Is it possible to eliminate health disparities in the United States? Why or why not? What are some of the key strategies advocated by the readings? Do you notice any similar themes in the assigned articles?

SOCIAL DETERMINANTS OF HEALTH INEQUITIES

Integrating Social Theory Into Public Health Practice The innovative practice

that resulted from the Ot- tawa Charter challenges pub- lic health knowledge about programming and evalua- tion. Specifically, there is a need to formulate program theory that embraces social determinants of health and local actors' mobilization for social change. Likewise, it is imperative to develop a the- ory of evaluation that fosters reflexive understanding of public health programs en- gaged in social change.

We believe advances in contemporary social theory that are founded on a cri- tique of modernity and that articulate a coherent theory of practice should be con- sidered when addressing these critical challenges. {Am J Public Health. 2005; 95:591-595. doi:10.2105/ AJPH.2004.048017)

Louise Potvin, PhD, Sylvie Gendron, PhD, Angele Bilodeau, PhD, and Patrick Chabot, PhD

DURING THE LAST DECADE,

there has been an acute need for theoretical innovation in the fields of population and public health. Although the crucial question about the social deter- minants of health have led to sig- nificant theoretical contribu- tions,' the innovative public health practices prompted by the Ottawa Charter for Health Pro- motion are still undertheorized, because they cannot be ap- praised through the traditional scientific bases of public hesilth.̂ For example, if we accept that health is a resource at the core of everyday life,'' we need concep- tual tools that allow us to have an in-depth understanding of everyday life.

Subsequently, public health action has evolved from a bio- medical orientation to a social orientation that assumes the in- volvement of multiple actors. Public health practice is largely supported by progressive policy, and it has shifted toward the de- velopment of alliances with an increasingly broad range of so- cial actors. This is seen in the growing number of reports about overlapping actions and integra- dve programs.''

Because the theoretical foun- dations of public health have been based, since the beginning of the 20th century, largely on behavioral psychology, biomed- iccil science, and public adminis- tration,^ our capacity to under- stand and form theories about the complex interactions in- volved in these programs is lim- ited. This, in turn, constrains our ability to further direct innova- tion and transform practice. We

argue for a renewal of the knowl- edge base that drives public health practice so that develop- ments in contemporary social theory can be integrated into public health practice.

INCOMPLETE KNOWLEDGE BASE FOR PUBLIC HEALTH POLICY AND PRACTICE

The Ottawa Charter has Ccilled for and promoted new forms of intervention that are guided by values of empowerment and community participation and that imply health is produced into the core of social life—how people live and organize their lives be- cause of their social conditions.̂ '̂ Unfortunately, these values are all too often juxtaposed on ex- pert models within which stan- dardized activities are prescribed as a set of bodily or behavioral practices that reduce the preva- lence of individual risk factors among the population. This leaves practitioners with very few relevant instruments and models for implementing the basic prin- ciples of the Ottawa Charter^ and the evolving policy discourse. In fact, there is little theory for in- voking, and reflecting upon, the social and relational dimensions of public health practice.

Innovative public health prac- tice is increasingly understood to be the permeation of health is- sues into the social realm, where a growing number of situations traditionally regarded as social problems are reinterpreted within a health framework. Illicit drug use is an example where, in many jurisdictions, policy is shift-

ing from a socio-judicial ap- proach to a harm-reduction model that includes access to psychosocial rehabilitation ser- vices and low-threshold drug substitution treatments in super- vised injection sites. Another ex- ample is the intense support in- tervention through front-line health services involvement in in- tegrative social-development ac- tions that responds to the needs of vulnerable young children and their adolescent parents. In our opinion, this "healthification" of social issues,̂ which justifies the overlapping actions for social change repeatedly called for by current public health policy, is an important way of incorporating contemporary social theory into the theoretical foundations of public health practice.

