Equity is out of fashion? An essay on autonomy and health policy in the individualized society

Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions

This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and evidence on the impact of various social determinants of health. The contributions of different disciplines—epidemiology, sociology, political economy, and the human rights perspective—to the field are acknowledged, but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The author identifies the areas of inquiry needed to help translate knowledge into action.

The Structural Configurations of Alcohol in Denmark: Policy, Culture, and Industry

This article analyzes recent developments in Danish alcohol policy, culture, and industry. It reveals cross-sector dynamics and complexities that are often downplayed in existing literature. It traces how a stable “structural configuration” emerged in the 1960s-1980s between the three domains, based on liberalization. A particular adolescent alcohol culture of intoxication, however, emerged in the 1990s, raising public awareness and calls for policy intervention. Contrary to what may have been expected, this did not represent a break with the liberal alcohol configuration in policy, culture, and industry, but an increased segregation of adolescent consumption from adult consumption, exposing the former to severe legal and moral regulation. This analysis of historic-structural dynamics helps explain why adolescent drinking is dependent on more than isolated causal links such as between policy events and consumption.

The concept of ‘‘equity’’ in health-promotion articles by Nordic authors - A matter of some confusion and misconception

Aims: This paper focuses on equity in health, one of the key principles of the Ottawa Charter. It aims at analysing and discussing how the concept was defined, applied, and integrated in health-promotion articles by authors with a Nordic affiliation. Methods: Abstracts were first identified by the search word ‘‘health promotion’’ as a key word. The search was limited to 1986—2008 and abstracts written in English by authors with a Nordic affiliation. Abstracts/articles for the present study were subsequently selected from these abstracts using the search word ‘‘equity’’ and analysed by quantitative and qualitative content analysis. Findings: A majority of the 18 articles in the study did not include any proper definition of the term ‘‘equity in health’’. Most articles dealt with health in general or ‘‘Health for All’’ aspects and did not focus on specific strategies for vulnerable individuals or groups. The theoretical papers had a clear focus on equity aspects even though the concept of equity was sometimes included in an implicit way. In contrast, most papers reporting empirical studies did not specifically target equity aspects. Instead, the analysis gave the impression that many authors used the term ‘‘equity’’ synonymously with ‘‘equality in health’’. Conclusions: The findings may indicate that the concept of ‘‘equity in health’’ has been attenuated or even forgotten by Nordic health-promotion researchers and needs to be re-established as a strong concern within health promotion.

"I like to be an informed person but..." negotiating responsibility for treatment decisions in cancer care

Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients' roles and responsibilities do not however always map neatly onto patients' actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants' complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients' expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine.

Quality or equality? The Norwegian experience with medical monopolies

Background

In order to maintain both quality and efficiency of health services in a small country with a scattered population, Norway established a monopoly system for 38 highly specialized medical services. The geographical distributions of these services, which are provided by one or two university hospitals only, were analysed.

Methods

The counties of residence for 2 711 patients admitted for the first time in 2001 to these 31 monopolies and 7 duopolies were identified.

Results

The general tendency observed was that with increasing distance from residential home to monopoly hospitals there was a declining coverage of these health services. The same pattern was found even with regard to explicit diagnoses or treatments such as organ transplantations (except renal transplantations). Duopolies seemed to yield a more even geographical distribution of the services.

Conclusion

Monopolies may serve as a useful means for maintaining quality in highly specialized medical services, but seem to have an inherent tendency to do this at the expense of geographical equality.

Polarization in the reaction to health-risk information: a question of social position?

