Showing papers in "Social Theory and Health in 2011"

Neoliberal globalisation and health in a time of economic crisis

Abstract: The 2008 global financial crisis has been one of the outcomes of more than three decades of neoliberal globalisation policies. These reforms, implemented by the international financial institutions such as the International Monetary Fund, the World Bank and the World Trade Organisation, under the pressure of wealthy nations and transnational corporations, have also produced negative health effects. The advent of these economic measures since the late 1970s and early 1980s coincided, in fact, with reduced worldwide gains in both economic growth and life expectancy. They also have generated larger economic and health gaps between and within countries. This article reviews the major bodies of evidence on the multiple links between neoliberal globalisation policies, economic inequalities and health. It also discusses the future prospects for global health in light of contemporary policy responses to the crisis by national governments and the G-20.

Foucault's progeny: Jamie Oliver and the art of governing obesity

Abstract: Jamie Oliver is an English celebrity chef who has publicly politicised the relationships between class and food in Britain. No longer a simple chef, Oliver is presented as an evangelical saint, salvation of British school dinners, advocate for young disadvantaged kids, and now with his latest series Ministry of Food, a saviour of the British obesity epidemic. In this series, the population of Rotherham is surveilled and targeted as representative of poor eating habits and lifestyles in Britain. In need of urgent intervention, the townsfolk are urged to make themselves anew and ‘fight’ their way out of the obesity epidemic. Moving beyond a mechanistic application of Foucault, this article examines the intersections of different technologies that give rise to specific lifestyle interventions, and the forms of resistance they generate. Through a convergence of the cultural technology of reality TV and technologies of self-governance, this article argues that a novel form of obesity intervention is being re-invented in a health promoting, neoliberal environment.

A resource-based theory of social capital for health research: Can it help us bridge the individual and collective facets of the concept?

Abstract: The overall aim of this article is to present a resource-based definition of social capital for health research that bridges the two notions of the concept the individual and the collective. Initia ...

The practical ethics of genetic responsibility: Non-disclosure and the autonomy of affect

Abstract: Some have argued that advances in molecular genetics will lead to the geneticisation of identity and the subsequent reduction of the human subject to their genetic complement. In this article, we advance the more cautious argument that far from reducing subjectivity to genetics, genetic knowledge is incorporated and resisted in complex ways. We draw our analysis from a sample of individuals who have attended a clinical genetic service in South Wales. In-depth qualitative interviews (n=61) were conducted with family members to explore the ways in which genetic risk foregrounds patterns of relatedness and responsibility. A surprisingly high incidence of non-disclosure of risk was reported in our study. Families provided complex explanations of guilt, blame, character and surveillance to justify deferring or delaying disclosure of risk. We explain these findings in terms of conditions immanent to the materiality of everyday experience. Our account of ‘practical ethics’ combines discursive and pre-discursive explanations to explore the role of inheritance, kinship and affect in the modulation of genetic responsibility.

Surveillance of risks in everyday life: The agency of pregnant women and its limitations

Abstract: Risk management in pregnant women's everyday lives represents a central feature of the experience of pregnancy. We aim to analyse how the agency of pregnant women and the decisions they make are affected by social influences that reinforce medical norms and moral expectations towards motherhood. With data from a qualitative study conducted in Switzerland, we describe diverging positions on professional norms, distinguishing women who strive to eliminate uncertainty and ensure strict control of the biological development of their pregnancy from women who resist medical norms. Concrete resistance through personal bargaining with the normative framework was reported and justified through a range of arguments, allowing individual representations to match dominant expectations. Concurrently, we highlight the fact that social reinforcement of medical norms and moral expectations regarding proper motherhood limit possible deviations. This study contributes to the analysis of lay strategies towards health risks, emphasizing the articulation of agency and social influences that characterize the extension of risk surveillance in society.

