Social Theory & Health

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Article
In this paper we explore the importance of relationality and care for understanding women’s alcohol use, using a theoretical framework comprising concepts from feminist ethics of care, the sociology of personal life, and feminist approaches to governmentality. A key focus is how care giving responsibilities and expectations in families appear to be particularly significant for creating or constraining possibilities for drinking practices. We draw on findings from a qualitative study about alcohol use and stress with 26 women, aged 24-67 years, in the North East of England, UK. We consider how care practices in families feature in the accounts of alcohol use by women with and without children, and how the symbolic and material aspects of social class interact with care to alter the drinking practices women engage in. The interpretation extends scholarship on women’s drinking, by adopting a relational approach to identity and linking private care practices and alcohol use to social and political structures. Public health approaches for preventing or reducing heavy drinking practices are predominantly situated within biomedical or psychological paradigms. Intervention approaches to reduce women’s drinking that draw on our theoretical framework could offer potential for reducing harmful alcohol use in a more meaningful way.
 
Article
In this study, we analyse how collective illness identities are created and sustained among people with type 1 diabetes using sociological perspectives on identity formation and symbolic boundaries. Drawing on 24 in-depth interviews, we show how collective illness identities are established and maintained through both inclusionary and exclusionary mechanisms. Informants discussed their collective illness identity by invoking common experiences and interests while also establishing experiential, biomedical and moral boundaries that distinguished them from other social groups. In particular, we highlight how the informants distanced themselves from type 2 diabetes on the basis of the latter’s status as a ‘lifestyle disease’. Our findings demonstrate the importance of boundary work for collective illness identity formation and the management of stigma, and the ambivalent relationship between illness identities and biomedical knowledge.
 
Interaction effects between type of welfare state and pandemic wave on COVID-19 cases per 100,000, deaths per 100,000, and excess deaths. Note Authors’ calculations
Interaction effects between type of welfare state and pandemic wave on COVID-19 cases per 100,000, deaths per 100,000, and excess deaths with all significant covariates. Note Authors’ calculations
Article
The COVID-19 pandemic has resulted in more than 282 million cases and almost 5.5 million deaths (WHO Coronavirus Disease (COVID-19) Dashboard, 2022). Its impact, however, has not been uniform. This analysis examines differences in COVID-19 cases and mortality rates amongst different welfare states within the first three waves of the pandemic using repeated measures Multivariate Analysis of Covariance (MANCOVA). Liberal states fared much better on the number of COVID-19 cases, deaths, and excess deaths than the Conservative/Corporatist welfare democracies. Social Democratic countries, in turn, did not fare any better than their Conservative/Corporatist counterparts once potential confounding economic and political variables were accounted for: countries’ economic status, healthcare spending, availability of medical personnel, hospital beds, pandemic-related income support and debt relief, electoral events, and left-power mobilization. The pandemic-related welfare responses after the first wave were similar across all three types of western democracies, but the differences in pandemic outcomes remained. The somewhat better outlook of the Liberal states could be attributed to the so-called social democratization of the Anglo-American democracies, but also to the fact that neoliberalism could have flattened the previous differences between the welfare states typologies and could have brought states closer to each other, ideologically speaking, in terms of welfare provision.
 
Article
This paper establishes a relational, post-anthropocentric and materialist approach to the Covid-19 coronavirus pandemic. Analysis of the ‘pandemic assemblage’ reveals that the virus has subverted the social and economic relations of capitalism, enabling its global spread. This insight establishes a materialist framework for exploring socio-economic disparities in Covid-19 incidence and death rates, via a more-than-human and monist analysis of capitalist production and markets. Disparities derive from the ‘thousand tiny dis/advantages’ produced by people’s daily interactions with human and non-human matter, making sense of the unequal occupational patterning of coronavirus incidence. This more-than-human approach supplies a critical alternative to the mainstream public health and scientific perspectives on the pandemic, with important implications for current and future policy to counter future microbiological outbreaks.
 
Article
This paper will explain the concept of double perspective and the impact that this cultural understanding may have on the health of the Indigenous peoples of Scandinavia. In inter-cultural communication, one set of meanings may be discernible to the outsider while a whole extra set of restricted or underlying meanings are only accessible for those people who have the cultural knowledge to discern them. These different sets of meanings embody a double perspective. It is not dual perspectives on the same reality but rather seeing two separate but overlapping realities. We will discuss the layers of meaning which are involved in the interactions between public healthcare institutions, clinicians and staff, and Indigenous people including the Sámi. These interactions are influenced by the impact of colonization and the ongoing epistemicide of Indigenous thought. By realising the improved resilience that a double perspective brings to Indigenous peoples, an awareness of the inclusion and exclusion of Indigenous persons, cultures and histories should become established in public institutions and in everyday life. A double perspective carries Sámi resilience, and should be understood as a key to support individual health, and also the collective wellbeing of a people living on their traditional yet colonized land.
 
Organizational structure of the health system in Iran
Ministries and organizations involved in the rural FPP in Iran
Article
Compared with many metropolitan residents, Iranians living in rural areas have a poorer health status partly due to the inequitable access to healthcare services. However, despite policy efforts to ameliorate the disparities, the gap in healthcare between rural and urban residents is growing wider according to several published studies. Among the fundamental causes of these disparities, dominant discourses play a critical role. This paper seeks to unpack the relations of power operated by socio-politically constructed discourses around rural health-promoting interventions, including rural Family Physician Program (FPP). We adopted a Foucauldian Discourse Analysis (FDA) to examine how well-intentioned efforts to advance equity policy may unintentionally maintain discourse and practices that reinforce inequity. We followed the analytic steps, outlined by Carabine, for distinguishing discourses in order to select and analyze 25 documents, 31 interviews, and 21 observations. The analysis revealed three interconnected discourses with supporting roles constructed in opposition to the putative role of the designed program: the rural FPP to achieve the government’s ideological purposes about justice and equality (the discourse of deficits), the rural FPP to align with the urban-oriented medical curriculum (the discourse of career disadvantages) and the rural FPP to represent discipline perceptions about rural communities (the discourse of rural inferiority). These oppositional role constructions can hinder the proper functioning of this policy, usually in favor of urban claims on rural space.
 