We defined contemporary so- cial theory by referring to 2 large bodies of social sciences work undertaken since the 1960s that refiect on and critique the condi- tions of modernity. The theories in the first body of work reject both the determinism of a purely structuralist perspective and the idealism of a entirely voluntaryist conception of human action. Contemporary social theorists such as Pierre Bourdieu and An- thony Giddens believe human subjects are actors whose agency—or capacity to act delib- erately or to exercise willful power—is constrained by—yet re- produces and transforms—the so- cial structure through a dialecti- cal relationship. The second body of work includes theories that explore and critique the role of reason and rationality in the regulation of human practice and

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in contemporary society, such as the work of Jurgen Habermas, Michel Foucault, Ulrich Beck, Anthony Giddens, Michel Callon, Bruno Latour, and others.

Therefore, our underlying as- sumptions are (1) there is a con- flict between the innovative prac- tices emerging in public health and public health's scientific base, and (2) we must integrate relevant social theory into the theoretical foundations that in- form—and potentially transform- contemporary public health prac- tice. We present 2 challenges to this integration of social theory that refer to the interrelated—and fundamental—processes of public health programming and evalua- tion. We also present some pro- posals taken from advances in contemporary social theory that set the stage for a reconsidera- tion of both the nature of public health practice and the epistemo- logical position from which to evaluate and further develop public health practice.

TWO CURRENT CHALLENGES FOR PUBLIC HEALTH

I\iblic health interventions are often grouped into a limited number of core functions. In many jurisdictions, these func- tions are related to health protec- tion; mortality, morbidity, and risk factor surveillance; disease prevention; and health promo- tion. Cutting across these func- tions are the 2 fundamental find interrelated processes of pro- gramming and evaluation. They are the prism through which we have identified 2 crucial chal- lenges for contemporary public health theory and practice: (1) formulating program theory that takes into account the social determinants of health and the

mobilization of diverse actors for social change, and (2) developing evaluation theory that fosters a reflexive understanding of the in- tegrative public health programs engaged in social change. Al- though these challenges have been independently addressed by other researchers,'"'" it is our contention that they are closely interrelated and that, taken to- gether, they critically call into question the bureaucratic/struc- tural model upon which public health practice has been tradi- tionally based.

The bureaucratic/structural model is a decontextualized in- terpretation of scientific knowl- edge by experts, e.g., pharmaceu- tical drug development models,'^ and a bureaucratic, vertical, top- down approach to programming and evaluation." We maintain that this approach does not pro- vide adequate conceptual instru- ments to reflect upon and repro- duce the innovative practices that are being implemented by the most innovative public health practitioners when addressing the social determinants of health. We need programs that build on broad partnerships in which vari- ous types of knowledge are brought together to illuminate an issue, i.e., relevant actors must be mobilized to create local solu- tions. A prerequisite for such pro- grams is horizontal relationships between the various partners through a democratic participa- tory process.

Formulating a Program Theory

The first challenge is to formu- late program theory that takes into account the social determi- nants of health and the mobiliza- tion of diverse actors for social change. Social epidemiology studies have shown that health

and diseases are affected not only by the conditions in which individuals live but also by socie- tal organization." These forms of organization, which are reflected in the different social strata that shape our societies, mold our connection with the world and have an effect on health. Socio- economic factors,'*'^ race/ ethnicity," gender,'* and stages of life'** refiect our social stratifi- cation. This stratification is asso- ciated with the social determi- nants of heeilth that, according to Link and Pheelan,^" represent fundamental causes of popula- tion health. Social organization, as defined by relationships cre- ated among and between various strata, thus forms the framework upon which health and disease phenomena develop.

Numerous studies have shown the existence of spatial configura- tions in the distribution of health and disease, which suggests that living environments vary accord- ing to the degree they facilitate or impede population health.^' However, the abundance of re- sults that establish an empirical link between health and place is not refiected on a conceptual level.'" Although we agree with Macintyre's call to better concep- tualize the social aspects of health, we further argue that such theoretical knowledge must be linked with, and even emerge from, the various social change programs that are experimented with by numerous organizations when attempting to address health inequalities. It is this form of public health programming, in which health penetrates the so- cial realm, that requires strong theories to support further inno- vative public health practice.

