Bring in the social context: Towards an integrated

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Scandinavian Journal of Public Health, 2011; 39(Suppl 6): 19–25
ORIGINAL ARTICLE
Bring in the social context: Towards an integrated approach to
health promotion and prevention
THOROLFUR THORLINDSSON
Faculty of Social Science, University of Iceland, Iceland
Abstract
Aims: In this paper I take up the quest for an integrated approach to health promotion and prevention that incorporates the
social context. I suggest that an integrated theory of public health has to rethink the individual society relationships and move
beyond the dominance of socialization theory and individual level analysis. Methods: A theoretical analysis of key issues in an
integrated theory of public health. Results: I maintain that we must shift the attention away from the individual to the social
organization and the embeddedness of the social actor in the ongoing social networks and relationships; we must pay
attention to the definition of levels of analysis and the relationships between them; we must emphasize the social mechanisms
that influence people in social relationships and networks and connect various levels; we must reconsider some of the
epistemological and methodological ideas that have been taken for granted and pay attention to issues of emergence and
reductionism and the use of multiple methods. Conclusions: I conclude by suggesting that if public health is to move
forward and develop better theories, and more efficient ways of prevention and health promotion, it needs to
move beyond reductionist models of social behaviour and develop a transdisciplinary approach that integrates
various elements from different disciplines and different levels of analysis.
Key Words: Health promotion, integrated theory, science-practice, social context
Introduction
The quest to include the social context in health
promotion was publicly voiced more than 40 years
ago by Rogers [1], who asked ‘‘can the health
sciences resolve societies’ problems in the absence
of a science of human values and goals’’. It is,
however, only in the last decade or so that this
quest has gained some real momentum. Thus, several
public health scholars have recently suggested that
public health needs to develop an integrated
approach to community oriented health promotion
and prevention that includes the macro-social level
[2,3]. These scholars take different points of departure, but they all note that targeting the behaviour of
individuals without attending to the social levels that
influence health outcomes is not the most effective
approach to prevention and health promotion.
Theoretical and methodological advances, as well
as practical prevention and health promotion work,
have helped to document the importance of the social
context. The emergence of communities as crucial
social units in health promotion and preventive work
has highlighted the need to go beyond the individual
level and bring the macro-social organization of the
community level into play. This approach relies
heavily on the macro-social organization of the
community that provides key elements for building
coalitions for running successful programmes and
interventions. The better that our knowledge of these
structural characteristics is, the more effective we are
in promoting health and wellbeing and coping with
problems of external validity.
Multilevel analysis of public health issues has also
shown that there are contextual influences on health
outcomes that cannot be reduced to the individual
level [4]. This has increased interest in understanding
how the social organization of neighbourhoods and
communities helps or hinders the development of
healthier communities.
Correspondence: Thorolfur Thorlindsson, Department of Sociology, University of Iceland, Oddi, Sturlugata, 101 Reykjavik, Iceland. E-mail: [email protected]
(Accepted 24 November 2010)
ß 2011 the Nordic Societies of Public Health
DOI: 10.1177/1403494810394549
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20
T. Thorlindsson
The demand for evidence-based practice brings
increased attention to the macro-social level because
it plays a key role in bridging the science practice gap
[3,5,6]. Our success in generalizing research findings
reported in scientific journals to particular social
settings, groups or populations depends on our
knowledge of the wider social context. This is especially relevant in health promotion and prevention,
where we are carrying out social or behavioural
interventions that may be affected by socioeconomic
conditions, cultural values, the structure of social
relationships and other aspects of real world settings.
How well we succeed in taking the social context of
application into account determines the external
validity of our findings. The evidence that has been
given the greatest credence in academia comes from
the randomized controlled trials’ approach that is
effective in eliminating bias and therefore has high
internal validity. This approach lacks external validity, however [7,8]. Increasing the external validity of
our findings is necessary to bridge the gap between
science and practice.