Article
Ambivalence, the vacillation between conflicting feelings and thoughts, is a key characteristic of scientific knowledge production and emergent biomedical technology. Drawing from sociological theory on ambivalence, we have examined three areas of debate surrounding the early implementation of HIV pre-exposure prophylaxis, or PrEP, for gay, bisexual, queer, and other men who have sex with men in Canada, including epistemology and praxis, clinical and epidemiological implications, and sexual politics. These debates are not focused on the science or efficacy of PrEP to prevent HIV, but rather represent contradictory feelings and opinions about the biopolitics of PrEP and health inequities. Emphasizing how scientists and health practitioners may feel conflicted about the biopolitics of novel biomedical technologies opens up opportunities to consider how a scientific field is or is not adequately advancing issues of equity. Scientists ignoring their ambivalence over the state of their research field may be deemed necessary to achieve a specific implementation goal, but this emotion management work can lead to alienation. We argue that recognizing the emotional dimensions of doing HIV research is not a distraction from “real” science, but can instead be a reflexive site to develop pertinent lines of inquiry better suited at addressing health inequities.
 
Article
This paper interrogates qualitative data regarding the changing experiences of mental health service and welfare state interventions for those who self-identify as experiencing long-term mental distress. We focus on austerity-related reforms in the English welfare and mental health policy architecture to explore the socio-cultural and material bases of benefit claims-making in relation to long-term illness and incapacity. Recent neoliberal social policy reforms contest the ontological status of mental distress, in effect recasting distress as a ‘moral’ status. This tendency is reinforced via three primary dynamics in contemporary mental health and welfare policy: the delegitimisation of sick role status in relation to mental distress; the foregrounding of individual responsibility and concomitant re-orientation of services towards self-help; and an increasing punitive conditionality. These intersecting processes represent an institutionalisation of ‘blame’ in various policy contexts (Scambler in Sociol Health Illn 31(3): 441–455, 2009; Sociol Rev Monogr 66(4):766–782, 2018), the moral stigmatisation of mental distress and escalating experiences of oppression for mental health service users and welfare recipients. Shifting conceptions of distress are thereby entwined with transformations in social policy regimes and political economies. Presenting distress as a personal failure legitimates austerity-related restrictions on benefit and service entitlements as part of a wider project of neoliberal welfare state transformation.
 
Mapping of Held's (2006) ethics of care theory characteristics to Russell et al.'s (2013) rural healthcare access conceptual framework dimensions
Article
Access to healthcare and health seeking behaviours of rural people often hinge on the existing relationships between healthcare providers and (prospective) healthcare users. However, rich micro-level health professional-healthcare user relationships and the unique relational context of rural settings are largely missing from dominant rural healthcare access conceptual frameworks. We argue rural healthcare access conceptualisations require revisiting from a relational perspective to ensure future healthcare access policy accounts for the relational nature of healthcare in rural contexts. Ethics of care is a moral theory informed by feminism which rejects liberal individualist notions and emphasises interdependence. We used Held's ethics of care characteristics to examine Russell and colleagues' healthcare access framework and dimensions for rural and remote populations. This process revealed Held's ethics of care characteristics are only somewhat evident across Russell et al.'s dimensions: most evident in the acceptability and accommodation dimensions, and most absent in the availability and affordability dimensions. Future rural healthcare access frameworks need to pay further attention to the relational aspects of rural healthcare, particularly around the availability and affordability of healthcare, to bolster future efforts to improve healthcare access for rural people.
 
Article
Scholars have documented tensions that develop as a result of the integration of complementary and alternative medical practices (CAM) into conventional medicine, but few studies have analyzed the process of integration. I use the Mindfulness-Based Stress Reduction program (MBSR), an increasingly popular CAM intervention, as a case study to investigate this process. Drawing on interviews and salient texts, I argue that MBSR leaders (MBSR teachers, doctors, and researchers) have fostered a cultural environment that allows the paradigms of alternative and conventional medicine to coexist: a new epistemological pluralism. Rather than exclusively defining MBSR as either CAM or conventional medicine, MBSR leaders strategically moved back and forth across contradictory epistemological paradigms, enabling them to maintain the integrity of mindfulness and its approach to “healing” while simultaneously conforming to the structural constraints of conventional medical institutions. This study contributes to theoretical research on institutions by suggesting that although this process may look like institutional isomorphism with CAM therapies conforming to the standards of conventional medical institutions, institutional actors’ comfort with contradictions and hybridized views supports institutional heterogeneity and possibly even divergence.
 
Article
Foucault's argument that a major break occurred in the nature of power in the Euro-pean Eighteenth century-an unprecedented socialization of medicine and concern for the health of bodies and populations, the birth of biopolitics-has become since the 1990s a dominant narrative among sociologists but is rarely if ever scrutinized in its premises. This article problematizes Foucault's periodization about the politics of health and the way its story has been solidified into an uncritical account. Building on novel historiographic work, it challenges the modernist bias of histories of biopolitics and public health and considers an earlier and more plural history of collective practices of health of which the story told by Foucault is just one important episode. Finally, it discusses the implications of this revised model for wider sociological debates on the link between modernity, health and the body.
 
Article
In the Indian Subcontinent, many commercial advertisements still use white children's images to promote their products and push forward the idea that Indian children need to become better versions of themselves, both physically and mentally. Such views are neither encouraged nor accepted in the western world. We argue that these ideas are not new and that they were introduced during the British Raj. We further argue that the hegemonic culture promulgated by the British colonial rulers is still prevalent in this postcolonial era and is being used by international and local manufacturers, intentionally or unintentionally, as part of their promotional activities for Indian consumers. Drawing from historical and contemporary evidence, we offer arguments to this claim and analysis of the workings of the hegemonic culture in producing such advertisements.
 
