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Swiss Journal of Sociology, 44 (2), 2018, 203–215
Vulnerability in Health Trajectories: Life Course Perspectives
Vulnerabilität in Gesundheitsverläufen: Lebenslaufperspektiven
Vulnérabilité dans les trajectoires de santé : perspectives du parcours de vie
Stéphane Cullati*, Claudine Burton-Jeangros**, and Thomas Abel***
It is now widely acknowledged that the unequal distribution of good health across the
population results from the inuence of a range of social determinants. ese shape
often sharply distinct health patterns across and among socially disadvantaged and
advantaged groups. is study of health inequalities has been recently re-visited and
partly renewed by life course researchers (Burton-Jeangros etal. 2015; Bartley 2016).
Life course perspectives aim at providing a more comprehensive understanding of the
development of inequalities over time in specic individual health trajectories. Both
macro contexts (e. g. historical time and changing cultural representations, economic
booms and recessions) and micro contexts (e. g. family situation, working conditions,
social networks) inuence how health trajectories unfold over the life course and
therefore contribute to how health inequalities develop among and across sub-popu-
lations. Despite the general expansion of education (Meschi and Scervini2014) and
a partial decrease of gender inequalities (Dorius and Firebaugh2010) in the second
half of the twentieth century, health inequalities continue to grow in many auent
countries (Mladovsky etal. 2009; Mackenbach etal. 2016). Research shows this
to be associated with an increase in basic socioeconomic inequalities (e. g. income)
observed over the last decade (Duvoux 2017). For a better understanding of these
various trends, more research at the crossroad of sociology of health and life course
epidemiology is needed (Burton-Jeangros etal. 2015).
* NCCR “LIVES– Overcoming Vulnerability: Life Course Perspectives,” Institute of Demography
and Socioeconomics, University of Geneva, CH-1211 Geneva.
Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva,
CH-1211 Geneva, email@example.com.
** NCCR “LIVES– Overcoming Vulnerability: Life Course Perspectives,” Institute of Demography
and Socioeconomics, University of Geneva, CH-1211 Geneva, firstname.lastname@example.org.
*** Institute of Social and Preventive Medicine, University of Bern, CH-3012 Bern,
204 Stéphane Cullati, Claudine Burton-Jeangros, and Thomas Abel
SJS 44 (2), 2018, 203–215
2 Life course studies of health
A recent discussion of the classical WHO denition of health (WHO 1946)
emphasized the need to adopt a dynamic approach, hence suggesting to consider
health as “the ability to adapt and self-manage” (Huber etal. 2011). In empirical
research the individual and social patterning of health has so far tended to be only
roughly observed, through trajectories categorized with the following taxonomy:
“stability” (in good or poor conditions), “decline,” “improvement,” and uctuations
(Colerick Clipp etal. 1992). Nevertheless, this description of empirical patterns
has been hampered by the lack of population-based longitudinal data covering the
full life course. From a theoretical point of view, the pattern of health trajectories
has frequently been described along the following model: (having the best) grow-
ing, followed by (longest possible) maintaining and (latest and slowest possible)
declining health (Hertzman 1999; Ben-Shlomo etal. 2016). After the develop-
ment phase associated with childhood, health tends to slowly decline in adulthood
(Pinquart 2001; Cullati etal. 2014b), as individuals ageing is often progressively
impaired with increasing loss of functional and cognition abilities. Along with
biological ageing, patterns of health trajectories are not straight and linear (Halfon
etal. 2014; Ben-Shlomo etal. 2016) but uctuate by individuals’ characteristics
and living contexts. Variability of health trajectories is linked with both biological
factors, such as genes-environment inuences on physiological functions, brain and
microbiota developments, and a range of social factors associated with individual
life courses that shape these trajectories in an important manner (Vineis et al.
2016). Indeed, the household in which individuals grew up, the schools they at-
tended, the neighbourhoods in which they lived, their socioeconomic conditions in
adulthood (McDonough etal. 2005; Cullati 2015), their employment (Stone etal.
2015; Benson etal. 2017) and family histories (Dupre etal. 2009; Benson etal.
