Capitals and capabilities: Linking structure and agency to reduce health inequalities
Highlights
► Draws attention to capital interaction as key in providing options for health-relevant agency. ► Provides theoretical guidance to consider structurally transformative agency and its potential for reducing social inequalities in health. ► Proposes the capability approach as a theoretically meaningful concept for public health action.
Introduction
Understanding and reducing social inequalities in health have been key issues and a central challenge in public health. Both structural conditions and individual agency have been identified for their roles in influencing these inequalities. Since the spawning of the Ottawa Charter (World Health Organization, 1986), promoting the public’s health by enabling people to increase control over and improve their health is a laudable goal that has become the benchmark for health promotion. The Charter’s proponents deliberately underscored the importance of structure and agency; social structural forces were believed to be creating and sustaining health inequalities and individuals were understood to be able to productively influence social structural conditions affecting their health through their actions (WHO-EURO, 1984). While some agreement has been reached since the writing of the Charter with regard to the importance of the structure–agency processes in the quest towards the reduction of inequalities in health, how exactly to enable people to act in favour of their health remains unresolved in health promotion.
We suggest that a better understanding of the basic dynamics behind the creation of health inequalities through social inequalities might help lead to an answer. More specifically, we examine the conditions and the role of individual and collective agency in the social reproduction and modification of social inequalities in health. It is here that social theory, in particular medical sociological theory, can provide guiding insights. We draw and expand on two related literatures: the structure–agency debate within sociology over the past 30 years (Bourdieu, 1986, Frohlich et al., 2001, Giddens, 1984, Hays, 1994, Sewell, 1992) and research concerned with theoretical approaches to health inequalities (Abel, 2007, Cockerham, 2005, Frohlich et al., 2002, Popay et al., 2003, Williams, 2003, Williams, 1995). We do not aim to engage in direct dialogue with the vast social scientific literature on the structure–agency debate, but instead, draw on a few fundamental issues from it in order to move towards an understanding of the mechanisms lying between social and health inequalities, including perspectives applicable for social change.
Section snippets
Structure and agency in the current discourse on health inequalities
The discussion regarding the role of the social structure on shaping human activity has permitted for a strong understanding of its patterns and its potential relevance to health (Frohlich et al., 2002, Popay et al., 2003, Singh-Manoux and Marmot, 2005, Williams, 2003). First, structures are laden with differences in power and thus empower individuals and classes differentially. Second, the term social structure often implies stability (Sewell, 1992), which has led to sophisticated descriptions
The structuring of choices
We begin our theoretical foray with some of the basic concepts Max Weber developed in his writing on lifestyles. Weber is particularly important here for two reasons. First, his discussion of “Lebensführung” (life conduct) helps us make the claim that agency and social structure are both critical for understanding how health is unequally produced (Cockerham, Abel, & Lüschen, 1993). Second, and in a related manner, the “Lebensführung” concept helps us move beyond a notion of agency as being
Capitals and the (re)production of social inequalities
Weber’s view on the dialectic interplay between life choices and life chances laid the ground for later analyses including some of Bourdieu’s work (Bourdieu, 2007). However, Weber’s analysis is insufficient in accounting for social differences in the contemporary patterning of health lifestyles (e.g. Cockerham et al., 1997). Moreover, Weber was concerned with status group formation and his definition of life chances (structurally anchored probabilities) does not clearly address the issue of how
Capital interaction and health inequalities
There is a high degree of complexity among capitals in their different forms. Three of these relationships (conversion, accumulation and transmission) have been discussed by Bourdieu (1986) and here we add a fourth principle of interaction we call “conditionality”. All four forms of interaction are important for the purposes of our argument.
First, different forms of capital, in their acquisition and use, are dependent and conditional on each other. For instance, cultural capital is essential in
From understanding social reproduction of health inequalities to reducing them: the capability approach as a nexus between explanation and public health action?
Drawing on Weber’s dualism of life chances and choices, we view that despite material and normative constraints people do have some element of choice in their behaviours affecting their health. These choices arise out of the conditions they face and the opportunities they enjoy. In the production and maintenance of health, therefore, there is an important role for individual agency. The question can then be posed: “What theory of agency permits for individual and structural change”?
Following
Capitals and capabilities in health promotion practice: the BIG project
BIG is short for “Bewegung als Investition in Gesundheit (BIG) – Movement as an Investment for Health”, and is aimed at promoting health through the promotion of physical activity among women in difficult life situations (www.big-projekt.de). The city-based project addresses women of low socio-economic status known from national statistics to represent the population group most physically inactive with a high prevalence of sedentary lifestyles, and thus high levels of associated conditions such
Discussion and conclusion
In this final section we first briefly summarize our line of argument and how it might lead to new questions in the current discourse in Medical Sociology. We then close our paper with a discussion of the relevance of our theoretical argument for public health and health promotion.
Previous theoretical explanations of social inequality and health have convincingly argued that the (re)-production of health inequalities cannot be explained on the basis of a theoretical or empirical divide between
Acknowledgements
Support for this work was provided by the Swiss National Science Foundation under grant number 105313_130068_/1. K.L. Frohlich holds a New Investigator Award from the Canadian Institutes of Health Research and held an Alexander von Humboldt Senior Research Award over the course of the writing of this paper. The authors wish to thank the reviewers at Social Science & Medicine and following people for their thoughtful input into the writing of this paper: William Cockerham, Lowell Levin, Joanna
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