Power, intersectionality and the life-course: Identifying the political and economic structures of welfare states that support or threaten health

Elite class self-interest, socioeconomic inequality and U.S. population health

Class-based perspectives on the persistent social gradients in health within modern welfare states largely focus on the adverse consequences of unfettered neoliberalism and entrenched meritocratic socioeconomic selection. Namely, neoliberal-driven economic inequality has fuelled resentment and stress among lower-status groups, while these groups have become more homogeneous with regard to health behaviours and outcomes. We synthesise several sociological and historical literatures to argue that, in addition to these class-based explanations, socioeconomic inequality may contribute to persistent social gradients in health due to elite class self-interest-in particular elites' preferences for overdiagnosis, overprescription and costly high-technology medical treatments over disease prevention, and for increased tolerance for regulatory capture. We demonstrate that this self-interest provides parsimonious explanations for several contemporary trends in U.S. health inequality including (A) supply-side factors in drug-related deaths, (B) longitudinal trends in the social gradients of obesity and chronic disease mortality and (C) the immigrant health advantage. We conclude that sociological theories of elite class self-interest usefully complement theories of the psychosocial effects of neoliberalism and of meritocratic social selection while answering recent calls for research on the role advantaged groups play in generating inequalities in health, and for research that moves beyond technological determinism in health sociology.

Bureaucracy and burden: An Intersectionality-Based Policy Analysis of social welfare policy with consequences for carers of people with life-limiting illness

BACKGROUND

For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications.

AIM

To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations.

DESIGN

The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study.

SETTING/PARTICIPANTS

Data were collected via semi-structured interviews with participants who were bereaved carers (n = 12), welfare workers (n = 14) and palliative care workers (n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data.

RESULTS

Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage.

CONCLUSIONS

This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.

Automating data collection methods in electronic health record systems: a Social Determinant of Health (SDOH) viewpoint

Social Determinant of Health (SDOH) data are important targets for research and innovation in Health Information Systems (HIS). The ways we envision SDOH in "smart" information systems will play a considerable role in shaping future population health landscapes. Current methods for data collection can capture wide ranges of SDOH factors, in standardised and non-standardised formats, from both primary and secondary sources. Advances in automating data linkage and text classification show particular promise for enhancing SDOH in HIS. One challenge is that social communication processes embedded in data collection are directly related to the inequalities that HIS attempt to measure and redress. To advance equity, it is imperative thatcare-providers, researchers, technicians, and administrators attend to power dynamics in HIS standards and practices. We recommend: 1. Investing in interdisciplinary and intersectoral knowledge generation and translation. 2. Developing novel methods for data discovery, linkage and analysis through participatory research. 3. Channelling information into upstream evidence-informed policy.

The Political Economy of Public Health Inequalities and Inequities in India: Complexities, Challenges, and Strategies for Inclusive Public Health Care Policy

This article examines the political economy of health inequalities and inequities in the public health care system in India and identifies potential areas for interventions to promote equal and equitable health care for marginalized people. Drawing on the Political Economy of Health Model of Research, this article reiterates the inadequacy of policy frameworks and programs in ensuring accessible, affordable, and quality public health care services to all. We argue that for policies to be successful, policymakers should consider the diverse social registries of class, caste, religion, gender, region, ethnicity, and age, as well as their intersections. We also argue that health care policies and programs need to be: (a) dynamic and flexible, (b) intersectional and backed up by sufficient grassroots research, and (c) equitable at every stage of policy formulation, implementation, and evaluation.

Social welfare needs of bereaved Australian carers: Implications of insights from palliative care and welfare workers

An individual and psychological emphasis has influenced practice and research on bereavement following informal care provision in the context of life-limiting illness. Consideration of the potential for bereavement to be shaped by intersecting social and structural inequities is needed; and should include an understanding of interactions with government institutions and social policy. This qualitative study employed interpretive description to explore the way in which palliative care workers and welfare sector workers perceive and approach experiences and needs of bereaved carers receiving government income support or housing assistance in Western Sydney, an area associated with recognised socioeconomic disadvantage. A total of 21 palliative care workers within a public health service and welfare workers from two government social welfare services participated in in-depth interviews. Data were analysed using framework analysis. Participants highlighted social welfare policy and related interactions that may impact bereavement, potentially related to financial, housing and employment precariousness. Personal, interpersonal and structural factors perceived to shape the navigation of welfare needs were explored, alongside needed professional and structural changes envisioned by workers. With limited forms of capital, vulnerably positioned carers may encounter difficulties that heighten their precariousness in bereavement. Transactional organisational cultures alongside health and welfare agencies that function in a siloed manner appear to contribute to structural burden for carers, following death due to life-limiting illness. Palliative care and welfare workers also associated elements of their work with bereaved carers with their own experiences of helplessness, frustration and distress. Findings point to a need for the development of interagency strategies in addition to policy underpinned by more nuanced understandings of vulnerability in bereavement, post-caring.

