From Health Behaviours to Health Practices: Critical Perspectives — A Special Issue of Sociology of Health & Illness

The journal Sociology of Health & Illness has just published a special issue, entitled “From Health Behaviours to Health Practices: Critical Perspectives.” The articles and their abstracts are listed below:

From health behaviours to health practices: An introduction
Simon Cohn

The concept of health behaviour has become ubiquitous in health-related research and intervention studies, as well as among policymakers. Developed from psychology, it is based on a number of key underlying assumptions that enable it to be integrated in an existing health research paradigm. However, by conceiving individual health behaviour as discrete, stable, homogeneous and measurable, many other aspects of health-related activities, in particular those relating to power and sociality, are excluded. As a consequence, any genuine contribution from medical sociology or related disciplines is, at best, limited. To counter this, it is proposed that reconceptualising what people do in terms of health practices, rather than health behaviour, captures the emergent and contingent properties of people’s activities in particular situations. Rather than serving as a direct replacement term, and thus reproducing the same epistemological assumptions, it is argued that its very flexibility and capacity to articulate different theoretical orientations is likely to be its major strength.

Actors, patients and agency: A recent history
David Armstrong

This article examines the history of patients’ behaviour since the middle of the 20th century. It describes a number of strategies that have served to encourage patients to exercise increasingly autonomous behaviour. The effect has been to instil a sense of agency in previously passive patients.

A socially situated approach to inform ways to improve health and wellbeing
Christine Horrocks and Sally Johnson

Mainstream health psychology supports neoliberal notions of health promotion in which self-management is central. The emphasis is on models that explain behaviour as individually driven and cognitively motivated, with health beliefs framed as the favoured mechanisms to target in order to bring about change to improve health. Utilising understandings exemplified in critical health psychology, we take a more socially situated approach, focusing on practicing health, the rhetoric of modernisation in UK health care and moves toward democratisation. While recognising that within these new ways of working there are opportunities for empowerment and user-led health care, there are other implications. How these changes link to simplistic cognitive behavioural ideologies of health promotion and rational decision-making is explored. Utilising two different empirical studies, this article highlights how self-management and expected compliance with governmental authority in relation to health practices position not only communities that experience multiple disadvantage but also more seemingly privileged social actors. The article presents a challenge to self-management and informed choice, in which the importance of navigational networks is evident. Because health care can become remote and inaccessible to certain sections of the community, yet pervasive and deterministic for others, we need multiple levels of analysis and different forms of action.

A relational approach to health practices: Towards transcending the agency-structure divide
Gerry Veenstra and Patrick John Burnett

Many health scholars find that Pierre Bourdieu’s theory of practice leaves too little room for individual agency. We contend that, by virtue of its relational, field-theoretic underpinnings, the idea of leaving room for agency in Bourdieu’s theory of practice is misguided. With agency manifested in interactions and social structures consisting of relations built upon relations, the stark distinction between agency and structure inherent to substantialist thinking is undermined, even dissolved, in a relational field-theoretic context. We also contend that, when treated as relationally bound phenomena, Bourdieu’s notions of habitus, doxa, capital and field illuminate creative, adaptive and future-looking practices. We conclude by discussing difficulties inherent to implementing a relational theory of practice in health promotion and public health.

Environmental justice and health practices: Understanding how health inequities arise at the local level
Katherine L. Frohlich and Thomas Abel

While empirical evidence continues to show that people living in low socio-economic status neighbourhoods are less likely to engage in health-enhancing behaviour, our understanding of why this is so remains less than clear. We suggest that two changes could take place to move from description to understanding in this field; (i) a move away from the established concept of individual health behaviour to a contextualised understanding of health practices; and (ii) a switch from focusing on health inequalities in outcomes to health inequities in conditions. We apply Pierre Bourdieu’s theory on capital interaction but find it insufficient with regard to the role of agency for structural change. We therefore introduce Amartya Sen’s capability approach as a useful link between capital interaction theory and action to reduce social inequities in health-related practices. Sen’s capability theory also elucidates the importance of discussing unequal chances in terms of inequity, rather than inequality, in order to underscore the moral nature of inequalities. We draw on the discussion in social geography on environmental injustice, which also underscores the moral nature of the spatial distribution of opportunities. The article ends by applying this approach to the ‘Interdisciplinary study of inequalities in smoking’ framework.