2017), the (normative and non-normative) transitions they experienced as well as
the dierent adversities they met during their life, aect chances of growing and
remaining in good health. e mutual inuences of dierent life spheres like work
and family impact the health trajectories in adulthood (Knecht etal. 2011; Cullati
2014; Cullati etal. 2014a; Knecht etal. 2016), as well as the period and country
in which individuals live (Sacker etal. 2011; Burton-Jeangros and Zimmermann-
Sloutskis 2016). Individual health trajectories also depend on individuals’ ability
to adapt to their living contexts, to cope with stress, such as a stressful psycho-social
environment at work (eorell 2000; Eatough etal. 2016), a poor relational envi-
ronment in the family (Lehman etal. 2009; Berg etal. 2017), life-time adversity
(Seery etal. 2010), and adapt to a health impairment (Cooper and Bigby 2014) or
the health impairment of their partner (Berg and Upchurch 2007). A sociological
perspective is thus more specically interested in documenting whether the health
trajectories of dierent social categories (dened for example along gender, social
Vulnerability in Health Trajectories: Life Course Perspectives 205
SJS 44 (2), 2018, 203–215
class or migration background) develop in parallel over time, reecting a constant
gap across these categories, or whether they diverge as individuals age, which would
indicate that, along the cumulative dis/advantage model (Dannefer 2003), social
processes dierently impact individuals as they age, or whether adaptation to the
living context vary between these categories.
A challenge for future life course studies is to consider dierent time processes
aecting individual health, such as short-term stressors (e. g. changing jobs, marital
breakup, adverse events) versus long-term adverse eects (e. g. living in poor circum-
stances for several decades). Combining life course models of health trajectories
(growing, maintaining and declining) (Hertzman 1999; Ben-Shlomo etal. 2016)
with adaptive regulation models (Boker 2015), or short-term regulatory processes
(Spini etal. 2016), is a methodological challenge, but it would improve our know-
ledge of the development of health vulnerability over the life course.
3 Vulnerability and health
Research on vulnerability rst developed in environmental science and broadened
to research elds like human development, ageing studies, life course and welfare
states studies. e concept can account for nations’, groups’ and individuals’ dif-
culties to handle a specic situation. In life course research, vulnerability has been
dened as a lack of resources putting individuals at risk of experiencing negative
consequences of stress and thus reducing their ability to eectively cope with adverse
events and recover from stress, or to take advantage of opportunities when facing
normative and non-normative events or transitions (Spini etal. 2013; Spini etal.
2017). Resources are many in types (physiological, cognitive, relational, economic,
social, cultural and institutional) and are theoretically available to most individuals.
However, depending on their genetic background and social organization processes,
levels of resources are not distributed evenly across individuals living in the same
society; such resources are dierent for individuals living in dierent societies, as
between high- and low-income countries. Furthermore, those inter-individual
dierences in level of resources can be explained by life course processes, like the
Cumulative Advantage and Disadvantage (CAD) model (Dannefer 2003) or the age-
as-level hypothesis (Lynch and Smith 2005). In the CAD model, these dierences
are expected to grow over ageing through rising divergence between the better os
and the worst os. By contrast, the age-as-leveller hypothesis suggests that higher
mortality of disadvantaged individuals reduces inequalities among those who stay
alive. e evolution of these inter-individual dierences in level of resources will
be aected by stressors and shocks (hazards, life adverse events) experienced during
the life course, be they chronic or event-based (Wheaton 1994).
206 Stéphane Cullati, Claudine Burton-Jeangros, and Thomas Abel
SJS 44 (2), 2018, 203–215
In the context of life course studies of health, and in line with the above
denition of vulnerability (Spini etal. 2017), we propose to consider that health
vulnerability emerges at the articulation of two distinct processes. On one hand, a
lack of resources is generating dierences in health trajectories between individuals, or
groups, over the life course. On the other hand, limited resources hinder recovering
from poor or disadvantaged conditions and coping with stressors, and the absence
of such compensating mechanisms maintains or even accentuates dierences in
Dierences in health trajectories can have two patterns. First, in adulthood, it
results from an acceleration, earlier start, or a combination of both, of health decline,
resulting in a growing health gap between individuals or social groups over the adult
life course (Dannefer 2003; Cullati etal. 2014b). Available resources, whether
genetic, socioeconomic, relational, or a combination of these, can be determinant in
the acceleration and/or earlier start of health decline. Second, dierences in health
trajectories in middle age or at older age can lie in structural and inter-personal stress
exposures in critical and sensitive periods of the life course, resulting in a constant
and long-term gap across individuals or social groups in later health trajectories.
