Structural Approaches in Public Health

Marni Sommer, Richard Parker, Marni Sommer, Richard Parker

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136766190
• Edition: 1
• Topic: Medicina
• Subtopic: Salud pública, administración y atención

A CHOICE Outstanding Academic Title 2014!

That health has many social determinants is well established and a myriad range of structural factors – social, cultural, political, economic, and environmental – are now known to impact on population well-being. Public health practice has started exploring and responding to a range of health-related challenges from a structural paradigm, including individual and population vulnerability to infection with HIV and AIDS, injury-prevention, obesity, and smoking cessation.

Recognising the inadequacy of public health responses that focus solely on individual behaviour change to improve population health outcomes, this text promotes a more holistic approach. Discussing the structural factors related to health and well-being that are both within and outside of an individual's control, it explores what form structural approaches can take, the underlying theory of structure as a risk factor and the local realities, environments, and priorities that public health practitioners need to take into consideration. Anchored in empirical evidence, the book provides case studies of innovative and influential interventions – from the 100% condom program, to urban planning, injury prevention, and the provision of adequate clean drinking water and sanitation systems – and concludes with a section on implementing and evaluating structural public health programs.

This comprehensive text brings together a selection of internationally-recognised authors to provide an overview for students and practitioners working in or concerned with public health around the globe.

1 Introduction

Structural approaches in public health

Marni Sommer and Richard Parker

DOI: 10.4324/9780203558294-1

The field of public health in the early twenty-first century has seen a resurgence of interest in what can be described as ‘structural approaches’ (Blankenship et al. 2000). In relation to topics as diverse as hiV/AIDS and other newly emerging or re-emerging infectious diseases, injury and violence prevention, and the growing global incidence of chronic or non-communicable diseases, increasing attention has focused on the structural factors — social, cultural, political, economic, and environmental — that shape and constrain individual, community, and societal health outcomes. This emphasis on structural factors that make both individuals and the communities to which they belong vulnerable to negative health outcomes has also led to a growing focus on structural and environmental interventions in public health — interventions that seek to alter the context within which health and illness are produced and reproduced (Blankenship et al. 2006; Gupta et al. 2008; Parker et al. 2000; Sweat and Denison 1995).

The growing use of structural approaches in contemporary public health is not an entirely novel phenomenon. On the contrary, the history of public health offers a wide range of case examples in which practitioners and policymakers, often for moral, economic, or social (rather than health-related) reasons, have implemented structural interventions aimed at changing the social conditions in which people live (Porter 1997). In the nineteenth and early twentieth centuries, for example, reformers in the United States, Europe, and other industrializing nations focused on the problematic conditions of populations living in increasingly crowded urban environments. Advocating for the need to address people’s working and living conditions, often from the perspective of wanting to reduce the risks of perceived immoral behaviour posed by unsanitary surroundings, significant efforts were made to implement structural interventions such as improved water supplies and laws on tenement housing. Such efforts, implemented through effective interdisciplinary action, which at times impinged on the civil liberties of selected populations, had an enormous influence on population health outcomes, and in particular on the rates of infectious disease (Rosen 1993; Rosner and Markowitz 1985; Schmid et al. 1995). These types of interdisciplinary approaches diminished in the early twentieth century, however, with the rise of the germ theory of disease, a turn by public health clinicians and practitioners toward the laboratory, and a focus on the individual and his or her behaviour as the key to reducing health-related risks (Tomes 1998).

Over the course of the twentieth century, more individualistic and behavioural approaches came to dominate both theory and practice in relation to health promotion and disease prevention and were applied to almost all major public health challenges (Matarazzo 1980). The outcomes of such approaches were often disappointing. Efforts to improve population health, ranging from health education on diet and exercise, to guidance on wearing condoms at every sexual encounter, driving more safely, and avoiding injuries in the home or work environment, were all found to be limited in their effectiveness given the numerous influences shaping, and constraining, individual behaviour and choice. Such influences emerged from the structural realities affecting people’s lives and the social forces, or the social drivers, influencing the distribution of health and illness (Auerbach et al. 2011). For example, the toxic food environment of high-income countries, now spreading to low- and middle-income countries, combined with the change in everyday activity levels and the physiology of automatic eating behaviour, has prevented many individuals from maintaining a healthy weight. The social, economic, and gendered realities of people’s lives in numerous contexts prevented the use of condoms with every sexual encounter. Inadequate road construction and insufficient traffic safety legislation and enforcement made safe driving a reality far removed from individual control. Injuries in a range of settings, including in the home or resulting from the use of unsafe equipment in the workplace, were unavoidable as long as the infrastructure within which they occurred remained unchanged. While individual behaviour and agency play an important role in protecting and maintaining a person’s health, many of the priority public health interventions that focus on the individual alone, with little to no attention to the structural and environmental influences shaping their lives, proved to be insufficient to accomplish the stated public health goals of reducing morbidity and mortality. Such individually focused interventions nonetheless continued to dominate the public health arena for much of the twentieth century.