Article
The marketization of public healthcare has brought about organizational transformations, affecting health professionals' ways of working in hospitals and outpatient organizations. As a result of the reforms in the 1990s, the principle of business-like healthcare has been introduced in the Italian health system. This paper presents the main findings of a study of specialist doctors working in two local health organizations in the Tuscany region. Drawing on semi-structured interviews with specialist doctors working in an outpatient setting, the article examines the manifold reactions to changes of the medical profession within outpatient settings. In particular, the combination of professional and organizational dimensions has been taken into consideration. The results show that a change is involving outpatient specialist doctors' identity: organizational change affects several dimensions of the medical professional ethos. The change has been understood by categorizing three major types of approaches to medical professionalism, which are aimed to understand the complexity of the domain and to summarize professionals' reactions: the first is linked to a traditional model of professionalism; the second accepts partially business-like organizational issues, while trying to create individual spaces of autonomy in daily tasks; the third co-opts new organizational issues, which become part of the medical professional ethos.
 
Structure of SRH models
Reporting heterogeneity by education level
Article
Since the strong predictive power of self-reported health (SRH) for prospective health and social outcomes has been established, researchers have been in a quest to build a theoretical understanding of this widely used health measure. Current literature based predominantly in a biomedical perspective asserts a linear relationship between physical conditions and perception of health. Discrepancies from this expected relationship are considered an important weakness of SRH. Systematic discrepancies between physical conditions and reporting of SRH have been documented across different socio-economic groups. Evidence identified for educational groups shows that for the same level of health status, lower-educated groups report poorer levels of perceived health. This raised doubts whether it is useful to use SRH to measure social inequalities in health within and between countries. To date, sociologists of health have not engaged in the discussion of reporting heterogeneity in SRH. After reviewing existing evidence, we contend that the discrepancy in SRH reporting across social groups argued to be a weakness of SRH as a health measure is a strength from a sociological perspective. SRH as a social measure of health is a better predictor than objective measures of health precisely because it captures the lived experience of the embodied agent.
 
Contribution to the overall variance by variable categories to the first and second dimension. The dotted line indicates the average contribution (3.7%) given the number of categories
The cloud of categories. A map placing indicators of body investment modes into distinct practices. The categories normal BMI and age group 35–49 are placed on top of each other. The same holds for the overweight BMI category
A summary of the four distinct body investment strategies found in the cloud of categories
Three plots representing the cloud of individuals with point estimates and associated 95% confidence ellipses of the supplemental variable categories
Article
What characterises the similarities and differences in body investments among professions in the Danish healthcare field? This can be important when healthcare professionals relate to each other and to bodies of patients regarding differences in class, gender, age, and disease group. The study takes inspiration from Bourdieu's sociology and the concept of health capital. We ask whether health capital can explain distinctions in the empirical data? We used the explorative-descriptive method mul-ticorrespondence analysis (MCA) on data from 440 respondents gathered through an online survey. The respondents range from chief physicians to healthcare students. MCA makes it possible to condense frequency statistics and examine patterns of body investments through an examination of variables such as food intake, exercise, and medicine use that are then further related to supplementary variables such as social class and age. The analysis supports the concept of health capital and shows that some groups in the Danish healthcare field have a more instrumental body perception , such as the young age group (e.g. open to surgery, consume medicine, high exercise), while the upper-middle-class and older respondents have a more naturalis-tic perception of the body (e.g. read often, eat vegetables, practice yoga).
 
Article
This paper revisits Jessop’s governance of welfare framework, suggesting that in the post-financial crisis era of austerity we need to look again at its analytical dimensions. The paper reformulates Jessop’s Schumpeterian Welfare Postnational Regime ideal-type framework through critique, and then applies its reformulated Galbrathian, Affluent Postnational Oligarchy ideal-type to the case of the English NHS to present a new political economy of health.
 
Article
Recent work in the intersections of feminist technoscience studies and critical disability studies provides a wealth of perspectives with which to challenge ableist and curative imaginaries that remain in the foreground of emerging accessible technologies (Hamraie in Hypatia 30(1):307–313, 2015; Kafer in Feminist, Queer, Crip. Indiana University Press, Bloomington, 2013; Shildrick 2015). These visions frequently cast such technologies as harbingers of a future where disability is all but eliminated. Perhaps no other device best exemplifies this trend than eSight, makers of a wearable headset, whose mission is “to make blindness history by 2020” (eSight in Make Blindness History by 2020, 2018e. https://web.archive.org/web/20190117025248/https://www.makeblindnesshistory.com/). The company uses viral marketing and crowdfunding campaigns with ‘tear-jerker’ (their words) videos of users regaining their sight or being able to see for the first time, inviting viewers to become donors and “see what happens when you give the gift of sight” (eSight in Moments. https://www.esighteyewear.com/moments, 2008b). In this paper, we explore the promises and perils of such visions of disabled lives and advocate for accessible futures (Kafer in Feminist, Queer, Crip. Indiana University Press, Bloomington, 2013), rather than just able-bodied ones. Crip technoscience offers a new way of thinking about disability and technology that crucially needs to be reflected in how these devices, narratives—and their users—are fashioned, reproduced and taken up; disability’s desirable future is more than just a marketing spectacle.
 
Comparison of medical school and biology major course requirements
Comparison of medical school and sociology major course requirements
Comparison of medical school and philosophy major course requirements
Article
The college-level pathway to medical school (i.e., the “premed path”) includes all coursework, extra-curriculars, shadowing, volunteering, high-stakes examination (e.g., MCAT®), and application-related processes. Although medical school admission committees routinely insist their interest in diverse and “well-rounded” applicants, the premed path (PMP), through formal and informal mechanisms, is constructed to favor those from high in socioeconomic status (SES) privileged backgrounds, and those majoring in typical premed majors such as in the Biological Sciences. In these respects, the PMP is an example of Discriminatory Design—an entity constructed and sustained in a manner that (un)intentionally discriminates against certain groups of individuals. We begin this paper by providing a brief description of the PMP (within the U.S. specifically) and conceptual and theoretical overview of the discriminatory design framework. We then explore how the PMP is an example of discriminatory design through the distinct but related role(s) of financial, social, cultural, and (what we term) (extra)curricular capital. Using data gleaned from interviews with premedical students, content analyses of the curricular structure of particular majors and publicly available data on the various “costs” associated with the PMP, we detail how the PMP is reflective of discriminatory design, spotlighting specific barriers and hurdles for certain groups of students. Given the persistent lack of representation of students from minoritized groups as well as those from diverse academic backgrounds within medical schools, our goal is to spotlight key features and processes within the PMP that actively favor the pursuit of certain majors and students from more privileged backgrounds. In turn, we conclude by offering medical schools and undergraduate institutions specific recommendations for remediating these barriers and hurdles.
 