Chronic illness as incalculable risk: Scientific uncertainty and social transformations in medicine

Abstract: This article employs Ulrich Beck's (1992, 1999) formulation of incalculable risk to analyze chronic disease in contemporary western society and the resultant social transformations across multiple levels of scale. Specifically, we explore the social structures in which management of contemporary health risks is embedded, as well as how the social psychological implications of risk incalculability affect individuals. These micro-level phenomena in turn feed back into cultural transformations in health knowledge and health-care institutions. We discuss the rising significance of health lifestyles following the epidemiological transition as a starting point from which to analyze the incalculable nature of chronic disease risk, paying special attention to the ways that fracturing medical knowledge underlies the development of a variety of often opposing lifestyle practices. Medicine has responded to these developments by institutionalizing a diversity of alternative health-care models, and we organize these complex processes around macro- and micro-levels of scale using Beck's theory of risk in contemporary society as a starting place.

The concept of the lifeworld as a tool in analysing healthcare work: exploring professionals’ resistance to governance through subjectivity, norms and experiential knowledge

Abstract: Health-care work is increasingly practiced within governance frameworks. These ‘softer’ forms of new public management typically seek to shape working practices and cultures around key organising principles such as risk, knowledge and performance. Yet the implementation of these control mechanisms through standards, monitoring and auditing is problematic, with limited evidence of success. This article highlights the important contribution that understandings of the lifeworld can offer in analysing resistance to governance frameworks, through a positive critique of Habermas. Drawing on qualitative data from interviews with health-care professionals, evidence of both opposition and acquiescence to governance frameworks suggests a state of reflexivity as much as ‘colonisation’. The components of the lifeworld – culture, society and personality – thus represent important bastions of resistance, regulating system intervention through standards of perceived truth, legitimacy and authenticity. Habermas's concerns about the continuing sustainability of this struggle against instrumentalism are considered.

Health care systems as determinants of health outcomes in transition countries: Developing classification

Abstract: In recent research, much attention has been paid to the divergent health outcomes that have emerged across the region of Central and Eastern Europe (CEE). Although rare the focus of research, one important source of variation in health outcomes can possibly be traced to the evolution of health-care systems. In this article, they and their transformations are relocated at the epicentre of the health story. First, the health-care systems in transition are classified into a typology through a combination of qualitative assessment of Health in Transition (HiT) Reports from the World Health Organisation (WHO), and cluster analysis based on the literature-driven framework. This resultant classification is then utilised in a panel regression using the fixed effects and panel-corrected standard errors model on the WHO Health for All data set for 25 transition countries of CEE and Central Asia across transition years 1989–2007. Through this, the research adds an important strand to the HiT and health-care classification literature. First, the study shows that the health-care systems of transition countries can be classified into separate groups. Second, evidence is presented that the structural differences in health care, reflected in the typology, partially explain cross-country health outcomes.

A critical review of theoretical frameworks for health service use among older immigrants in the United States

Abstract: Research on older immigrants’ health service use in the United States is important for making intelligent plans for and delivering services to this population. However, despite the growing importance of the topic, there has been little discussion in the literature regarding the comparative merits of different theoretical approaches in explaining health service use behavior among older immigrants in the host country. In this article, cognitive models, dynamic approaches and the health behavioral model are discussed in relation to their applications to the older immigrant population. Considering systemic barriers to health service use among older immigrants in the United States, which are beyond an individual level, this article proposes a modified Andersen model to explain health behaviors among older immigrants, based on its comprehensiveness. The model's flexibility also allows the incorporation of key concepts from cognitive models and the Network Episode Model that are relevant to the target population.

The social space of health inequalities in Portugal

Abstract: The main purpose of this research was to analyse the effects of the social structure on unequal patterns of morbidity and mortality in Portugal. The data source was based on the analysis of individual clinical files of inpatients from two hospitals who died in 2004 (N=1935). Data were collected from these files on social and health dimensions so as to define each person's social class, health-related lifestyle, life trajectory and illness trajectories A theoretical framework inspired by Cockerham and Bourdieu's concepts as well as both multiple correspondence analysis and cluster analysis were used to visualise the complex multidimensional social space of this health inequality field. The results show that over the life course, individuals positioned in different social classes experience distinct health and disease trajectories. The unequal distribution of the diseases and the causes of death in the social space reveal a structure of social inequalities based on the differentiated possibilities of accessing and using health resources.