Recognizing the limitations of mainstream health education and behavioural prevention programmes, in the past two decades attention began to shift to structural approaches and interventions as an important alternative to concentrating on individual health behaviours (Blankenship et al. 2000). This renewed interest in structural and contextual factors that shape health-related risks and vulnerability to disease has been especially strong in work focusing on HIV and AIDS, where the relatively limited success of health education and behavioural interventions has led researchers and policymakers to explore alternative strategies, ranging from community mobilization activities to reduce the spread of HIV, to the use of anti-discrimination legislation and similar policies aimed at protecting those already living with HIV (Blankenship et al. 2006; Gupta et al. 2008; Parker et al. 2000; Sweat and Denison 1995). Increasingly, there has been a growing trend toward focusing on structural and environmental factors not only in research and programmes focusing on HIV and AIDS, but across a wide range of topical areas and in countries and communities around the world. Examples include the impact of improved accessibility to clean water to combat diarrhoeal disease; the mandated use of seat belts and motorcycle helmets aimed at reducing traffic injuries; the banning of tobacco use; and the prohibition of certain kinds of foods and beverages known to cause cancer or obesity-related chronic diseases (Brownson et al. 2006; Katz 2009; Schmid et al. 1995). Indeed, by the early twenty-first century, many leading figures in public health policy and practice had returned to focusing attention on confronting and changing the structural and environmental factors in the everyday world around us that pose major health risks — and on promoting public health policies aimed at creating a healthier environment (Farley and Cohen 2005).

As important and widespread as the renewed uptake of such structural and environmental approaches has been, it is still limited and fraught with controversy about the extent to which policymakers and public health experts have the right to protect people from the consequences of their own behavioural choices (Bayer et al. 2006). In addition to the important ethical debates generated by this turn to structural and environmental approaches and interventions, another key factor limiting their uptake in many settings has been a relative lack of consensus concerning the definition of what constitutes structure together with a range of differing theoretical frameworks that exist for conceptualizing structural factors (Blankenship et al. 2000). While researchers trained in the social sciences and those trained in public health or behavioural medicine may use the same terminology, they frequently mean very different things when they describe the workings of structure (Parker et al. 2000).

In much of the social science research on structural factors that impact health, primary emphasis has focused on the role of social inequality in structuring health-related vulnerabilities. Medical anthropologists or medical sociologists are more likely to frame the discussion of structural factors in relation to aspects of political economy and emphasize how broad macro-economic processes and social structural inequalities such as class, race or ethnicity, and gender shape the vulnerability of different groups to a range of health conditions. They have thus tended to focus on the negative health impact of what they frequently describe as ‘structural violence’ (Farmer 2002, 2004; Parker 2002) and explore the ways in which multiple and intersecting forms of inequality create a kind of synergy — quite literally producing what have been described as ‘syndemics’ that affect poor and marginalized populations (Singer and Clare 2003). This focus, in turn, has led many researchers working at the interface of social science and public health to emphasize the need for broad social and economic transformations in order to truly change negative health outcomes (Farmer 2005), and to focus on intervention approaches aimed at community mobilization and collective empowerment as key to promoting population health (Laverack and Labonte 2000; Parker 1996; Wallerstein 1992).

In contrast, public health and health behavioural researchers, while sensitive to the importance of social structural inequalities, are more likely to conceptualize structural and environmental factors as aspects of health policy and institutional programmes and practices that influence the context in which health behaviours take place. Indeed, perhaps because of the lack of consensus concerning its meaning, they are less likely to use the term ‘structure’, and instead frequently speak in terms of ‘environmental and policy approaches’ (Brownson et al. 2006; Schmid et al. 1995). Even when they do use the language of structure and structural interventions, they downplay the social science focus on macro-economic structures (that are seen as only minimally subject to transformation), placing greater emphasis on policy changes that might influence more ‘proximal’ aspects of the context and environment in which health behaviours take place, rather than ‘distal’ factors such as the broader structures of social inequalities (Krieger 2001).

