Whose fault is it? People's own conceptions of the reasons for health inequalities

Understanding Critical Health Literacy Among Adolescents: Psychometric Properties of the CHLA Questionnaire in Lower Secondary Schools in Norway

BACKGROUND

Schools are important arenas for the promotion of critical health literacy (CHL) among adolescents. Key domains of CHL are information appraisal, understanding social determinants of health, and abilities to act on determinants of health. In this paper, we examine the psychometric properties of the Critical Health Literacy for Adolescents Questionnaire (CHLA-Q).

METHODS

A cross-sectional survey study was performed at 5 schools in Norway. Respondents included 522 pupils aged 13-15 years old. Confirmatory factor analysis (CFA) was conducted to examine the structural validity. Internal reliability was assessed using ordinal Cronbach's alpha.

RESULTS

The estimated model had acceptable closeness of fit. Five of 6 scales displayed adequate internal reliability.

CONCLUSION

The results indicate acceptable fit of the CHLA-Q framework and that 5 of the 6 scales are applicable to inform future research and interventions. More research is needed on measurement of the second domain of CHL.

Qualitative Methodology in Translational Health Research: Current Practices and Future Directions

Translational health research is an interdisciplinary field aimed at bridging the gap between basic science studies, preventative studies, and clinical practice to improve health-related outcomes. Qualitative research methods provide a unique perspective on the emotional, social, cultural, and contextual factors that influence health and healthcare and thus are recognized as valuable tools for translational health research. This approach can be embedded within a mixed method design which complements the quantitative findings. This methodological paper aims to provide a comprehensive review of the fundamental concepts and methodologies used in qualitative research, emphasizing their utilization and significance in translational health research. Several approaches to qualitative research methodology are discussed in this review, including ethnography, phenomenology, grounded theory, case study, and action research. Theoretical frameworks such as the social-ecological model, intersectionality, and participatory action research are also examined to provide a structure for understanding and interpreting complex health issues. This methodological paper also reviews commonly used sampling techniques such as purposive, snowball, convenience, theoretical, and maximum variation sampling, along with data collection methods such as in-depth interviews, focus groups, observation, document analysis, and participatory methods. Moreover, data analysis techniques such as thematic analysis, grounded theory, content analysis, narrative analysis, and reflexive analysis, are discussed in the context of translational health. Overall, this review highlights the challenges and opportunities of using qualitative methods in current practice, while also discussing future directions and providing valuable guidance and insights to researchers interested in conducting qualitative research in translational health.

Policy actors' perceptions of public participation to tackle health inequalities in Scotland: a paradox?

BACKGROUND

Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities.

METHODS

In 2019-2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking.

RESULTS

Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges.

CONCLUSIONS

Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities.

Responsibility in Medical Sociology: A Second, Reflexive Look

Personal responsibility has emerged as an important element in many countries' public health planning, and has attracted substantial debate in public health discourse. Contemporary medical sociology typically resists such "responsibilization" as victim-blaming, by privileged elites, that obscures important structural factors and inequities. This paper, based primarily on a broad review of how contemporary Anglophone medical sociology literatures treat responsibility and blame, points out advantages of taking responsibility seriously, particularly from the individual's perspective. These advantages include: empowerment; responsibility-as-coping-mechanism; moral dignity; and the pragmatic logic of doing for oneself, rather than passively awaiting societal reforms. We also offer possible reasons why sociologists and their subjects view these issues so differently, and suggest some areas for future research.

Developing Indicators to Measure Critical Health Literacy in the Context of Norwegian Lower Secondary Schools

A critical health literacy (CHL) approach is recommended for promoting health in the school context. This construct is complex and includes three interconnected domains: (A) appraisal of critical information, (B) awareness of the social determinants of health (SDH), and (C) collective action to promote health and well-being. In recent literature reviews, no measurement instrument that covers all three domains of CHL in the school-context was found. Our aim was to develop self-reported measurement scales for each domain of CHL. The development process reported in this study was conducted in two stages. In the first stage, an initial item pool was generated based on literature reviews and focus group interviews (N = 15) with adolescents (steps 1–2). In the next steps, items were adjusted and removed based on the feedback from an expert panel and from representatives from the target group (steps 3–5). In stage two, we aimed to reduce the number of items and develop scales for each domain. We then piloted the current draft, which consists of 28 items (N = 114). A sub-sample (N = 10) of the participants were interviewed after they completed the survey to examine the instrument’s face validity. Cronbach’s α was used to assess the internal reliability of the scales; the reliability was promising for scales A (α = 0.83) and C (α = 0.85) but was below the recommended value for scale B (α = 0.61). The model fit indices were promising (TLI_scaleA = 0.97, RSMEA_scaleA = 0.055, TLI_scaleB = 1.05, RMSEA_scaleB = 0.00, TLI_scaleC = 0.95, RMSEA_scaleC = 0.074). The piloted version of scales A and C were positively correlated with subjective health literacy, health-related quality of life, and subjective health; however, we found no such correlations for scale B. The post-survey group interviews led to some adjustments in scales A and B. The revised version of CHLA-Q must be tested using a larger sample; this will enable more robust statistical testing of the properties of the items and the scale.

'The Lay Gaze'-Rural Norwegian men's assessment of others' health based on pictures

In this article, we explore lay men's understanding of the relationship between other's bodily appearance and health-'the Lay Gaze'. We applied the theoretical concepts of biopower, medical gaze, bodyism and healthism-the ideology where one feature is that a slim body is equivalent to a healthy body-and interviewed 18 adult and elderly men in rural Norway, representing a heterogeneous group regarding age, ethnicity and education. To explore the interviewees' subjective perception or 'gaze', the interviewees were presented with eight pictures of different people. Our main findings were, first, that the sample of a relatively heterogeneous group of adult and elderly lay men in rural Norway talk similarly about body appearance and health and follow the healthism discourse with an embedded association between body appearance and health assessment. Second, we found some variation regarding how interviewees define other standards for the elderly and black people.