There is increasing support for social-change programs at all lev- els of the health system's deci-

sionmaking bodies, when a dis- course promoting practice that fosters integrative approaches on the basis of partnerships among all relevant actors is articulated. For example, the World Health Organization has made intersec- toral action a key intervention strategy.̂ ^ In a recent document. Health Canada stated that an in- tegrated health promotion and prevention strategy should em- ploy a "setting approach" on the basis of intersectoral partnerships that bring together a multiplicity of actors from both social institu- tions and civil society. '̂' Simi- larly, Sweden's "Health on Equal Terms" policy is the result of an exercise that involved all sectors of society.̂ "'

In response to these and other repeated recommendations for developing and implementing social-change programs on the basis of broad reciprocal partner- ships, many examples of innova- tive practices are appearing in the literature. In essence, practi- tioners develop alliances and share resources v«th concerned groups and create local solutions. Such practices are not just a mat- ter of bringing individuals to- gether under the umbrella of a program planned and imple- mented by public health profes- sionals. The purpose is to estab- lish enduring partnerships with all actors in a community who are concerned with issues that af- fect health.^^ Moreover, these projects cover a vast spectrum of the social and life sciences and promote the exchange of rele- vant knowledge between both professional and lay individuals. Such broad dialogues, carried out in a nonhierarchical mode, can create knowledge essential in which readily available solutions cannot be implemented.^^ These interventions developed with—

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rather than applied to—communi- ties call for a change in program planning paradigms. A general- ized paradigm shift would help move planning and partnership practices from the mere creation of consultative processes to coap- propriation of programs by, and empowerment of, mobilized ac- tors from the community.

Numerous innovative interven- tions reported in the literature have illustrated how the evolu- tion of practice opens up new di- rections for theoretical work that we think ought to be grounded in emergent practices. Unfortu- nately, current thinking about public health program develop- ment, as exemplified by models such as PRECEDE/PROCEED, fosters a rationality that gives pri- ority to the identification of pub- lic health priorities through ob- jective means. In the case of PRECEDE/PROCEED " those objective means are a sequence of social, epidemiological, and educational diagnostics estab- lished at the beginning of the planning process. Thus, the first challenge facing public health is to organize and integrate knowl- edge about social determinants of health and innovative partner- ship practices to support the de- velopment of theory that is suit- able for social-change programs in public health.

Developing a Theory About Evaluation

The second challenge is to de- velop a theory about evaluation that fosters refiexive understand- ing of public health programs en- gaged in social change. There is a lively debate about what con- stitutes appropriate approaches and methodologies for evaluating and drawing valid scientific knowledge from the innovative public health practices already

We are very fa- miliar with the abundant litera- ture on evidence-based practices and the numerous attempts to adapt this discourse to the evalu- ation of new public health prac- tices.^" However, we believe that the parameters defining opposite opinions in this debate do not allow for the proposal of proper conceptual and methodological tools.

The 2 extreme positions in this debate illustrate the age-old opposition that has existed be- tween positive science and rela- tivist approaches to knowledge. The former provides generaliz- able and context-free results that, in principle, allow the elaboration of evidence-based programs to solve objectively defined prob- lems; the latter proposes a con- textualized interpretation on the basis of a consensus that brings together the points of view of all relevant actors and thus bears strong potential to improve local practices. We believe that pre- senting the dilemma around these 2 paradigms only serves to create an impasse." In our view, consensus is not possible or de- sirable, because it masks power struggles and it restricts the de- velopment of innovative solutions through informed dialogue and compromise. Moreover, profes- sionals and practitioners who try to implement social-change pro- grams rarely find conceptual tools pertinent to their practice in the evidence-based discourse.^^ They rightly argue that generaliz- able estimates of effects consti- tute only 1 of mciny indicators that reflect on their practice. These indicators are not very useful because they are synthetic, distal, and do not provide infor- mation on the dynamics of change. Additionally, when used at the exclusion of other types of

indicators, they may be blind to some of the other, and possibly more effective, mechanisms trig- gered by the program. As we will show, theoretical propositions of contemporary social theory jus- tify this unease. The problem is not that practitioners have under- standably become somewhat reluctant to participate in evalua- tion; rather, it is that the per- ceived relevance of such an exer- cise is low. Thus, the current challenge is to develop a relevant framework that v«ll foster a sys- tematic reflection of practices in- volved in social-change programs so that the programs can be repli- cated and refined. To do this, we must go beyond the parameters of the "paradigmatic" discourse.