Conceptualizing holism in international interdisciplinary critical perspective: Toward a framework for understanding holistic health

Abstract: The concept of holism is defined in disparate ways. This article offers foundational understandings of this term from various parts of the world, illustrating the virtually universal, historical, as well as contemporary nature of ideas such as interconnectedness, unity and oneness. Throughout human history, holistic worldviews were dominant until the past 400 years or so. At present, a revival of holistic thought-forms is taking place in many parts of the world. The purpose of this article is to sketch the landscape of holistic philosophical foundations, discuss systems science in this context and apply these underpinnings to holistic health in the hope that it will increase our understanding of both the conceptual foundations of holism, as well as its applications to health promotion, disease prevention, treatment of ill health and palliation. The article will conclude with the recommendation that holistic health-care practitioners take social inequities into account, so that this integrative health-care can become a means for individuals to take action for wellness, as well as a means to create structural changes toward equitable resource distribution.

The invention of patient-centred medicine

Abstract: This article, based on a plenary presentation to the 13th biennial conference of the European Society for Health and Medical Sociology, challenges the implicit theme of the meeting, that radically changing societies have significant impacts on health and well-being. This analysis, it is argued, masks the fact that it is the ways in which we construe health and well-being that makes a major contribution to what we understand by ‘radically changing societies’.

Artificially maintained scientific controversies, the construction of maternal choice and caesarean section rates

Abstract: Caesarean section rates are continuing to rise in many countries. This is despite mounting evidence that unnecessarily high rates are associated with adverse health outcomes for mothers and their offspring and create a significant economic burden on health systems. This article draws on Bruno Latour's account of the ‘artificially maintained scientific controversy’ to explore how professional bodies have managed to resist calls for reform by casting doubt on this evidence. Having undermined the evidence in question, these bodies insist that deference must be paid to maternal choice. However, choice is never problematised and the focus on maternal choice is used as a way of maintaining current practice. Science and technology studies has made us accustomed to being on our guard against unfounded claims to scientific certainty. This article demonstrates that we must also be wary of the opposite phenomenon, namely, of doubt being cast on a credible body of scientific evidence so as to justify inertia. When a narrative of scientific uncertainty is tied to fine sounding but ultimately spurious calls to respect patient autonomy, those with a vested interest in preserving the status quo are armed with a potent device with which to block demands for change.

Taking welfare state regime research globally: An application of the Wood and Gough typology to individual health

Abstract: Seldom do studies on welfare regimes and health take a global perspective. Usually most research on this genre concentrates on high-income countries only, few studies include low- and middle-income countries, and even fewer examinations combine a large number of countries to obtain a worldwide view. For this, we need global welfare regime typologies that would allow for such examinations. Given this, we investigated the usefulness of the Wood and Gough welfare regime typology on 49 countries by examining the association between welfare regimes and self-reported individual disability worldwide. The World Health Survey data were examined on 207 818 people from 49 countries using the welfare regime classification developed by Wood and Gough. Multilevel logistic regression was used to investigate links between disability and welfare regimes while also accounting for individual-level socioeconomic factors. Variations in individual disability prevalence were found within the different welfare regimes. For example, odds of poor health prevalence for citizens within the insecurity Sub-Saharan African regime as compared with the European-conservative regime were OR=1.83 95 per cent CI: 0.85–3.95. Living in a state-organized regime was associated with lower odds of disability prevalence, as higher odds of disability prevalence were observed in all non-state regimes (with the exception of the productivist regime). For instance, the people in the productivist regime of East Asia reported similar prevalence of poor health odds as compared with the European-conservative regime (OR=0.94 95 per cent CI: 0.45–1.99). This short report found that the Wood and Gough typology enables the study of welfare regimes and health globally, and appears to be a useful tool in welfare regime type research. The productivist regime seems to have health protective features that are on par with European welfare state regimes. We recommend that this finding is investigated further in future empirical analyses.

