PUBLIC HEALTH IN LATROBE VALLEY: A FOCUS ON CITIZENRY PARTICIPATION & SOCIAL CAPITAL

Bonnie Rowe, March 2019

The purpose of this research is to explore the link between participatory democracy and social capital, in the context of public health. This paper will explore the existing literature and present a case study on the Latrobe Health Assembly (LHA), a 45-person participatory forum established in Latrobe Valley, Victoria in 2017. The fledgling LHA is considered to be a public health innovation, given that an initiative such as this has not been trialled elsewhere in Australia in the context of responding to complex public health and social issues.

The LHA was established with the express intent of giving local community members a voice in health and wellbeing decisions that affect them, ideally leading to improvements in health outcomes. The LHA aims to realise this vision by creating a participatory forum for community members to have a say in decisions related to health and wellbeing in the region.

Evidence shows considerable interconnectedness between three research paradigms at play in the context of the LHA; that is, participatory democracy, social capital and public health. Field (2016) defines social capital as ‘a way of defining the intangible resources of community, shared values and trust upon which we draw in daily life.’ This paper will focus on three aspects of trust: one, intra-group bonding within social groups; two, inter-group linking across groups of similar status; and three, inter-group bridging across cleavages of social division.

Research, including that by Putnam (2000) in his seminal text Bowling Alone, suggests that epidemiological gains are possible when social capital is higher. This may be due to links with social determinants of health, such as social and community context and neighbourhood and built environment. Overall improvements in mental health, reduced chronic disease, reduced loneliness, as well as other broader social gains such as reduced crime rates are all revealed as potential outcomes. Many researchers, including Putnam himself, posit that social capital and empowerment through participation are contributing factors in the context of these reported improvements.

Analysis of the literature in relation to opportunities for potential improvements in health outcomes reveals four themes. The review will consider these themes, in the context of public health, and consider what elements are necessary for participatory endeavours to ultimately achieve improvements in public health outcomes. This paper will consider the thread that runs through these themes, in a bid to determine the elements of a conceptual lens that can translate to practical, tangible real-world application. This lens will then be applied to a case study of the LHA. 

The case study will draw on interviews with seven community members, as well as existing secondary data related to community perceptions of the LHA. The purpose of the case study is firstly to explore perceptions of the process to establish the LHA as a participatory body, and secondly, to understand whether its establishment has led to increases in social capital, namely trust and reciprocity. In particular, the case study will explore bonding versus bridging social capital, as it relates to the LHA, noting that research suggests that bridging social capital is a necessary precursor for community-wide public health improvements.

In concluding, the paper will draw together insights from the literature and the LHA case study. The overarching objective of this research is to continue to add to the emergent body of literature on the process to invite citizen participation and the potential health and wellbeing outcomes that may occur as a result of successfully doing so, in the context of public health policy.

Improving public health through participation and social capital

‘A healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum potential’, World Health Organisation (WHO, 2019)

For many years, shifts in approaches to complex issues related to public health have reflected a similar trend towards a greater emphasis on understanding the sociological drivers underpinning the health of communities. So much so, it is now widely recognised that a focus on the social determinants of health is necessary when attempting to facilitate positive public health outcomes. This means that, more and more, consideration is being given to the other factors, beyond simply investing in health services, which contribute to the development and maintenance of good public health outcomes.

As the WHO recognises, it is indeed sociological factors, those which ‘enable people to support each other’, that deserve equal time and attention in the context of public health policy. These social factors include, but are not limited to, engaged and empowered citizenry and prospering social capital. It is at the nexus of participation and social capital that the establishment and ongoing operations of the LHA will be considered. The LHA, which was established following a government inquiry into a coalmine fire that burned for 45 days, intends to offer an alternative mode of citizen engagement and decision making, in the hope of making inroads into many long standing health and social issues in the region.

The literature is resoundingly consistent. There is much empirical support for the link between social capital and positive societal outcomes, which includes health and wellbeing gains. Putnam (2000) devotes considerable attention to this point in Bowling Alone. In his book, which takes a purely American-centric view, Putnam suggests that states with higher social capital indexes experience societal gains across a large number of indicators – providing examples of reduced percentages of low-birth-weight babies, reduced infant mortality, less premature death by suicide or homicide and even reductions in the number of heart attacks. Australian research by Cuthill (2003) further highlights the link between both social and human capital, and its interrelatedness with community well-being.

There appears to be significant support in the research that links social capital specifically to trust, amongst other things (Putnam, 2000). It is this link that many authors contend forms the basis of the improvements in public health outcomes. Blacksher (2013) contends that social capital, and more specifically, participation has been integral to public health policy for over six decades. In fact, on this point, Blacksher (2013) concludes that its virtue has been enshrined in the World Health Organisations Declaration of Alma-Ata.

At point three in the declaration, the ‘right and duty to participate individually and collectively in the planning and implementation of their health care’ is set out. This highlights that for at least the past forty years, it has been recognised that participation, voice and empowerment in decisions that affect one’s health are essential to the attainment of health and wellbeing, in the broadest sense of the word. Wilkinson (1996) finds that social and economic structures continue to be the most powerful influence on health, finding that exploring the determinants of health through social science continues to be warranted.

One of the examples that Putnam draws on in Bowling Alone emanates from Roseto, Pennsylvania. Here he gives the example of statistically significant fewer heart attacks occurring within this community, which numerous studies have indicated are not due to substantial differences in lifestyle choices. Instead, it has been found that the community displays higher levels of social capital, with the community perceived to be ‘tight knit’ (Putnam, 2000). Putnam asserts that, overall, ‘public health is better in high-social-capital states’ (Putnam, 2000). Szreter and Woolcock (2004) build on this, positing “in none is the importance of social connectedness so well established as in the case of health and well-being”.

Here, the authors suggest that social capital is synonymous with other sociological concepts, such as cohesion, social support, integration or civil society. The authors review the literature, and through their work, identify that social capital has been linked to a significant range of population health outcomes. These include improved child development, increased adolescent well-being, increased mental health, reduced overall mortality, lower susceptibility to binge drinking, reductions in rates of depression, reduced self-reported loneliness, reduced risks from chronic and degenerative conditions and reduced rates of smoking.

Of particular relevance to Latrobe Valley, in regional areas where social capital is lower, higher levels of stress and isolation have been reported, along with decreases in children’s welfare (Szreter and Woolcock, 2004). Suffice to say, based on the empirical evidence, which Szreter and Woolcock (2004) suggests is “impressive” in terms of the ‘volume and diversity’, social capital appears to be an important determinant of public health.