The challenges of rural family physician program in Iran: a discourse analysis of the introduction to criticizing power imbalance between rural health and mainstream urban health

Compared with many metropolitan residents, Iranians living in rural areas have a poorer health status partly due to the inequitable access to healthcare services. However, despite policy efforts to ameliorate the disparities, the gap in healthcare between rural and urban residents is growing wider according to several published studies. Among the fundamental causes of these disparities, dominant discourses play a critical role. This paper seeks to unpack the relations of power operated by socio-politically constructed discourses around rural health-promoting interventions, including rural Family Physician Program (FPP). We adopted a Foucauldian Discourse Analysis (FDA) to examine how well-intentioned efforts to advance equity policy may unintentionally maintain discourse and practices that reinforce inequity. We followed the analytic steps, outlined by Carabine, for distinguishing discourses in order to select and analyze 25 documents, 31 interviews, and 21 observations. The analysis revealed three interconnected discourses with supporting roles constructed in opposition to the putative role of the designed program: the rural FPP to achieve the government’s ideological purposes about justice and equality (the discourse of deficits), the rural FPP to align with the urban-oriented medical curriculum (the discourse of career disadvantages) and the rural FPP to represent discipline perceptions about rural communities (the discourse of rural inferiority). These oppositional role constructions can hinder the proper functioning of this policy, usually in favor of urban claims on rural space.

Caring precariously: An interpretive description of palliative care and welfare worker perspectives on end of life carers navigating social welfare

BACKGROUND

Caring at end-of-life is associated with financial burden, economic disadvantage, and psychosocial sequelae. Health and social welfare systems play a significant role in coordinating practical resources and support in this context. However, little is known about social policy and interactions with public institutions that shape experiences of informal carers with social welfare needs at end-of-life.

AIM

To explore ways in which palliative care and welfare sector workers perceive and approach experiences and needs of the carers of people with life-limiting illnesses who receive government income support or housing assistance, in an area of recognised socioeconomic disadvantage.

DESIGN

An interpretive descriptive study employed in-depth, qualitative interviews to explore participants' reflections on working with carers of someone with a life-limiting illness. Data were analysed using the framework approach.

SETTING/PARTICIPANTS

Twenty-one workers employed within three public services in Western Sydney were recruited.

RESULTS

Workers articulated understandings of welfare policy and its consequences for carers at end-of-life, including precariousness in relation to financial and housing circumstances. Identified resources and barriers to the navigation of social welfare needs by carers were categorised as personal, interpersonal and structural.

CONCLUSIONS

Caring at end-of-life while navigating welfare needs was seen to be associated with precariousness by participants, particularly for carers positioned in vulnerable social locations. Findings highlighted experiences of burdensome system navigation, inconsistent processes and inequity. Further exploration of structural determinants of experience is needed, including aspects of palliative care and welfare practice and investment in inter-agency infrastructure for supporting carers at end-of-life.

Toward an Intersectional Approach to Health Justice

Despite unprecedented global wealth creation, health inequity-the unjust health inequality between classes and groups among and within countries-persists, reviving the relevance of social justice as a lens to understand and as an instrument to intervene in these issues. However, the theoretical aspects and polysemous character of social justice as applied in the field of public health are often assumed rather than explicitly explained. An intersectional justice approach to understanding health inequality, inequity, and injustice might be useful. It argues that preexisting class-, race/ethnicity-, and gender-based health injustice and the socially differentiated impacts of the COVID-19 pandemic are shaped, interconnectedly, by economic maldistribution, cultural misrecognition, and political misrepresentation. Pursuing health justice requires analyses, strategies, and interventions that integrate the economic, cultural, and political spheres of redistribution, recognition, and representation, respectively. Such an intersectional approach to health justice is even more relevant and compelling in light of the COVID-19 pandemic. This article is broadly about class, race/ethnicity, and gender political economy of public health-but with a narrower focus on maldistribution, misrecognition, and misrepresentation, shaping social and health injustices.

Narrative review of affinities and differences between the social determinants of oral and general health in Canada: establishing a common agenda

BACKGROUND

This article overviews Canadian work on the social determinants of oral and general health noting their affinities and differences.