e life course perspective suggests indeed that a bad start in life, like experiencing
adversities (Greeneld 2010; Danese and Tan 2014) or growing up in low socioeco-
nomic conditions, can have long-term adverse health consequences ( Wadsworth and
Kuh1997), like poor quality of life (Blane etal. 2004; Wahrendorf and Blane 2015),
poor physiological risk factors of cardiovascular disease (Blane etal. 1996), chronic
conditions (Blackwell etal. 2001), poor health behaviours (Cheval etal. 2018) and
mortality (Hayward and Gorman 2004; Galobardes etal. 2008). Adversity during
adulthood, such as poor work and unstable family conditions, also result in poor
health outcomes later: single motherhood from young adulthood to middle age
(Berkman etal. 2015) and poor mid-life occupational conditions (Platts etal. 2015)
for example, have been shown to be associated at older age with reduced quality
of life and negative health outcomes, including accelerated health decline. During
old age, social participation is associated with lower mortality (Holt-Lunstad etal.
2010) and with improvement in self-rated health (Ichida etal. 2013), while social
network ambivalence is linked with cardiovascular reactivity (Uchino etal.2001),
and negative emotional support from family or friends impairs self-rated health
(Craigs etal. 2014). All these mechanisms conrm the delayed impact on health
of vulnerable circumstances encountered at dierent stages of the life course.
Along with structural advantages and disadvantages, the life course perspective
also emphasizes the role of “linked lives” in the development of health vulnerabil-
ity. Indeed, between individual circumstances and macrosocial environments, the
unfolding of health trajectories need to be considered in the meso-level context of
families. Individuals live in interdependence or in networks of shared relationships.
Persisting inequalities between women and men in the labour market reect the
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interdependence of their life histories, especially in the family unit (Drobnic and
Blossfeld 2004). Individual trajectories are constantly connected with the ones of
other family members, in relational patterns that can be either favourable or detri-
mental to health circumstances. However, the framing of respondents’ life by their
partner’s characteristics has so far been largely neglected by the life course research
in general (Bird and Krüger 2005), and in life course epidemiology in particular.
4 Contemporary societies and accumulation of disadvantages
In societies characterized by individualization and diversity of life styles ( Giddens
1991), bio graphic risks (Beck 1992), and gender de-standardisation of occu pational
careers (Levy and Widmer 2013), the interplay of agency and structures is of par-
ticular importance, as one of the life course principle (Elder 1998). Socio logical
conceptualizations of agency and structure can contribute to our understanding of the
processes by which inequalities in health trajectories occur over time and how social
factors (i. e., socioeconomic position, working conditions, marital and family lives,
lifestyles, gender, migration, discrimination) impact on health trajectories (Abel and
Frohlich 2012). Agency can hamper development of health vulnerability over the
life course. For example, the impact of physical activity has been shown to reduce
mortality as much as medical drugs (Naci and Ioannidis 2013). Individuals may
impact their cognitive ageing by endorsing either supportive (learning, exercise and
sexual activity) or detrimental (sleep deprivation, alcohol consumption) behaviours
(Shors etal. 2012). Alternatively, agency can accelerate health vulnerability, such
as when compliance to misleading social norms result in bad life course outcomes
(Widmer and Spini 2017), like when endorsement of risky health behaviours is a
marker of social acceptance.
Simultaneously, structures can provide, or not, to individuals the resources and
opportunities they need to live a healthy life. Educational and health care systems,
family, work and housing policies, social security all inuence life course trajectories,
oering to individuals resources at dierent stages of their life and thus aecting
their chances of staying in good health as long as possible. Socially disadvantaged
groups are structurally positioned in unfavourable conditions in society (e. g. poor
working and housing conditions) and have less material and non-material resources
to cope with the adversities of life. Such structural disadvantaged positions put them
at higher risk of experiencing health decline earlier in their life course or at a faster
rate of decline. e accumulation of such diculties is associated with health risks
that are themselves a potential source of non-normative transitions such as job loss
or divorce due to poor health conditions. Considering the social determinants of
health in a life course perspective particularly emphasizes the crucial role of social
protection regimes as mechanisms that protect most vulnerable categories from the
208 Stéphane Cullati, Claudine Burton-Jeangros, and Thomas Abel
SJS 44 (2), 2018, 203–215
new social risks generated by current arrangements in regard to work and family
lives (Ranci 2010).