Since the Declaration of Alma-Ata, there have been gains related to citizens having opportunity to participate in health-related decisions, yet participation is by no means systemic. To illustrate this point, Florin and Dixon (2004) provide examples of how the National Health Service (NHS) in the United Kingdom has attempted to include patients and the public through multiple means, yet on the whole these endeavours appear to be underwhelming.

Examples provided by the authors include the statutory obligation on NHS organisations to consult with patients and the public during health service planning; the establishment of the Patient Advisory and Liaison Services; the establishment of the Independent Complaints Advocacy Service; patient forums being established to bring patient’s perspectives; and the establishment of The Commission for Patient and Public Involvement in Health to set standards, provide training, and monitor new arrangements (Florin & Dixon, 2004).

These examples demonstrate that the approach to citizen participation in health and wellbeing policy setting and implementation can occur across a continuum, that is, there are both proactive approaches (patient forums) and reactive mechanisms (Complaints Advocacy Service). At one end of the continuum, examples such as the Brazilian Health Councils, exist. These councils demonstrate how health policy and resource allocation can be set following participation from across civil society groups, health and wellbeing providers, and government officials, although several studies have indicated that these councils are not particularly influential in the context of healthcare policy (Martinez & Kohler, 2016). At the other end of the continuum, reactive bodies, such as complaints commissioners, reside. On the face of it, it would appear that while the intention to include citizens in health policy decision making is admirable, execution is inconsistent. This may be because, as yet, there is no comprehensive evidence base to justify why such mechanisms are being attempted. 

While trials to increase participation of citizens may vary in terms of design, implementation and efficacy, many authors recognise that participation is necessary in relation to the advancement of the broader health equity and social justice agenda (Blacksher, 2013; de Leeuw & Wise, 2015). De Leeuw and Wise (2015) suggest that both participatory and deliberative processes improve how resources are allocated, leading to greater health equity. Notably, there is diversity in terminologies used to reference participation and deliberation within a health policy context, in fact, the list is quite extensive (Blacksher, 2013). Terms Blacksher (2013, p.2) identifies include:

…citizen engagement, collaborative decision-making, public participation, public involvement, public deliberation, deliberative engagement, deliberative democracy, community engagement, community organizing, community empowerment, participatory research, participatory governance, and participatory budgeting, among others.

The variation in terminology across this list suggests that a common language or shared understanding of participation in the context of health has not yet been established, given the range and nuance in meaning suggested through the various terms. Nonetheless, consideration of alternate mechanisms for engaging with community through participation (as a process), in a bid to improve social capital (as an outcome), is not a nascent area of study. There are numerous examples where alternative modes of governance have been attempted, in a bid to achieve something other than incremental changes in public health.

Based on this, it is clear that a policy impetus exists and more detailed analysis of the literature is warranted, in order to understand the elements of participation and social capital that can lead to improvements in health outcomes. To this end, reading studies of political science and public health reveals four themes when considering the necessary factors or conditions under which participatory democracy is suitable in the context of public health policy. These include:

1. An impetus for new modes of citizen engagement: participation, deliberation and associationalism
2. Questions of origin: top down (liberal) versus bottom up (social)
3. Philosophical differences: the ‘social capital’ spectrum
4. Sociological structures: bonding, bridging, linking and trust

An exploration of each of these themes will now be presented. The themes will then be used to inform the case study of the LHA.

An impetus for new modes of citizen engagement: participation, deliberation and associationalism

The tide seems to be turning in established Western democracies. In the face of rising populism and surging protest votes, citizens are displaying a general malaise towards (or of more concern, revolt against) traditional structures of representative democracy (van der Meer & Thompson, 2017).

This demise is apparent through declines in voter turnout and party membership across the board. On this point, suggests Zittel and Fuchs (2007), there are few trends as well established in comparative politics.

These emerging trends in democratic ideals largely demonstrate rising citizen apathy toward existing forms of representation. All too frequent is the cry that ‘the elite’ no longer represent the views of the people, that they are too far removed, or ‘out of touch’ with the citizenry to which they outwardly espouse service. Zittel and Fuchs (2007) provide a somewhat pessimistic view on the matter, claiming that representative democracy is in fact ‘a system of government in crisis’. Other authors, including van der Meer, Zittel, Fuchs, Fukuyama, Putnam, Blacksher and Cornwall all contend, to a greater or lesser extent, that declining political trust is undermining the utility of representative democracy.

In response, scholars and citizens alike are looking to alternative forms of governance, hoping to identify methods to repair trust, restore balance and reconfigure the manner in which the voice of the people is heard within the parliament. Alternative forms of democracy posited through the literature as the new frontier include forms of participatory and deliberative democracies, and to a lesser and more emergent extent, associationalism.

Participatory democracy emerged in the literature as a viable alternative to representative democracy in the 1960s and 70s, driven in part by the cultural quest for more democracy and greater equality in political opportunity and power (Zittel, 2006). Participation, in this sense, is conceived as the opportunity to invite citizen engagement in political decision making, in a bid to create a greater sense of collective responsibility. Participatory theory suggests direct participation of citizens in a broad range of civic decisions, including the regulation of key societal institutions (He, 2002). The inclusion of citizens more actively in the political sphere may, in part, help to rebuild political trust, which has been in decline for decades in many democracies around the world (van der Meer & Thompson, 2017).

Deliberative democracy can be conceptualised as an extension of participation, in that it provides citizens with a forum through which their views can be shared, considered, debated and then drawn upon to inform a subsequent decision (Warren, 2002). Traditionally, citizens engage with the polity through voting, leading to the election of political representatives. Yet voting, in and of itself, provides no direct tie between government decisions and individual citizens’ preferences. Deliberative democracy, therefore, aims to result in collective judgements, informed through a process of respectful, considered, empathetic debate.

Russell (2017), in a summary of deliberative processes in Australia, identified the impacts of deliberative processes on: political decision making; societal context; mediating decisions; and participants. On this last point, the author suggests that deliberation can lead to shifts in participants’ perspectives, deliberative capacity and broader political engagement.

Of note, there are numerous notable examples whereby participatory processes have been adopted in Australia, particularly in relation to contentious public issues. This includes two citizens’ juries that were held in 2016 to consider the potential to increase South Australia's involvement in the nuclear fuel cycle; the 100 person citizens’ jury that was established in Geelong to make recommendations on how their community would be democratically represented by a future council; and the 31 person Byron Shire Community Solutions Panel that was established in order to consider how infrastructure spending should be prioritised.

Russell also argues that the role of citizen deliberation should be to add another layer in the 'influential sphere' around policy-making. To this end, Russell suggests that the proper role of citizen deliberation is in influencing rather than making political decisions. This is controversial because other authors suggest that for participation to be truly meaningful, genuine autonomy and authority is required (Blacksher, 2013; Cornwall, 2008).