METHODS

A literature search identified Canadian journal articles addressing the social determinants of oral health and/or oral health inequalities. Analysis identified affinities and differences with six themes in the general social determinants of health literature.

RESULTS

While most Canadian social determinants activity focuses on physical and mental health there is a growing literature on oral health-literature reviews, empirical studies and policy analyses-with many affinities to the broader literature. In addition, since Canada provides physical and mental health services on a universal basis, but does not do so for dental care, there is a special concern with the reasons behind, and the health effects-oral, physical and mental-of the absence of publicly financed dental care.

CONCLUSIONS

The affinities between the social determinants of oral health and the broader social determinants of health literature suggests the value of establishing a common research and action agenda. This would involve collaborative research into common social determinants of oral and general health and combined policy advocacy efforts to improve Canadians' living and working conditions as means of achieving health for all.

Life-Course Circumstances and Frailty in Old Age Within Different European Welfare Regimes: A Longitudinal Study With SHARE

OBJECTIVES

This study aimed to assess whether cumulative disadvantage in childhood misfortune and adult-life socioeconomic conditions influence the risk of frailty in old age and whether welfare regimes influence these associations.

METHOD

Data from 23,358 participants aged 50 years and older included in the longitudinal SHARE survey were used. Frailty was operationalized according to Fried's phenotype as presenting either weakness, shrinking, exhaustion, slowness, or low activity. Confounder-adjusted mixed-effects logistic regression models were used to analyze associations of childhood misfortune and life-course socioeconomic conditions with frailty.

RESULTS

Childhood misfortune and poor adult-life socioeconomic conditions increased the odds of (pre-)frailty at older age. With aging, differences narrowed between categories of adverse childhood experiences (driven by Scandinavian welfare regime) and adverse childhood health experiences (driven by Eastern European welfare regime), but increased between categories of occupational position (driven by Bismarckian welfare regime).

DISCUSSION

These findings suggest that childhood misfortune is linked to frailty in old age. Such a disadvantaged start in life does not seem to be compensated by a person's life-course socioeconomic trajectory, though certain types of welfare regimes affected this relationship. Apart from main occupational position, our findings do not support the cumulative dis/advantage theory, but rather show narrowing differences.

Welfare regimes modify the association of disadvantaged adult-life socioeconomic circumstances with self-rated health in old age

BACKGROUND

Welfare regimes in Europe modify individuals' socioeconomic trajectories over their life-course, and, ultimately, the link between socioeconomic circumstances (SECs) and health. This paper aimed to assess whether the associations between life-course SECs (early-life, young adult-life, middle-age and old-age) and risk of poor self-rated health (SRH) trajectories in old age are modified by welfare regimes (Scandinavian [SC], Bismarckian [BM], Southern European [SE], Eastern European [EE]).

METHODS

We used data from the longitudinal SHARE survey. Early-life SECs consisted of four indicators of living conditions at age 10. Young adult-life, middle-age, and old-age SECs indicators were education, main occupation and satisfaction with household income, respectively. The association of life-course SECs with poor SRH trajectories was analysed by confounder-adjusted multilevel logistic regression models stratified by welfare regime. We included 24 011 participants (3626 in SC, 10 256 in BM, 6891 in SE, 3238 in EE) aged 50 to 96 years from 13 European countries.

RESULTS

The risk of poor SRH increased gradually with early-life SECs from most advantaged to most disadvantaged. The addition of adult-life SECs differentially attenuated the association of early-life SECs and SRH at older age across regimes: education attenuated the association only in SC and SE regimes and occupation only in SC and BM regimes; satisfaction with household income attenuated the association across regimes.

CONCLUSIONS

Early-life SECs have a long-lasting effect on SRH in all welfare regimes. Adult-life SECs attenuated this influence differently across welfare regimes.

