Elsevier

Social Science & Medicine

Volume 73, Issue 7, October 2011, Pages 953-959
Social Science & Medicine

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

https://doi.org/10.1016/j.socscimed.2011.07.010Get rights and content

Abstract

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.

Highlights

► Builds a multi-level model of structure and agency from approaches by Giddens, Sewell and Ostrom. ► Applies this model to health promotion and to central claims of the Ottawa Charter. ► Uses a local-level health promotion project to illustrate the explanatory power of the model. ► Interaction of structure and agency on multiple levels helped establish women-only hours at a municipal swimming pool.

Introduction

In the social sciences, there has been a long-standing dispute between proponents of structuralist approaches and advocates of action theory. In public health, this controversy has recently resurfaced in the discourse concerning the “inequality paradox” presumably created by certain kinds of health promotion interventions (Allebeck, 2008, Frohlich and Potvin, 2008, Frohlich and Potvin, 2010, McLaren et al., 2010). The debate also draws attention back to the most famous theoretical endeavor to link the concepts of “structure” and “agency”, Anthony Giddens’s theory of structuration (1984).

Giddens attempts to overcome the fundamental shortcomings of two opposed approaches in social sciences: the structuralist approach, which tends to neglect the efficacy of human action in shaping structures, and the individualistic approach, which is prone to underestimate the efficacy of structures in shaping human action (e.g. Giddens, 1984, 207ff). Instead of taking sides, Giddens defines “structure” as sets of rules and resources that are produced and reproduced by “human agency”, i.e. the capabilities of individuals to act. Thus, both sides are conceptualized as interdependent and mutually reinforcing.

Other social science theories on structure and agency have further elaborated Giddens’s critique of the dualism of structural and individualistic approaches. For example, for Sewell (1992, p. 2), structural approaches are struggling with the fundamental problem of “causal determinism”. Structures appear “to exist apart from, but nevertheless to determine the essential shape” of human action, thus, reducing “actors to cleverly programmed automatons”. In another comprehensive theoretical contribution to the structure--agency debate, Archer (1995, p. 6ff) suggests to recognize the importance of “the interplay” of structure and agency in order to overcome one-dimensional theorizing, be it either a reduction to structural conditioning of human action or to the elaboration of structures by human actors. At the same time, Sewell (1992) and Archer (1995) also criticized certain elements of Giddens’s structuration theory and provided promising approaches to reformulating the interplay of structure and agency, particularly with respect to the integration of a concept of structural change.

As a matter of fact, both structural and agentic approaches are genuine perspectives of health promotion. On the one hand, the very concept of health promotion is originally based on a fundamental critique of approaches focusing on individual lifestyles and health education. Instead, health promotion approaches emphasize the importance of the “structure” of lifestyle, i.e. the social conditions for individuals’ daily life conduct (Anderson, 1984, Kickbusch, 1986, Rütten, 1995, Wenzel, 1983, pp. 1–18; also see the recent discussion on the social determinants of health, e.g. in WHO, 2008).

On the other hand, the Ottawa Charter (WHO, 1986) defines the five key domains of health promotion in a way that clearly refers to agency (building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and re-orientating health care services). Agency in health promotion occurs on two levels: First, by definition, any health promotion action contains agency. Second, agency is an important outcome of health promotion action, e.g. when interventions aim at improving the (agentic) capabilities of individuals (e.g. personal skills that “increase the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health”, WHO, 1986) or of communities (community actions as “empowerment of communities – their ownership and control of their own endeavours and destinies”, WHO, 1986).

It has been convincingly argued (McQueen, 2007, McQueen, 1996, Potvin et al., 2005) that health promotion practice needs well-founded theories. But while structure and agency are fundamental perspectives of health promotion practice, there is a lack of adequate health promotion theory. To be sure, there exists a number of approaches that might help us link certain aspects of structure and agency in health promotion theory. Socioecological models, as developed e.g. by Stokols (1992) and Green, Richard, & Potvin (1996), theorize about the influence of both individual behavior and the environment on people’s health, and several frameworks, such as Intervention Mapping (Bartholomew, Parcel, Kok, & Gottlieb, 2006) and PRECEDE-PROCEED (Green & Kreuter, 1991) have applied this concept to health promotion planning. Some particularly promising approaches that we might build upon stem from the early discourse on the structure of lifestyle (Abel, 1991, Cockerham et al., 1997, Rütten, 1995) and the more recent debate on collective lifestyles (Frohlich and Potvin, 2008, Frohlich et al., 2001). This literature has identified some shortcomings of Giddens’s theory. In particular, the concepts of habitus (Bourdieu, 1977) and capabilities (Sen, 1985) have been added to the structure--agency approach to overcome its limitations (Abel, 2008, Abel, 2007, Williams, 2003, Williams, 1995).

However, there are still two major shortcomings in Giddens’s approach that have not been adequately dealt with in health promotion theory building to date: First, Giddens’s main focus is rather static, basically ignoring the idea that structures can be altered in any way. It is quite clear that any theory of health promotion that does not include a concept of change is rather limited in its explanatory power. Second, Giddens does not adequately consider the various levels at which social interaction takes place. In particular, this pertains to the policy-making level, which has been a key arena of health promotion efforts ever since the Ottawa Charter. Consequently, it will be necessary to make some additional modifications to Giddens’s original concept.

In this article, we will proceed as follows: First, we will briefly summarize the basic tenets of Giddens’s theory. Second, we will introduce Sewell’s (1992) modification of the approach, which presents five “axioms” for structural change. Third, we add Ostrom’s (Kiser and Ostrom, 1982, Ostrom, 2007) distinction between the operational level and the collective-choice level. Fourth, we apply this multi-level model to the field of health promotion and connect it to the basic claims of the Ottawa Charter. Fifth, we use examples from a local health promotion project to illustrate how structure and agency at different levels interact to promote health. In the conclusion, we provide an outlook on how the approaches of Giddens and Ostrom might be combined even more closely to form a “unified” approach of structure and agency on various levels.

Section snippets

Theoretical framework

In order to initiate the development of a comprehensive theory on the interplay of structure and agency in health promotion, we will outline a general theoretical framework in this section. This framework will build on elements of different theories which are relevant for our multi-level model and will explore potential relationships among these elements.

A multi-level model of the interplay of structure and agency in health promotion

Our model on the interplay of structure and agency in health promotion is shown in Fig. 1. As outlined above, it uses the general framework provided by Giddens, with additions from Sewell and Ostrom. At the core are Giddens’s dual, mutually reinforcing constructs of structure and agency. On the collective choice level, potential examples from health promotion contexts include the “pair” of participation of different stakeholders in policy-making processes and the rules-resources sets in policy

Discussion

Attempting to combine concepts from two of the most high-profile social science theories of the 20th century and applying them to the Ottawa Charter is, as we frankly admit, a bold endeavor. We realize that the proposed approach has a number of limitations and shortcomings. For one, theoretical models should be parsimonious. In particular, when dealing with complex phenomena such as health promotion, a reduction of the potentially relevant elements is necessary. As a consequence, the

Conclusion and outlook

The main goal of this article has been to introduce the policy context to the theoretical discussion on the interplay of structure and agency in health promotion. By adding the collective choice level to the often-discussed operational level of individual health behavior, we hope to spark a discussion on the conceptual usefulness of the interplay of structure and agency specifically for health promotion policy. Moreover, by demonstrating how the two levels are intertwined, the model allows us

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