PRISMA flow diagram
Article
Local health systems are increasingly tasked to play a more central role in driving action to reduce social inequalities in health. Past experience, however, has demonstrated the challenge of reorienting health system actions towards prevention and the wider determinants of health. In this review, I use meta-ethnographic methods to synthesise findings from eleven qualitative research studies that have examined how ambitions to tackle social inequalities in health take shape within local health systems. The resulting line-of-argument illustrates how such inequalities continue to be problematised in narrow and reductionist ways to fit both with pre-existing conceptions of health, and the institutional practices which shape thinking and action. Instances of health system actors adopting a more social view of inequalities, and taking a more active role in influencing the social and structural determinants of health, were attributed to the beliefs and values of system leaders, and their ability to push-back against dominant discourses and institutional norms. This synthesised account provides an additional layer of understanding about the specific challenges experienced by health workforces when tasked to address this complex and enduring problem, and provides essential insights for understanding the success and shortcomings of future cross-sectoral efforts to tackle social inequalities in health. Supplementary information: The online version contains supplementary material available at 10.1057/s41285-022-00176-6.
 
Article
Health researchers are encouraged to involve patients and the public in each stage of the research process. Patient and public involvement (PPI) seeks to redress an apparent ‘democratic deficit’ in the production of health research. While many claims have been made of the benefits of involving and increasingly co-producing research with patient and public members, it has proven difficult to measure its impact. To inform understanding of why involvement initiatives ‘fail’ or ‘succeed’, this paper focuses on the relational dynamics of PPI and co-production. Through an examination of the discourse of relationships in UK health research guidance it is argued that while emphasis is placed on ‘sharing power’, there persists limited understanding of the constraints of institutional structures and how power asymmetries come to be performed, reinforced or resisted in PPI and co-production settings. To reshape and rethink existing practices I examine the theories that underlie PPI and co-production referring to Habermas’ (The theory of communicative action, Polity Press, Cambridge, 1987) and Mouffe’s (Social Research 66:745–758, 1999; Politica Comun, https://doi.org/10.3998/pc.12322227.0009.011, 2016) contrasting perspectives on the role of public participation in democratic designs. I suggest that power differentials cannot simply be eradicated or bracketed by guidelines and rhetoric, and that PPI and co-production must be understood as profoundly relational and interactional processes.
 
Article
Depression is regularly declared to be equivalent to a bodily illness, yet critics have long contested this ‘medical’ view of mental disorders. Following the ideas of Szasz and Foucault, we describe an alternative ‘moral’ view of depression, which emphasises the agency of the individual and presents depression as a potentially problematic but meaningful response that can be regarded as an aspect of character. We use popular internet blogs by people with depression to explore these contrasting conceptions, which can also be found in other research and information on depression. In blogs, the medical view is used to challenge what bloggers perceive as a persistently influential moral view, by deflecting criticism and responsibility and disowning unwanted aspects of the self. At the same time, bloggers make positive use of the moral concept of depression when discussing recovery. The moral view enables people to take active steps to address their difficulties and to integrate the experience of depression into their understanding of themselves in a challenging yet rewarding process of personal development. We suggest that the moral view of depression represents an enduring aspect of our understanding of ourselves, which the medical view has been superimposed onto, but has not managed to suppress.
 
Article
The paper is based on the study of the websites of egg donation centres and ART clinics based in Delhi, India. The treatment of infertility with the help of egg donor-IVF has not only birthed offspring for the infertile but also new social phenomena that challenge the existing paradigms and ontologies of social sciences. The binaries of nature-culture that are crucial in the cognition of social reality need to be reinterpreted in the light of unprecedented changes generated by egg donation. Ova donation is perhaps the only context in which the altruistic and commercial motives co-exist, the former promoting the latter, diluting the opposition between gift and commodity. In analysing these developments, sociological concepts need to be refreshed. The conjunction of biology and technology, third party involvement and the intrusion of market forces bring about denaturalization of childbirth on the one hand, and ‘culturing up’ of nature, on the other. Furthermore, relations of family parenthood and kinship that were conventionally premised on shared biogenetic material have to be reconceptualised at intervention of donor-IVF. Sociological study of donor-IVF calls for reconfiguration of nature-culture and gift-commodity in a symbiotic relationship rather than that marked by diametrical opposition.
 
Article
The principle of family and carer involvement is scattered throughout much recent mental health policy. Inspired by Bacchi’s ‘what’s the problem represented to be’ approach to policy analysis, we consider guidelines relating to depression in the UK and Denmark, two examples of European health systems which have undergone reforms based on neoliberal principles effectuating austerity politics. The analysis shows how carer involvement recommendations in depression guidelines reflect a responsibilisation agenda rather than a sound evidence and that the policies represent the problem to be a potentially risky patient along with consequential bureaucratic risks of involving the caregiver. In order to put the political agenda into perspective, we outline qualitative research on family life with depression which we argue could have informed ‘evidence-based’ guidelines. This research emphasises the complexity of family life with depression in which the origins of depression, maintaining factors, family context, pathways to treatment, treatment models and other routes to recovery all interact in a way that means the requirement for ‘carer involvement’ as simplified in current guidelines is naïve at best. We consider the gap between evidence and policy and note that carer involvement recommendations reflect a failure to understand depression within a context of complex dynamic family relationships.
 
Article
The integration of mental health services into primary care is a globally acclaimed strategy to close the treatment gap for mental disorders, but it has also been criticised for encouraging the medicalisation of everyday life. In Chile, this strategy has gained support and spread quickly in the last decades, and today, all primary public care centres have incorporated a mental health service. However, although some reports highlight problems that have arisen with integrated primary care, the critical social analysis of its impact on services, teams and communities is scarce. This article aims to analyse how primary public mental healthcare services (PPMHSs) in Chile could be contributing to medicalise life. Health policies, reports, evidence from research on local public health issues and the author’s experience are examined to develop the arguments. It is suggested that issues with the universal health access and integrated primary public care policies and the institutionalised use of standard classifications of mental disorders support the survival of a reductionist biomedical disease model and a trend to psychopathologise life. We conclude that these factors underpin the medicalisation of everyday life in primary public mental healthcare services in Chile. Critical engagement with daily practice is necessary to prevent PPMHSs from disempowering people and communities by providing them with medicalised solutions, instead of generating agency in their everyday problem-solving behaviours.
 