'I've become so healthy that I can't live anymore': exploring 'health as balance' discourses and the construction of health and identity among young urban South African adults

Social science research on health in South Africa tends to focus on illness and how to address health problems. Qualitative empirical research focussing on lay understandings and experiences of healthiness, or health discourses, in South Africa is fairly limited. This article addresses this gap by critically exploring how young South African adults used discourses of balance to make sense of what it means to be a healthy person and highlights the implications of these discourses for identity. Foucault's concepts of 'technologies of the self' and 'techniques of discipline' are discussed as a theoretical grounding for this paper. Data were collected from 20 in-depth semi-structured interviews, and analysed using Foucauldian discourse analysis. This paper will specifically explore a key discourse identified through the analysis: 'health as balance' and 2 interrelated sub-discourses which fall within it. Through this discourse, healthiness was constructed as requiring a broad focus on improving all aspects of one's life ('health as holistic') and the avoidance of any behaviours or emotions which could be classified as extreme ('health as moderation'). Constant, careful management of the self, or 'calibration', functions to both perpetuate a cycle of 'anxiety and control' and to obscure ways in which health discourses can be harmful or problematic.

Understanding adolescent health risk behaviour and socioeconomic position: A grounded theory study of UK young adults

Health risk behaviours such as tobacco smoking, excessive alcohol consumption, drug use, unhealthy diet and unprotected sexual intercourse contribute to the global burden of non-communicable diseases and are often initiated in adolescence. An individualistic focus on 'health risk behaviours' has resulted in behaviour change strategies that are potentially ineffective and increase inequalities. We conducted a grounded theory study of 25 young adults to increase the limited qualitative evidence base surrounding young people, health risk behaviours and socioeconomic inequalities. We found that health risk behaviours were perceived as class markers, manifesting as class stigma, leading some participants from lower socioeconomic backgrounds to employ strategies to avoid such behaviours. Peers and family were core constructs for understanding the relationship between health risk behaviours and socioeconomic life trajectories. However, individualism and choice were consistently expressed as the overriding narrative for understanding health risk behaviour and socioeconomic position during the transition to adulthood. The use of 'personal responsibility' discourse by young adults, we argue, highlights the need for a public health focus on achieving structural changes as opposed to individualised approaches to avoid reinforcing neoliberal ideologies that serve to marginalise and maintain social inequalities.

Is health politically irrelevant? Experimental evidence during a global pandemic

OBJECTIVE

To investigate how health issues affect voting behaviour by considering the COVID-19 pandemic, which offers a unique opportunity to examine this interplay.

DESIGN

We employ a survey experiment in which treatment groups are exposed to key facts about the pandemic, followed by questions intended to elicit attitudes toward the incumbent party and government responsibility for the pandemic.

SETTING

The survey was conducted amid the lockdown period of 15-26 April 2020 in three large democratic countries with the common governing language of English: India, the United Kingdom and the United States. Due to limitations on travel and recruitment, subjects were recruited through the M-Turk internet platform and the survey was administered entirely online. Respondents numbered 3648.

RESULTS

Our expectation was that respondents in the treatment groups would favour, or disfavour, the incumbent and assign blame to government for the pandemic compared with the control group. We observe no such results. Several reasons may be adduced for this null finding. One reason could be that public health is not viewed as a political issue. However, people do think health is an important policy area (>85% agree) and that government has some responsibility for health (>90% agree). Another reason could be that people view public health policies through partisan lenses, which means that health is largely endogenous, and yet we find little evidence of polarisation in our data. Alternatively, it could be that the global nature of the pandemic inoculated politicians from blame and yet a majority of people do think the government is to blame for the spread of the pandemic (~50% agree).

CONCLUSIONS

While we cannot precisely determine the mechanisms at work, the null findings contained in this study suggest that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election.

TRIAL REGISTRATION

Initial research hypotheses centred on expected variation between two treatments, as set forth in a detailed pre-analysis plan, registered at E-Gap: http://egap.org/registration/6645. Finding no difference between the treatments, we decided to focus this paper on the treatment/control comparison. Importantly, results that follow the pre-analysis plan strictly are entirely consistent with results presented here: null findings obtained throughout.

The impact of working conditions on the health of taxi drivers in an urban metropolis

Purpose

This descriptive qualitative study explores how working conditions impact the health of taxi drivers in Toronto, Canada.

Design/methodology/approach

Drivers were recruited between September 2016 and March 2017. A total of 14 semi-structured qualitative interviews and one focus group (n = 11) were conducted. Transcripts were analyzed inductively through a socioecological lens.

Findings

The findings of this study are as follows: drivers acknowledged that job precariousness (represented by unstable employment, long hours and low wages) and challenging workplace conditions (sitting all day and limited breaks) contribute to poor physical/mental health. Also, these conditions undermine opportunities to engage in health-protective behaviors (healthy eating, regularly exercising and taking breaks). Drivers do not receive health-enabling reinforcements from religious/cultural networks, colleagues or their taxi brokerage. Drivers do seek support from their primary care providers and family for their physical health but remain discreet about their mental health.

Research limitations/implications

As this study relied on a convenience sample, the sample did not represent all Toronto taxi drivers. All interviews were completed in English and all drivers were male, thus limiting commentary on other experiences and any gender differences in health management approaches among drivers.

Practical implications

Given the global ubiquity of taxi driving and an evolving workplace environment characterized by growing competition, findings are generalizable across settings and may resonate with other precarious professions, including long-haul truck operators and Uber/Lyft drivers. Findings also expose areas for targeted intervention outside the workplace setting.

Originality/value

Health management among taxi drivers is understudied. A fulsome, socioecological understanding of how working conditions (both within and outside the workplace) impact their health is essential in developing targeted interventions to improve health outcomes.