Based on this, in order to maximise political influence through deliberation, both transparency and publicity of the deliberations are critical. Russell’s (2017) paper also raises questions around the political legitimacy of these deliberative bodies, forcing a reflection on whether deliberation is indeed about an outcome (the decision) or the intended impact (the influence the deliberation has on the broader political sphere – i.e. does it change things). Here, she raises the pertinent question of empowerment versus advice, and suggests that for deliberation to be truly empowering, decision-making power must reside within the designated deliberative body. In fact, this view resounds across the literature and is an important insight into the level of genuine decentralised autonomy and power that must be entrusted within these groups, in order for them to be deemed a truly worthwhile and meaningful endeavour.

Proponents of participation and deliberation herald these forms of democracy as the mechanism through which civic society and the elite can be reengaged. As argued by Florin and Dixon (2004), moves to these more contemporary forms of democracy may even be the panacea to the ‘democratic deficit’ of the modern era, although fifteen years on, this assertion may be somewhat of an oversimplification.

Critics of participation are less prone to idealism and romantic notions of the power of the collective citizenry. Criticisms include claims that participatory democracy is driven by normative concerns, with little empirical basis (Zittel, 2006). Zittel (2006) goes on to suggest that advocates of participation are considered by some academics as ‘utopian dreamers obsessed with the question of how things should be rather than how things can be in real world settings’, a challenge to which this research seeks to respond.

Extending the participatory paradigm, associative democracy aims to promote individual liberties, social justice and political participation, with associationalists holding a belief that these are presently undermined by excessive market and state forces (Carter, 2002). Associationalism, which takes a socialistic approach to governance, advocates for greater decentralisation of state power through the transference of power from the state to citizen bodies (Carter, 2002). Fung (2003) identifies that associations can enhance democracy in at least six ways, including:

1. Through fostering civic virtues and engendering political skills
2. Providing checks and balances to government and resisting power
3. Through the fundamental value of associative life through enabling social connections
4. Providing a forum for public deliberation
5. Enhancing the quality of equality of representation
6. Enabling direct participation in governance by fostering opportunities for citizens and groups to contribute

Building on Fung’s model, as shown in the third point above, associationalism is important to consider in the context of participation, because it provides an avenue through which citizens can mobilise and contribute ideas. Associations, alternatively termed special interest groups, allow citizens to more actively and loudly proclaim their preferences and exert their political will. This sense of citizenry activation led Alexis de Tocqueville and others to identify associationalism as a founding element of social capital (Carter, 2002; Putnam, 2000).

Participatory deliberation and by extension, associationalism, are increasingly becoming necessary within thriving democracies, and both of these democratic constructs are connected with social capital.

Questions of origin: top down (liberal) versus bottom up (social)

The second pertinent point of consideration that emerges in the literature relates to the origin of, or impetus for, the participatory process. Given that one desired outcome of participation is citizen empowerment, a reflection on the effectiveness of participation initiated and set up by elites is warranted.

A liberal take on participation is more sympathetic to a top-down mandate to participate, which one could argue is inherently flawed and, from a socialist perspective at least, oxymoronic. This would certainly be true if the objective of participation and associationalism within health policy is empowerment, which one would suggest it is, particularly in the context of the underlying intent of the Ala-Mata.

In the context of health policy, which involves the collective practices of a whole society rather than only the choices of individuals, it may be more appropriate to think about participation through a socialist lens, with participation ideally driven by the activism and self-awakening of a disengaged citizenry. This is consistent with Blacksher’s (2013) view that participation should provide meaningful opportunity for participation in problem solving and policy setting. She questions whether participation is truly legitimate if it is orchestrated by government rather than the grass roots and citizen-led.

This tension reflects a common question raised in the literature around the optimal point of origin for participation. On this, Putnam (2000) urges readers not to give into the false debate around ‘top down versus bottom up’ origins. He instead argues that there is no correct place for participation to originate for it to be impactful and to restore civic engagement. Putnam concludes that both grass roots activism and government-directed participation are necessary elements in the restoration of social capital, given the scale of the wicked problem (Putnam, 2000).

Blacksher (2013), in analysing the types of participation, presents a similar quandary, presenting utilitarian versus empowerment models of participation. The definition she provides suggests that the LHA represents a utilitarian model of participation. Applying her definition, the LHA is a model whereby government is seeking to persuade people to collaborate with and contribute resources to an externally developed initiative, through an intermediary body it has established. If the converse were true, the LHA would be an empowerment participation model – established by the community taking responsibility for identifying their health and wellbeing problems, identifying opportunities to drive change, and then collectively taking action to improve the community’s health and wellbeing. It may be that it was hoped the LHA would evolve into this. The Victorian Government initiated the LHA as part of its Hazelwood Implementation Plan. By definition, this makes it utilitarian by design. The paradox of government leading the charge to establish a forum for citizens to participate is both ironic and reflected in the current climate in the region.

The research is quite clear that in order for citizens to have faith in the participatory process, there has to have been genuine attempts to hear from a diverse range of voices. As de Leeuw and Wise (2015) argue, in instances where deliberative and participatory decision-making processes are applied appropriately with cultural competence, desirable outcomes can be attained. However, in practice, results of moving to participatory models have had mixed results.

For example, Cornwall (2008) describes the empowerment model trialled in a municipal health council in northeast Brazil. De Leeuw and Wise (2015) suggest this type of model is the most common way of setting up participation in health, namely through Participatory Budgeting. The health councils in Brazil are legally empowered to approve the budgets, accounts, and spending plans related to health planning and policy setting. These councils comprise 50 per cent health service users, 25 per cent health workers and the remaining 25 per cent are health managers. This distribution of membership mirrors that of the LHA, with 22 out of 45 of the LHA members representing health care workers and managers, with the remaining notionally representing community.

Cornwall analyses the councils through Fung and Wright’s ‘empowered participatory governance’ (EPG) framework, ultimately determining that the political and civil sphere are impossible to disentangle. This means that while participation attempts to eliminate political party lines, ultimately political ideology impedes the deliberation. Further, Cornwall observes that for EPGs to be successful, there has to be an equal distribution of power between members. If, she argues, power is unequally distributed between members, ‘trenches instead of bridges’ are formed as a result. This, in the context of bonding and bridging social capital, is a point that will be returned to later in the paper.

