Katherine L. Frohlich

Transcending the Known in Public Health Practice: The Inequality Paradox: The Population Approach and Vulnerable Populations

Using the concept of vulnerable populations, we examine how disparities in health may be exacerbated by population-approach interventions. We show, from an etiologic perspective, how life-course epidemiology, the concentration of risk factors, and the concept of fundamental causes of diseases may explain the differential capacity, throughout the risk-exposure distribution, to transform resources provided through population-approach interventions into health. From an intervention perspective, we argue that population-approach interventions may be compromised by inconsistencies between the social and cultural assumptions of public health practitioners and targeted groups. We propose some intervention principles to mitigate the health disparities associated with population-approach interventions.

A theoretical proposal for the relationship between context and disease

Studies of ‘context’ are increasingly widespread. These studies often become entrenched in methodological debates rather than being conceptually satisfying. We suggest that part of the problem lies in an inappropriate use of ‘classic’ methods used by epidemiologists to study context and that it may be useful to study, instead, the relationship between agency (the ability for people to deploy a range of causal powers), practices (the activities that make and transform the world we live in) and social structure (the rules and resources in society). We utilise two examples from the current literature to illustrate these problems; the study of lifestyles and social inequalities in disease outcomes. We develop the notion of collective lifestyles as a tentative solution, inspired by Pierre Bourdieu’s theory of social action, Anthony Giddens’ structuration theory and Amartya Sen’s capability theory. Collective lifestyles are defined as an expression of a shared way of relating and acting in a given environment. It is proposed that context is created by relationships between people.

The social context of smoking: the next frontier in tobacco control?

A better understanding of the social context of smoking may help to enhance tobacco control research and practice

Capitals and capabilities: linking structure and agency to reduce health inequalities.

While empirical evidence continues to show that low socio-economic position is associated with less likely chances of being in good health, our understanding of why this is so remains less than clear. In this paper we examine the theoretical foundations for a structure-agency approach to the reduction of social inequalities in health. We use Max Webers work on lifestyles to provide the explanation for the dualism between life chances (structure) and choice-based life conduct (agency). For explaining how the unequal distribution of material and non-material resources leads to the reproduction of unequal life chances and limitations of choice in contemporary societies, we apply Pierre Bourdieus theory on capital interaction and habitus. We find, however, that Bourdieus habitus concept is insufficient with regard to the role of agency for structural change and therefore does not readily provide for a theoretically supported move from sociological explanation to public health action. We therefore suggest Amartya Sens capability approach as a useful link between capital interaction theory and action to reduce social inequalities in health. This link allows for the consideration of structural conditions as well as an active role for individuals as agents in reducing these inequalities. We suggest that peoples capabilities to be active for their health be considered as a key concept in public health practice to reduce health inequalities. Examples provided from an ongoing health promotion project in Germany link our theoretical perspective to a practical experience.

Social capital and core network ties: A validation study of individual-level social capital measures and their association with extra- and intra-neighborhood ties, and self-rated health

Research on social capital and health has assumed that measures of trust, participation, and perceived cohesion capture aspects of peoples neighborhood social connections. This study uses data on the personal networks of 2707 Montreal adults in 300 different neighborhoods to examine the association of socio-demographic and social capital variables with the likelihood of having core ties, core neighborhood ties, and high self-rated health (SRH). Persons with higher household income were more likely to have core ties, but less likely to have core neighborhood ties. Persons with greater diversity in extra-neighborhood network capital were more likely to have core ties, and persons with greater diversity in intra-neighborhood network capital were more likely to have core neighborhood ties. Generalized trust, perceived neighborhood cohesion, and extra-neighborhood network diversity were shown associated with high SRH. Conventional measures of social capital may not capture network mechanisms. Findings suggest a critical appraisal of the mechanisms linking social capital and health, and the further delineation of network and psychosocial mechanisms in understanding these links.

Understanding the dimensions of socioeconomic status that influence toddlers’ health: unique impact of lack of money for basic needs in Quebec’s birth cohort

Study objectives: To examine the unique impact of financial difficulties as measured by a lack of money for basic needs on the occurrence of health problems between the ages of 17 and 29 months, controlling for mother’s level of education and neonatal health problems. Design and participants: Analyses were performed on the 29 month data of the Quebec longitudinal study of child development. This longitudinal study followed up a birth cohort annually. Interviews were conducted in the home with the mother in 98.8% of cases. This information was supplemented with data from birth records. At 29 months, the response rate was 94.2% of the initial sample (n = 1946). The main outcome measures were mothers’ report of acute health problems, asthma episodes, and hospitalisation as well as growth delay and a composite index of health problems (acute problems, asthma attack, growth delay). Main results: Children raised in a family experiencing a serious lack of money for basic needs during the preceding year were more likely to be reported by their mothers as presenting acute health problems, a growth delay, two or more health problems, and to have been hospitalised for the first time within the past few months as compared with babies living in a family not experiencing a lack of money for basic needs regardless of the mother’s level of education and of neonatal health problems. Conclusion: Financial difficulties as measured by a lack of money for basic needs have a significant and unique impact on toddlers’ health.