The Russian-doll model of the evolution of empathy. Various components of the empathic response, which have been added layer upon layer during evolution, remain functionally integrated. At its core is the perception–action mechanism, which induces a similar emotional state in the observer as in the target. Its most basic expressions are motor mimicry and emotional contagion. The doll’s outer layers, such as empathic concern and perspective-taking, build upon this core socio-affective basis while increasingly requiring emotion regulation, self–other distinction and cognition. Even though the doll’s outer layers depend on prefrontal functioning, they remain fundamentally linked to the core perception–action mechanism. Adapted with permission from: de Waal (2003)
Article
In this paper, we argue that the notion of a clinically-situated empathy (e.g. physician empathy), is potentially problematic as it perpetuates an emotion-deficient version of empathy within medicine and medicine education research. Utilizing classic and contemporary empathy theory from various social science disciplines, we discuss how empathy in the general sense differs conceptually from clinically-situated empathy—paying particular attention to the role of emotional contagion. To highlight this contrast, we draw upon Hojat et al.’s model of physician empathy and how this body of work reflects broader medical-cultural norms that problematize the role and impact of emotions within the clinical encounter. Alternatively, we present a more encompassing model of empathy drawing upon the fields of social-psychology and social-neuroscience in order to bring the notion of “feeling with” and emotional contagion more specifically, into medical education, medical education research, and medicine more generally.
 
Article
This paper seeks to examine whether knowledge about treatment, mental well-being and socio-demographic variables can predict patients’ trust in surgeons. A cross-sectional study was conducted in Norway. A total of 147 participants completed a questionnaire with items on knowledge, mental well-being, socio-demographic background, and trust in doctors in elective surgery. Our findings indicate that knowledge about treatment was a significant predictor of trust, and that the lowest levels of knowledge were associated with lower levels of trust. Most participants reported moderate/high well-being, however, patients with the lowest well-being scores had significantly lower trust in surgical doctors. We discuss these findings in the context of other relevant research and provide a theoretical discussion on the issue using Luhmann’s theory of trust. We argue that both knowledge and trust have forward-looking aspects, meaning that knowledge is to some extent acquired to cope with the future and trust is also related to expectations of the future. This theoretical approach can provide a framework for understanding our empiric findings. As knowledge was a significant predictor of trust, and is related to future expectations, information given to patients should focus on issues that may affect their personal future health.
 
Article
This paper considers the experience of informal carers for people with mental health problems from the point of view of social epistemology, where human knowledge is seen as a social achievement and people’s social position informs the kinds of knowledge they accumulate and deploy. Based on interviews with 31 carers for people with mental health problems, three areas of localised, specified epistemological activity were identified. First, the management of knowledge involved in shaping the situation to gain professionals’ recognition. Relatedly, the second theme concerned the participants’ construction of what it was that the professionals knew but which was felt to be withheld from carers. Finally, there were aspects of being a carer, such as dealing with the emotional friction in the caring relationship which either ‘nobody tells you about’ or which ‘you can’t tell anyone’. Examining these experiences through the lens of social epistemology highlights the interactive and personal work that carer participants did to create, shape and manage both knowledge itself and their relationships with health professionals and the cared-for person.
 
Article
How ‘evidence’ is conceptualised, generated and deployed in meso-level policy implementation on the ground is critical to health delivery. Using the case of a large-scale health service reconfiguration in northwest England, this study began as a narrative investigation into how different data types and sources are prioritised as NHS administrative structures change over time. During the research, one unpopular reconfiguration decision, the downgrading of a hospital, was challenged using judicial review. Suddenly, a key decision was being based not upon ‘facts and data’ type evidence but upon evidence of adherence to administrative procedure. This transferred focus away from the ever-shifting categories and hierarchies of data ‘types’ towards an emphasis on process. By comparing two deliberative contexts—committee and judicial review—this article proposes that evidence can be understood as simultaneously entity and process. As health service reconfigurations continue in response to austerity, integration agendas, evolving organisational landscapes, and demographic and political change, it is increasingly important to recognise the different meanings and uses of evidence.
 
Article
Socially disadvantaged ischemic heart patients are more likely to report poor patient satisfaction and problematic patient-provider communication than patients without social disadvantages. These inequalities are often understood with the use of concepts emphasising the individual’s cognitive abilities, such as health literacy. This study aims to explore Danish socially disadvantaged ischemic heart patients’ lived experiences of healthcare interactions through the lens of cultural health capital, and thereby further our understanding of more underlying structural, social and interpersonal factors shaping social inequalities in cardiac treatment. The study was carried out as a nationwide critical hermeneutic study in Denmark between October 2018 and August 2019. Data consist of qualitative interviews with 30 participants and supplementary observations. The findings showed that the healthcare interactions were characterised by unequal power balances. The healthcare professionals dominated the norms of the clinical encounter and thereby what kind of cultural health capital that held the highest exchange value. Furthermore, the participants felt inferior compared to patients with a higher social status who managed to display valued parts of the cultural health capital, and thereby receive more attentive treatment. The findings indicate that treatment of this group of patients should acknowledge the patients’ habitus and life circumstances.
 
Article
Chronic obstructive pulmonary disease (COPD) is an illness associated with intersectional poverty and stigma in old age; people with COPD are susceptible to anxiety, loneliness and isolation. People with COPD who contract COVID-19 are at high risk of serious complications, intensive medical needs and death and are, therefore, required to socially distance particularly assiduously. This paper offers an embodied phenomenological analysis of the emerging theoretical literature exploring the impact of social distancing upon people with COPD. Firstly, people with COPD are aware of how respiratory illness feels, are anxious about COVID-19 and afraid of being denied care. Future research might consider how people with COPD may be susceptible to “coronaphobia” and mental health consequences of the pandemic. Secondly, COPD tends to affect older people within the most intersectionally marginalised socioeconomic groups. Future research should remain mindful that people with COPD may be among the most lonely and least able to access health and social care services online than others. Thirdly, pandemics are known to intensify pre-existing social stigmas. Researchers and practitioners alike should be conscious that people with COPD may become increasingly stigmatised, especially those from intersectionally disadvantaged minorities.
 