Parallels between other examples of participation in health can be made with research around the application of participatory action research. Minkler (2000) identifies two successful examples of participatory action research related to health research. The primary purpose of participatory action research (PAR) in health is to ‘place the researcher in the position of co-learner and put a heavy accent on community participation and the translation of research findings into action for education and change’ (Minkler, 2000, p.192). The objectives of the LHA resemble the purposes of PAR, in that the model is attempting to involve citizens in the problem-solving process, while incorporating contextual local nuance. Minkler’s research demonstrates that PAR can realise significant social benefit, positing that PAR led to many positive stories of success, such as communities working with the relevant agencies to restore bus services in isolated neighbourhoods and residents forming a “bucket brigade," through working together to undertake air quality sampling.

Given the research on participation in the field of health, and especially Mill’s (1871) pointed comment that capitalist structures are intentionally designed to limit the social advancement of the working class, a level of bottom up citizen activation is fundamental. Participation can be effective when both endorsed by government and initiated by citizens, but participation will never be effective when it is driven by government alone. In the context of the privatisation of the power stations in Latrobe Valley, neoliberalism has arguably contributed to the current levels of disengagement demonstrated in the region. For this reason, it is difficult to image a scenario whereby a government-initiated participatory forum, such as the LHA, would be the sole catalyst for citizenry reactivation.

Philosophical differences: a ‘social capital’ spectrum

Putnam’s seminal text, Bowling Alone, instigated significant academic and policy interest in the value of social capital. Here, Putnam (2000) defines social capital as the value of social networks, derived from, in the main, the level of trust and reciprocity that flows between individuals within the network. Field (2016) further expands on this by describing ‘social capital’ as a way of defining the intangible resources of community, shared values and trust upon which society draws in daily life.

Szreter and Woolcock (2004) recognise that social capital definitions range across a spectrum. At one end of such a spectrum, neo-classical economists view social capital as a quantifiable ‘unit’, the property of individuals, such as their skills or capacity (i.e. human capital). At the other end of the spectrum, many political scientists, such as Fukuyama, suggest that societies overall can have high or low social capital. Social capital, in this respect, constitutes a sociological frame for memberships in churches, unions, political parties, sport clubs, choirs, community theatres, and so forth. Today, it is conceivable that this frame can extend to the membership of virtual associations and online movements. Importantly, trust between citizens, or citizens’ trust in the political system itself, commonly emerges as central to many definitions of social capital presented throughout the literature.

Wollebaek and Selle (2002) repeat Putnam’s oft remarked claim that trust between citizens is established through face to face interactions. Building on this, the authors explore the variances in associationalism, which Putnam believes is the prime source of social trust. The authors describe thick trust, which refers to significantly higher levels of trust within homogenous groups and often involves distrust of various outgroups. This concept daws upon in-group and out-group theory in social psychology. Thin trust, the authors describe, is that which occurs loosely and on the surface between members of different social groups.

Edwards, Franklin and Holland (2006) offer a more nuanced review of the spectrum of views about social capital in the literature, recognising that normatively, social capital has morphed over time as the fidelity of the concept has been tested. Edwards et al. (2006) discuss the views of Coleman, Putnam and Bourdieu - three seminal social capital academics. Coleman’s views on social capital are underpinned by a rational model, which assumes that the relationships and networks individuals form are driven by self-interest. Putnam’s interpretation assumes that the focus of social capital is on mutual obligation and cooperation. Finally, Bourdieu’s account of social capital draws parallels between social capital and the maintenance of capitalist society and its inequalities. According to Edwards et al (2006) Bourdieu is the most radical of the three authors. This assertion is made as Coleman’s rational analysis is closer to methodological individualism and neoliberalism, while Bourdieu’s analysis of cultural capital is closer to methodological collectivism and socialism, and Putnam treads a middle-path opting for a variation on methodological collectivism and social democracy.

Contrasting the alternative perspectives highlights the complexity of the social capital paradigm. This is because it necessitates the question of whether pursuing increases in social capital is desirable. On this point, Arneil (2006) posits that Putnam’s original conception of social capital is rooted in republicanism, which in her view, is problematic. Putnam’s republicanism is anti-liberal and collectivist, and thus related a form of democratic socialism. It is opposed to liberalism, methodological individualism, rational choice, and mainstream economics. Cultural homogeneity is a common critique of republicanism. Indeed, cultural tolerance is one of the strengths of liberalism. To this end, the author contends that Putnam idealised social capital through the lens of social homogeneity and shared cultural norms, failing to recognise the value that diversity of thinking can introduce within a civility-united society.

Social capital opponents contend that an acute focus on social capital reflects a concern with the ‘excesses of current individualism and a nostalgia for a lost cohesive past’ (Edwards et al., 2006). Social capital theory is not without critics, who most notably challenge whether the concept has sufficient empirical support to warrant the degree of attention it has garnered. Putzel (1997) suggests that Putnam does not make a strong case for 'strong state, strong communities'. Putzel holds the view that Putnam takes an institutional theorist perspective as he bemoans the seeming decline of civility, suggesting that this is an oversimplification of a fraught, complex and interwoven problem.

It is true that social capital is a focus of much academic interest, primarily due to empirical evidence that identifies correlations between it, and many markers of a well-functioning society. These benefits include, at the societal level, greater economic and civic equality (Putnam, 2000) and at a policy level, improved public health outcomes and less crime, as examples. In the main, social capital scholars align with the contention that participation in civil associations generates trust and reciprocity (Hanson, 2018). Szreter and Woolcock (2004) reiterate the link between social capital and associationalism which Putnam originally identified. The authors posit that social capital has achieved longevity in the literature owing to the attention paid to the role and strength of civic associations.

The authors pose a framework to describe how social capital aligns with the theoretical underpinnings present in public health and epidemiology, in a bid to define the essential components of a ‘healthy society’. This framework centres on the distinction between bonding, bridging and linking forms of social capital. The authors suggest that these forms of social capital need to exist in relatively rich equal measures. In these instance, the authors suggest that the polity will be composed of an active and politically conscious civic society, one that importantly comprises diverse citizens and various associations.

Geissel (2009) also articulates that participation contributes to social capital through the very nature of the social interaction it facilitates. The author suggests that participatory forums establish opportunities for groups of people, who would not otherwise engage with each other, to meet face to face. It is this interaction, she argues, that leads to the development of social trust and shared norms of reciprocity. Geissel (2009) further strengthens the normative link between participation and social capital through the identification from across the literature of four criteria for judging whether participatory governance has been successful. The criteria include:

1. Has it been effective? Does a political system have a capacity to solve collective problems and attain the shared objectives of a constituency?
2. Is it legitimate, through political support and increased input from citizens?
3. Has it contributed to social capital?
4. Has it enhanced the skills of the citizenry?