In light of the rising interest in the social context, it
is somewhat surprising that research on communities
has for decades tended to neglect social organization
[2,9,10]. While there are notable exceptions to this
trend [11–13], public health scholars and mainstream academic researchers have been surprisingly
reluctant to shift their focus from the individual level
to include the social level of analysis [2,3]. As Green
[2] has pointed out the emphasis on the individual as
opposed to the social context, with few notable
exceptions, has continued to dominate the contribution of the social sciences to public health up until
now. Green challenges sociology to contribute to a
system science approach to public health problems.
In this paper I take up the quest for an integrated
theory that incorporates the social structure of community [2,3,5,11]. I focus on the intersection
between public health and sociology, maintaining
that an integrated approach will have to take the
social context into account and pay attention to
collective social forces that cannot be reduced to the
individual level. I suggest a conceptual framework
that includes both macro- and micro- social levels as
well as the individual level. I also argue that an
integrated theory of public health has to rethink the
individual society relationships and go beyond
approaches that limit the social influence to processes
of socialization and/or the rational exchanges on
competitive markets. Both these approaches rule out
the idea that embeddedness in ongoing social relationships shapes behaviour and influences health
outcomes. We must also focus on the social mechanism that operated in ongoing social relationships
and mediate the influences between the social context and the individual level.
The academic roots of the individual bias
The notion that individual characteristics determine
behaviour is deeply rooted in academic social science.
Several prominent social science disciplines operate
with an atomized conception of human society,
portraying it as a collection of independent individuals. This view of the social actor is enforced by
common sense interpretations of behaviour; highlighted by political ideology; and reinforced by
methodological and epistemological assumptions.
The leading traditions of the 18th and 19th centuries
held that individual cognition and experience was the
key to knowledge. Thus, Kant saw knowledge as the
rational construction of the mind, and morality and
ethics as an individual phenomenon. The empiricist
tradition focused on individual experience of the
objective empirical reality, emphasizing the object in
its concreteness.
Knowledge was rooted in individual experience,
individual perception or individual cognition. Some
critical but often subtle assumptions of the dominating social science paradigms, which provide strong
resistance to the notion of social structure, are
inherited from the great philosophers of this period.
They have proved to be resistant to change, dominating social science view of the social actor up to
this day.
The novel concept of social structure was foreign
to these philosophical and epistemological traditions,
when Durkheim [14] introduced it as the defining
characteristic of the new discipline of sociology.
Knowledge without a subject, which was what
Durkheim was proposing, fell outside the dominant
academic paradigm. The idea that knowledge is in
part socially and historically situated, rebelled against
epistemological traditions that guided the scientific
world-view at the time. The notion of an objective
structure of social relations, obligations, and duties,
which could not be reduced to individual actions,
seemed absurd.
Some of the leading sociologists following up on
Durkheim’s work interpreted his theory in an individualistic light. Parsons’ [15] voluntaristic interpretation of Durkheim’s work combined with the
individualistic trend of American social science
influenced generations of social scientists to limit
social influences on behaviour to the internalization
of norms and values by individuals. These theories,
which limited social influence on behaviour to a
process of socialization, undermined the notion of
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Towards an integrated approach to health promotion and prevention
social organization and promoted theories of behaviour at the individual level. Thus, sociology joined
psychology and economics in promoting the individual level bias of the classics.
Reductionism and the individual level bias in
social science and public health
The main point of my argument is that all theories
that limit social influences to socialization promote
reductionism, which leads to individual level bias in
the analysis of social and public health issues. This
individual level bias has been exported from social
science to public health. It has lead to serious
shortcomings in prevention and health promotion
research and practice. Let us consider briefly the
contribution of three social science disciplines to
public health in this respect.
The individual model of human behaviour in
public health draws heavily from psychology, which
according to Green [2] may have resulted in experimental reductionist methodologies and the individual level analysis.