[The study of health in men from a gender perspective: where we come from, where are we going]

Comprehensive and in-depth analyses of differences and inequalities in health require a broad-based approach to the study of masculinities and men's health. Interest in this issue has grown in parallel to increased concern over specific risks and vulnerabilities faced by men, but also due to the need to involve them in programs capable of promoting progress towards gender-based health equity. This article attempts to reframe these issues from the perspective of public health, providing a wider viewpoint on men's health situated within debates on the social determinants of health and the analysis of health inequalities. Based on a relational gender approach, we formulate some recommendations regarding policy and research agendas, which we argue can contribute to advancing the study and development of programs from a gender-based perspective in health.

Reframing inequality? The health inequalities turn as a dangerous frame shift

Background

Politicians in many countries have embraced the notion that health inequalities derive from socioeconomic inequalities, but European governments have for the most part failed to enact policies that would reduce underlying social inequalities.

Methods

Data are drawn from 84 in-depth interviews with policy-makers in four European countries between 2012 and 2015, qualitative content analysis of recent health inequalities policy documents, and secondary literature on the barriers to implementing evidence-based health inequalities policies.

Results

Institutional and political barriers are important barriers to effective policy. Both policy-making institutions and the ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.

Conclusions

Medicalizing inequality is more appealing to most politicians than tackling income and wage inequality head-on, but it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities.

Risk work or resilience work? A qualitative study with community health workers negotiating the tensions between biomedical and community-based forms of health promotion in the United Kingdom

Emplaced health promotion interventions, delivered by community health workers are increasingly being used internationally. However, the application of epidemiological risk knowledge to individuals within such communities is not straightforward and creates tensions for community health workers who are part of the communities that they are serving. Situated qualitative interview data were co-produced with community health workers employed in a superdiverse, deprived, post-industrial region of the United Kingdom, using photo-voice methods, to develop an account of how they made sense of the challenges of their work. The analysis draws on and develops theories of risk work and resilience work, which draw on practice theory. The key findings were that, first, being a critical insider enabled community health workers to make sense of the diverse constraints on health and lifestyles within their community. Second, they understood their own public health role as limited by operating within this context, so they articulated their occupational identity as focused on supporting clients to make small but sustainable changes to their own and their families’ lifestyles. Third, the uncertainties of translating population based risk information to individual clients were (at least partially) resolved at an embodied level, with the community health workers identifying as accessible and trusted role models for the value of changed lifestyles. The article is important for policy and practice as it provides a critique of a rapidly evolving new mode of delivery of public health services, and insights on the development of this new public health workforce.

"Don't stop believing!" From health religiosity to an equality-enhancing hermeneutic of health promotion

Purpose: Health beliefs are usually regarded as subjective understandings of one’s health. They can, however, be re-interpreted by drawing on the understanding that the structural features of the health discourse resemble the characteristics of a religion and on the spiritual dimension of health with its possibly salutogenic influence. The applicability of the notion of “health religiosity” and its consequences for individual health promotion are explored.

Method: Data consist of already existent semi-structured interviews. These have been reanalyzed in a deductive-hermeneutical way by using a five-dimensional concept of religiosity as deductive template.

Results: The concept of religiosity proved to be productive and revealed that all health dimensions in the case are infused with spiritually ennobled ideas.

Conclusion: We conclude that, irrespective of their factual accuracy, the salutogenic potential of ennobled ideas may best be utilized by understanding them hermeneutically. An exploration of a narrative hermeneutic approach to individual health promotion is suggested as the merging of meaning horizons in a hermeneutic dialogue is expected to increase awareness of spiritualized aspects of health beliefs. This may mitigate healthism and health disparities. Moreover, three challenges for individual health promotion are anticipated: realizing the situation, recognizing its complexity and resisting a simplistic practical approach.

Who knows best? A Q methodology study to explore perspectives of professional stakeholders and community participants on health in low-income communities

Background

Health inequalities in the UK have proved to be stubborn, and health gaps between best and worst-off are widening. While there is growing understanding of how the main causes of poor health are perceived among different stakeholders, similar insight is lacking regarding what solutions should be prioritised. Furthermore, we do not know the relationship between perceived causes and solutions to health inequalities, whether there is agreement between professional stakeholders and people living in low-income communities or agreement within these groups.

Methods

Q methodology was used to identify and describe the shared perspectives (‘subjectivities’) that exist on i) why health is worse in low-income communities (‘Causes’) and ii) the ways that health could be improved in these same communities (‘Solutions’).

Purposively selected individuals (n = 53) from low-income communities (n = 25) and professional stakeholder groups (n = 28) ranked ordered sets of statements – 34 ‘Causes’ and 39 ‘Solutions’ – onto quasi-normal shaped grids according to their point of view. Factor analysis was used to identify shared points of view. ‘Causes’ and ‘Solutions’ were analysed independently, before examining correlations between perspectives on causes and perspectives on solutions.

Results

Analysis produced three factor solutions for both the ‘Causes’ and ‘Solutions’. Broadly summarised these accounts for ‘Causes’ are: i) ‘Unfair Society’, ii) ‘Dependent, workless and lazy’, iii) ‘Intergenerational hardships’ and for ‘Solutions’: i) ‘Empower communities’, ii) ‘Paternalism’, iii) ‘Redistribution’. No professionals defined (i.e. had a significant association with one factor only) the ‘Causes’ factor ‘Dependent, workless and lazy’ and the ‘Solutions’ factor ‘Paternalism’. No community participants defined the ‘Solutions’ factor ‘Redistribution’. The direction of correlations between the two sets of factor solutions – ‘Causes’ and ‘Solutions’ – appear to be intuitive, given the accounts identified.

Conclusions

Despite the plurality of views there was broad agreement across accounts about issues relating to money. This is important as it points a way forward for tackling health inequalities, highlighting areas for policy and future research to focus on.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3884-9) contains supplementary material, which is available to authorized users.

What do the British public think of inequality in health, wealth, and power?