This set of criteria assumes there is a link between participation and social capital and suggests that participatory governance can cause an increase in social capital. This is an important point in the context of this research. In other research exploring the effectiveness of participatory governance within the Agenda 21 action plan, Geissel (2009) found that, overall, participatory forums do cause increased social capital.

Sociological structures: bonding, bridging, linking and trust

Consistently through the literature, trust is presented as fundamental to the attainment of improved public health outcomes (Lindstrom & Mohseni, 2009). In 2009, Lindstrom and Mohseni, for example, argued that social capital promotes health through multiple means, including through decreasing stress, establishing benevolent social norms and values and increasing access to health services. This prompted them to research the impact of social capital on health outcomes through the lens of horizontal trust among citizens and vertical trust between individuals and institutions (also termed political trust) (Lindstrom & Mohseni, 2009). This contrast appears to be similar to the vertical versus horizontal network paradigm suggested by Wollebaek and Selle (2002), particularly as it relates to the distribution of power. Lindstrom and Mohseni’s (2009) research found that low political trust was signi?cantly and positively associated with poor mental health.

This research is noteworthy because it identified a gap in the literature that specifically explores 'linking social capital' that is, trust, between institutions. In the context of Latrobe Valley, this is particularly pertinent, given the complex and somewhat fraught relationship between government and the community, and possibly even distrust among different institutional health stakeholders. The research shows that inter-institutional linking social capital can improve self-reported mental health. This finding is consistent with that made by Beaudoin (2009). While reiterating the existing literature that suggests a link between social capital and improved health outcomes, including high self-rated health, lower child mortality rates, lower neighbourhood deaths, this research also found that bonding social capital is more strongly correlated with positive mental health.

In her research into Communal Councils in South America, Hanson (2018) identified that participatory forums are prone to ingrain mistrust further within already fractured communities, if the membership or the process to recruit members is opaque. These South American councils were established in a bid to transition the political sphere from capitalism and representative democracy towards twenty-first century socialism and local participation. The councils are decreed in legislation and are intended to be devoid of influence by the political elites. On this last point, Florin and Dixon (2004) question whether participation is at odds with the Westminster system of government. The authors reflect that under this system of government, ministers are accountable to the people i.e. the Minister for Health is accountable for all public investments in public health. This raises an interesting question about whether the influence of the elite can be truly disaggregated, should participatory or deliberative processes be adopted. It is not clear how the divulgence of power and responsibility for delivering health outcomes sits in the context of increased citizen autonomy in decision-making.

Rothstein and Stolle (2008) purport that the attitudinal concept of generalised trust is the most important part of social capital. This is within a taxonomy of other key concepts, including access to and membership in various types of networks, and reciprocity. Similarly, He (2009) suggests that participatory democracy theory stresses the importance of direct participation, trust and diverse associations. Trust, as argued by Rothstein and Stolle (2008) is a necessary precursor for social capital. Yet these authors go further to explore the distinction between generalised trust and political trust.

While suggesting that the literature has traditionally held that generalised trust is a fundamental underpinning of political trust, the research by Rothstein and Stolle (2008) challenges this. The authors disentangle trust in ‘partisan institutions’ (parties, members, parliament, and government) from trust in ‘order institutions’ (civil and public servants, including police, army and legal institutions). Through analysis of the World Values Survey, the authors determine that there is no correlation between generalised trust and trust in partisan institutions, and yet a correlation emerges between generalised trust and trust in order institutions.

A further distinction is made between horizontal and vertical trust, which Wollebaek and Selle (2002) suggest relies on symmetrical versus asymmetrical power dynamics. This is interesting in the context of the LHA, which comprises community members and, arguably, members of the ‘elite’, including senior public servants and executives from key health and wellbeing agencies. The authors build on Putnam’s original view that social capital is unlikely to be generated when individuals from different classes interact, due to the imbalance in power, which means that reciprocity is unlike to occur. Based on this, it is questionable whether a participatory forum such as the LHA, with a mismatched membership, is able to establish vertical trust and thus may have limited impact on generating social capital within the region.

Findings from Hanson’s (2018) ethnographic research are cause for concern in the context of Latrobe Valley, as the research suggests that participatory forums can lead to unintended consequences, such as deepened mistrust and distrust between neighbours, as well as potentially transferring frustration and blame away from government and on to the community (Hanson, 2018). Political and public trust is likely already quite low in Latrobe Valley. This is owing to several decades of adverse events, such as the privatisation of the power stations, widespread asbestos related illness, the Hazelwood Mine Fire and most recently, the closure of the power station. These broader societal and economic events are difficult to disentangle from comparably poorer population health outcomes in the region and also may suggest that attempts to establish participatory forums should be considered carefully.

Putnam makes an important distinction between bonding and bridging social capital, particularly as it relates to the transfer of trust in or between social groups. Bonding social capital is described as exclusive, in that it creates stronger in-group loyalty, and strengthens ties within homogenous, socially-similar groups. This in turn leads to enhanced access to internal resources. In contrast, bridging social capital is described as inclusive, in that it forges networks across social groups. Bridging social capital is believed to strengthen relationships between heterogeneous, socially diverse groups, which leads to enhanced access to external resources (Beaudoin, 2009; Putnam, 2000).

Geissel’s research suggests that ‘bridging social capital’ can be enhanced through participatory processes. When surveyed, participants in Geissel’s (2009) research reported that the LA21 process led to an increased sense of trust between citizens and the elite 'for the first time'. This possibility that participatory processes can restore trust in elites is particularly pertinent in the context of the Latrobe Valley, an area in Victoria that has historically been challenged by the level of distrust that exists between the community and the political class. Latrobe Valley and the specifics of the broader context, will be introduced in the sections that follow.

Geissel’s research identified that the LA21 forums did not lead to cronyism or favouritism, which was the original concern. The research suggests that the design of the participatory procedure itself – including participant selection and buy in from key decision-making bodies – is the most critical component for ensuring that participatory governance can have the greatest impact (Geissel, 2009).

The literature supports the assertion that participation, associationalism and social capital are interrelated concepts. However, nuance here is important. When reflecting on Tocqueville's 'associationalism', Putzel (1997) points out that social capital is not always desirable, nor does it always contribute to or nurture democratic ideals. The example of the KKK highlights a group within which social capital is likely high, yet the group diminishes broader societal outcomes. Drawing on this example, intra-group bonding social capital may have been high but it developed at the cost of inter-group bridging social capital and society-wide social capital more generally.

Summary of the literature

Overall, there is a substantial amount of research that reports similar findings related to participation and social capital in the context of public health. Through the research, trust emerges as a fundamental necessity in the context of social capital, and the advancement of public health. It appears that for broader social capital gains and more substantial improvements in public health to be realised, participatory forums have to provide a link between diverse groups, thus acting as a bridge between heterogeneous sectors of a community. Where ‘the loudest voices’ continue to be heard, or where grass roots activism is not present, significant gains in public health are unlikely to be realised over the longer term.