In spite of these important differences, both in relation to terminology and in relation to conceptualization, there has nonetheless been a growing approximation in recent years between social science and public health approaches to issues of inequality as well as to interventions aimed at responding to their negative health impact. This is perhaps especially evident in the increasingly widespread uptake in public health of frameworks focusing on the ‘social determinants’ of health (Marmot and Wilkinson 1999) and the ‘fundamental causes’ of disease (Link and Phelan 1995). In emphasizing the social and economic conditions that shape health outcomes — and that have maintained health disparities over time — such approaches have provided an important point of convergence for both public health and social science thinking on the relationship between social inequality and health. They have also focused new attention on factors such as prestige and power as central to understanding differential health outcomes, and helped the field move beyond notions of proximal and distal causes of health disparities in examining processes through which power differentials operate in producing health and disease (Krieger 2008). Through the work of the World health organization’s (WHO) Commission on the Social Determinants of Health (CSDH) (CSDH 2008), and the extensive activities that this Commission’s work has stimulated at the country level around the globe, extensive new space has opened for social science and public health research on the structural dimensions of health globally in the early twenty-first century. Perhaps never before has so much attention focused on these issues — nor have conditions been so favourable for seeking to address the health impact of social inequalities through the design and implementation of structural and environmental interventions.

In spite of these positive recent developments, many challenges continue to confront work on these issues. Just as differing notions of what structure is and how it operates has made the analysis of structural factors and the design of interventions more difficult, measuring the effectiveness of structural interventions has also raised major challenges. In contrast to individually or even culturally focused interventions that are evaluated in terms of individual behavioural changes, structural or environmental interventions are evaluated in terms of social transformations, such as community mobilization or social movement empowerment. Measuring change at this scale involves a whole new set of considerations that the field has only begun to understand and confront (Bonell et al. 2006).

It is in relation to these important challenges that the current volume on Structural Approaches in Public Health seeks to make a key contribution. The chapters brought together here aim to map out the ways in which the notion of structure has been conceptualized in relation to health, both over time and across a range of different disciplinary perspectives. They also explore how structural interventions have been conceived and implemented in various contexts to address different topics related to population health. Finally, they explore some of the important challenges that must be addressed in seeking to assess the impact of structural interventions in practice. Taken together, they make a case for the central importance of structural approaches in confronting the most pressing practical challenges in the field of public health today, and point the way forward in relation to the continued refinement of these approaches in the future. In the discussion to follow, we will briefly summarize the contents of the chapters that have been included in each of the three major sections of this volume and present our vision of how to further develop this field of work.

Defining structural factors

As mentioned above, one of the key challenges to the broader adoption of structural approaches has been the relative lack of consensus on precisely what so-called ‘structural approaches’ actually entail. While diversity in conceptual frameworks can be highly productive, in this case, it has been an impediment to more fruitful discussion and debate. One of the major obstacles has been the perception that different scholars and scientists are talking about the same thing when, in fact, their intended meanings are quite different. It is thus useful to look at some of the different ways in which definitions of structure have been articulated in various disciplinary and even epistemological traditions.

The chapters in the first section of Structural Approaches in Public Health do exactly that. They explore a number of the different ways in which notions of structure and structural factors affecting health outcomes have been conceptualized, both historically, as well as from different disciplinary and epistemological perspectives. These chapters examine the similarities and differences in existing definitions of structural factors in an effort to highlight areas of definitional understanding and consensus among the leading experts within the field. The section also includes chapters on structure as a risk factor, structural violence as a local and global challenge, and descriptions of theoretical approaches as applied to structural and environmental approaches.

The first chapter in this section, Chapter 2, ‘The history of structural approaches in public health’, by James colgrove, amy Fairchild, and David Rosner, provides a rich overview of the historical evolution of structural approaches within public health. It begins with a discussion of interventions framed in the nineteenth century as ecological and environmental approaches, highlighting the dramatic impact such approaches had on improving the health of the poor. Such interventions prefigured the modern conception of structural approaches. The authors then describe the shift in the field toward more individual-focused interventions as attention to bacte...