Understanding behaviour change in context: examining the role of midstream social marketing programmes

This research examines how midstream social marketing programmes that adopt a relational and community‐based approach create opportunities for individuals to make incremental changes to health behaviour. Specifically, it applies Bourdieusian theory to explore how interactions between community healthcare workers (CHWs) and members of the public generate impetus for change and foster individual agency for improved health. Qualitative interviews were carried out with members of the public and CHWs engaged in a Smokefree home and cars initiative. The findings suggest that although CHWs are challenged by resource constraints, their practices in working with individuals and families build trust and enable dialogue that bridges smoking‐related health insight with home logics. These interactions can promote individual agency with a transformative effect through small changes to smoking‐related dispositions, norms and practices. However, tensions with the habitus of other household members and other capital deficits can inhibit progress towards embedding new practices. The study concludes that interventions built upon community relationships show potential for addressing limitations of information‐focused campaigns but there is a need to also respond to key social structures relating to the field of action for new health dispositions to become embedded in practice.     

Understanding how Afghan women utilise a gender transformative and economic empowerment intervention: A qualitative study

The processes through which women's economic empowerment interventions are envisaged to improve women's health are strongly embedded in notions of building women's agency and autonomy. Yet despite the ubiquity of such interventions, there remains incredibly little qualitative work exploring how women actually utilise interventions to reshape their lives and wellbeing. Drawing on 9 focus groups discussions among 52 women who participated in the Women for Women International intervention in Afghanistan, an economic strengthening and social empowerment intervention, we explore processes of change. Data showed women learnt new skills around numeracy and animal husbandry; they perceived themselves to have become more respected within the household setting; they invested cash they received for intervention attendance in businesses, primarily their husband's or family's, and saved cash. Women did not, however, report their relationships to have been radically restructured. Rather women described incremental changes in their relationships within their household and used what they gained from the intervention to secure and sustain this. This conceptualisation of agency and empowerment reflects approaches to understanding agency, which move away from ‘action-oriented’ understandings, to ones that recognise ‘distributed agency’ as pathways to change through interventions.     

'The illness is part of the person': discourses of blame, individual responsibility and individuation at a centre for spiritual healing in the North of England

While the growth in usage and practice of varying forms of complementary and alternative medicine (CAM) continues apace, social science has increasingly turned to CAM's often individualistic approach to health and illness. CAM has been perceived as both partly a cause of and a response to the well-documented ideology in modern healthcare of 'individual responsibility for health'. This occasionally manifests in a 'victim-blaming' ideology amongst both orthodox and CAM practitioners alike. These issues emerged as key themes in an ethnographic study of a Centre for spiritual healing in the North of England. By drawing upon a range of qualitative data gained through the researcher's participation at this healing centre, I argue that the healers' focus on individual responsibility for health is not so much a part of the current socio-political health ideology of 'victim-blaming', rather, it is illustrative of an important contemporary social phenomenon: the movement towards the subjectification and personalisation of public life.     

In a vigilant state of chronic disruption: how parents with a young child with type 1 diabetes negotiate events and moments of uncertainty

Living as a parent and self-care surrogate of a young child with type 1 diabetes (T1D) is demanding and a disruption to ‘normal’ routinised daily living. Research has mainly focused on the time of diagnosis as a one-time biographical disruption. In this article, we will show how, in the case of families with young children with T1D, the biographical disruption can be viewed as a continuous state of vigilance that affects family functioning and ‘normal’ living. We will show this by focusing on the temporal events and moments that keep the families in a state of what we will term ‘chronic disruption’. The events are the transitions from hospitalisation to home, home to nursery, nursery to daycare, and daycare to school and preparations for social activities concerning the child. The moments are more fluid, ranging from daily interruptions when daycare workers and teachers call parents with doubts about self-care to negotiations with institutions and municipalities and a constant state of worry.     

Building on the positive in children's lives: a co-participatory study on the social construction of children's sense of agency

This study is grounded on the argument that agentic experiences and their reflection in supportive social contexts are crucial protective elements mediating children's socio-emotional well-being. Drawing on the socio-cultural perspective, we investigate the ways in which agency is manifested in children's social interactions while they reflect upon their self-taken photos of positive events in their lives. The empirical data were collected with primary school children via the ‘children as co-researchers’ methodology, and were examined via a micro-level interaction analysis of video-recorded photo-reflection situations. The results illuminate interactions in which the children are constructing, maintaining and contesting the cultural practices of what it means to have agency in their social settings in and outside school. The study contributes towards a more nuanced understanding of the relationship between co-participatory practices upon positive in children's lives and the promotion of children's sense of agency that engenders their socio-emotional well-being.     