For the sake of health! Reflections on the contemporary use of social capital and empowerment in Danish health promotion policies

Abstract: Social capital and empowerment are increasingly used as key concepts integrated into methods of building healthy communities and as means of explaining inequities in health status within the field of Health Promotion. Although applying these concepts in a public health context offers a more holistic and socially oriented approach to health, problems arise when they are used in an imprecise and inconsistent manner. Health Promotion ideology tends to be transformed into politico-ideological complexes of power that enforce either a republican or a neoliberal perception of what the good life consist of. This may lead health professionals to participate in political projects dressed as pure health promotion that risk neglecting the various ways people may become empowered or socially engaged in their communities. We use two examples to illustrate these tendencies. Both examples arise from community building projects that demonstrate intertwined use of empowerment and social capital as part of political discourse. However, it is our primary aim to account for the different origins of the concepts in order to clarify their differences and similarities and to discuss their potentials in the context of Health Promotion. We draw on a range of theories such as those suggested by Bourdieu, Coleman, Putnam, Mayo, Rappaport and Eklund.

Why parents cross for children's health care: Transnational cultural capital in the United States–Mexico border region

Abstract: To investigate how cultural capital functions in transnational health fields, the experiences of 13 low-income parents of Mexican-decent living in El Paso, Texas and 11 low-income Mexican parents living in Ciudad Juarez, Mexico are considered as they negotiate the US-Mexican border for health care for their children with asthma. Parents on both sides crossed to receive affordable care, ‘better’ services, and/or the ‘correct’ diagnosis. When parents did not cross, it was because of a lack of documentation, incomplete knowledge and other constraints. To understand these crossing behaviors, the concept of transnational cultural capital, that is the transnational power to achieve desired ends in a health-care field that spans borders, is introduced, building off Pierre Bourdieu. Transnational cultural capital is relevant in other transnational settings, such as large urban areas whereby immigrants, have the option to access treatments from their home country, the United States, and other naturopathic remedies.

Capital transactions, disruptions and the emergence of personal capital in a lifeworld under attack

Abstract: Focusing on the experiences of parents caring for their children with Batten disease this article gives an overview of Batten disease as an exemplar of a long-term disabling, degenerative condition characterised by an omnipresence of biological pathology and consequence – represented, adumbrated and organised primarily through biomedical expertise. The utility of Bourdieu's concepts of field, capital and habitus is explicated and illustrated using data from an in-depth qualitative study on Batten disease. Through applying Bourdieusian constructs, we argue that it is possible to heuristically describe a Batten field militated by the biology, with forms of capital that accord to, and represent, biomedical interest and expertise. However, we illustrate a new form of capital that develops – personal capital – borne from systematic exclusion from existing forms of capital, and the sequestration of available capital in the field by expert systems that leave parents with an acutely aware, reflexive stance rooted in responding to ‘everyday’ lifeworld. This acts as a sounding board producing new personal systems of valuation seen here as ‘personal capital’. This personal capital allows the person to reject, harness, filter and ‘trans-value’ other forms of capital in light of their immediate circumstances, and personal pursuits in the lifeworld.

Improving access to quality care for female slum dwellers in urban Maharashtra, India : researching the need for transformative social protection in health

Abstract: Although quality health facilities in Mumbai and Pune are plenty, slum dwellers do not benefit fully from these. Next to financial barriers, low quality treatment and discrimination form major hurdles to entering public care. A lot of them prefer to buy services from ill-qualified private providers. Without social protection in health (SPH), their predicament often boils down to the uneasy choice between forgoing treatment and risking impoverishment. Currently, some SPH interventions try to protect poor urbanites and increase their access to quality care. This article provides more insight into the health service encounter experienced by female slum dwellers. Using data from focus group discussions with members of three SPH interventions and in-depth interviews with providers, challenges faced by the women during their health seeking process are discussed. By using Bourdieu's theoretical concepts on field, capitals and habitus, this study shows that a more subtle reproduction of social inequities and domination in the medical field forces slum dwellers to either forgo treatment, buy ineffective care from private providers, or passively accept the abuse in the public sector. These insights demonstrate the need for transformative SPH interventions to address the power imbalances in society that create and sustain the social vulnerability of poor people when seeking health.