Despite the importance of public opinion for policy formation and the political salience of inequality, the public's views about the desirability of equality, not only in health but also in economics and politics, has attracted little attention. We report the results of an on-line survey administered in late 2016 in Great Britain (N = 1667 with a response rate of 35-50%). The survey allowed for testing the sensitivity of public opinion across two other variables: absolute versus relative (everyone should have the same versus inequality should be reduced) and bivariate versus univariate (inequality in one domain is judged in relation to inequality in another versus inequality in a domain is judged independently of other domains). It also allowed examination of how far support for equality in one domain overlaps with support for equality in another. We find that for health, economic and political equality a relative conception of equality attracts more support than an absolute conception, and that for health and political equality a bivariate conception attracts more support than a univariate conception. We also find that conceptions of equality affect how much overlap exists between support for different forms of equality, with a bivariate and relative conception resulting in more overlap than a univariate and absolute conception. We also find evidence for Walzer's 'complex equality' theory in which people tolerate inequality in one domain if it does not control inequality in another.

On mountains and prophets: targeting majorities to support minorities by using norm-critics in health education

This debate article advocates for norm-critics instead of empowering coping and pedagogy of tolerance as an educational approach to mitigate stigmatization as well as blame and guilt for health-deviant minorities within the field of health disparities. Norm-critics is a way of making members of the (presumably healthy) normative majority uncover and question their health-related norms and raise awareness for the processes by which members of that majority re/construct images of stereotypic figures (such as “the fatso” or “the couch-potato”) with certain personal character traits which are to be condemned and, in doing so, limit the acting space of those identified as examples of those figures. The approach, its theoretical background, arguments promoting norm-critics, and some suggestions for its practical application are presented. It is concluded that norm-critics render a valuable and much needed addition to the health intervention repertoire.

What have the social sciences ever done for equity in health policy and health systems?

Background

The social sciences can be defined as the scientific study of human society and social relationships.

Main text

A number of underpinning disciplines within the social sciences, notably sociology, social psychology and anthropology, as well as interdisciplinary fields like science and technology studies and migration studies, offer both theoretical insights and methodological approaches which can productively enhance the study of equity in health systems and policy research. In particular, qualitative research in general and the use of narrative methods in particular can help illuminate individual experience and the interaction of multiple structural influences on that experience.

Conclusion

This article sets the theoretical scene for a special issue of the journal on social sciences and equity.

Understanding lay perspectives on socioeconomic health inequalities in Britain: a meta-ethnography

The links between socioeconomic circumstances and health have been extensively studied in Britain but surprisingly few studies consider lay perspectives. This is problematic given popular efforts to reduce health inequalities appear to be based on assumption that public understanding is limited (this is evident in efforts to raise awareness of both 'upstream' causes of health inequalities and health-damaging behaviours). The results of this meta-ethnography, involving 17 qualitative studies, fundamentally challenge this assumption. We show, first, that people who are living with socioeconomic disadvantage already have a good understanding of the links between socioeconomic hardship and ill-health. Indeed, participants' accounts closely mirror the research consensus that material-structural factors represent 'upstream' determinants of health, while 'psychosocial' factors provide important explanatory pathways connecting material circumstances to health outcomes. Despite this, people living in disadvantaged circumstances are often reluctant to explicitly acknowledge health inequalities, a finding that we suggest can be understood as an attempt to resist the stigma and shame of poverty and poor health and to (re)assert individual agency and control. This suggests that work to increase public awareness of health inequalities may unintentionally exacerbate experiences of stigma and shame, meaning alternative approaches to engaging communities in health inequalities discussions are required.

The ambiguities of self-governance: Russian middle-aged middle-class women's reflections on ageing

In a youth-centred culture, where ageing is associated with physical and mental decline, investment in a youthful appearance promises access to socially valuable resources. The need for regular care for the self, primarily through consumption, constitutes part of the narrative of successful or positive ageing. Due to its emphasis on self-reliance and efforts to remain healthy, productive and youthful, the discourse of successful ageing has been seen as intersecting with a neoliberal rationality, or a shift of responsibility for risks associated with ageing from the state to the individual. While some authors criticise an emphasis on individual effort to maintain personal wellbeing for a lack of attention to structural factors, others view such an approach favourably as a way of transcending state paternalism. In this paper, I engage with the discourse of ‘responsibilisation’ drawing on the interviews with middle-aged, middle-class women from Moscow about their experiences of ageing. I employ the theoretical framework of ‘governmentality’ to demonstrate how the interviewed women's attempts to make sense of what it meant to age ‘appropriately’ within their milieus informed both their awareness of a need to improve and reinvent the self constantly through consumption in the context of post-Soviet Russian society, and their questioning of and resistance to this pressure.

"How the other half live": Lay perspectives on health inequalities in an age of austerity

This paper examines how people living in two socially contrasting areas of Stockton on Tees, North East England experience, explain, and understand the stark health inequalities in their town. Participants displayed opinions that fluctuated between a variety of converging and contrasting explanations. Three years of ethnographic observation in both areas (2014-2017) generated explanations which initially focused closely on behavioural and individualised factors, whilst 118 qualitative interviews subsequently revealed more nuanced justifications, which prioritised more structural, material and psychosocial influences. Findings indicate that inequalities in healthcare, including access, the importance of judgemental attitudes, and perceived place stigma, would then be offered as explanations for the stark gap in spatial inequalities in the area. Notions of fatalism, linked to (a lack of) choice, control, and fear of the future, were common reasons given for inequalities across all participants. We conclude by arguing for a prioritisation of listening to, and working to understand, the experiences of communities experiencing the brunt of health inequalities; especially important at a time of austerity.

‘I Sat Filling in This Form While Smoking and It Was Divine’. An Analysis of Free-Text Comments from Smokers Who Report They Have No Intention of Quitting in the Next Six Months

Introduction: Smokers unmotivated to quit are neglected by smoking cessation research. Free-text comment analysis is a potentially useful way to gain insight into this group's beliefs.

Aims: To analyse the free-text comments provided by smokers unmotivated to quit as part of a randomized controlled trial of computer-tailored feedback for smoking cessation.