Making sense of YouTubers: how Swedish children construct and negotiate the YouTuber Misslisibell as a girl celebrity

When children use the Internet, they commonly choose to watch their favorite YouTubers. In this article, we aim to deepen the understanding of how children make sense of YouTubers as a phenomenon, and the role of microcelebrities in children’s everyday life. The study is based on group interviews with 9- and 12-year-old Swedish children, and pays specific attention to how they make sense of the video “?Pin up tutorial (JFR.SE)?,” produced by the YouTuber Misslisibell. In the analysis, we explore how the children construct and negotiate Misslisibell as celebrity, celebrity endorser, and young girl. Particularly salient were children’s negotiations around the YouTuber’s celebrity status, children’s normative discussions around Misslisibell’s YouTube practices related to her young age, and children’s various interpretations of the video as advertising, “tips,” and as a space for learning. These multifaceted and sometimes contradictive ways of making sense show the multiplicity of meanings YouTubers have for children.     

Women,weight, poverty and menopause: understanding health practices in a context of chronic disease prevention

Socioeconomic inequalities in health persist despite major investments in illness prevention campaigns and universal healthcare systems. In this context, the increased risks of chronic diseases of specific sub‐groups of vulnerable populations should be further investigated. The objective of this qualitative study is to examine the interaction between socioeconomic status (SES) and body weight in order to understand underprivileged women's increased vulnerability to chronic diseases after menopause. By drawing specifically on Pierre Bourdieu's sociocultural theory of practice, 20 semi‐structured interviews were conducted from May to December of 2013 to investigate the health practices of clinically overweight, postmenopausal women living an underprivileged life in Canada. Findings emphasise that poor life conditions undermine personal investment in preventive health and weight loss, showing the importance for policy makers to bring stronger consideration on upstream determinants of health.     

What counts and how to count it: Physicians’ constructions of evidence in a disinvestment context

Internationally, there is an increasing focus on quality and sustainability measures oriented to reducing inefficiencies in health provision. The use of assisted reproductive technologies (ART) for older women represents a case study in this area. This paper analyses the constructions of evidence brought to bear by ART physicians in the context of deliberative stakeholder engagements (held 2010) around options for restricting public subsidy of ART in Australia. Physicians participated in two deliberative engagements during which they were presented with results of a systematic review of ART effectiveness, as well as ethical and cost analyses. These sessions were part of a broader research program of engagements held with policymakers, community members and consumers. Physicians deliberated around the data presented with a view to formulating an informed contribution to policy. The ensuing discussions were transcribed and subject to discourse analysis. Physicians questioned the evidence presented on the grounds of ‘currency’, ‘proximity’, ‘selectivity’ and ‘bias’. We outline physicians’ accounts of what should count as evidence informing ART policy, and how this evidence should be counted. These accounts reflect implicit decisions around both the inclusion of evidence (selection) and the status it is accorded (evaluation). Our analysis suggests that participatory policy processes do not represent the simple task of assessing the quality/effectiveness of a given technology against self-evident criteria. Rather, these processes involve the negotiation of different orders of evidence (empirical, contextual and anecdotal), indicating a need for higher-level discussion around ‘what counts and how to count it’ when making disinvestment decisions.     

Reducing symbolic‐violence in the research encounter: collaborating with a survivor of domestic abuse in a qualitative study in UK primary care

This paper explores ideas of symbolic violence inherent in the research encounter (Bourdieu 1999). After defining symbolic violence and how the concept enters into domestic violence and abuse (DVA) research, we discuss the challenges arising from a (DVA) survivor taking on the role of interviewer in a qualitative study nested within a UK primary care based trial: IRIS (Identification and Referral to Improve Safety). KS, a survivor of DVA, conducted interviews with 12 women who had been referred to a domestic violence agency by primary care clinicians taking part in the IRIS trial in two UK cities (Bristol and east London) during 2009. Field notes were kept during all of the research meetings with KS and these were included in analysis. Our analysis maps the research pathway of ‘non‐violent communication’ and discusses the role of social symmetry and proximity in the research encounter. We conclude that while a welcoming disposition, empathy and active listening are all generic skills to qualitative research; if a researcher can enter fieldwork with a claim of social proximity and symmetry, their use of these generic skills is enhanced through a process of shared objectification and empowerment talk. We explore the limitations of social proximity, its relationship to feminist and anthropological theories of ‘insider’ research and its relevance to primary care research.     

早发型重度子痫前期不良结局及其关联因素的回顾性研究

目的探讨早发型重度子痫前期不良结局及其影响因素的关联性。方法回顾性分析2015-2016年吉林大学第一医院收治的早发型重度子痫前期患者699例,分为无不良结局组576例和不良结局组123例;其中母体不良结局47例,胎儿不良结局56例,母体及胎儿同时发生不良结局20例。应用t检验和Logistic回归分析各因素与早发型重度子痫前期不良结局的关联性。结果在所有不良结局中,胎儿宫内窘迫占34.15%。不良结局组中妊娠28周前发生不良结局33例占26.83%,妊娠28~34周90例占73.17%。乳酸脱氢酶和ALT升高是发生不良结局的危险因素,乳酸脱氢酶升高是胎盘早剥发生的危险因素,白蛋白降低和乳酸脱氢酶升高是胎儿窘迫发生的危险因素。结论在早发型重度子痫前期期待治疗的同时重视危险因素的变化、根据化验结果评估患者病情严重程度并适时终止妊娠有助于改善母婴结局。     