Reducing social inequities in health through settings-related interventions — a conceptual framework

Introduction: The creation of supportive environments for health is a basic action principle of health promotion, and equity is a core value. A settings approach offers an opportunity to bridge these two, with its focus on the interplay between individual, environmental and social determinants of health. Methods: We conducted a scoping review of the literature on theoretical bases and practical applications of the settings approach. Interventions targeting social inequities in health through action on various settings were analyzed to establish what is done in health equity research and action as it relates to settings. Results: Four elements emerged as central to an equity-focused settings approach: a focus on social determinants of health, addressing the needs of marginalized groups, effecting change in a setting’s structure, and involving stakeholders. Each came with related challenges. To offer potential solutions to these challenges we developed a conceptual framework that integrates theoretical and methodological approaches, along with six core guiding principles, into a ‘settings praxis’. Conclusions: Reducing social inequities in health through the creation of supportive environments requires the application of the settings approach in an innovative way. The proposed conceptual framework can serve as a guide to do so, and help develop, implement and evaluate equity-focused settings-related interventions. (Global Health Promotion, 2013; 20(2): 39–52).

Commentary: Structure or agency? The importance of both for addressing social inequalities in health

In their paper entitled ‘Rose’s population strategy of prevention need not increase social inequalities in health’, McLaren et al. offer a cogent response to our earlier paper ‘The inequality paradox: the population approach and vulnerable populations’. It is a pleasure, and was indeed our goal, to see a lively debate sparked by our initial musings. It is therefore an equal pleasure to respond to their paper as part of a further debate. McLaren et al.’s argument rests in part on the idea that not all population prevention interventions influence social inequalities in health to the same extent. They argue that their influence depends on whether the strategy is what they call structural or agentic; the former targets the conditions in which behaviours occur, the latter, behaviour change among individuals. They conclude that structural interventions are less likely to worsen social inequalities in health than agentic strategies. While this distinction is interesting it may be somewhat distracting given that social inequalities in health, we have argued in the past, arise due to the interplay of ‘both’ structure and agency. While McLaren et al. rightly cite Anthony Giddens as an important 20th century thinker with respect to the structure/agency debate, they fail to mention that among Giddens’ most important contributions to sociology has been his structuration theory. Structuration theory is based on the idea that both agency, defined as the ability to deploy a range of causal powers, and structure, objectified as the rules and resources in society, give rise to people’s social practices, which are the activities that make and transform the world we live in (referred to by people in public health as behaviours). Using the heuristic of collective lifestyles, it has been argued that an adequate tackling of inequalities in health should address all three aspects of structuration theory (agency, social structure and social practices) rather than structure or agency alone. Indeed, we thank the authors for bringing us back to some of our earlier reflections with regard to the structure/agency relationship as it plays a crucial role in our new argument regarding vulnerable populations. By using the term vulnerable populations, we sought to move away from risk factor epidemiological thought, which tends to focus largely on behaviour alone, and suggest that some groups are vulnerable with regard to their agency, their position with regard to the social structure and their social practices. It is only by focusing on all three that one would be able to reduce social inequalities in health, as all three are at the base of these inequalities. However, we agree with McLaren et al. that the use of the term vulnerable populations is not without problems, including potential stigmatization. One might consider instead the concept of exclusionary process developed by the Social Exclusion Knowledge Network of the WHO Commission on the Social Determinants of Health. Their critique of the notion of vulnerability is that it emphasizes a state without identifying causes, and that it becomes a characteristic of people and not the result of a process. On the contrary, an exclusionary process originates in the unequal distribution of four types of resources: material, cultural, social and political. It is the unequal distribution of these resources that reproduces health inequalities. This notion of exclusionary processes points to the importance of working upstream in order to address some of the original causes that led to the unequal distribution of these resources. A final note is warranted regarding our perspective on participation. The authors suggest that participatory strategies may ultimately be agentic if structural conditions are not addressed. It is true that the public health literature tends to be ideological and offers little theoretical breadth with regard to the conditions required in the participatory process. In our view participatory planning is a political process. This process Published by Oxford University Press on behalf of the International Epidemiological Association

Playing for health? Revisiting health promotion to examine the emerging public health position on children's play

Concerns over dwindling play opportunities for children have recently become a preoccupation for health promotion in western industrialized countries. The emerging discussions of play seem to be shaped by the urgency to address the childrens obesity epidemic and by societal concerns around risk. Accordingly, the promotion of play from within the field appears to have adopted the following principles: (i) particular forms of play are critical for increasing childrens levels of physical activity; and (ii) play should be limited to activities that are not risky. In this article, we argue that these emerging principles may begin to re-shape childrens play: play is predominantly instrumentalized as a means to promote childrens physical health, which may result in a reduction of possibilities for children to play freely and a restriction of the kinds of play designated as appropriate for physical health. We argue that within this context some of the social and emotional elements of health and well-being that children gain through diverse forms of playing are neglected. This has implications for health promotion because it suggests a narrowing of the conception of health that was originally advocated for within the field. Additionally, this reveals a curious paradox; despite the urgency to promote physical activity through play, this position may limit the range of opportunities for children to freely engage in play, in effect reducing their activity levels. We propose an example that promotes play for children and better aligns with the conception of health as outlined in the Ottawa Charter.

Tobacco control and the inequitable socio-economic distribution of smoking: smokers’ discourses and implications for tobacco control

Warning: this article contains strong language. This paper focuses on the ways in which social context structures smokers’ views of, and reactions to, tobacco control. This exploratory study examined the interactions between tobacco control and smokers’ social contexts and how this may be contributing to inequalities in smoking. We found in our sample that higher socio-economic status (SES) smokers are more likely to positively respond and adapt to tobacco control messages and policies, viewing them for their future health betterment. Lower SES smokers in our study, on the other hand, are in conflict with tobacco control and feel intransigent with regard to the effects that tobacco control is having on their smoking. A better understanding of how social context structures peoples perceptions of tobacco control may help us to understand why social inequalities in smoking are deepening, and potentially what can be done better in tobacco control to decrease them.