By Anna Isaacs
It has been seven years since the WHO Commission on the Social Determinants of Health launched its report demonstrating categorically the profound impact of social and economic inequalities on health outcomes and declaring that “social injustice is killing people on a grand scale”. The powerful effects of socioeconomic, structural and political influences over individual behaviours on our health are well known and well discussed. Yet, so often in public health research, we seem to park this knowledge at the door and continue working on behavioural health interventions that bring minimal, short-term benefits, if any at all. We may nod to the importance of culture, or socio-economic status, or even incorporate a socio-ecological perspective, but it is incredibly rare for such research to challenge, or even examine, the more fundamental factors that result in ill health.
Since starting my PhD, I have been struck by this repeatedly. Examples abound in applied public health strategies, such as the ‘Drinkaware’ posters displayed around Glasgow last summer, suggesting that parents would be responsible for their children’s future violent behaviour if their children were to drink underage. It is common in academic research too, however, where health interventions are reported on that didn’t change behaviours on the scale intended. The necessity of focusing on structure is agreed by many, yet too rarely applied in practice. This “cognitive dissonance” amongst public health researchers is well documented in the critical public health literature (e.g., Raphael) and discussed repeatedly between academics at conferences, in presentations and in informal discussions.
So why do we continue conducting our research on interventions we know may only make a minimal difference? Why is there such reluctance to radically rethink the manner in which we are trying to improve the public’s health? Perhaps obviously, one of the most critical reasons is because it’s extremely hard. It’s simple enough to plan and deliver a small-scale behavioural health intervention, tailored to the intended population and likely to be of benefit at least to a few people. Those sorts of projects make sense. Try and plan a health intervention that tackles the root causes of health inequality, and things become rather trickier. Where would you even start? And what is the end point? Certainly a lot of work needs to be done at the policy level where more fundamental causes of inequality can be addressed. However, I don’t believe that gives public health researchers free reign to ignore the wider issues and only focus on the low hanging fruit. For one, it doesn’t work, but more critically it places the responsibility for ill health in the wrong hands, absolving those who are actually responsible, and allowing the fundamental causes of ill health and inequality to remain hidden and unchallenged.
Avoiding this problem in my PhD research (looking at access to and use of preventive health services by migrants in Glasgow) is far easier said than done. I want to follow the suggestion of the anthropologist Merrill Singer, that academics should engage in ‘systems-challenging praxis’ rather than ‘systems correcting praxis’, making sure that we are actively challenging the systems and structures that promote ill health, rather than simply making tweaks to the current system. Is it possible to carry out research that helps to improve people’s health in the short term without helping to maintain or even bolster the structures that create long-term unequal health outcomes?
I have tried to consider what theoretical positions and methodologies might help me to address this dissonance in my own research. So far for me this has meant grounding my research firmly in a social justice approach – where the pursuit of justice and equity is central to my research aims. I have explored critical theories that try to link health at an individual level to what happens at a societal and structural level so that that while I address health issues at a local level, their root causes are not ignored or supported. I have also focused on methodologies (e.g., walk-along interviews and participatory approaches) that aim to reduce some of the power imbalances inherent in research. I’m aware however that I may still be a long way off making more than a tokenistic gesture to what can feel like an unreachable goal.
Have you grappled with these contradictions in your own work? Am I misrepresenting behavioural health research? Are there examples of research or projects that are aimed at both an individual and societal level? What new directions should we be thinking about?