Tracking biomedicalization in the media: Public discourses on health and medicine in the UK and Italy, 1984-2017

This article examines historical trends in the reporting of health, illness and medicine in UK and Italian newspapers from 1984 to 2017. It focuses on the increasing "biomedicalization" of health reporting and the framing of health and medicine as a matter of technoscientific interventions. Methodologically, we relied on two large datasets consisting of all the health- and medicine-related articles published in the online archives of The Guardian (UK) and la Repubblica (Italy). These articles underwent a quantitative analysis, based on topic modelling techniques, to identify and analyse relevant topics in the datasets. Moreover, we developed some synthetic indices to support the analysis of how medical and health news are "biomedicalized" in media coverage. Theoretically, we emphasise that media represent a constitutive environment in shaping biomedicalization processes. Our analyses show that across the period under scrutiny, biomedicalization is a relevant, even if sometimes ambivalent, frame in the media sphere, placing growing centrality on three dimensions: i) health and well-being as a matter of individual commitment to self-monitoring and self-surveillance; ii) biomedicine as a large technoscientific enterprise emerging from the entanglement between research fields and their technological embodiments; iii) the multiverse reforms of welfare systems in facing the trade-off between universal health coverage and the need to render the national healthcare system more sustainable and compatible with non-expansionary monetary policies and austerity approaches in managing state government budgets.

Assuming policy responsibility for health equity: local public health action in Ontario, Canada

In Canada's liberal welfare state the public is given little exposure by governmental authorities to the importance of promoting health equity through public policy action on the social determinants of health (SDoH). Not surprisingly, Canada lags in implementing health equity-enhancing public policy. In Ontario, Canada's most populous province, a local public health unit (PHU) took on the task of promoting health equity by developing the video animation Let's Start a Conversation about Health and Not Talk about Health Care at All. In the wake of this work, an additional 17 local PHUs (of 36) adapted it for local use. By placing these activities within Nutbeam's and de Leeuw's concepts of critical health literacy as an essential component of health promotion, we examine how these PHUs came to adopt the video, their intended uses, and supports and barriers encountered. These efforts by local PHUs to promote health equity through action on the SDoH have implications for those in jurisdictions where State attention to these issues is lacking.

Impact of Political Economy on Population Health: A Systematic Review of Reviews

Background. Although there is a large literature examining the relationship between a wide range of political economy exposures and health outcomes, the extent to which the different aspects of political economy influence health, and through which mechanisms and in what contexts, is only partially understood. The areas in which there are few high-quality studies are also unclear. Objectives. To systematically review the literature describing the impact of political economy on population health. Search Methods. We undertook a systematic review of reviews, searching MEDLINE, Embase, International Bibliography of the Social Sciences, ProQuest Public Health, Sociological Abstracts, Applied Social Sciences Index and Abstracts, EconLit, SocINDEX, Web of Science, and the gray literature via Google Scholar. Selection Criteria. We included studies that were a review of the literature. Relevant exposures were differences or changes in policy, law, or rules; economic conditions; institutions or social structures; or politics, power, or conflict. Relevant outcomes were any overall measure of population health such as self-assessed health, mortality, life expectancy, survival, morbidity, well-being, illness, ill health, and life span. Two authors independently reviewed all citations for relevance. Data Collection and Analysis. We undertook critical appraisal of all included reviews by using modified Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria and then synthesized narratively giving greater weight to the higher-quality reviews. Main Results. From 4912 citations, we included 58 reviews. Both the quality of the reviews and the underlying studies within the reviews were variable. Social democratic welfare states, higher public spending, fair trade policies, extensions to compulsory education provision, microfinance initiatives in low-income countries, health and safety policy, improved access to health care, and high-quality affordable housing have positive impacts on population health. Neoliberal restructuring seems to be associated with increased health inequalities and higher income inequality with lower self-rated health and higher mortality. Authors' Conclusions. Politics, economics, and public policy are important determinants of population health. Countries with social democratic regimes, higher public spending, and lower income inequalities have populations with better health. There are substantial gaps in the synthesized evidence on the relationship between political economy and health, and there is a need for higher-quality reviews and empirical studies in this area. However, there is sufficient evidence in this review, if applied through policy and practice, to have marked beneficial health impacts. Public Health Implications. Policymakers should be aware that social democratic welfare state types, countries that spend more on public services, and countries with lower income inequalities have better self-rated health and lower mortality. Research funders and researchers should be aware that there remain substantial gaps in the available evidence base. One such area concerns the interrelationship between governance, polities, power, macroeconomic policy, public policy, and population health, including how these aspects of political economy generate social class processes and forms of discrimination that have a differential impact across social groups. This includes the influence of patterns of ownership (of land and capital) and tax policies. For some areas, there are many lower-quality reviews, which leave uncertainties in the relationship between political economy and population health, and a high-quality review is needed. There are also areas in which the available reviews have identified primary research gaps such as the impact of changes to housing policy, availability, and tenure.

Intersectoral Expectations for Promoting Mental Health: A Qualitative Case Study of Islamic Republic of Iran

Background

The prevalence of mental diseases is 23.6% in Iran. Taking intersectoral measures is said to be effective in promoting mental health and reducing the burden of the diseases caused by social determinants. The aim of this study was to determine the role of national organizations in promoting mental health in Iran.