Dissemination of risk information is ubiquitous in contemporary society. We explore how individuals react in everyday life to health-risk information, based on what they report in personal interviews. Health-risk information was without exception recognized as unstable and inconsistent. This conformity, however, did not extend to the narratives regarding how health-risk information should be handled. Two opposite positions (ideal-typical strategies) are presented. Either you tend to process and evaluate new information or you tend to ignore it as a whole. Our attempt to reveal the underlying rationality in these two very different approaches involved the exploration of three different avenues of interpretation and brings together two scientific paradigms--economics and sociology--that provide the framework for our analysis. First, we suggest that a greater long-term experience of explicit choice implies that this kind of action becomes more natural and less resource consuming, whereas a reliance on habits in daily life--a natural adjustment to a lack of resources--makes it is more costly to bother about new information. Second, with fewer resources in the short run, fewer opportunities to mitigate bad outcomes, and greater exposure to social and material risks, one is less likely to devote resources to deal with health-risk information. Third, there are several possible links between a low propensity to take account of risk information and a high relative importance of genuine uncertainty in one's life. These theoretical perspectives provide a viable set of hypotheses regarding mechanisms that may contribute to social differences in the response to health-risk information.

Equity in health care from a communitarian standpoint

Equity in health and health care is an important issue. It has been proposed that the pursuit of equity in health care is being hampered by the dominance of individualism in health care practices. This paper explores the way in which communitarian ideals and practices might lend themselves to the pursuit of equity. Communitarians acknowledge, respect and foster the bonds that unite and identify communities. The paper argues that, to achieve equity in health care, these bonds need to be recognised and harnessed rather than ignored. The notion of individual autonomy in the context of the community is examined. Alternative concepts of autonomy--social autonomy and community autonomy--are seen to be more respectful and nurturing of both the individual and the community. Moreover, these concepts appear desirable for the pursuit of health care equity goals. The paper concludes with some thoughts about how equity in Australia's health care system can reasonably progress within a communitarian vision. Disadvantaged communities are discussed throughout, in particular, Australian Aboriginal communities.

Habit versus choice: the process of decision-making in health-related behaviour

Social differences in the role of habits in health-related behaviour are explored within both sociology and economics, where we define habits as non-reflective, repetitive behaviour. The corresponding theoretical perspectives are the habitus theory, the theory of individualization, and habits as rational decision rules. Sixteen thematically structured interviews are analysed using qualitative methodology. Three aspects of habits emerged from the narrative: the association between habits and preferences, habits as a source of utility, and the relationship between habits and norms. We find that people in lower social positions are more inclined to rely on their habits and are accordingly less likely to change their behaviour. These differences are reinforced as not only the disposition to maintain habits but also the tendency to conceive of the habitual as something good seems to be strengthened in lower social positions. We also note that the intensified individualization that characterizes current society erodes the basis for habit-governed behaviour, which may also contribute to social differences in well-being. Finally, we find that the scientific dialogue has enriched both scientific paradigms, and suggest as a tentative hypothesis that the traditional economic rational-actor model may be relatively less applicable to those with limited resources.

Dentistry and distributive justice

There is a growing concern in most countries to address the problem of inequities in health-care within the context of financial restraints on the public purse and the realities of health professions that are influenced strongly by the economic priorities of free-market economies. Dental professionals, like other health professionals, are well aware that the public expects oral health-related services that are effective, accessible, available and affordable. Yet, there is remarkably little reference in the literature to the theories of distributive justice that might offer guidance on how an equitable oral health service could be achieved. This paper considers three prominent theories of distributive justice--libertarianism, egalitarianism and contractarianism--within the controversial context of basic care and quality of life. The discussion leads towards a socially responsible, egalitarian perspective on prevention augmented by a social contract for curative care with the aim of providing maximum benefit to the least advantaged in society.

Annotated Bibliography on Equity in Health, 1980-2001

The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.

Time trends in alcohol habits. Results from the Kirseberg project in Malmö, Sweden

This paper reports on a pilot demonstration to implement an alcohol consumption reduction project in the community of Kirseberg, located in the city of Malmö, Sweden. The objective is to present data on time trends in alcohol use habits and alcohol-use-related problems in the Kirseberg population and to discuss potential effects of the alcohol prevention activities. It was possible to implement an alcohol consumption prevention community program successfully. The analysis of time trends in alcohol use habits and alcohol-use-related problems was, however, mainly inconclusive, but indicated a decrease in alcohol consumption and alcohol-use-related problems among young and middle-aged men.