Cumulative data file]. Retrieved from University of Connecticut/Ann Arbor (US), UC Berkeley website: http://sda.berkeley.edu/cgi-bin/hsda?harcsda+gss10
Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent acceptance? Baltimore, MD: Paul H. Brooks.
Stainback, W., & Stainback, S. (1987). Facilitating friendships. Education and Training
in Mental Retardation, 22(1), 18-25.
Statistics Canada, Social and Aboriginal Statistics Division. (2008). General Social Survey, Cycle 22 – Social Engagement [Data file]. Retrieved from
Stewart, N. (1985). Winning friends at work. New York, NY: Ballantine Books.
Stewart, J., & Russell, M. (2001). Disablement, prison, and historical segregation. Disablement, Prison, and Historical Segregation, 53(3), 1-7.
Stone, H.W., Cross, D.R., Purvis, K.B., Young, M.J. (2003). A study of the benefit of
social and religious support on church members during times of crisis. Pastoral Psychology, 51(4), 327-340. doi:10.1023/A:1022537400283
Stroman, D. F. (2002). The disability rights movement: From deinstitutionalization to self-determination. University Press of America.
Svendsen, G., & Sorensen, J.F.L. (2006). The socioeconomic power of social capital: A
double test of Putnam's civic society argument. International Journal of Sociology and Social Policy, 26(9/10), 411-429. doi: 10.1108/01443330610690550
Syrotuik, J., & D’Arcy C. (1984). Social support and mental health: Direct, protective
and compensatory effects. Social Science & Medicine, 18(3), 229-236.
Taylor, S.J., & Bogdan, R. (1989). On accepting relationships between people with
mental retardation and non-disabled people: Towards an understanding of acceptance. Disability, Handicap & Society, 4(1), 21-36.
Todd, S. (2000). Working in the public and private domains: Staff management of community activities for and the identities of people with intellectual disability.
Journal of Intellectual Disability Research, 44(5), 600-620.
Tozen, R., Atkin, K., & Wenham, A. (2013). Continuity, commitment and context: Adults siblings of people with autism plus learning disability. Health & Social Care in the Community, 21(5), 480-488.
van Alphen, L.M., Dijker, A.J.M., van den Borne, H.H.W., & Curfs, L.M.G. (2009). The significance of neighbors: Views and experiences of people with intellectual disability on neighboring. Journal of Intellectual Disability Research, 53(8), 745-
757. doi: 10.1111/j.1365-2788.2009.01188.x
Verdonschot, M.M.L., de Witte, L.P., Reichrath, E., Buntinx, W.H.E., & Curfs, L.M.G. (2009). Community participation of people with an intellectual disability: A review of empirical findings. Journal of Intellectual Disability Research, 53(4), 303-318. doi: 10.1111/j.1365-2788.2008.01144.x
Victor, C.R., Scambler, S.J., Bowling, A., & Bond, J. (2005). The prevalence of, and risk
factors for, loneliness in later life: A survey of older people in Great Britain. Ageing & Society, 25, 357-375. doi: 10.1017/S0144686X04003332
Walker, H.M., Calkins, C., Wehmeyer, M.L., Walker, L., Bacon, A., Palmer, S.B., …
Johnson, D.R. (2011). A social-ecological approach to promote self-determination. Exceptionality, 19(1), 6-18. doi: 10.1080/09362835.2011.537220
Walker, R.B., & Hiller, J.E. (2007). Places and health: A qualitative study to explore how
older women living alone perceive the social and physical dimensions of their neighbourhoods. Social Science & Medicine, 65(6), 1154-1165.
Webber, M., Reidy, H., Ansari, D., Stevens, M., & Morris, D. (2015). Enhancing social networks: A qualitative study of health and social care practice in UK mental health services. Health & Social Care in the Community, 23(2), 180-189.
West, M., Kregel, J., Hernandez, A., & Hock, T. (1997). Everybody's doing it: A national
study of the use of natural supports in supported employment. Focus on Autism and Other Developmental Disabilities, 12(3), 175-181.
White, G. W., Simpson, J. L., Gonda, C., Ravesloot, C., & Coble, Z. (2010). Moving
from independence to interdependence: A conceptual model for better
understanding community participation of centers for independent living
consumers. Journal of Disability Policy Studies, 20(4), 233-240.
World Health Organization. (2001). International Classification of Functioning.
Retrieved from http://www.who.int/classifications/icf/en/
World Health Organization and World Bank Group. (2011). World Report on Disability. WHO: Geneva.
Williams, J.M. (2008). Building social capital: The communityworks, inc. experience.
Journal of Vocational Rehabilitation, 29(3), 157-163.
Ziersch, A. M., & Baum, F. E. (2004). Involvement in civil society groups: Is it good for your health? Journal of Epidemiological Community Health, 58, 493-500.
Ziersch, A.M., Baum, F.E., MacDougall, C., & Putland, C. (2005). Neighbourhood life
and social capital: The implications for health. Social Science & Medicine, 60(1), 71-86. doi: 10.1016/j.socscimed.2004.04.027