Another academic discipline that has promoted
individual level analysis is economics. Both classical
and neoclassical economics assume that human
behaviour is shaped by utilitarian motives of selfinterested rationally calculating individuals, attempting to maximize their gain. This concept of the
market driven actor has ruled out social relations
limiting social action to the individual level, resulting
in a society of atomized individuals and an economic
system driven by a self-regulating market. Some
scholars assume that part of the self-regulation
comes from well socialized individuals, whereas
other argue that classical and neo-classical economics
operate with an ‘‘undersocialized’’ conception of the
social actor [16]. While it may be debated to what
extent economics and the utilitarians assume socialized actors, it is clear, that according to them,
behaviour is not affected by the actors’ embeddedness in ongoing social relationships. Norms and
values only influence individual behaviour to the
extent that they are internalized through processes of
socialization. This celebration of classical and neoclassical economics of the utilitarian tradition has
penetrated all segments of society including public
health.
The third discipline, sociology, is the only discipline that systematically examines the social organizational factors that shape the behaviour of groups. It
is therefore the most obvious place to start to look for
a contribution that helps to bring social organization
to public health [1,2]. But as Green [2] has observed,
21
the contribution of sociology to promote macrosocial organization perspectives in public health is
disappointing. He points out that academic disputes
within the discipline of sociology, where prominent
sociologists have promoted individual level analysis,
may have delayed this process. As we have pointed
out above, one reason for this individual level bias is
that sociologists have relied on a theory of socialization to explain social influences on individual behaviour. Parsons’ [15] influential theory of voluntaristic
behaviour is a good example of this. Methodological
individualism that has characterized too much of
sociological analysis is another example.
Several scholars have argued that there has been a
strong tendency among sociologists to assume that
social actors are almost perfectly socialized, leaving
little room for individual variables to influence
behaviour [16,17]. Wrong [17] referred to this
tendency as the ‘‘oversocialized’’ conception of the
social actor. The social actor is seen as a conformist
who has internalized norms and values to perfection.
Wrong warned against this conception, pointing out
how it distorted reality, which is almost always
characterized by conflicts and disagreements.
Granovetter [16] points out that the concept of the
‘‘oversocialized’’ actor, who has successfully internalized values and norms, fails to take into account
the social involvement of the actor in social networks
and relationships. Once the individual has been so
well socialized that all the social influences are
contained inside his or her head or body, the ongoing
social relations become irrelevant. Social actors
simply follow the script written for them by the
social environment or the social categories that they
happen to occupy.
I am not arguing that socialization is of little
importance. To the contrary I assume that socialization is of central importance in shaping the individual
and mediating social influences. But there are other
social processes that are vital in influencing human
behaviour and thus determining health outcomes.
Social determinants need not be contained in the
head and the body of individuals to be significant.
They can be contained in the social organization of
the group or the social context.
The balance between the social organizational
influences on the group level and the socialization
influences that result in individual behaviour is in
reality often hard to separate because the influences
overlap. Also, the balance of influences will vary
empirically between groups, historical periods, and
over the lifespan. The main thing is, however, that we
specify how social mechanisms – other than socialization – work to influence behaviour and attitudes in
ongoing social relationships.
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22
T. Thorlindsson
Social organization and the embeddedness of
the social actor in social relationships
Social action always occurs in a social context that
exists in part outside the individual. What is missing
in theories, which rely on socialization alone to
explain human behaviour, wherever they fall on the
spectrum between the ‘‘oversocialized’’ and ‘‘undersocialized’’ conception of the social actor, is that all
attempts at purposive action are embedded in a
concrete ongoing system of social relations. Actors do
not behave like isolated individuals outside the social
context, nor do they follow a pre-written social script
determined by their membership in a particular
group or social category. Social relationships and
networks constrain and control behaviour; they
channel opportunities and diffuse information and
knowledge. They can foster shared world-views and
attitudes, can create solidarity or can cause stress and
conflict. They can influence our beliefs, reinforce
some norms and values, and undermine others. The
patterns of social interaction are anchored in core
social processes that bind individuals to social
groups. These core processes include attachment,
bonding, trust and norms of reciprocity, and the
closure of social structures [11,18,19]. The stronger
these core processes are, the stronger the roots of
norms and values in the local community. The denser
the social relationships and networks, the more
powerful they are. This social organization of community has received considerable attention in public
health research that indicates that community characteristics can have a powerful influence on individual welfare and health [4,11,19,20].