5 Contributions to the special issue
is special issue gathers six empirical papers based on either quantitative or quali-
tative data, representing a range of European countries. Papers are either single-
country studies (Switzerland, France, Germany) or multi-country studies, using the
Survey of Health, Ageing and Retirement in Europe (SHARE). ree papers are
population-based cohort studies (one of teenagers, two of older people) and three
are studies of sub-groups populations (children following an obesity management
programme, survivors of childhood cancer and young adults with mental disorders).
Two papers use non-research databases (administrative data or medical records) and
two use self-reported retrospective data. Finally, two studies empirically tested the
CAD hypothesis (Dannefer 2003). Contributions in this issue are organised fol-
lowing the chronological life course, from childhood to old age.
e rst article, written by Andrea Lutz (in French), is an ethnographic study
of obese or overweight children and their parents following a paediatric obesity
management programme in a Swiss tertiary hospital. Families were recruited at
the beginning of the programme and data was collected through interviews with
the family and observations of medical consultations. e author explored the
association between the family social position and the compliance with medical
recommendations. Acceptance or resistance with medical recommendations was
assessed at the beginning of programme and a few months later. Results showed
that compliance with medical recommendations increased for all children. A gradi-
ent between socially advantaged and disadvantaged families was observable before
the programme and remained stable over the course of the programme. Among
disadvantaged families, lack of nancial resources was perceived as a barrier in
adopting a healthy diet. Families with high educational levels were more familiar
with nutrition and physical activity recommendations compared to family with
low educational backgrounds. e author interprets these results in the light of
the theory of habitus of Pierre Bourdieu, explaining the dierential internalisation
of medical recommendations by social positions.
e article of André Berchtold etal. examines individual trajectories of somatic
complaints from the age of 16 to 30 a cohort of 1 161 young adults living in
Switzerland. Somatic complaints included minor health symptoms, like headaches,
stomach aches, sleep disturbance, lack of appetite, lack of concentration, vertigo,
nervousness and fatigue. e prevalence of somatic symptoms among those young
adults increased over time and frequency of symptoms was associated with future
life milestones achievement. Using data from the Transition from Education to
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SJS 44 (2), 2018, 203–215
Employment study (TREE), Berchtold and colleagues aimed at identifying patterns
of somatic complaints trajectories and at assessing if these patterns are associated
with socio-economic and critical life events factors. ey build sequences of somatic
symptoms and clustered them, using a hidden mixture transition distribution model.
Based on indices of t and a combination of covariates inuencing the probability
of belonging to a cluster, a nal model with ve groups was discussed. e clusters
are characterised by the variability of somatic complaints over time and average
scores of somatic complaints. ese groups were distinct at study baseline and
remained distinct during the whole study follow-up. ey were associated with
gender, educational achievement and the experience of critical life events. Berchtold
and colleagues also showed that higher consumption of tranquilisers and sleeping
pills was associated with higher overall somatic scores. As these groups of somatic
complaints trajectories were already distinct at the age of 16, it suggested that ado-
lescents with poor somatic complaints trajectories were experiencing a situation of
vulnerability before inclusion in the study, i. e. before adolescence, and that these
conditions continued throughout adolescence and young adulthood. Dierences
between trajectories were largely inuenced by early experiences and less by transi-
tions (entry to the labour force, founding of a family life) and life events taking
place over the course of young adulthood. Berchtold etal.’s ndings contribute
to the understanding of health vulnerability by showing that the onset of somatic
complaints is linked with early-life, thus providing preliminary evidence that sup-
ports the critical/sensitive period model (Kuh and Ben-Shlomo 2004).
e article by Isabel Baumann etal. focuses on employment of young adults
with mental disorder living in Switzerland. Following the CAD hypothesis ( Dannefer
2003), the authors expected that an early onset of mental disorders would be more
strongly and negatively associated with employment prospects compared to a later
onset. ey also expected handicapped children beneting from special needs educa-
tion to be more likely to nd a job than those attending regular education. Using
data from the Swiss Federal Social Insurance Oce, they examined the association
between educational trajectories, educational attainment and type of diagnosis
(externalising vs. internalising problems) and being currently employed. Baumann
etal. showed that special needs education for adolescent with mental disorder was
associated with being currently employed, independent of educational attainment.