Based on evidence collected through the literature review, it would appear that participatory democracy may lead to increased social capital, which can lead to improvements in public health. Therefore, it is appropriate that these types of participatory approaches are trialled, particularly in areas where other forms of governance have had little to no effect. For this reason, the LHA, as a participatory forum that allows community members to engage in health and wellbeing decisions, is a warranted alternative model to explore.

The four key themes emerging from the literature will now be utilised to inform a case study review of the LHA. This will allow for a greater understanding of the precursors, conditions and considerations that underpin attempts at participation in the context of health policy.

Case study: the LHA – participation in action

The LHA is a 45-member participatory forum, which was established by the Victorian Government following the Hazelwood Mine Fire Inquiry. The Inquiry was established following the coalmine fire at Hazelwood in 2014. The fire burned for 45 days, blanketing surrounding towns with smoke (“Hazelwood Mine fire inquiry - Victorian Government response and actions”, 2019). Through the Inquiry, it was identified that the Latrobe Valley has a long history of disadvantage, both economic and social. This meant that resilience in the community was low, and as such, the consequences of the fire were far reaching and further exacerbated many long-standing health and social issues in the region.

The Inquiry led to the identification of 246 recommendations that the Victorian Government then committed to undertaking. Of these, many related to public health and wellbeing. Notably, the region was designated a Health Innovation Zone, the first of its kind in Australia ("Latrobe Health Innovation Zone", 2018). The intention of designating the area an innovation zone was to create a climate where new innovations in public health are encouraged, nurtured and trialled. One pertinent example of this is the establishment of the LHA. The LHA was intended to provide an avenue for increased community participation, with the aim of improving health and facilitating the increased integration of health and wellbeing services.

The LHA was established in 2016 and is supported by the Latrobe Regional Hospital. The hospital provides the necessary backbone support, including the provision of back office supports such as payroll and human resources. The LHA is supported by an Executive Officer, and several full time employees, who perform various administrative and supporting functions. The LHA is an incorporated entity and is overseen by a Board, which comprises a Chair and five mandated members from eminent health stakeholders in the region, including the Department of Health and Human Services, the Latrobe Regional Hospital, Latrobe Community Health Service, the Gippsland Primary Health Network, and the Latrobe City Council. The LHA is chaired by board member Professor John Catford, an internationally well regarded public health academic, and who was a prominent advocate for better health and wellbeing in the region throughout the Mine Fire Inquiry. There are four community board members. The non-Board LHA members comprise representatives from health and wellbeing organisations or local community members who live in the Latrobe Valley community.

The original members of the LHA were selected by the Department of Health and Human Services, following an open application process. A request for applications was advertised in local media, including the largest local newspaper, the Latrobe Valley Express. It was a public submission process but there is little publically available information describing the selection process. At the time, there was little publicly available information about the selection criteria, the decision-making process, or the members who were ultimately selected.

The current list of LHA members is available on the LHA website (“Latrobe Health Assembly”, 2019). This includes representatives from organisations such as the Department of Health and Human Services, Latrobe Valley Authority, Worksafe, Berry St, EPA Victoria, the Department of Environment, Land, Water and Planning (DELWP), Chronic Disease Prevention Alliance, Interchange and the Commonwealth Department of Health. Of the current 45 members, 22 are not listed as having their membership being associated with an organisation in the region. The online biographies describe many as active members of the community, who work in related fields, such as at the local university, as local teachers, or who volunteer in a range of community organisations.

In order to respond to the gap identified in the literature, that is, whether the process to establish a participatory forum can contribute to the enhancement of social capital and more specifically, build trust between heterogeneous groups, the LHA will be considered in more depth as a case study in debates about social capital, participation and public health.

In order to develop the case study, primary and secondary data was drawn upon. This included interviews with seven interviewees (n=7) who live, work or study in the Latrobe Valley. They were selected utilising convenience sampling. Interviews were conducted via telephone, comprising 12 open-ended questions and lasting no more than thirty minutes. Two interviewees were men and five were women. No other demographic data was gathered on the interviewees.

The interview questions were developed in order to ascertain the interviewee’s level of civic engagement, their perceptions of the process to recruit members to the LHA and to understand whether the establishment of the LHA has led to the enhancement of social capital in the region, through increased bonding or bridging social capital. The research was designed in such a way that each interview provides qualitative data, adding to existing secondary data, including recent Latrobe Valley community surveys and evaluation reports.

A community survey was conducted by Deloitte in July 2018 as part of an evaluation of the Latrobe Health Initiatives, which includes the LHA. This survey received 170 responses, and results were made publically available. Analysis conducted by Deloitte (2018) suggested that there was no statistical difference between the demographics of the survey respondents and the Latrobe Local Government Area (LGA), based on population parameters sourced from the Latrobe City Council’s Community Profile. This means that the survey respondents are generally representative of the population, noting that the survey was conducted via Facebook, meaning that only citizens with access to a computer were able to respond.

Survey analysis also suggested that survey respondents were more likely to be members of ‘engaged circles of Latrobe Valley community groups’ (Deloitte, 2018). This means that survey results may be skewed to represent responses from respondents who are already active in the health and wellbeing space. This is evidenced by the fact that 83 per cent of respondents selected Strongly Agree or Agree when asked to respond to the statement ‘I know how to access information about health and wellbeing’.

Participation, deliberation and associationalism

Research by newDemocracy, a not-for-profit think tank that specialises in establishing and running forums for participatory and deliberative democracy, suggests that citizen participation is ideally invited through a stratified random selection process (Carson, 2018). Added to this, one of the key criteria for successful citizen juries is representativeness. newDemocracy suggest that 35-43 randomly selected participants is an ideal range in a citizen jury-type forum, based on several real world examples of previously established citizen juries. It is noted that interviewees expressed a range of opinions on whether the LHA was representative of the community, with one stating that the ‘process led to representativeness of the community’ and another suggesting that ‘overall it was fair, although members of disadvantaged or marginalised groups are missing.’

Based on publically available demographic information about the current membership of the LHA, it is not clear whether the LHA reflects the broader Latrobe community. Almost half of the members are already associated with health and wellbeing services in the region. It is unlikely that significantly marginalised or isolated community members are aware of the LHA’s existence, with one interviewee noting that due to the circumstances faced by many disadvantaged members of the community ‘these people have genuine concerns about how to live day to day, and are not at all worried about this other ‘stuff’’. Carson argues that for citizens to have trust in the participatory body, it is necessary for them to believe that ‘people like me’ have been invited to contribute to the decision making process (Carson, 2018).