The interplay of networks, norms and values forms
the micro-social dimensions of social organization
that crystallizes in neighbourhoods and communities. It is important to distinguish it from the macrosocial level. Macro-level structure of social organization can be described in terms of economic and
demographic characteristics such as poverty, income
equality, house ownership, residential mobility, proportion of single family households, ethnic composition and formal institutional structure. These are
relatively enduring characteristics that are relatively
resistant to change, in part because they are rooted in
the larger structures of society. Research indicates
that these social structural characteristics influence
various important health outcomes [4,14,19,21].
We therefore need to distinguish between three
levels: the macro- and micro-scial levels of social
organization as well as the individual level [22,23],
not two levels as has been the dominating practice in
public health. Understanding the cross-level influences between the three levels is a real challenge for
public health because of the complexity involved. It
includes specifying both top-down effects from the
macro-social level to the individual level and bottomup effects from the individual level to the two social
levels. The social mechanisms that influence people
in ongoing relationships are central for understanding of cross-level interaction because they provide the
bridge between social levels. They work on the group
level through social control, imitation, social diffusion, social pressure, social support, or even collective emotions and mood that spread through social
networks. Although these social processes are a
collective asset of groups, they can also function as
individual level resources as well. Access to resources
(social capital) that reside in social networks can
provide leverage, social support, and help individuals
to obtain desirable goals [19]. Individual outcomes
will vary according to their involvement and their
social location in social networks. Because individual
participation in social networks varies, particular
individuals may not benefit from social capital
(resources that are inherent in networks) even
though they live in a community that is high in
social capital. In the same vein, some individuals who
live in a community that is poor in social capital may
benefit from their involvement in networks that
produce social capital. Adolescents who do not
participate in sport or youth clubs will not benefit
individually from what these have to offer. They may,
however, benefit on the group level because of their
association with peers who participate in sport. In the
same way particular individuals may, for example,
become isolated in a relatively well-integrated community and individuals who live in a poorly integrated community may be involved in close-knit
social networks that help to integrate them into that
community.
Macro-social variables do not directly influence
individual health outcomes. Their influences are
mediated through micro-social processes, characterized by social networks in which the individual is
embedded. Thorlindsson’s and Bernburg’s [4] multilevel analysis of Icelandic adolescents provides an
example of this. They found that residential mobility
had a contextual influence on both adolescent suicide
attempts and adolescent suicidal ideation. These
contextual influences were to a large extent mediated
through two social mechanisms, normlessness and
imitation. Residential mobility influenced adolescent
suicide, because it disrupted social ties that attach
adolescents to conventional norms. It also influenced
adolescent suicide attempts and ideation, because it
increased contact with suicidal others, facilitating
imitation–suggestion.
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Towards an integrated approach to health promotion and prevention
It is important to recognize that the same social
mechanisms that mediate the relationship between
the macro-social and the individual levels also
account for the emergence to the social level.
Because there are many micro-social variables that
can interact in complex ways to influence these
mechanisms the outcomes on the individual level
may vary considerably. How they play out on the
individual level will depend on how the macro-social
characteristics are mediated through micro-social
mechanisms. This means that the relationship
between all the three levels of analysis is not a logical
deterministic one. The micro-social level will in
principle operate in some degree ‘‘independently’’
from the macro level. To what degree this happens
needs to be empirically determined each time.
This may explain why aggregate or contextual findings may appear inconsistent with individual level
results [24].
Looking beyond socialization theory to include
the social mechanisms that work through the
embeddedness of social actors in ongoing social
relationships calls for a radical change of thinking
about health promotion and prevention. It calls
for a shift from individual analysis to a
multilevel approach that includes several levels
simultaneously.
The quest for an integrated paradigm in
publich health work
Integration is an inherent aspect of a holistic
approach to health promotion and prevention. The
concept of integration has several recurrent themes
and different meanings in public health. It can refer
to an integration of science and practice or an
integration of several sectors or institutions that
deal with health. One important type of integration
in public health is the integration across disciplines
and levels of analysis. The need for this type of
integration is highlighted by an increased knowledge
indicating that risk factors belonging to different
disciplines tend to cluster together. It is a logical
response to the fact that important chronic health
conditions and health problems are rooted in
the larger social, cultural, political and economic
fabric [25].
