UK community health promotion has lost its power to bring about lasting change. Dr Katie Powell considers how sociology can help.
Community empowerment is ostensibly intended to improve health by empowering people ‘to increase control over their lives’ (World Health Organisation, 2021), but this valuable tool of health promotion has lost its focus on the political issues that give some groups greater control than others.
A big influence on this has been the “inward gaze” (Popay et al. 2020) directed by successive governments upon the characteristics and health behaviours of people in disadvantaged communities (see, for example, activities supported by the Public Health England programme: Health Inequalities: Starting the Conversation). In the context of widening health inequalities following the Covid-19 pandemic (Marmot et al 2020), the UK urgently needs more politically-engaged health promotion to achieve any change.
Theories from the social sciences that define ‘place’ and its relation to health disadvantage are plentiful but remain under-used in health promotion and public health research and practice more generally (Bambra et al, 2019; Holding et al. 2021; Smith and Schrecker, 2015). These theories provide a starting point for explaining how interventions might influence the long-term social and political processes that shape health inequalities. Their absence from policy arenas affects how problems are defined and which actions are pursued to address them. This contributes to the ‘lifestyle drift’ (Popay et al. 2010) – well documented in public health commissioning and implementation, in which individualised behavioural interventions to reduce inequalities predominate, despite acknowledgement of sociopolitical influences.
Why are theories of power and place under-used in health promotion?
Power inequalities make it hard to challenge the status quo
Research shows high levels of understanding about the sociopolitical drivers of health inequalities among lay people (Garthwaite and Bambra, 2017; Elwell-Sutton, 2019), health policy makers (Lynch, 2017) and public health practitioners (Public Health England, 2014) but people fearing a threat to their own status or economic position are less likely to acknowledge the role of these influences (Bottero 2020; Garthwaite and Bambra, 2017; Fuller 2016). In the context of place-based health promotion, service providers under financial pressures to meet organisational targets show a tendency towards lifestyle drift (Powell 2017, Williams and Fullagar, 2019).
Individualised, behavioural frameworks dominate public spaces
When intervention developers do draw on theoretical frameworks, psychological behavioural theories – like the health belief model and the transtheoretical behaviour change model – dominate (Glanz and Bishop, 2010). Likewise in popular discourse: research shows that the influence of social circumstances on health inequalities is often underplayed in UK media (Elwell-Sutton et al. 2019) and the dominance of medicalised, behavioural framings of health inequality in the public sphere limit policy action on the social determinants of health (Baker et al. 2018).
Sociological theories of power are often abstruse, and not conducive to empirical testing
Within sociology, power has often been theorised as top-down, mediated by social structures, systems or mechanisms. But there is no agreement over the nature of social structures (Martin and Lee, 2015), and no accepted theory of power among social scientists. Complicating things further, these structures are often considered by social theorists as unobservable, and only discernible through their effects. Theory may consequently seem irrelevant or too abstract to those beyond social science communities who are concerned with the immediate practical or policy challenges of addressing inequalities.
Few spaces exist to co-produce knowledge on sociopolitical issues
The lack of shared spaces to develop collectively-held explanations for local health inequities limits opportunities to voice sociopolitical accounts. For example, research shows that explicit, co-ordinated action on health inequalities has slipped down the agenda in public health practice in the context of public austerity and cuts to public health budgets (Holding et al., 2021).As a result, there is limited coherence across academic, policy, practitioner and lay narratives on the issue, hampering co-ordinated action (Harris et al. 2015; Holding et al. 2021).
Recent evidence shows that formal engagement of the public in the development and implementation of local public health policy is less likely when resources are cut (Baxter et al. 2020). Developing spaces for collaborative knowledge development and action on health inequalities between diverse groups is urgently needed.
How can sociologists support the use of theory in health promotion?
Mapping the power dynamics involved in local issues of inequality using existing power frameworks holds out the promise of identifying new targets for intervention (that might previously have been considered immutable at a local level) such as labour or advertising practices.
Finding the right power framework will be crucial. McCartney et al (2020) have developed a power framework informed by fundamental causation theory to support a “collaborative analysis” to “map the ways in which power relations manifest for [a specific] population.” The framework helps to identify sources of power and the spaces where they manifest. Fox and Powell (2021) have recently developed an approach to the study of health, power and place that focuses on the micropolitics of day-to-day interactions, as a means to understanding opportunities and constraints for health. This overcomes the impossible task of tackling ‘structural’ determinants of health.
Developing methods to support the integration of usable theories into practice could support the more ambitious and co-ordinated local action needed to address inequalities in health.
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