Why behavioural health promotion endures despite its failure to reduce health inequities
Fran Baum and Matthew Fisher 

Increasing rates of chronic conditions have resulted in governments targeting health behaviour such as smoking, eating high-fat diets, or physical inactivity known to increase risk for these conditions. In the process, many have become preoccupied with disease prevention policies focused excessively and narrowly on behavioural health-promotion strategies. These aim to improve health status by persuading individuals to change their health behaviour. At the same time, health promotion policy often fails to incorporate an understanding of the social determinants of health, which recognises that health behaviour itself is greatly influenced by peoples’ environmental, socioeconomic and cultural settings, and that chronic diseases and health behaviour such as smoking are more prevalent among the socially or economically disadvantaged. We identify several reasons why behavioural forms of health promotion are inadequate for addressing social inequities in health and point to a dilemma that, despite these inadequacies and increasing evidence of the social determinants of health, behavioural approaches and policies have strong appeal to governments. In conclusion, the article promotes strategies addressing social determinants that are likely to reduce health inequities. The article also concludes that evidence alone will not result in health policies aimed at equity and that political values and will, and the pressure of civil society are also crucial.

Behaviour change and social blinkers? The role of sociology in trials of self-management behaviour in chronic conditions
Bie Nio Ong, Anne Rogers, Anne Kennedy, Peter Bower, Tom Sanders, Andrew Morden, Sudeh Cheraghi-Sohi, Jane C. Richardson, and Fiona Stevenson 

Individual-focused self-management interventions are one response to both an ageing society and the purported increase in chronic conditions. They tend to draw on psychological theories in self-management interventions, but over-reliance on these theories can reinforce a narrow focus on specified attitudinal and behavioural processes, omitting aspects of living with a chronic condition. While advances have been made in health behaviour change theory and practice, scant attention has been paid to the social, with the question of social context remaining under-theorised and under-explored empirically. This is particularly noticeable in trials of behaviour change interventions for self-management. The common sociological critique is that these ignore context and thus no explanation can be given as to why, for whom and under what circumstances a treatment works. Conversely, sociologists are criticised for offering no positive suggestions as to how context can be taken into account and for over-emphasising context with the risk of inhibiting innovation. This article provides an overview of these issues and provides examples of how context can be incorporated into the rigid method of trials of self-management for chronic conditions. We discuss modifications to both trial interventions and design that make constructive use of the concept of context.

Thinking about changing mobility practices: How a social practice approach can help
Sarah Nettleton and Judith Green

Policy efforts directed at encouraging physical activity have had minimal success to date. Drawing on Bourdieu’s theory of practice, we suggest that a social practice framing might provide useful ways of thinking about why and how some practices do and could change. This article takes three case studies of transformations in mobility practices to explore conditions of possibility for change, using a secondary analysis of qualitative data from studies on cycling in London and fell running in the English Lake District. Three modes of transformation: unthinkable, thwarted and resisted, are rooted in differential interrelationships of field, habitus and doxa in these contrasting cases. We suggest that the notion of tacit, practical knowledge is more useful to understanding why change is thinkable or unthinkable than participants’ reasoned accounts of their practice; that where new social fields are available that are congruent with habitus, change is possible and that where field and habitus are tightly aligned, the conditions of possibility for change are reduced. Efforts directed at changing practice might usefully focus not on behaviour or environments but on identifying the social fields in which mobility practices are likely to be malleable. The sociology of public health needs to focus less on health behaviour and more on social practice.

Providers’ constructions of pregnant and early parenting women who use substances
Cecilia Benoit, Camille Stengel, Lenora Marcellus, Helga Hallgrimsdottir, John Anderson, Karen MacKinnon, Rachel Phillips, Pilar Zazueta, and Sinead Charbonneau 

The research literature indicates that problematic substance use as a form of health behaviour is poorly understood, being sometimes viewed as deviance, at other times as a disease, and most often as a combination of these states. The use of substances by women who are pregnant or new parents is often conceptualised within an individualised framework. Yet drinking alcohol and using other drugs during pregnancy and early parenthood cuts across social divisions and is shaped by socio-structural contexts including health care. There is a growing body of literature that critically examines public health interventions that are aimed at implementing harm reduction and health promotion techniques in service delivery to help pregnant and early parenting women who are identified as problem substance users. We examine qualitative data from representatives of a recent harm reduction intervention, focusing, in particular, on providers’ individual conceptualisations of the problematic behaviour. Our results show that most study participants regard any substance use during pregnancy, birth and the postpartum period as fundamentally unacceptable. This framing of problematic substance use is accomplished via gendered responsibilisation of women as foetal incubators and primary caregivers of infants. We discuss our results in light of the current literature and suggest policy implications.