Mapping of research perspectives on health as capital underlying the conceptualization of health capital in this article
Article
Emerging perspectives of health as individualized and privatized capital seem promising to shed light on the construction of individual health in the face of the growing individualization of healthcare. This article reviews extant perspectives of health as capital, reflecting upon how a conceptualization of health capital might be conceived by two of the main contrasting traditions: human capital theory affiliated with the Chicago School of Economics and Bourdieusian concepts of social field and capital. Arguing that a Bourdieusian perspective is potentially more fruitful to capture the importance of social and cultural dimensions in the construction of individual health, this article arrives at a conceptualization of health capital as the aggregate of the actual or potential resources possessed by a given agent that have the capacity to affect the position of agents in the social field of health. Drawing on Bourdieu's conceptualization of forms of capital, this article discusses the efficacy, the legitimation, and the positioning of health capital, uncovering its potential for understanding contemporary trends in health practices and health discourse.
 
Article
Schools have long been sites of public health intervention on the bodies of children. Increasingly, these interventions also act on the bodies of educators. Our case study is an intervention focused on the future health of children’s bodies (‘The Daily Mile’), which, we argue, also resulted in the surveillance of educators’ bodies. We draw on Bourdieu’s concept of hysteresis to explore how those bodies can become ‘unruly’ during implementation, in both resisting and being positioned as reluctant. Hysteresis, an under-utilised Bourdieusian concept, proved useful for exploring embodiment at a point when there were mismatches between habitus and the changing field of primary education. We show how the non-participation of some actors (e.g. teachers) was positioned as part of a broader resistance to health as a dominant value, whereas non-participation of less-privileged social actors (e.g. Teaching Assistants) was problematised in different ways. We argue that attending to moments of hysteresis, in which the changing symbolic values of physical capital become explicit, surfaces not just how dominant discourses (e.g. healthism) become reproduced in fields, but also how they change and are resisted, and with what effects.
 
Article
This article analyzes the contemporary transformation of the medicalization of pain relief in the organization of the perinatal care system in Quebec. The consequences of this transformation are analyzed specifically through the common recourse to epidural anesthetics to relieve women’s pain during childbirth. Relying on 6 months of ethnographic fieldwork, 26 semi-structured interviews and 24 life history interviews, I discuss the relevance of the concepts of medicalization and demedicalization for a theoretical analysis of this transformation. By taking into account in the analysis the three levels of medicalization suggested by Conrad and Schneider (conceptual, interactional and institutional), I argue that the expertise related to the relief of pain during childbirth is transferred from health professionals to women through a naturalization of women’s competences process. Beyond the notion of social control, I revisit the use of the concept of medicalization to analyze how pain during childbirth could be simultaneously the subject of a double and continuous process of demedicalization and of medicalization. I conclude that the transformations of the Quebec perinatal system cannot be completely part of a demedicalization process but rather part of a form of medicalization where the different levels of medicalization are modulated.
 
Article
This article draws on the findings of a small-scale, qualitative study exploring patients’ reactions to specialist advice regarding healthy footwear to develop and explore the ways in which the concept of ‘resistance’ can be understood in clinical encounters. Whilst wearing ‘inappropriate’ shoes can cause discomfort and exacerbate existing conditions, foot health professionals may continue to experience resistance to efforts to encourage patients to make footwear changes. Theoretically, resistance to professional advice has been seen not merely as a barrier, but a ‘tool’ to spark further, more personalised consultation to encourage real, long-term changes. Whilst such developments are welcome, we contend that some patients may be more able than others to openly resist, and resistance may not always be overt and obvious, but rather may take the form of an ‘illusion of compliance’. Additionally, some patients may consciously resist advice as a means to retain a sense of control over their treatment and bodies. Our insights extend and develop the concept of resistance in a theoretical and practical sense and have applicability in wider neoliberal healthcare contexts.
 
Article
As the medicalization of ‘‘obesity’’ has become more formalized, bariatric surgery is taking on new meaning in both medicine and society. Through repeated qualitative interviews (3 interviews every 3 to 5 months) and deploying interpretative phenomenological analysis, we examine the discourses and perceptions of patients post-bariatric surgery (n = 15). Results suggest participants’ perceive bariatric surgery not as a cure, but a tool, alleviant, prophylaxis and suppressant. The findings highlight that responsibility for a healthy future is constructed as a matter of individual responsibility and pressing concern.
 
Article
Forensic mental health care is situated across both criminal justice and healthcare systems and is subject to political, cultural, legal and economic shifts in these contexts. The implementation of strength- and recovery-based models of care should be understood in light of these social and structural processes. Drawing on novel empirical fieldwork and the extant literature, we argue that full realisation of strength- and recovery-based principles is at odds with aspects of late modern social control. Not wholly compatible, we highlight how concepts of empowerment, autonomy, identity and connectedness can unhelpfully rub-up against the concepts of punitiveness, otherness and risk management. Conceptually this is problematic, but in frontline forensic psychiatry settings, this has real lived-experience detrimental effects for patients – as our data demonstrate. To address this, a human rights approach might be fruitful. Grounding arguments for strength- and recovery-based principles in the heuristic framework of human rights can offer a set of common values to stimulate reform in forensic mental healthcare. The right to respect for private and family life, home and correspondence under Article 8 of the European Convention on Human Rights and Fundamental Freedoms offers a particularly promising, robust and well-defined framework for these future changes – as we outline.
 