THEORETICAL MARKERS FOR ADVANCING PUBLIC HEALTH PRACTICE

Our examination of the post-Ottawa Charter public health practice challenges mir- rors 3 theoretical bodies of work by contemporary social theorists that refiect on the con- ditions of modernity; (1) the unintended consequences inher- ent to human activity in com- plex systems, (2) the critique of the bureaucratic/structural plan- ning model, and (3) a reflexive epistemology to overcome the objectivist/subjectivist dilemma.

The first marker stems from the work of German sociologist Ulrich Beck, who hypothesized that risk is a by-product of techno-sciendfic activity that has been directing developments in most fields of human action. Beck argues that because risk is situated in the future and in the realm of the possible, rather than that of the empirical, positive sci- ences are blind to their exis- tence. Consequently, techno-

scientific solutions are bound to induce unforeseeable conse- quences that institutional science is incapable of anticipating, thus laying the foundations for more complex problems to materialize in the future. '̂'

More than 30 years ago, IUich '̂' identified varied iatro- genic unintended effects inherent to techno-scientific medical activ- ity. In the field of public health, improving population health indi- cators goes together with the un- desirable effect of increasing health inequalities. In Western societies, significant efforts to construct and consolidate mod- em health systems, including public health, during the last dec- ades are associated with spectac- ular gains for a vnde range of health indicators.''^ A growing ntimber of studies, however, show that these gains have not benefited everyone equally, which suggests that an increase in health inequalities is an unin- tended consequence of such im- provements. For example, today the number of smokers is 4 times higher among individuals who have not completed high school than among university graduates''®; infectious diseases that were thought to be under control, such as tuberculosis, have a higher incidence among poor neighborhoods in large North American cities^'; and, studies have shown that even in systems where universal access is guaranteed, health service utiliza- tion^* and survival rates among individuals from more privileged socioeconomic classes are higher than among persons from disad- vantaged groups.''^ The differ- ences observed in the results of health interventions according to social class suggest that our inter- ventions might contribute to widening the gap in morbidity

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UWi.

and mortality between the rich and the poor."""'

The second marker is the critique of the bureaucratic/ structural model at the root of vertical programs designed in top-down systems, which is founded on the administrative systems described by Max Weber.''̂ These systems can be recognized by the preponderance of institutionalized rules and pro- cedures that map out courses of action. They leave little room for contextual elements and con- cerns or any contribution of non- institutional actors. Their struc- ture is such that power and decisions are based on expertise and authority. In this model, pro- gram development is presented as a strict sequence of hierarchi- cal steps that proceed from planning to implementation to evaluation and, eventually, to sustainability/institutionalization on the basis of results from the previous steps.̂ ^ The decision to proceed to the next step is con- ceived as a discrete event that is justified by evidence-based data.

Recent publications have shed light on a number of shortcom- ings to this model. Empirical ob- servations have shown that sev- eral events that characterize program implementation and sustainability occur concur- rently.'*'' A literature review of program longevity shows that al- though evaluation results con- tribute to decisions about the fu- ture of programs, the processes that lead to these decisions begin well before evaluation results are available and are based on much more comprehensive informa- tion.''' Several programs can readily be conceptualized as rep- resentative of another model. In opposition to an essentially rules- and-procedures model, this other model implies dynamic configu-

rations that are founded on strategic objectives defined by all relevant actors, whose goals and purposes also depend on context, knowledge, and interactions with other systems of action.®

The third marker is derived from the theoretical work of Pierre Bourdieu, who hypothe- sized that a theory of practice can only be suitably developed by transcending the opposition between subjective and objective knowledge and by situating prac- tice itself as the very subject of research. According to Bourdieu, an objective stance assumes that the nature of the social world is given and predetermined cind, therefore, the representations that shape our practices can only be elaborated at the expense of a rupture between rationality and experiential knowledge.'*'' Other- wise, a subjective stance prevents the consideration of the objective relational systems that shape our practices. To get beyond the in- evitable character of such a di- chotomy between subjective and objective approaches to knowl- edge of practices, Bourdieu sug- gests a reflexive approach, where the object of knowledge is not limited to a system of objective relationships between events, which is the case in program logic models that are based on scientific knowledge.