The interplay of structure and agency in health promotion: integrating a concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice

The recent debate in public health about the "inequality paradox" mirrors a long-standing dispute between proponents of structuralist approaches and advocates of action theory. Both views are genuine perspectives of health promotion, but so far they have not been adequately linked by health promotion theory. Using Anthony Giddens's concepts of structure and agency seems promising, but his theory has a number of shortcomings that need to be amended if it is to be applied successfully to health promotion. After briefly assessing Giddens's theory of structuration, this paper proposes to add to it both the concept of structural change as proposed by William Sewell and the policy dimension as described by Elinor Ostrom in her distinction between "operational" and "collective choice" level. On this basis, a multi-level model of the interaction of structure and agency in health promotion is proposed. This model is then connected to central claims of the Ottawa Charter, i.e. "build healthy public policy", "create supportive environments", "strengthen community actions", and "develop personal skills". A case study from a local-level health promotion project in Germany is used to illustrate the explanatory power of the model, showing how interaction between structure and agency on the operational and on the collective choice level led to the establishment of women-only hours at the municipal indoor swimming pool as well as to increased physical activity levels and improved general self-efficacy among members of the target group.     

Exploring informed choice in the context of prenatal testing: findings from a qualitative study

Purpose This study explored whether and how a sample of women made informed choices about prenatal testing for foetal anomalies; its aim was to provide insights for future health policy and service provision. Methods We conducted semi‐structured interviews with 38 mothers in Ottawa, Ontario, all of whom had been offered prenatal tests in at least one pregnancy. Using the Multi‐dimensional Measure of Informed Choice as a general guide to analysis, we explored themes relevant to informed choice, including values and knowledge, and interactions with health professionals. Results Many, but not all, participants seemed to have made informed decisions about prenatal testing. Values and knowledge were interrelated and important components of informed choice, but the way they were discussed differed from the way they have been presented in scientific literature. In particular, ‘values’ related to expressions of women’s moral views or ideas about ‘how life should be lived’ and ‘knowledge’ related to the ways in which women prioritized and interpreted factual information, through their own and others’ experiences and in ‘thinking through’ the personal implications of testing. While some women described non‐directive discussions with health professionals, others perceived testing as routine or felt pressured to accept it. Conclusions Our findings suggest a need for maternity care providers to be vigilant in promoting active decision making about prenatal testing, particularly around the consideration of personal implications. Further development of measures of informed choice may be necessary to fully evaluate decision support tools and to determine whether prenatal testing programmes are meeting their objectives.     

Bonding and bridging neighborliness: An individual-level study in the context of health

Although previous research provides a compelling picture of social capital's role in predicting health outcomes, only a modicum of research has tested the more detailed roles of the dimensions of bonding and bridging social capital, with no research focusing exclusively on bonding and bridging neighborliness or ethnicity. To help fill this gap in the literature, the current study measures individual-level bonding and bridging neighborliness for four U.S. ethnic groups—and then, with cross-sectional data from a 2007 national telephone survey of U.S. adults, employs ordinal logistic regression and OLS regression to test the individual-level predictors of self-rated health and stress, when controlling for BMI and demographics. Bonding neighborliness was associated with self-rated health and inversely associated with stress, whereas bridging neighborliness was not significantly linked to either health outcome. When also controlling for neighborhood composition, the bonding neighborliness findings remained generally consistent, while the association between bridging neighborliness and self-rated health gained significance. These results indicate the protective effects that bonding neighborliness can have on health outcomes, as well as the more modest protective effects of bridging neighborliness. These findings have implications for future research and practice, highlighting the potential of health interventions and policies that target the development of bonding social capital.     

Changing organisations: a study of the context and processes of mergers of health care providers in England

This paper presents findings from a study of the context and processes of provider mergers in the NHS in England. Mergers are an example of organisational restructuring, a key lever for change in the UK health care sector and elsewhere, although it is only one strategy for organisational change. The framework for the study is key themes from the organisational change literature: the complexity of the effects of change; the importance of context; and the role of organisational culture. The drivers for health care mergers and the evidence for these are analysed. Using documentary analysis and in-depth qualitative interviews with internal and external stakeholders, the first part of the paper reports on stated and unstated drivers in nine mergers. This provides the context for four in-depth case studies of the process of merger in the second and third years post-merger. Our study shows that the contexts of mergers, including drivers of change, are important. Merger is a process without clear boundaries, and this study shows problems persisting into the third year post-merger. Loss of management control and focus led to delays in service developments. Difficulties in the merger process included perceived differences in organisational culture and perceptions of 'takeover' which limited sharing of 'good practice' across newly merged organisations. Merger policy was based on simplistic assumptions about processes of organisational change that do not take into account the dynamic relationship between the organisation and its context and between the organisation and individuals within it. Understanding the process of merger better should lead to a more cautious approach to the likely gains, provide understanding of the problems that are likely in the period of change, and anticipate and avoid harmful consequences.