Article
The existing international research evidence shows that second- and third-generation migrant women often have a family history of labor migration and experience mental health problems due to the multi-dimensional problems and precarious life situations in which they are enmeshed. Our qualitative study builds on the suggestion of diverse authors to investigate cultural aspects and dynamics that affect the help-seeking process. Since different research approaches and foci have been used to cast light on this issue, we argue that research risks to rely on an essentialist and pejorative notion of culture. In this study, we adopt an affirmative and productive notion of cultural difference that allows us to uncover the biographies of diasporic Muslim women with mental health problems to capture their strategies of meaning making and agency as rooted in their specific historical, social, political, and cultural contexts.
 
Article
Current legislation and policy frameworks regulating the detention and treatment of mentally disordered offenders in England and Wales are predicated on the assumption that a minority of patients have enduring violent tendencies and pose a serious long-term risk to the safety of others. This paper seeks to consider the manner in which notions of risk and the imperative to contain and minimise the potential for harm, present and impact patients in secure and forensic mental health settings. Within this, we consider how mental health stigma and Beck’s concept of the Risk Society can affect the thoughts and actions of those who may be held accountable for rare but potentially serious harmful events. We consider what changes may need to be enacted within secure and forensic mental health services to reduce the incidence and severity of consequent risks of harm to patients and their mental health recovery.
 
Article
The analysis of factors and actors that lead to the increasing medicalisation of common mental health issues is generally focused on the healthcare system (the medical profession, in particular) or other related fields (the pharmaceutical industry, the media, or governments, among others). In this article, I in turn examine how and which processes in a society as a whole might drive to unpleasant emotions of everyday life being managed through medical and, particularly, pharmaceutical solutions, rather than employing other resources. Using reflexive thematic analysis and drawing upon Elias’s process sociology, I present the analysis of 21 in-depth interviews with healthcare providers and users of services who are or have been treated for depression or anxiety disorders in Spain. It is concluded that the trends of scientisation and individualisation, coupled with demands for emotional self-control, enable the growing medicalisation of emotions. Professional help seeking represents rationalisation, whereas suffering unpleasant (yet non-disordered) emotions is viewed as irrational.
 
Article
This article discusses the forthcoming diagnostic classification of Prolonged Grief Disorder in light of sociological perspectives. By placing death and grief at the center of human life and culture, the beginning pathologization of grief may be discussed in regards to contemporary societal transformations. First, it will be discussed how grief can be viewed as an emotion that in many ways is essential for our self-understanding, self-relation and relation to others. Then, through the perspective of Zygmunt Bauman, it is discussed how death, and thereby grief, can be seen as constitutive for society and culture and how medicalization has played an important role in transforming our relationship to death and grief by a process of deconstruction. This perspective is then supplemented with Hartmut Rosa’s discussion of accelerating society to illuminate why grief is now a disorder that requires psychiatric treatment. The article ends with a discussion of why these tendencies are problematic in regards to our conceptualization and understanding of grief.
 
Article
Despite the acknowledgement that mental health inequalities are shaped by the interaction of macro-level (structural) and micro-level (individual, agentic) powers, dominant paradigms in mental health research have been ill-equipped to integrate those different levels of influence theoretically and empirically. As a result, an explanatory ‘deficit’ persists as to the causal mechanisms underpinning the impact of social inequalities on mental well-being, particularly mental health recovery. To redress this gap, critical realism has been put forward as a useful metatheoretical alternative. This paper begins by offering a succinct critique of extant mental health recovery research. Mental health recovery is problematised in relation to its dynamic embeddedness in contextual, including macro-structural, conditions. The core tenets and principles of critical realism are then invoked to address the identified philosophical and theoretical inadequacies. This paper argues that critical realism offers promise for explaining how inequality-generating mechanisms, such as social exclusion, may impede recovery. The analytico-conceptual potential of critical realism has remained largely untapped by the extant mental health scholarship. Critical realism offers a holistic and inclusive set of conceptual tools to re-examine the structure–agency nexus in order to advance mental health recovery and inequalities research, and an equity-based policy agenda.
 
Article
Consensual non-monogamy is a specific subculture that includes swingers, persons in open relationships and those who are polyamorous. While most previous studies have sought to either detail the subcultural norms for these groups or assess their risks for sexually transmitted infections, we aimed to better understand the narratives of persons who engage in consensual non-monogamy. Our goal was to understand the structure and nature of their reported lifestyles, and to better understand these theoretically. To do this, we interviewed 14 persons (7 males, 7 females), and analysed their data thematically. We then discussed these findings using the works of Deleuze & Guattari and Gayle Rubin. Our analysis and discussion identified that consensual non-monogamy could be described as a series of Deleuzian becomings that were nevertheless stratified, and which aligned but differed from what Rubin called the charmed circle of sexuality.
 
Concepts inherent in a research paradigm
Multi-, inter- and transdisciplinarity. Based on definitions by Stokols et al. (2013)
Article
Within the past few decades, the academic discipline of public health has taken root in universities around the world. As a young and multidisciplinary field with a dual-research/practice focus and a tradition that emphasises method development, the use of theory in public health research has often been neglected. In this article, we argue that explicit utilisation of theory is crucial to further the development of public health as an academic discipline. By examining three core areas of academic activity at universities—education, research and public outreach—we illustrate the role theory plays in establishing public health as an independent research discipline. We discuss the importance and benefits of including theoretical reasoning in teaching, research articles and communication with non-academic audiences. We also highlight the role of postgraduate students and junior researchers who, thanks to a combination of experience and receptiveness, play an important role in developing public health theory. We believe that a key to a successful process of establishing public health as an academic discipline lies in the development of a transdisciplinary approach to the research subject. This will equip public health researchers with appropriate tools to take on the public health challenges of the future.
 
Article
Healthy living blogs are ideal sites to analyze how biopedagogy (the teaching of body regulation) operates through social media produced by everyday people. Drawing from a theoretical framework grounded in neoliberal governmentality, biopower, and individualization, this paper endeavors to understand how healthy living blogs function as pedagogical sites where body management is taught. To address this question, the food discourse on 459 healthy living blog posts, written by highly successful and foundational women bloggers from the United States, was analyzed. The analysis reveals that the blogs operate as biopedagogical sites, incorporating key elements of truth, subjectification, and power (Harwood in: Wright and Harwood (eds) Biopolitics and the ‘obesity epidemic’: governing bodies, Routledge, New York, 2009). Epistemic logics are also revealed as key building blocks of biopedagogy. The bloggers draw from a knowledge and belief system in the same way that medical professionals rely on scientific knowledge and evidence to support health claims. Healthy living blogs use bodily knowledge and evidence in support of their food choices. As a result, they teach body regulation through the logics of body knowledge and body mastery. The concept of the “blogspert” is offered to describe the way in which bloggers’ authority as health experts is produced through anecdotal evidence that they have successfully cultivated bodily knowledge towards losing or managing weight.
 