Method: A random sample of 58,660 smokers were sent a smoking behaviour questionnaire (SBQ). The responses and follow-up outcomes of those providing free-text comments were compared to those who did not to assess the representativeness of the former group of smokers. The comments of participants unmotivated to quit (631) were thematically analysed.

Results: Those who provided a comment differed from those who did not on variables including education level and quit attempts at six-month follow-up. Emergent themes included; justification of smoking and restricting smoking instead of quitting.

Conclusions: The findings illustrate the value of free-text comments in identifying issues important to respondents. The identified themes highlight areas for future research in smokers unmotivated to quit including cutting down as a path to quitting and explicit messages regarding the inability of positive health behaviours to balance out the negative impact of smoking on health.

Trial registration: Current Controlled Trials ISRCTN05385712.

Falling from Grace or into Expert Hands? Alternative Accounts about Falling in Older People

Falls in older people are a priority area for both research and clinical intervention in the United Kingdom. There is, however, currently an absence of research exploring the meaning and interpretation of a fall.

Semi-structured interviews were conducted with 20 therapists and with eight older people with fractured hips. The therapists' accounts appeared to draw on a ‘risk discourse’ which constructed a fall as a predictable and preventable event, highlighting individual patient characteristics as causative factors and suggesting that therapists were more knowledgeable about this subject. The accounts of the older inpatients, conversely, made use of a ‘moral discourse’, in which commendable personal qualities and competencies were emphasised.

It is suggested that this work has implications for therapy in that many falls prevention initiatives and health promotion materials may be falsely premised on an acceptance of vulnerability by older people.

Community nursing achievements in tackling inequalities in health in Northern Ireland

Targeting health and social need is an important theme in the Northern Ireland Regional Strategy, Health and Well-being into the Next Millennium: A regional strategy for health and social well-being, 1997-2002 (Department of Health and Social Services for Northern Ireland, 1996), which is concerned with addressing inequalities in health status and social well-being. This paper describes a project which assessed the contribution made by nurses, midwives and health visitors to targeting health and social need (THSN). While there is a considerable body of research and information on variations in health and social well-being, few evaluative research interventions improve the health of disadvantaged groups. The initial project was commissioned by the Department of Health and Social Services (DHSS) for one year, had a timetable that covered three phases and was jointly conducted by the schools of nursing at The Queen's University of Belfast and the University of Ulster.

In the first phase a survey questionnaire was distributed to a purposive sample of nurses working with both community and voluntary groups to assess their contribution to THSN (n=1000). The paper describes the results from the 392 questionnaires returned (a response rate of almost 40%) and the work carried out in phase 2 of the study, in which the responses were analysed to allow further investigation. By using selection criteria devised by the Project Advisory Board, the interventions were reduced to 22. In an overview of each of these, a number of characteristics kept recurring that could serve to define aspects of 'good practice'.

The results highlight nursing competencies gained through their work, the lessons learnt and the problems and difficulties encountered. Importantly, the 22 case studies demonstrate the efforts made by nurses and health professionals to change behaviour, practice, the community and the environment.

The paper concludes that the use of qualitative research opens the door to measures of social position that reflect the ways in which people define themselves and the relationships which sustain them. Although there is still some way to go in understanding the different approaches to evaluation, an environment which fosters the monitoring and assessment of practice might be created in the future within the nursing community.

The Sacred Self: Suffering Narratives in Old Age

This article is based on ongoing qualitative research that explores elders' (80+) experiences of suffering. We show how respondents link the subject of suffering to a personal sense of the sacred in order to find meaning for suffering. We describe the major concepts of this article: the sacred, suffering, aging identity, and narrative. Through case studies, we show how an individual's sense of the sacred and experiences of suffering are revealed through the use of metaphors and symbols in the narrative. A key finding of this article is that concepts and experiences of suffering and a personal sacred emerge contextually from an elder's individual biography and communal history, as well as from present life circumstances.

Healthism in Denmark: State, market, and the search for a “Moral Compass”

This article focuses on contemporary responses to public health messages in Denmark, a country whose system of social welfare is, like that of the United Kingdom and the rest of Europe, undergoing increasing levels of marketization and privatization. Drawing primarily upon Robert Crawford’s analysis of healthism as a neoliberal project, the aim of this article is to develop critical understandings of how individuals respond both bodily and emotionally to ideologies of health and the body in the context of a changing marketplace for the consumption of health and its messages. This article will analyze perceptions and practices of health in Denmark. The findings will then be discussed in relation to dimensions inspired by the work of Crawford, who regards “health” as a “super-value,” an outcome of individual security strategies, and mode of citizenship in the marketplace. The article argues that Crawford’s discussion does not fully capture the ways in which people use their bodies to valorize themselves. First, the perception of the state is perceived as being aligned with commercial interests. As a consequence, neither state- nor market-based (i.e. commercial health product and service providers) health advice is fully trusted. Instead, the opinions of non-market actors such as peers and friends as well as of alternative practitioners that are considered outside the market since they do not represent corporate interests become more attractive among citizen-consumers who are concerned about their health. The article concludes with a discussion of the implications of our findings for theorization of public health and health policy.

Moral Argumentation in Talk about Health and Old Age

This study examines the ways in which people aged 90 or over construct and negotiate meanings of health in research interviews. Detailed analyses of two interview cases illustrate the flow of these negotiations within interviews, and how the interviewees balance different moral arguments. First, the interviewees try to manage the face-threat posed by the questioning about health. Second, their health accounts move on the axis of advocating good health and activity and conceding impaired health and diminished activity. They apply various rhetorical devices to challenge the traditional discourse of old age as decline. On the other hand, aligning oneself with the category of ‘old’ makes ill-health and inactivity legitimate, but brings along other kinds of moral obligations. Finally, the results are discussed in relation to cultural discourses of old age and health, and their moral implications.