For Bourdieu, knowledge of practice, or practical knowledge, can only be reflexive and dia- logic. This means that practical knowledge can only result from the confrontation between the objective systems of relation- ships that structure practice and the subjective experience of social actors whose practices re- produce and transform the struc- ture. The results of this con- frontation are then introduced into the knowledge-production

process itself Thus, the reflexive knowledge that is required for planning, implementing, and evaluating social-change pro- grams also includes a dialectical relationship between these 3 ele- ments; an objective representa- tion of the social world, a subjec- tive system of knowledge, and the structural conditions in which they take place and that tend to reproduce them.''''''^ A reflexive approach to knowledge requires a double movement of objectification of the social world and integration of objec- tive knowledge into the struc- turation of the subjective experi- ence. Therefore, a reflexive action is always an action that is perpetually moving to position it- self in space and time so that no point of view is completely inter- nal (subjectivist approach) or ex- ternal (objectivist approach). Hence, any reflexive practice is situated within a space that transforms itself continually with social interactions. Such dynamic processes of program implemen- tation and evaluation have been described in relationship with participatory approaches to in- terventions that are derived from broad partnerships.^

CONCLUSION

The challenges of elaborating program and evaluation theory that takes social change into ac- count highlight the limits of prac- tice models that are based on dissemination of expert knowl- edge to practitioners. Because these models leave little room for local actors' knowledge in the face of standardized expert solutions, they do not explain the mechanisms through which programs are adapted and trans- formed and then alter the local environment. To resolve the

challenges associated with emer- gent and innovative practice, public hecilth must renew its own theoretical foundations. In fact, because it presents pro- grams as objects that are more or less independent of their con- texts, and because it overshad- ows the network of actors who uphold them, the scientific basis that underlies public health ig- nores a substantial part of the dynamic and social nature of public health programs, i.e., their capacity to adapt, innovate, and propose pertinent, effective, and transformative actions in re- sponse to local dilemmas.

We maintain that the knowl- edge base that should enable the reproduction and transformation of practice in alignment with the principles of the Ottawa Charter and the emerging progressive policy is the result of translating a dialectical link between these innovative programs and their evaluation. Public health pro- grams cannot be reduced to a hi- erarchical sequence of proce- dures; rather, they function as systems of action designed to transform social reality. As such, we believe that the knowledge base of public health should be situated more coherently within a theoretical perspective that seeks to understand and gtiide our contemporary world. It is time to consider social theory as a way of reconciling public health practitioners, decisionmak- ers, and researchers. •

About the Authors Louise Potvin, Syivie Gendron, and Angele Bilodeau are with the Lea-Roback Centre for Research on Social Health Inequalities of Montreal, Quebec. Louise Potvin and Angele Bilodeau also are with the Depart- ment of Social and Preventive Medicine, University of Montreal. Angele Bilodeau is also with the Public Health Directorate, Montreal Agency for Health and Social Services. Syivie Gendron is also with the

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School of Nursing, University of Montreal. Patrick Chabot is with the Groupe de Recherchi sur les Aspects Sodaux de la Prevention, University of Montreal.

Requests for reprints should be sent to Louise Potvin, PhD, Social and Preventive Medicine, University of Montreal, PO Box 6128, Station Centre-ville, Montreal, QC H3C 3/7 Canada (e-mail: louise.potvin@ umontreal.ca).

This article was accepted November 13, 2004.

Contributors L. Potvin originated the content and wrote the article. S. Gendron and A. Bilodeau contributed to the develop- ment of the content, provided public health practice insight, and assisted with rewriting the final draft. S. Gendron also was responsible for final language edit- ing. P. Ghabot contributed to the original development of the bureaucratic model of programming critique.

Acknowledgments Louise Potvin holds the Chair on Com- munity Approaches and Health Inequali- ties funded by the Canadian Health Ser- vices Research Foundation and the Canadian Institute for Health Research (CHSRF-CIHR #CPI-022605). Sylvie Gendron was lunded by a joint Canadian Institute for Health Research, Sodal Sci- ences and Humanities Research Council, and National Health Research and De- velopment Program postdoctoral fellow- ship awaixi (CIHR/SSHRC/NHRDP #765-2000-0092).

Human Participant Protection No protocol approval was needed for this study.

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