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.

References

Bambra, C., Smith, K.E., Pearce, J. (2019). Scaling up: the politics of health and place. Social Science & Medicine 232, 36-42

Baker, P., Friel, S., Kay, A. et al. (2018). What enables and constrains the inclusion of the social determinants of health inequities in government policy agendas? A narrative review. Interational Journal of Health Policy Management, 7, 101-111.

Baxter,S., Barnes, A., Lee, C. et al. (2020). Addressing Health Inequity: Increasing Participation and Influence in Local Decision-making. NIHR School for Public Health research briefing.  

Bottero, W. (2020). A Sense of Inequality. Roman and Littlefield.

Elwell-Sutton, T., Marshall, L., Bibby, J. et al. (2019). Reframing the conversation on the social determinants of health. Health Foundation. 

Fox, N. and Powell, K. (2021). Place, health and dis/advantage: a sociomaterial analysis. Health.

Fuller, D. Neudorf, J., Bermedo-Carrasco, S. et al. (2016). Classifying the population by socioeconomic factors associated with support for policies to reduce social inequalities in health. Journal of Public Health 38(4), 635–643.

Glanz, K. and Bishop, D.B. (2010). The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health. 31, 399-418.

Garthwaite, K. and Bambra, C. (2017). “How the other half live”: Lay perspectives on health inequalities in an age of austerity. Social Science and Medicine 187: 268–275.

Harris, J., Springett, J., Booth, A. et al. (2015) Can community-based peer support promote health literacy and reduce inequalities? A realist review.  Journal of Public Health Research, 3 (3).

Holding, E., Fairbrother, H., Griffin, N. et al. (2021). Exploring the local policy context for reducing health inequalities in children and young people: an in-depth qualitative case study of one local authority in the North of England, UK. BMC Public Health 21, 887.

Lynch, J. (2017). Reframing inequality? The health inequalities turn as a dangerous frame shift, Journal of Public Health, 39(4), 653–660,

Marmot, M., Allen, J., Goldblatt, P. et al. (2020). Build Back Fairer: The COVID-19 Marmot Review. Health Foundation.

Martin, J.L. and Lee, M. (2015). Social Structure. In: Wright, J.D. (ed.), International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Vol 22, pp. 713-718. Oxford: Elsevier.

McCartney, G, Dickie, E. Escobar, O., Collins, C. (2020). Health inequalities, fundamental causes and power: towards the practice of good theory. Sociology of Health and Illness, 43, 20-39

Public Health England (2014). Local conversations on health inequalities: summary of findings.

Popay, M. Whitehead, M. and Hunter, D. (2010). Injustice is killing people on a large scale—but what is to be done about it? Journal of Public Health, 32(2), 148–149

Popay, J. Whitehead, M., Ponsford, R. et al. (2020). Power, control, communities and health inequalities I: theories, concepts and analytical frameworks. Health Promotion International.

Powell, K., Thurston, M. and Bloyce, D. (2017) Theorising lifestyle drift in health promotion: explaining community and voluntary sector engagement practices in disadvantaged areas. Critical Public Health, 27, 554-565.

Smith, K., and Schrecker, T. (2015). Theorising health inequalities: Introduction to a double special issue. Social Theory & Health, 13, 219–226.

Williams, O. and Fullagar. S. (2019). Lifestyle drift and the phenomenon of ‘citizen shift’ in contemporary UK health policySociology of Health and Illness, 41, 20-35.

Dr Katie Powell is a research fellow in Public Health at the University of Sheffield. She is a member of the Health Equity and Inclusion Research Group  Connect via https://twitter.com/DrKatiePowell


2 Comments

Alex Scott-Samuel · 24th May 2021 at 14:17

Having spent over 40 years reflecting on these issues (1, 2), I really welcome Katie’s contribution.
My view (2) is that until we have a discipline of health politics, a political science of health, sitting alongside the sociology of health and illness, health economics and health psychology, it will remain challenging to develop theory, to obtain research funding and most importantly, to advocate for the application of health-political research prescriptions in the real world.

Equally important are the fantasy paradigms (3) from which emerges the ‘fake news’ about health determinants that characterises the health systems and the political systems of capitalism. These of course require not behavioural but political solutions and political advocacy, which I commend to all researchers. My belief is that, however superficially impressive, the research that emanates from what I call ‘microscopists’ – those who see political issues like health inequalities as complex puzzles to be studied as it through a microscope – is inevitably inferior to the research of politically committed health scientists. Clearly, researchers who find the development of a new indicator of health equity as exciting as a research solution that would reduce racism or poverty, are submerged in an unethical discourse that is wholly without substance.

Sadly the description above characterises much prominent research in the fields of health science, social science and public health. Change is long overdue.

References
(1) Scott-Samuel A. The politics of health. Community Medicine (now Journal of Public Health), 1979, 1, 123-6.

(2) Bambra C, Fox D, Scott-Samuel A. Towards a politics of health. Health Promotion
International, 2005, 20, 187-193

(3) Scott-Samuel A, Smith KE. Fantasy paradigms of health inequalities: Utopian thinking? Social Theory & Health 2015, 13, 418-436
http://www.alexscottsamuel.info/a/3.pdf

Sam Friedman · 26th May 2021 at 14:55

I find these suggestions very useful, but somewhat abstract. What is missing, in my opinion, is the ways in which social movements have been fundamental in creating many advances in human health. In the United States, where I live, mass strikes by rank and file coal miners in the late 1960s won gains in healthcare for them and to some degree improved working conditions that were devastating their health. They also helped empower the environmental movement that resulted in the Environmental Protection Act and major gains in human health. These gains began to be whittled away when the movements lost steam, since capital’s need for profit means that any slackening of social movement mobilization opens the way for bureaucratic and budgetary slicing of gains. In the HIV/AIDS struggles, major gains were based on the power of illegal needle exchanges and of community mobilizations by activists rooted to some degree in emerging gay communities. In South Africa, mass mobilization led to access to antiretroviral therapy.

Thus, the sociology of social movements is critical. I would add that in my opinion the best analyses of this have been by Marxist analysts with strong ties to social movements.

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