Methods

An applied descriptive qualitative method was used. The data were collected by reviewing the literature, interviewing with experts, and holding focus group discussions. To identify the roles of organization, a two-dimensional matrix was drawn.

Results

The roles of 31 national organizations in five groups were determined. Then, the intersectoral organizational expectations in two key areas were extracted. The key roles determined were mostly related to the Ministry of Education, Islamic Republic of Iran Broadcasting, Ministry of Labor and Social Welfare, and the Ministry of Sports and Youth.

Conclusions

Due to the growing burden of mental disorders in the country, informing national organizations and attracting their active participation based on intersectoral expectations and developing interaction mechanisms among them can be an effective step in promoting mental health and reducing the environmental factors threatening mental health.

A Hierarchy of Power: The Place of Patient and Public Involvement in Healthcare Service Development

Amidst statutory and non-statutory calls for effective patient and public involvement (PPI), questions continue to be raised about the impact of PPI in healthcare services. Stakeholders, policy makers, researchers, and members of the public ask in what ways and at what level PPI makes a difference. Patient experience is widely seen as an important and valuable resource to the development of healthcare services, yet there remain legitimacy issues concerning different forms of knowledge that members of the public and professionals bring to the table, and related power struggles. This paper draws on data from a qualitative study of PPI in a clinical commissioning group (CCG) in the UK. The study looked at some of the activities in which there was PPI; this involved researchers conducting observations of meetings, and interviews with staff and lay members who engaged in CCG PPI activities. This paper explores power imbalances when it comes to influencing the work of the CCG mainly between professionals and members of public, but also between different CCG staff members and between different groups of members of public. The authors conclude that a hierarchy of power exists, with some professionals and public and lay members afforded more scope for influencing healthcare service development than others-an approach which is reflected in the ways and extent to which different forms and holders of knowledge are viewed, managed, and utilized.

Governmental Illegitimacy and Incompetency in Canada and Other Liberal Nations: Implications for Health

The welfare state literature on developing nations is concerned with how governmental illegitimacy and incompetency are the sources of inequality, exploitation, exclusion, and domination of significant proportions of their citizenry. These dimensions clearly contribute to the problematic health outcomes in these nations. In contrast, developed nations are assumed to grapple with less contentious issues of stratification, decommodification, and the relative role of the state, market, and family in providing economic and social security, also important pathways to health. There is an explicit assumption that governing authorities in developed nations are legitimate and competent such that their citizens are not systematically subjected to inequality, exploitation, exclusion, and domination by elites. In this article, we argue that these concepts should also be the focus of welfare state analysis in developed liberal welfare states such as Canada. Such an analysis would expose how public policy is increasingly being made in the service of powerful economic elites rather than the majority, thereby threatening health. It would also serve to identify means of responding to these developments.

Death Is a Social Justice Issue: Perspectives on Equity-Informed Palliative Care

All too often, palliative care services are not responsive to the needs of those who are doubly vulnerable, being that they are both in need of palliative care services and experiencing deficits in the social determinants of health that result in complex, intersecting health and social concerns. In this article, we argue for a reorientation of palliative care to explicitly integrate the premises of health equity. We articulate the philosophical, theoretical, and empirical scaffolding required for equity-informed palliative care and draw on a current study to illustrate such an approach to the care of people who experience structural vulnerabilities.

Understanding the micro and macro politics of health: Inequalities, intersectionality & institutions - A research agenda

This essay brings together intersectionality and institutional approaches to health inequalities, suggesting an integrative analytical framework that accounts for the complexity of the intertwined influence of both individual social positioning and institutional stratification on health. This essay therefore advances the emerging scholarship on the relevance of intersectionality to health inequalities research. We argue that intersectionality provides a strong analytical tool for an integrated understanding of health inequalities beyond the purely socioeconomic by addressing the multiple layers of privilege and disadvantage, including race, migration and ethnicity, gender and sexuality. We further demonstrate how integrating intersectionality with institutional approaches allows for the study of institutions as heterogeneous entities that impact on the production of social privilege and disadvantage beyond just socioeconomic (re)distribution. This leads to an understanding of the interaction of the macro and the micro facets of the politics of health. Finally, we set out a research agenda considering the interplay/intersections between individuals and institutions and involving a series of methodological implications for research - arguing that quantitative designs can incorporate an intersectional institutional approach.