Staying ‘in the zone’ but not passing the ‘point of no return’: Embodiment, gender and drinking in mid-life
Antonia C. Lyons, Carol Emslie, and Kate Hunt 

Public health approaches have frequently conceptualised alcohol consumption as an individual behaviour resulting from rational choice. We argue that drinking alcohol needs to be understood as an embodied social practice embedded in gendered social relationships and environments. We draw on data from 14 focus groups with pre-existing groups of friends and work colleagues in which men and women in mid-life discussed their drinking behaviour. Analysis demonstrated that drinking alcohol marked a transitory time and space that altered both women’s and men’s subjective embodied experience of everyday gendered roles and responsibilities. The participants positioned themselves as experienced drinkers who, through accumulated knowledge of their own physical bodies, could achieve enjoyable bodily sensations by reaching a desired level of intoxication (being in the zone). These mid-life adults, particularly women, discussed knowing when they were approaching their limit and needed to stop drinking. Experiential and gendered embodied knowledge was more important in regulating consumption than health promotion advice. These findings foreground the relational and gendered nature of drinking and reinforce the need to critically interrogate the concept of alcohol consumption as a simple health behaviour. Broader theorising around notions of gendered embodiment may be helpful for more sophisticated conceptualisations of health practices.

Complexities and contingencies conceptualised: Towards a model of reproductive navigation
Erica van der Sijpt

Current international attention to reproductive health behaviour is inspired by a western celebration of individual rights, autonomous action and rational choice. A predominant idea is that individuals should be free to act in accordance with their reproductive intentions and that, in doing so, they will attain their desired (and quantifiable) fertility outcomes. Yet such a framework leads to a misrepresentation of the reproductive dynamics on the ground, because individual fertility intentions are often not a priori defined, decisions are often not the result of rational calculation and reproductive happenings do not exist in a social vacuum. This article provides sociocultural evidence for a different conceptualisation of reproductive health behaviour. On the basis of long-term anthropological fieldwork in the East Province of Cameroon, I will analyse the complexities of fertility-related decision-making. Two case studies from the field will show that reproductive happenings are often characterised by indeterminacy and contingency. In order to understand the complex ways in which women give direction to these uncertainties, I propose an encompassing framework of reproductive navigation that explicitly acknowledges the influence of sociality and corporeality on fertility aspirations and actions.

Sustained multiplicity in everyday cholesterol reduction: Repertoires and practices in talk about ‘healthy living’
Catherine M. Will and Kate Weiner

This article is concerned with talk about and the practices of healthy living in relation to cholesterol reduction. It draws on qualitative interviews with 89 people who are current or former users of either cholesterol-lowering functional foods or statins for cardiovascular risk reduction. Focusing on data about everyday activities including food preparation, shopping and exercise, we illustrate four repertoires that feature in talk about cholesterol reduction (health, pleasure, sociality and pragmatism). Using Gilbert and Mulkay’s notion of a ‘reconciliation device’, we suggest ways in which apparently contradictory repertoires are combined (for example, through talk about moderation) or kept apart. We suggest that, in contrast to the interactiveness of the repertoires of health and pleasure, a pragmatic repertoire concerning food provisioning, storage and cooking as well as the realities of exercise, appears distinct from talk about health and is relatively inert. Finally we consider the implications of these discursive patterns for daily practices. Our data suggest there is little emphasis on coherence in people’s practices and illustrate the significance of temporal, spatial and social distribution in allowing people to pursue different priorities in their everyday lives. Rather than the calculated trade-offs of earlier medical sociology we draw on Mol to foreground the possibility of sustained multiplicity in daily practices.

Enjoy your food: On losing weight and taking pleasure
Else Vogel and Annemarie Mol 

Does healthy eating require people to control themselves and abstain from pleasure? This idea is dominant, but in our studies of dieting in The Netherlands we encountered professionals who work in other ways. They encourage their clients to enjoy their food, as only such joy provides satisfaction and the sense that one has eaten enough. Enjoying one’s food is not easy. It depends on being sensitive. This does not come naturally but needs training. And while one kind of hunger may be difficult to distinguish from another, feeling pleasure may open the doors to feeling pain. What is more, sensitivity is not enough: enjoying one’s food also depends on the food being enjoyable. A lot of care is required for that. But while engaging in such care is hard work, along the way clients are encouraged to no longer ask ‘Am I being good?’ but to wonder instead ‘Is this good for me?’ Both these questions are normative and focus on the person rather than on her socio-material context. However, in the situations related here the difference is worth making. For it entails a shift from externally controlling your behaviour to self-caringly enjoying your food.