Special needs education may protect individuals from the potential adverse eects
of the social norms dened by the school system and the labour market and thus
channel individuals into future sheltered vocational training programs and sheltered
employment. Special needs education may thus, be a protective factor against the
development of health vulnerability, by maintaining educational and relational
resources of individuals. e authors also found that onset of mental disorders
in late adolescence or young adulthood was associated with a higher risk of being
unemployed compared to individuals diagnosed in childhood and adolescence. is
210 Stéphane Cullati, Claudine Burton-Jeangros, and Thomas Abel
SJS 44 (2), 2018, 203–215
initial result needs to be conrmed with new research using eective age of onset
of mental disorder (such information was not available to the authors). Last, the
authors found that both types of mental disorders (externalising vs. internalising
problems) were associated with being unemployed.
e article of Agnès Dumas is a qualitative study of a cohort of 80childhood
cancer survivors living in France. Using in-depth interviews with patients diagnosed
between 1970 and 1985 and aged 36years (average) at the time of the interview,
the author assessed patient’s perceived long-term impact of cancer and their coping
strategies, how the cancer was incorporated in their identity and how cancer was
discussed with their family, friends, children and signicant others. e objective
was to assess gender dierences in health-related beliefs and stereotypes. First, the
author showed that cancer was surrounded by a lack of family communication
when participants were children, explained by the medical context of the 1970s and
1980s where priority was given only to patient survival, not patient communication.
Reactions to this silence was dierent between men and women: men were satised
with it while women wanted to have known more. Second, men displayed more
frequently than women a passive attitude toward their treatment (e. g., avoidance
of or delay in medical follow-ups), and were more reluctant to seek medical care.
is result was in line with the existing literature on social norms of “masculinity”
and conrmed the view that men living with cancer are more likely to prioritize the
preservation of their health than to the preservation of their “masculinity,” or male
identity. According to Dumas, reluctance to undergo medical surveillance reected
compliance of male cancer patients with the “hegemonic masculinity” norm, despite
having a risk of cardiovascular mortality eight times higher compared to the general
population. Dumas’ contribution to the understanding of health vulnerability is
double: rst, it shows that health vulnerability is embedded in an historical context,
i. e. here a period that preferred a lack of communication about cancer; second,
agency is a driver of health vulnerability, through conformity to misleading norms
(Widmer and Spini 2017), i. e. “hegemonic masculinity” in the present case, that
results in noncompliance with medical recommendations.
e article of Valérie-Anne Ryser et al. studies the association between health
status and life satisfaction in the second half of life, to assess whether individuals who
experience low levels of life satisfaction are also more likely to be in poorer health
status, suggesting a potential accumulation of disadvantage (Dannefer 2003). e
study was based on the SHARE database, waves2 and4 (treated as cross-sections),
including 12countries, and tested health-related inequalities with the concentration
index. To order participants from worst to best health status, the authors build a
continuous latent health index based on 32health indicators. e analysis was con-
ducted separately by country. Findings allowed identifying that the most vulnerable
groups were those for whom disadvantages in life satisfaction and disadvantages in
health status and other covariates cumulated. For example, higher life satisfaction
Vulnerability in Health Trajectories: Life Course Perspectives 211
SJS 44 (2), 2018, 203–215
was concentrated among respondents with better health status; poor life satisfaction
was concentrated among women, unmarried participants, and those with poor adap-
tation processes, and in all countries, but with large variations. e contribution of
Ryser et al. provides support to the CAD hypothesis in that individuals with health
disadvantages also report poor life satisfaction. e large inter-countries variation
in the association between health status and life satisfaction suggests implementing
national policy interventions, and support the life course perspective emphasizing
the role of context in the study of health vulnerability.
e article of Nadine Reibling et al. examined the role of fertility history on health
status at older age and whether this association varied across 13 European countries.