Many of the interviewees are already engaged within the health and wellbeing sphere in Latrobe Valley, meaning that they were likely in a privileged position to hear about the LHA when it was being established. One interviewee expressed a perception that the process to set up the LHA was just ‘another bureaucratic thing’ – reflecting a level of distrust in and cynicism about government that is somewhat commonplace within the Latrobe Valley (de Leeuw and Wise, 2015).

All of those interviewed reported a degree of civic participation. One reported being actively engaged with a political party, in grass-roots political action. All interviewees reported participation in a voluntary association. None were a member of a religious organisation nor did any donate blood. This data seems to suggest that this group of interviewees were all civically active, to some degree, with Interviewee D reporting four different modes of civic participation. As Putnam acknowledges, the collective level of civic participation amongst an interviewee group is unlikely to reflect broader rates of civic participation across the community. This means that interviewees are all interconnected with other members of the local community, either through one or multiple means. Where interviewees were engaging through multiple means, it is likely that some degree of linking social capital may be being generated.

Figure 1 Overview of self-reported civic participation by each interviewee

Origination

de Leeuw and Marilyn Wise (2015) note that in order for seismic shifts in social determinants of health to occur, citizens and communities have to be more strongly and effectively engaged in decisions related to their health and wellbeing. This indeed is the philosophy underpinning the establishment of the Assembly. Therefore, it is necessary to understand whether the citizenry in Latrobe Valley are aware of the LHA, and understand their level of engagement with it.

Of those interviewed, all interviewees stated that they were aware that the LHA was being established in 2016. Several stated that they had noticed advertisements for applications in the local paper. However, results from the Deloitte survey of the community suggest that 42 per cent of respondents had not heard of the LHA prior to participation in the survey. By inference, this means that they did not know that it had been established almost 18 months prior to the survey. This is significant, given the assertion made earlier that survey respondents were considered to be ‘health literate’ – based on the high numbers of respondents who reported to know how to access information about health and wellbeing.

Of those interviewed, there was a general level of scepticism about the process to establish the LHA in 2016. One interviewee stated that it was ‘quite a poor process’ and several stated that it was ‘not well understood’. One interviewee also noted the barriers the application process itself created, given that quite a lot paperwork was required to be completed as part of the application process, likening it to ‘applying for a job’.

The social capital spectrum

Given that the social determinants of poor health are inherently complex, it is not suggested that the LHA will be the panacea for the social and health challenges of the region. Yet it does offer a unique opportunity to engage with marginalised groups across the community in new ways. In order to achieve improvements in social capital within these groups, the LHA will need to ensure that regular engagement with the community occurs.

One interview stated that the ‘LHA needs to make better links, this would give the community the chance to hear about it – and see the honesty – see that they are genuinely trying to help.’ Another interviewee noted that the LHA could improve social capital ‘if it was showing that it was changing things and people could see that change. If it does that, it will get the trust of the community’. Comments such as these show that several interviewees have identified the opportunity that the LHA presents; namely, forming new links with community, in a space whether other community services, for a variety of reasons, have had variable success in the past. 

When reflecting on the human capital available in the context of the LHA, it is considerable. This is the case as the Board itself comprises of four executive officers from key health and wellbeing bodies in the region; the hospital, the council, the Primary Health Network and the community health service. There is also a senior representative from the Department of Health and Human Services, and an internationally regarded health promotion academic is the Chair of the Board.

Added to this, the LHA is supported by a backbone, which includes an Executive Officer and five staff members (“Latrobe Health Assembly”, 2019). The capability and capacity of the human resources available within the LHA are considerable. The challenge for the LHA therefore becomes one of translating the existing high levels of human capital, into social capital within and outside of the LHA.

Sociological structures – bonding, bridging, linking and trust

The literature related to bonding social capital does not espouse the value of this type of social capital in the context of public health. In fact, there appears to be a high degree of consensus in the literature, from Putnam’s original work onwards, that bonding social capital can be harmful in this context. On the whole, interviewees were sceptical of the LHA in relation to bonding social capital, with several comments like ‘I wouldn’t trust them as far as I could kick them’ and ‘the LHA has added no value in terms of trust, connectedness or capacity building on the ground’. While interviewees recognised that the establishment of the LHA could lead to greater trust amongst community members, the general view was that this has yet to occur. One interviewee noted that ‘at this point in time, <the LHA> visibility is limited and their engagement with the community is poor. The opportunity to build trust has so far been missed’.

It may be that this is the view of the interviewees because they have limited visibility of the LHA as a whole, nor do they have visibility of LHA Board meetings. Board meeting minutes are not publically available, although an annual report is accessible online. The Board meets monthly, and while the Board is primarily tasked with approving funding decisions, it may be that this forum provides an opportunity for collaboration across the key health and wellbeing organisations in the region. This could represent an opportunity for interagency-bonding social capital, as well as integrated system level planning.

Of the Deloitte survey respondents, when asked to identify what they needed to make them feel healthy, 59% selected ‘be connected with my community’ from a list (in a multi-response question) (Deloitte, 2018). This shows that the majority of respondents inherently recognise that connection between community members is a necessary underpinning in a human community. 

However, it is not yet clear how the LHA is creating bridges in the community between ordinary citizens, and members of the elite. At the time of the survey, 42% of survey respondents had not heard of the LHA (Deloitte, 2018). There is no suggestion that within the LHA itself, either in the Board meetings, or the broader Assembly that bonding social capital is not occurring. In fact, it is likely that it probably is. Based on the interviewees’ perceptions, continuing to foster links between disengaged members of the community and the LHA should be a continued point of focus. Given that there are four community member positions on the Board, alongside several health service executives, it is also possible that some bridging social capital is accumulating within the Board meeting forums.

The Deloitte (2018) research showed that levels of trust, and reciprocity, amongst community members in the Latrobe Valley is varied. When asked to think about their relationships with their community on aspects such as trust and reciprocity, participants’ responses were somewhat cautious. Of the 170 responses received, 51% of respondents felt that they Strongly Agreed or Agreed that ‘most people can be trusted’. This suggests that only 1 in 2 people in Latrobe Valley feel that they can trust other members of their community.

While this data does not distinguish who the community feel they can or cannot trust, it does show that levels of trust amongst community members are not particularly high. When asked the extent to which community members felt that they could get help from a friend when they need it (implying bonding social capital), 74% of respondents either Strongly Agreed or Agreed with this statement. The variation between the ‘trust most people’ (generalised trust) and help from friends (bonding social capital) suggests that communities members are more likely to report higher levels of trust between people they know, relative to reporting levels of generalised trust in the community. 