Talking about Cigarettes: Conversational Narratives of Health and Illness

In this article an argument is put forward that narratives of health and illness that are drawn from conversational rather than textual sources require a particular type of analysis. In common with other research on talk, it is argued that conversational narration is a joint activity and that the form and context of its telling can tell us as much about lay understandings of health as can the content of its stories. Analyses of narratives co-told during an interview are presented to consider how narration is used to rehearse plausible and implausible past, current and future actions and to bring off an entitlement to an unhealthy habit. The empirical material is drawn from a single interview selected from a collection of interviews on the subject of smoking. Only one interview is drawn upon to allow the narrative rather than the semiotic structurings of the material to be represented and analysed in depth.

‘I Think That It’s a Pain in the Ass That I Have to Stand Outside in the Cold and Have a Cigarette’

Smokers in Greece and the UK are habitually exposed to different levels of social disapproval. This qualitative study explored the accounts of smoking and disapproval offered by 32 UK and Greek smokers. Accounts were framed with reference to a highly moralized construction of smoking. Participants were sensitive to social disapproval of their smoking. While disapproval from those close to them was accepted, disapproval from the general public was not. Two discursive repertories ‘smoking works for me now’ and ‘the struggle to quit’ were identified as resources that participants drew upon to enable continued smoking while acknowledging the health issues. While there were many similarities in the accounts provided, there were important differences that seem to reflect the different ‘smoking worlds’ inhabited.

Mediation and the Construction of Contemporary Understandings of Health and Lifestyle

The practice of using media to promote the benefits of diet and exercise has been associated with the rise in prominence of a sense of personal obligation for one’s own health. This article contributes to recent critiques of the emphasis being placed on individual responsibility for health. We argue that if health psychologists are to develop an adequately social understanding of our role in promoting health, then we must begin to examine the influence of our practices and agendas on public understandings. Extracts from research accounts are used to illustrate the pervasiveness of media health messages in everyday life and the prominence of a sense of individual responsibility.

‘The Problem with Men’: Working-class Men Making Sense of Men’s Health on Television

Men have higher rates of premature death than women, and may arguably have higher rates of serious illness. One explanation often suggested to account for this is that men are considered to be stoical about illness and reluctant to seek help for it. This article explores the role of media representations in the construction of men’s views about health. We investigate how a small group of lower socio-economic status men make sense of the reluctance to seek help notion through an analysis of texts from three sources: a television health documentary, individual interviews with the men and a focus group discussion in which the men discuss the documentary. The television documentary frames its presentation to promote early detection and help-seeking. We conclude that televised coverage of men’s health is an important site of social discourse through which men’s health is rendered meaningful. However, it is not accepted passively, but negotiated, resisted and interpreted into men’s lives.

The Social Negotiation of People’s Views on the Causes of Illness

Over the last two decades increasing attention has been given to lay views of health and illness. An important area within this research is the views that different socioeconomic groups hold on the causes of illness. Generally it is concluded that people of lower socioeconomic status are more likely than those of more affluent standing to talk about the causes of illness in lifestyle rather than structural terms that involve overt connections with the material impact of social inequality. We draw on 20 semi-structured interviews with New Zealanders of lower socioeconomic status to explore the ways various causes are assigned to illness. Our participants voice multiple and often contradictory views when assigning cause, and include references to structural issues in addition to lifestyle risk factors and medical ideas about biological functioning and disease. There appears to be a range of sociocultural explanations available for these people to draw on when making sense of illness. We argue that the prevalence of structural explanations may be due, in part, to cultural shifts and increased critical reaction to various social reforms. Our findings support the idea that people’s views are socially constructed to account for the complexities of health and illness as part of everyday life.

Accounts of Quitting among Older Ex-smokers with Smoking-related Disease

This article uses a discourse analytic method to explore how a sample of ex-smokers with smoking-related illness position themselves, and are positioned by, the language they use in their accounts of quitting. The article suggests that discursive constructions (having ‘no choice’ and getting ‘another chance’) used by the respondents position them in a way that constrains behaviour by closing down the option of smoking and/or opening up the possibility of change. In each telling, the respondents' (non-smoking) identities are confirmed anew and this affirmation may assist in sustaining the change and provide protection against relapse. Moreover, the article suggests that the development and exchange of these stories may contribute to the growth of shared beliefs about the experience of quitting, opening up the option of quitting for current smokers. In so doing, accounts of quitting provided by ex-smokers undermine or resist dominant social understandings that even among those highly motivated to stop smoking, quitting is a difficult, if not impossible, endeavour.

Lay perceptions of health and environmental inequalities and their associations to mental health

Health inequalities are very well documented in epidemiological research: rich people live longer and have fewer diseases than poor people. Recently, a growing amount of evidence from environmental sciences confirms that poor people are also more exposed to pollution and other environmental threats. However, research in the social sciences has shown a broad lack of awareness about health inequalities. In this paper, based on data collected in Portugal, we will analyze the consciousness of both health and environmental injustices and test one hypothesis for this social blindness. The results show, even more clearly than before, that public opinion tends to see rich and poor people as being equally susceptible to health and environmental events. Furthermore, those who have this equal view of the world present lower levels of depression and anxiety. Following cognitive adaptation theory, this "belief in an equal world" can be interpreted as a protective positive illusion about social justice, particularly relevant in one of the most unequal countries in Europe.

Context and complexity: the meaning of self-management for older adults with heart disease

Self-management policies have presented opportunities for patients with long-term conditions to take control and actively improve their health. However, the work of self-management appears to be packaged in the form of essential and desirable skills and attributes required for success. This article presents the findings of a qualitative study, employing longitudinal diary interviews with 21 patients aged between 60 and 85 years diagnosed with coronary heart disease from three contrasting general practice areas. Drawing on concepts of the care of the self and the reflexive self, this article presents the diversity of self-management practices by older patients in the context of their lifeworld. Illustrated through individual case studies, it clearly identifies where patients are engaged self-managers with the agency, knowledge and self-discipline to modify their behaviour for an improved health outcome. This study highlights their life and illness perspectives as well as those of patients who are burdened with emotional insecurity, comorbidities and caring responsibilities. It shows the spectrum of relationships with health professionals that influence engaged self-management. We suggest that policy initiatives that favour behavioural change neglect social context and the individualised practices that are a necessary response to structural and psychosocial constraints.