The interdisciplinary nature of public health makes
it possible to consider several levels of analysis
simultaneously and develop multiple interventions
for prevention and health promotion. To accomplish
this, public health has to move beyond a fragmented
approach, where different strands of science are
merely juxtaposed towards a more transdisciplinary
23
integrated approach that integrates various levels of
analysis. Thus, public health has to overcome the
fragmented view of human beings created by highly
specialized scientific disciplines to build a more
unified and holistic view of the individual in society
and nature.
Sociology will never provide public health with this
kind of an integrated paradigm. Neither will psychology or economics nor any other social science
discipline. Such a paradigm can only come from
public health itself. Sociology can, however, contribute some important elements. It can bring in the
social context and the notion of social organization. It
can also help to specify the social mechanisms that
mediate the influences of the social context to
individual behaviour and account for the emergence
of the social context. Bringing the social context into
an integrated approach will help bridge the gap
between science and practice in evidence-based
health promotion and prevention, especially within
communities. It can help to strengthen the external
validity of programme evaluation. It can also help to
develop multiple interventions at multiple levels of
the social ecology [25]. Thus, sociology can respond
to the challenge proposed by public health more than
40 years ago [1].
Bringing in the social context, emphasizing the
embeddedness of social actors in ongoing social
relationships and highlighting the social mechanisms
that connect levels, contributes to a system approach
to health promotion and prevention.
Green [5] has argued for such an approach to
the complex problems that both scientists and
practitioners are facing in the real world. He sees
it as necessary for a more successful approach to
public health. Adapting a system approach
to public health, according to Green, may help us
to cope with the paradoxical challenge of evidencebased practice. Similarly, Wandersman [3] points
out that we need to integrate prevention science
with community centred models to bridge the gap
between science and practice He proposes an
integrated interdisciplinary approach that he calls
community science. Berkman et al.’s [11] community centred integration of several theories of social
influence of health points in the same direction.
They have developed a conceptual framework that
builds on Durkheim’s theory of integration,
Bowlby’s attachment theory and network theory.
They propose a cascading causal process beginning
with the macro-social level to psychological processes, which form integrative networks that influence health.
These public health scholars see the need to bridge
the research–practice gap as a central task. They all
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24
T. Thorlindsson
emphasize the community level as key to a social
setting for prevention and health promotion.
More importantly they see the need for public
health to move beyond the interdisciplinary approach
and develop a transdisciplinary approach that
integrates various strands of theory to promote
better health.
Conclusion
Breaking the dominance of socialization theory and
individual level analysis in public health calls for a
new way of thinking about health-related behaviour.
First, we must shift the attention from the individual
to social organization and the embeddedness of the
social actor in the ongoing social networks and
relationships. Second, we must pay attention to the
definition of levels of analysis and the relationships
between them. Third, we must emphasize the social
mechanisms that influence people in social relationships and networks and connect various levels.
Finally, we must reconsider some taken-for-granted
epistemological and methodological ideas and pay
attention to issues of emergence and reductionism.
While more work is needed on all these four issues,
the last one needs special attention. We need to
employ multiple methods and more mixed research
designs that help us to look at ongoing social
processes as well as demographic and epidemiological data. The time has also come to reconsider some
of the taken-for-granted epistemological conceptions
that we inherited from the 18th and 19th centuries
and move on to a more complex systems approach to
public health problems. If public health theory is to
move forward and develop more elegant academic
theories, and more efficient ways for prevention and
health promotion, it needs to move beyond reductionist models of social behaviour. The diversity of
theories and paradigms offers great opportunities for
public health workers. In fact, public health may find
itself in a period of a fruitful scientific revision
because it is situated in the middle of a paradigm
change in modern science that is characterized by the
emergence of scientific fields through extensive interdisciplinary work.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-forprofit sectors.
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