Figure 2 Overview of perceptions of trust and reciprocity based on community survey responses (Deloitte, 2018)

These results are consistent with feedback provided by interviewees. Of those interviewed, none of them suggested that the establishment of the LHA had led to them experiencing a greater sense of trust between their family and friends. However, there were several interviewees who suggested that there were greater numbers of conversations going on between groups already working together in the health-and-wellbeing space. Given that these groups already work together, this would suggest that there may be increased levels of social capital accumulating between these homogenous groups. For example, one interviewee stated that they interact with the LHA in their capacity as a professional, and reported noticing a shift in the openness of the local council to discuss broader social issues since the LHA had been operational.

When asked whether the LHA had led to greater experiences of trust with either local or state government, interviewee’s perceptions were also mixed. Given that the Latrobe Valley has traditionally been a marginal seat, several reflected on the investment in Latrobe Valley rather cynically. One interviewee felt that in fact the Andrews Government had abandoned its policy-setting responsibility by delegating this to community members through the establishment of the LHA and other such committees.

Other interviewees were more impartial in their views (applying a particularly utilitarian perspective), recognising the complexity of delegating governance and decision making powers to community members. Reflecting on the question of levels of trust with state government, one interviewee stated that ‘The Assembly is about enabling this type of trust but the reality is that it has yet to achieve this’. Another interviewee took a more optimistic view, recognising the symbolism of what the government had attempted to do, stating that ‘<the Victorian Government> are showing an acknowledgement of the issues and they are investing in these’. Importantly, the LHA represents the first time participatory health-and-wellbeing investments have been trialled in Victoria. It is therefore not unexpected that something new, such as this, would be treated with a degree of cautiousness and trepidation by community members, and the political elite alike.

Given the partisan nature of politics, it is not surprising that the ideological influences underlying representative political institutions correlate with general levels of trust. The fact that some interviewees reported scepticism in relation to the current government in Victoria and expressed generalised distrust overall reflect similar findings to those of Rothstein and Stolle (2008). While two interviewees shared negative views on the current local area representatives in the politic sphere (namely the Government and local counsellors), two spoke of the Department of Health and Human Services in a more favourable light. With relatively few interviews a sharper distinction between these two types of trust could not be made. This is an area for future exploration.

Figure 3 Overview of perceptions of representatives in government (Deloitte, 2018)

On the whole, it appears that levels of trust in partisan institutions in the Latrobe Valley are relatively low, as shown in Figure 3. Based on the data reported by Deloitte (2018), only 19 per cent of respondents responded that they Strongly Agree or Agree with the statement ‘I feel that Government representatives take into account concerns voiced by you and people like you when they make decisions that affect you’. The low level of positive responses to this question are not entirely unexpected, given Rothstein and Stolle’s research. Of more interest would be an exploration of whether the LHA has led to a greater level of trust between citizens and order institutions.

Discussion

Comparative political science is resounding: representative democracy is in decline. So too is social capital. Putnam’s warning that ‘our political practices would have to change, if social capital were permanently diminished’ is still salient. Questions around what this means for political system evolution abound, as civil society and existing political structures morph into something new and not yet well understood. 

With this context in mind, based on the LHA case study and the literature more broadly, several insights emerge as it relates to the application of participatory practices in the context of public health. These include:

1. The process to establish participation should be transparent, representative and ideally utilise stratified random sampling.
2. It is difficult or even unpalatable to suggest that governments should ‘dictate’ or ‘command’ citizens to participate, but participation requires effort and input from both the polity and citizens.
3.  Achieving effective participation is challenging – particularly for those who are already disengaged or disenfranchised. Citizens may require additional support to participate and to ensure that capacity to understand and generate ideas is nurtured and widespread.
4. It is unlikely that the establishment of the LHA will lead to greater trust between citizens and the representative institutions. However, it is possible that it may lead to greater trust between citizens and order instructions, which importantly would include the Department of Health and Human Services. Greater trust between citizens and order institutions can then lead to overall improvements in social capital. To achieve this, the order institutions need to recognise that for vertical trust to develop, genuine reciprocity has to occur in order to correct the power imbalance (bridging social capital).
5. The LHA should act as a conduit between different community groups in Latrobe Valley. This will likely lead to enhanced horizontal trust.
6. For the LHA to contribute to social capital, it should provide greater opportunity for Assembly members to engage with fellow citizens from heterogeneous groups across their community (linking social capital)

Participation can seek to provide a viable alternative to representation, yet it is not without complications. Participation should be well designed, planned and most importantly, transparent. Certainly in the context of health and social policy, participation should be empowering, focusing on the facilitation of horizontal trust between groups, and vertical trust between citizens and institutions. Simply providing a forum of those already active in the health and wellbeing sphere to collaborate in different ways may not lead to the broader social capital improvements which may be desired.

This may sound disparaging, but it is inadvertent. There are many gains to be achieved through inter-agency collaboration and inter-sectoral planning around complex social issues. There is a wealth of evidence to suggest that multidisciplinary approaches to tackling health and wellbeing issues, such as these, should be pursued. However, if the purpose of the LHA is to contribute to broader social momentum, that is, to create a tipping point as it relates to perceptions of health and wellbeing in the region, it has to create more than just stronger bonding social capital between health and wellbeing stakeholders.

Where bonding social capital is the ultimate outcome of an exercise in participation, an opportunity for broader public health gains is likely to have been missed. Bonding social capital represents a continued fragmentation of a civil society which many argue is already in decline. At this point in its maturity, it is likely that the LHA is providing opportunity for bonding between already homogenous groups. This is the case as, for example, many members already participate in community associations, work at local community services agencies, or interact together through other forums. One interviewee commented that the LHA is ‘an opportunity for health professionals to work together in different ways’, and while this is undoubtedly true, it suggests that many of those engaging with the LHA are already engaging in public discourse about health and wellbeing in the region.

The evidence appears to demonstrate that for social capital to lead to improved public health outcomes, it has to occur between heterogeneous groups. Research suggests that this is either between different, yet power-symmetrical groups, or in instances were power imbalance is neutered between order institutions and the citizenry. This presents an opportunity for the LHA.

Research suggests that social capital can improve when new networks links are forged, or simply strengthened. For this reason, it is commendable that the LHA has been established in the first instance, and that it is continuing to evolve in its understanding of itself, and what it may be able to achieve.  From both a public health and sociological perspective, the LHA could therefore operate as another hub in the context of social networks that already operate in the region. This would help to facilitate greater opportunities for the development of bridging or linking social capital, which the literature suggests is desirable in the context of aiming to improve public health.

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