Dualist ontology of structure
Combined model of social structuration
Article
The relationship between social position and health is a central issue in medical sociology. While researchers typically agree that health inequalities are ultimately determined by structural factors, the concept of ‘structure’ is often unspecified and vaguely understood. This paper contributes to our understanding of structure by clarifying and critiquing two main understandings of structure within health inequality research, respectively, ‘structure’ as synonymous with socioeconomic inequality and ‘structure’ as an arrangement of pre-given components. Inspired by the concept of structuration, I then outline a more practice-oriented conception hinging on a threefold distinction between structural determinants, structuring practices and structural outcomes. A model is then presented in which ‘structure’ is understood as the evolving conditions and outcome of practices in which actors produce, distribute and consume resources according to social schemas. The conclusion discusses the concept’s implications for researchers aiming to examine and reduce social inequalities in health.
 
Article
Healthcare on both sides of the Atlantic is a highly charged political and economic subject. This work considers US media coverage of the UK’s National Health Service (NHS), an under-researched area. We assess the framing of the NHS in editorials, opinion and feature articles during the time of the Obama administration to show how media can perform the role of lesson-drawing, a theory adopted from public policy research. The study also applies the notion of journalistic habitus in this context. Using these ideas, we address a hypothesis which holds that US coverage is framed around the flaws of the UK’s NHS. The paper considers how intermedia editorial and news values operate, with commentators drawing a range of negative lessons in both the Democrat- and Republican-supporting press. We find that the NHS was often posited as a flawed international variant of the single-payer model, where newspapers employed an ahistoric explanation of failure and decline.
 
Typical patient journal of a patient with prolonged sciatica complaints
Article
Sciatica is a common back problem with a generally positive natural course. This interview study was performed to gain increased insight into ambivalent and reluctant medicalization on the interactional level regarding the perceptions of Dutch patients and physicians about sciatica and its treatment options as a case study. While the concept of medicalization was introduced decades ago, nuanced perspectives on medicalization on the interactional level—ambivalent and reluctant medicalization—were added recently. Interviews were conducted with 10 patients and 22 clinicians and analyzed using these perspectives. The findings show that patients and clinicians share the problem definition of sciatica, which is stated to be the essence of medicalization. They differ from each other regarding the preferred course of action after diagnosis. Ambivalent and reluctant medicalization both highlight that medicalization in practice is often an uncertain and contested process, with medical intervention as a compromise result. In this case, the problem was not in the diagnosis but in reaching a treatment compromise, considering how much discomfort due to sciatica a patient could handle.
 
Article
Interviewing 67 primarily middle-class parents and children in a southern U.S. city, we learned that families know a great deal about the dangers of excess sugar consumption. However, in the private spaces of family life, families let down their guard and enjoy sugary treats, often treating them as symbolic markers of love and comfort. Theoretical concepts emerging from the dramaturgical perspective of Erving Goffman (1959) and from contemporary symbolic interactionists illuminate how sugar consumption is simultaneously shunned and celebrated in private family life. Moving beyond previous research, we track the ways sugary products facilitate love, sanity, and privacy to make daily family life bearable for both parents and children. We call the rhetorical and physical practices that enable excusable sugar indulgence Health Performance Strategies. Our findings on how families engage in these health performance strategies have broader implications for many other efforts to govern the health habits of families.
 
Visualisation of conceptual framework
Article
The conceptual ambiguity of public trust in the healthcare system poses problems for governance and public trust measurement. Therefore, we aimed to answer: what is public trust in the healthcare system? We conducted in the context of the English NHS an analysis of online news with readership comments concerning the care.data initiative; a secondary analysis of interviews about participants’ experiences and perceptions of biobanks; and an analysis of public focus groups about perceptions of the 100,000 Genomes Project. Further, we engaged with existing conceptual work and trust theory. This resulted in a full conceptual framework of public trust in the healthcare system. Public trust is established in anticipation of net benefits. Public trust legitimises the actions of the healthcare system as well as encourages the public to participate in healthcare-related activities. Further, levels of public trust are affected by spill-over effects from high or low levels of public trust in other parts of the government system. Last, many actors inside and outside the healthcare system influence public trust. Future research needs to translate this conceptual framework into policy guidelines and a measurement scale, as well as to validate the conceptual framework for healthcare systems other than the British NHS.
 
Article
Predictive testing information raises questions about risk communication, health responsibility, and about how to deal with the gap between knowledge of risks and options to act on this knowledge. For some diseases identified by predictive testing, specific treatments or interventions are available, while other diseases, thus far, remain untreatable or unpreventable; this triggers different forms of responsibility. Gender also often intersects with moral responsibility, regarding risk communication but also responsibilities of care which may become necessary with a family member’s onset of disease. The aim of the study was to analyze laypeople’s attitudes towards predictive testing with a special focus on forms of responsibility arising while dealing with uncertainty of risk information. We conducted seven focus groups with laypeople (n = 43) in four German cities in 2016. Participants were provided with different genetic testing scenarios (breast cancer, early-onset Alzheimer’s disease, pharmacogenetics in rectal cancer) for discussing their responsibilities and risk perceptions. We identified three different forms of responsibility: self-responsibility and self-care, family responsibility and care for others, and professional responsibility. For laypeople, the decision for predictive genetic testing seems voluntary and free from external constraint; however, both family and professional conditions influence an individual’s decision.
 
Top-cited authors
Deborah Lupton
  • UNSW Sydney
Malin Eriksson
  • Umeå University
Anne Hammarström
  • Uppsala University
Mehdi Ghazinour
  • Umeå University
Nasar Meer
  • University of Strathclyde