Ellen Annandale

Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

BackgroundConventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UKMethodsThis project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis.ResultsMany analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how peoples eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research.DiscussionBy innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

Social class and health in youth: Findings from the west of Scotland twenty-07 study

The assumption that social class inequalities in health are a persistent feature of the life-course has been questioned in a recent issue of this journal. On the evidence of mortality and chronic illness, the pattern in youth in Britain appears to be characterised by the lack of class differentials, a striking contrast to early adulthood where the familiar picture of health inequalities is observed. The possibility that this finding of relative equality in youth is a consequence of the limited, and potentially inappropriate, health indicators used has now been tested on a cohort of 15-year-olds in the West of Scotland. On a range of indicators, from subjective assessments to objective physical measures, very little evidence of class variation in health is found. The possible transience of the youth pattern is, however, indicated by findings from a cohort of 35-year-olds in the same study, among whom marked class gradients in health are apparent. Possible explanations for the transformation of a pattern of relative class equality in youth into one of inequalities in adulthood are discussed.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Central gender theoretical concepts in health research: the state of the art

Despite increasing awareness of the importance of gender perspectives in health science, there is conceptual confusion regarding the meaning and the use of central gender theoretical concepts. We argue that it is essential to clarify how central concepts are used within gender theory and how to apply them to health research. We identify six gender theoretical concepts as central and interlinked—but problematic and ambiguous in health science: sex, gender, intersectionality, embodiment, gender equity and gender equality. Our recommendations are that: the concepts sex and gender can benefit from a gender relational theoretical approach (ie, a focus on social processes and structures) but with additional attention to the interrelations between sex and gender; intersectionality should go beyond additive analyses to study complex intersections between the major factors which potentially influence health and ensure that gendered power relations and social context are included; we need to be aware of the various meanings given to embodiment, which achieve an integration of gender and health and attend to different levels of analyses to varying degrees; and appreciate that gender equality concerns absence of discrimination between women and men while gender equity focuses on womens and mens health needs, whether similar or different. We conclude that there is a constant need to justify and clarify our use of these concepts in order to advance gender theoretical development. Our analysis is an invitation for dialogue but also a call to make more effective use of the knowledge base which has already developed among gender theorists in health sciences in the manner proposed in this paper.

Women's health and social change

Introduction 1. Recovering gender and health in history 2. Making connections: feminism, sociology and health 3. Two traditions of research on gender and health 4. Women, health and reproduction 5. Moving beyond sex and gender 6. Morbidity and mortality in transition 7. The making of womens health: diversity and difference 8. Concluding remarks and ways forward

Constructing the ‘gender-specific body’: A critical discourse analysis of publications in the field of gender-specific medicine

Gender-specific medicine, a new and increasingly influential ethos within medical research and practice, has received little critical attention to date. The objective of this article is to critically examine the attributes of gender-specific medicine as imparted by its advocates. Through a critical discourse analysis of its two leading academic journals, we identify five interrelated discourses: of male/female difference; of hegemonic biology; of men’s disadvantages; of biological and social reductionism; and of the fragmented body. Together these comprise a master discourse of the ‘gender-specific body’. The discourse of the ‘gender-specific body’ is discussed in relation to the current neoliberal political agenda which frames healthcare as a market good and locates health and illness in individual bodies rather than in the wider social arrangements of society. We argue that the ‘gender-specific body’ threatens not only to turn back the clock to a vision of the biological body as fixed and determinate, but to extend this ever deeper into the social imagination. Lost in the process is any meaningful sense of the human body as a relatively open system which develops in interaction with its social world. We propose that, as it gains momentum, the ‘gender-specific body’ is likely progressively to circumscribe our thinking about the health of women and men in potentially problematic ways.