Explanations and expectations: drug narratives among young cannabis users in treatment

This article analyses how young people enrolled in drug addiction treatment in Copenhagen, Denmark, explain their cannabis careers and how they view their possibilities for quitting drug use again. Inspired by Mead and narrative studies of health and illness, the article identifies four different drug use 'aetiologies' drawn upon by the interviewees. These cover childhood experiences, self-medication, the influence of friends and cannabis use as a specific lifestyle. A central argument of the article is that these explanations not only concern the past but also point towards the future by assigning the interviewee a more or less agential position in relation to drugs. Further, the drug narratives are viewed as interactional achievements, related to the social context in which they were produced, namely, the institutional setting of the treatment centres. The article is based on 30 qualitative interviews with young people in drug addiction treatment.

Negotiating sexuality in home care settings: older lesbians and bisexual women's experiences

There is evidence that lesbians and bisexual women often face prejudice and stigma when accessing routine primary healthcare services. However, limited research to date has examined their experiences outside of primary healthcare contexts or the perspectives of older healthcare users. This paper presents findings from a qualitative study of older lesbians and bisexual women in Ontario who accessed publicly-funded home care services. In qualitative in-depth interviews, 16 women responded to questions about their decision making around disclosure of their sexuality, home care workers' reactions to disclosure and their experiences of receiving care. The thematic analysis of participants' responses demonstrated that they experienced isolation and ongoing anxiety, as well overt and subtle examples of heterosexism and discrimination. However, there was also evidence of participants' resilience and resistance to heteronormativity and sexual minority stress. These findings have implications for our understanding of lesbians' and bisexual women's healthcare experiences and for policy recommendations.

Social status and living with a chronic illness: an exploration of assessment and meaning attributed to work and employment

BACKGROUND

Traditional measures of social status are predicated on position in the labour market. There has been less attention directed to the meanings of social position for people with a long-term condition whose relationship to employment is precarious. Previous research has demonstrated that the MacArthur scale is capable of capturing contextualised aspects of social status, which makes it a useful tool for exploring changes in meaning.

AIMS

The paper explores the meanings and experiences of social status of people living with a long-term condition with particular reference to employment status.

METHODS

A sample of 300 participants was drawn from diabetes and chronic heart disease registers of General Practices in North West England. A cross-sectional survey with nested qualitative interviews was used in collecting and analysing the data.

FINDINGS

Having financial independence and participating in valued activities are more important for people with chronic illness than power and status mediated through the labour market. Income and the lack and loss of employment were given a central role in respondents' narratives reflecting the absence of acceptable alternative routes through which social status for those with a long-term condition can realistically be rebuilt outside of participation in the labour market.

CONCLUSION

Social participation, where people with chronic illness feel valued and of tangible utility to other people, might offer some opportunities for rebuilding social status outside the labour market. Chronic illness management interventions need to focus on improving people's engagement with such activities.

'This wound has spoilt everything': emotional capital and the experience of surgical site infections

In this article we explore the experience of suffering from a surgical site infection, a common complication of surgery affecting around 5 per cent of surgical patients, via an interview study of 17 patients in the Midlands in the UK. Despite their prevalence, the experience of surgical site infections has received little attention so far. In spite of the impairment resulting from these iatrogenic problems, participants expressed considerable stoicism and we interpret this via the notion of emotional capital. This idea derives from the work of Pierre Bourdieu, Helga Nowotny and Diane Reay and helps us conceptualise the emotional resources accumulated and expended in managing illness and in gaining the most from healthcare services. Participants were frequently at pains not to blame healthcare personnel or hospitals, often discounting the infection's severity, and attributing it to chance, to 'germs' or to their own failure to buy and apply wound care products. The participants' stoicism was thus partly afforded by their refusal to blame healthcare institutions or personnel. Where anger was described, this was either defused or expressed on behalf of another person. Emotional capital is associated with deflecting the possibility of complaint and sustaining a deferential and grateful position in relation to the healthcare system.

Fathers' views on their financial situations, father-child activities, and preventing child injuries

Unintentional injuries are a leading public health problem for children, particularly among those living at lower socioeconomic levels. Parents play an important preventive role, and the aim of this study was to examine fathers' views on the role of their family financial situation in preventing children's injuries. In-depth interviews were conducted with 15 fathers of children 2 to 7 years living in western Canada. Questions solicited fathers' views about their financial situation and their child injury prevention efforts. Data analysis was underpinned by masculinity theory and guided by constant comparative grounded theory methods. Findings included that fathers living with fewer financial limitations emphasized use of safety equipment and aligned themselves with provider and protector masculine ideals. Fathers with moderate financial constraint described more child-centered safety efforts and efforts to manage finances. Those facing greatest constraint demonstrated aspects of marginalized masculinities, whereby they acknowledged their economic provider limitations while strongly aligning with the protector role. These findings hold relevance for development of interventions aimed at reducing child injury risk inequities. Taking into account how masculinities may shape their beliefs and practices can inform design of father-centered interventions for men living at different points on the socioeconomic spectrum.

A qualitative study of the interactions among the psychosocial work environment and family, community and services for workers with low mental health

Background

The psychosocial work environment can benefit and harm mental health. Poor psychosocial work environments and high level work-family conflict are both associated with poor mental health, yet little is known about how people with poor mental health manage the interactions among multiple life domains. This study explores the interfaces among paid work, family, community and support services and their combined effects on mental health.

Methods

We conducted 21 in-depth semi-structured interviews with people identified as having poor mental health to examine their experiences of paid employment and mental health and wellbeing in the context of their daily lives.