Authors used the SHARE database and three indicators of health (number of chronic
conditions, self-rated health and depression). Findings suggest that parenthood and
the number of children was weakly associated with health in later life, in contrast
with the timing of the rst child which was strongly associated with health. However,
the pattern of the association was u-shape: delaying rst childbirth until 30years
was good for health, while it became detrimental after 35years, in particular for
women. Findings also show a dierential eect by cohort: timing of rst birth
became less important for later health in younger cohorts. Finally, wide variation
between welfare regimes were observed. Among women, the association between
fertility timing and health was weak in Eastern and Southern countries and strong
in Continental and Scandinavian countries. Among men, the association was strong
in Continental countries only, otherwise timing was weakly associated with their
health status. Reibling’s paper brings a contribution to the importance of timing
in normative transitions, and supports the hypothesis of sensitive periods (Kuh and
Ben-Shlomo 2004). It also emphasises the importance of time and broader national
contexts in understanding the potential benets of timing of rst birth.
e papers of this Special Issue show the potential of adding a life course
perspective to health inequalities research and to the study of health vulnerability.
Adopting a dynamic denition of health adds an important dimension in the under-
standing of how societies produce specic patterns of health across social categories.
e issue also conrms the importance of combining qualitative and quantitative
research to assess the complex mechanisms that articulate life circumstances, the
experience of critical events and health trajectories over the whole life course.
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Jean Michel Bonvin
Stephan Dahmen (dir./Hrsg.)
Reformieren durch Investieren?
Chancen und Grenzen des
Investir dans la protection
sociale – atouts et limites pour
L’Etat d’investissement social se présente comme une
stratégie de réforme de l’Etat social en vue de répondre
aux nombreuses critiques auxquelles il est actuellement
soumis. La conversion des États sociaux européens
à l’investissement social vise ainsi à restaurer leur
légitimité et à relever les déﬁs démographiques et
économiques posés aux États sociaux contemporains.
Suivant les partisans de cette conception, la réorientation
des dépenses sociales vers l’investissement dans la
formation et le développement du capital humain –
notamment en facilitant l’accès à l’emploi, en accroissant
les investissements dans les enfants et en privilégiant
une nouvelle conception de la politique sociale comme
facteur productif – permettra de réduire les inégalités
sociales et de contribuer à la viabilité des États sociaux
contemporains. Cet ouvrage examine la forme prise par
l’investissement social en Suisse et les effets qui en
résultent. Il discute de manière analytique et critique les
fondements idéologiques et les implications pratiques de
la stratégie de l’investissement social.
Jean-Michel Bonvin est professeur ordinaire de sociologie
et de socioéconomie à l’Université de Genève, Stephan
Dahmen est chargé d’enseignement et doctorant à la
Faculté des Sciences de l’éducation de l’Université
144 Seiten/pages, SFr. 28.—
Als Antwort auf den zunehmenden Druck, mit dem sich
der Sozialstaat konfrontiert sieht, hat sich das Konzept
sozialer Investitionen als Reformstrategie entwickelt. Der
sozialinvestive Umbau euro päischer Wohlfahrtsstaaten
verspricht sowohl Antworten auf drängende Legitimations-
fragen als auch auf gegenwärtige demograﬁsche und
ökonomische Herausforderungen des Wohlfahrtstaates zu
liefern. Die Neuausrichtung der Ausgaben des Sozialstaates
auf Investitionen in Human kapital, etwa durch die Verbes-
serung des Zugangs zu Beschäftigung, den Ausbau der
Investitionen in Kinder und eine konsequente Neubestimmung
von Sozialpolitik als Produktivfaktor ermögliche es sowohl
bestehende soziale Ungleichheiten zu reduzieren als auch die
Nachhaltigkeit moderner Wohlfahrtstaaten zu gewährleisten.
Welche Ausprägungen hat das Sozialinvestitionsparadigma in
der Schweiz angenommen und welche Auswirkungen ergeben
sich aus dem sozialinvestiven Umbau des Sozialstaates?
Das Buch liefert eine kritische Analyse und diskutiert die
ideologischen Grundlagen und praktischen Implikationen
Jean Michel Bonvin ist Professor an der Fachhochschule
Westschweiz (éésp) Waadt und Lehrbeauftragter an der
Universität Genf. Stephan Dahmen ist Lehrbeauftragter und
Doktorand in Erziehungswissenschaften an der Universität
Mit Beiträgen in deutscher und französischer Sprache.
Avec des contributions en allemand et en français.