New Connections: Towards a Gender-Inclusive Approach to Women's and Men's Health

The recognition within sociology that gender is not simply the provinceof women, but that men ‘have gender too’ has kindled a more gender-inclusive approach to the relationship between gender and health.‘Gender and health’, which until very recently was tantamount to a dis-cussion of women’s health, now not only extends to men, but holds outthe potential for a comprehensive appreciation of the social relations ofgender as they impact upon health in different societies. However, thishas yet to be realized. The current collection of articles aims to stimulatethe further development of this research agenda through a particularfocus on the sociological analysis of experienced health needs and theavailability and use of health services to meet these needs.The collection brings together papers presented in two sessions – oneon women’s health, another on men’s health – in the programme of ISAResearch Committee 15, Sociology of Health, at the World Congress ofSociology, in Durban in 2006. The sessions were prompted by two analyt-ical observations of the state of the art on gender and health.First, there currently is a curious absence of new theorizing and method-ological innovation in sociological research on women’s health, a situationthatseemsalmostparadoxicalafter30yearsofspearheadingtheoreticalandmethodologicaladvanceswithinwomen’sstudiesandthesociologyofgen-der. This is exemplified in the repetition of existing findings and theoreticalargumentsintheresearchonwomen’shealthoverthepastfiveyears.

A Conceptual Muddle: An Empirical Analysis of the Use of ‘Sex’ and ‘Gender’ in ‘Gender-Specific Medicine’ Journals

Background At the same time as there is increasing awareness in medicine of the risks of exaggerating differences between men and women, there is a growing professional movement of ‘gender-specific medicine’ which is directed towards analysing ‘sex’ and ‘gender’ differences. The aim of this article is to empirically explore how the concepts of ‘sex’ and ‘gender’ are used in the new field of ‘gender-specific medicine’, as reflected in two medical journals which are foundational to this relatively new field. Method and Principal Findings The data consist of all articles from the first issue of each journal in 2004 and an issue published three years later (n = 43). In addition, all editorials over this period were included (n = 61). Quantitative and qualitative content analyses were undertaken by the authors. Less than half of the 104 papers used the concepts of ‘sex’ and ‘gender’. Less than 1 in 10 papers attempted any definition of the concepts. Overall, the given definitions were simple, unspecific and created dualisms between men and women. Almost all papers which used the two concepts did so interchangeably, with any possible interplay between ‘sex’ and gender’ referred to only in six of the papers. Conclusion The use of the concepts of ‘sex’ and gender’ in ‘gender-specific medicine’ is conceptually muddled. The simple, dualistic and individualised use of these concepts increases the risk of essentialism and reductivist thinking. It therefore highlights the need to clarify the use of the terms ‘sex’ and ‘gender’ in medical research and to develop more effective ways of conceptualising the interplay between ‘sex’ and ‘gender’ in relation to different diseases.

Researching transformations in healthcare services and policy in international perspective: An introduction

Across countries healthcare systems face new pressures for change towards more cost-effective and sustainable health services for all citizens. In recent years health policy-makers have responded to these challenges mainly by introducing or reinforcing market mechanisms and by expanding managerial controls. This is leading to major transformations in health policy and, subsequently, to the organization and delivery of healthcare services. This collection brings an international perspective to the research on contemporary transformations in health policy and services, by focusing on countries as wide-ranging as the US and Western and Eastern European countries, to Japan, China and Australia and by addressing different healthcare sectors from hospital to home care. Together these international experiences help us to better understand both the risks of social inequality embedded in new health policies and the opportunities of mobilizing new resources towards better healthcare for all citizens.

Mainstreaming gender into healthcare: A scoping exercise into policy transfer in England and Germany:

Across the globe the concept of gender mainstreaming is indicative of substantive transformations, and healthcare is a particularly important policy arena. Yet existing research reveals only modest success in the implementation of gender policies in national healthcare systems, despite the availability of complex tools and guidelines. This article introduces an approach that links gender mainstreaming with approaches into policy transfer as dynamic processes of translation involving active players. In a scoping exercise the authors select England and Germany as case studies and draw on document analysis, other secondary sources and additional expert information. The analysis reveals varieties of translation of gender mainstreaming into national healthcare systems – even within the legal framework of the European Union – and the crucial relevance of feminist actors. The study raises more general questions on the nature of international policy-making in relation to national and local healthcare institutions and policy entrepreneurs.