Embodying psychosocial health inequalities: Bringing back materiality and bioagency

Abstract: In recent decades, psychosocial explanations of relationships between health and social economic inequalities have emerged. These approaches, it has been noted, de-emphasize the importance of material pathways. This article develops this critique by arguing for the relevance of sociomaterial spatiality and the materiality of social interaction. Psychosocial explanations see neurohormonal pathways as connecting the psychosocial and biological. This neurohormonal connection is developed here to include muscular, postural and other dimensions. Such approaches, furthermore, need to more adequately explicate the role and nature of agency. The notion of bioagency and its relationship to structure is used to address this issue. The conclusion briefly discusses the relevance of bioagency and materiality to psychosocial theorizing about health and social inequalities.

Do older women or older men report worse health? Questioning the ‘sicker’ older women assumption through a period and cohort analysis

Abstract: This study questions the ‘misery perspective’ generally used to understand gender, ageing and health. Using the General Household Survey time-series data, the article explores the changes in self-reported health for men and women aged 65 years and over across cohorts and historical time in the United Kingdom. It is found that although gender difference in reporting poor health existed for those born between 1880 and 1920, the difference was not observed for those born between 1921 and 1940. It is also found that compared to the 1970s and 1980s, gender difference in reporting poor health in old age decreased in the early 1990s and diminished to a negligible level in the 2000s. The results challenge the conventional understanding of comparative disadvantage of older women in the literature and illuminate that historical timing plays a role in the relationship between gender and ageing.

Biopower at the molar level: Liberal government and the invigoration of Danish society

Abstract: Over the last decade or so much social science research on the developments in the life sciences and biomedicine seems to be focusing too narrowly on individualization or, more recently, on geneticization, that is, the ‘molecular’ level. This article argues that current public health policies in Denmark can only be properly understood by paying attention to the interventions targeting society and the population, that is, the ‘molar’ level, as well. Although the racialized kinds of biopower of the nineteenth and most of the twentieth centuries may be history, the health and vigour of populations of states remains a crucial target of political concerns and interventions. In order to illustrate this, we examine the transformations in Danish public health interventions over the last decades. This case suggests that although ‘the social’ as a particular logic of governing may be on the retreat, the society and ‘its’ population today serves as a benchmark for a wide array public interventions seeking to make individuals and groups live a life that is longer and of a better quality. This new strategy, which goes well beyond reducing mortality and sickness, seems in principle to be without political limits.

Reflecting on HIV disclosure laws in the context of unsafe sex and the harm-reduction strategy

Abstract: In this article, we locate two discourses regarding the incidences of bareback sex practices. First, there is the greater reliance on safe sex practices, including going beyond condemnation of risky behaviour. Second, there is a disciplinary discourse of law and punishment. In the first instance, there is the promotion of the use of alternative (non-invasive) sex practices and condom use. In the second, there are highly selective and punitive disclosure laws specifically directed at unprotected sexual activity and other forms of risky or illicit behaviours that involve the transference of blood or other secretions. We believe, however, that a heightened understanding of the motivations behind unsafe sex is necessary to promote the implementation of public health interventions that will be better adapted to the reality of this population. There is, then, an urgent need to begin reflecting on the type of preventive strategies needed. To this effect, the aim of the current article is to initiate some reflections as well as a dialogue on the compatibility between the practice of bareback sex and a health risk reduction approach.

Great expectations: Legitimacy and emotions among out of hospital midwives

Abstract: In this article we examine the process by which a group of marginal health-care professionals portray the legitimacy of their skills and services to potential clients While extensive attention has been devoted to this construal of legitimacy through such affinitive alignments, much less attention has been given to elucidating the factors shaping how marginal social groups construct alternative professional legitimacy frameworks with which to contest dominant competitors Drawing on qualitative content analysis of direct entry midwives’ (DEMs) online descriptions of their practices and in-depth interviews, we explain how DEMs construe professional legitimacy through alternative cultural understandings of maternity care and experience Our study highlights three key components of DEMs’ professional legitimation: midwives’ alignment with professional associations and scientific research, the creation of new understandings of care relationships and space, and the role of emotions in defining the optimal birth experience We argue that the positive emotions associated with direct entry midwifery care become critical mechanisms for redefining both professionalism and the experience of birth within the boundaries of alternative practice