Results

The employment-related psychosocial work environment, particularly workplace relationships, employment security and degree of control over hours, strongly affected participants’ mental health. The interfaces among the life domains of family, community and access to support services suggest that effects on mental health differ according to: time spent in each domain, the social, psychological and physical spaces where domain activities take place, life stage and the power available to participants in their multiple domains. This paper is based on a framework analysis of all the interviews, and vignettes of four cases. Cases were selected to represent different types of relationships among the domains and how interactions among them either mitigated and/or exacerbated mental health effects of psychosocial work environments.

Conclusions

Examining domain interactions provides greater explanatory capacity for understanding how people with low mental health manage their lives than restricting the research to the separate impacts of the psychosocial work environment or work-family conflict. The extent to which people can change the conditions under which they engage in paid work and participate in family and social life is significantly affected by the extent to which their employment position affords them latitude. Policies that provide psychosocial protections to workers that enable them to make changes or complaints without detrimental repercussions (such as vilification or job loss) and increase access to welfare benefits and support services could improve mental health among people with paid work. These policies would have particularly important effects for those in lower socioeconomic status positions.

How has neuroscience affected lay understandings of personhood? A review of the evidence

The prominence of neuroscience in the public sphere has escalated in recent years, provoking questions about how the public engages with neuroscientific ideas. Commentaries on neuroscience's role in society often present it as having revolutionary implications, fundamentally overturning established beliefs about personhood. The purpose of this article is to collate and review the extant empirical evidence on the influence of neuroscience on commonsense understandings of personhood. The article evaluates the scope of neuroscience's presence in public consciousness and examines the empirical evidence for three frequently encountered claims about neuroscience's societal influence: that neuroscience fosters a conception of the self that is based in biology, that neuroscience promotes conceptions of individual fate as predetermined, and that neuroscience attenuates the stigma attached to particular social categories. It concludes that many neuroscientific ideas have assimilated in ways that perpetuate rather than challenge existing modes of understanding self, others and society.

Public views about health causation, attributions of responsibility, and inequality

Success in addressing health disparities and their social determinants will require understanding public perceptions of health causation, attributions of responsibility, and potential solutions. To explore these perceptions, the authors conducted 12 focus groups (6 with liberals, 6 conservatives; N = 93 participants) in a large U.S. Northeastern state. Participants communicated highly nuanced views about health causation and disparities, identifying layers of responsibility for health. However, individual behaviors and personal responsibility dominated the discussion and served as a counterargument to the significance of social determinants. Participants also showed limited awareness of the range of policies that could be adopted to address health disparities. As policy initiatives benefit from public support in gaining political traction, the authors suggest research paths and possible communication strategies for scholars and advocates.

Meaning of Health: The Perspectives of Aboriginal Adults and Youth in a Northern Manitoba First Nations Community

OBJECTIVE

To explore perspectives on the meaning of health to Aboriginal adults and youth living in a northern Manitoba First Nations community.

METHODS

Six focus groups with 29 youth and individual interviews with 10 adults were audio-recorded, transcribed verbatim and thematically analyzed.

RESULTS

Adults and older youth used aspects of health depicted in the Medicine Wheel to describe being healthy, but younger youth were not as specific. Both generations spoke about the importance of positive adult role models (emotional health), incorporation of traditional First Nations practices into everyday life (spiritual health), changes in diet and activity (physical health) and the significance of making good choices (mental health).

CONCLUSIONS

Participants incorporated aspects of current and traditional lifestyles into their discussion of health. Use of the Medicine Wheel to conceptualize health holistically on the part of both adults and older youth suggest that it may be an effective way to frame health promotion strategies for younger youth. Because it is in harmony with cultural values, such an approach may influence other members of this community to adopt healthful lifestyle practices.

Children's understanding of family financial resources and their impact on eating healthily

Socioeconomic inequalities in childhood are linked to childhood and adult health inequalities. They are particularly closely associated with inequalities in nutritional and consequently health status. Recent research links this to the high cost of nutrient-rich and low cost of nutrient-poor foods and explores how parents negotiate food purchase on a limited budget. However, we know little of children's perspectives on the material and social realities of their lives and their involvement in health-relevant behaviour. This contrasts with a growing body of research which emphasises children's active role in making sense of and participating in health practices while growing up and their potential to act in continuity with and as agents of change in family health cultures. This paper explores children's understanding of family finances and how they perceive this to relate to eating healthily. It draws upon data from a qualitative study of 53 children aged 9-10 from two socioeconomically contrasting schools in the North of England during 2010 and 2011. Data were generated in friendship group interviews and debates at school and individual interviews in the home, and analysed thematically. Children incorporated a variety of media information into their understandings and sought explanations from their personal experience. They had sophisticated ideas about the interrelationships between diet, cost and health and were acutely aware of how family finances influenced food purchase. Children proposed different strategies to facilitate eating healthily on a budget, but prioritised state and corporate responsibility in ensuring that eating healthily is affordable. This contrasts with current health-related policy, which does not address cost as a potential barrier to eating healthily in the home. Children also consistently conflated healthy eating with eating fruit and vegetables, highlighting a need to reinforce other important nutritional messages.

Exploring interpretation of complexity and typicality in narratives and statistical images about the social determinants of health

This article explores public responses to narratives and statistical images, predominantly graphs and maps, designed to raise awareness of social determinants of health and health disparities. We focus particular attention on respondents' interpretation of the complexity of health causality and the typicality of the situations described. We conducted 24 focus groups with liberal and conservative adults (n = 180 participants) living in a large U.S. northeastern state. Although some narratives showed potential for communicating the complex causality connecting social determinants of health (SDH) to health outcomes, contextual details sometimes disrupted generalization to a broader thematic message. Statistical images often prompted useful speculation about how the factors portrayed might be related, but tended to be regarded with suspicion and criticized for oversimplifying what were perceived to be extremely complex issues. These findings lend theoretical insight to narrative and visual persuasion in the context of social issues with complex causation. We discuss practical implications for those seeking to communicate about the social determinants of health.