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Reducing or reproducing inequalities in health?: An intersectional policy analysis of how health inequalities are represented in a Swedish bill on alcohol, drugs, tobacco and gambling
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.ORCID iD: 0000-0002-3972-5362
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.ORCID iD: 0000-0001-7087-1467
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
2022 (English)In: BMC Public Health, E-ISSN 1471-2458, Vol. 22, article id 1302Article in journal (Refereed) Published
Abstract [en]

Background: According to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations.

Method: A post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the “What’s the problem represented to be?” (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations.

Results: The recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation.

Conclusions: The problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

Place, publisher, year, edition, pages
BioMed Central, 2022. Vol. 22, article id 1302
Keywords [en]
Intersectionality, Post-structural policy analysis, Alcohol, Drugs, Tobacco, Gambling, Health inequalities, Health policy
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-193675DOI: 10.1186/s12889-022-13538-6ISI: 000825328000002Scopus ID: 2-s2.0-85133538572OAI: oai:DiVA.org:umu-193675DiVA, id: diva2:1651206
Funder
Public Health Agency of Sweden Umeå University, FS 2.1.6–339-20
Note

Originally included in thesis in manuscript form.

Available from: 2022-04-11 Created: 2022-04-11 Last updated: 2023-09-05Bibliographically approved
In thesis
1. Knowledge diversification in public health through intersectionality
Open this publication in new window or tab >>Knowledge diversification in public health through intersectionality
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Kunskapsbreddning inom folkhälsa genom intersektionalitet
Abstract [en]

Background

Knowledges about health inequalities and their causes are a central concern in public health. Generally, these relate to the social patterning of health and the forces that affect health conditions in daily life. However, public health decision making has been criticized for excluding knowledges of particular importance for health equity. This poses a challenge since knowledges and understandings shape what policies and interventions are viewed as relevant, reasonable or even possible to think of. If certain knowledges are left out, there is a risk that both knowledge making and decision making with respect to health inequalities will exclude important measures.

Since intersectionality encompasses a wide range of knowledge-making practices centered around social justice, it may contribute diverse knowledges of importance to health equity. Intersectionality has recently gained traction within public health and represents an important shift in conceptualizing how different dimensions of inequalities, such as sexism, classism and racism, interlock to generate social exclusion and marginalization instead of working separately, one by one.

Aim

The overall aim of this thesis is to explore the possibility of using intersectionality as a tool for knowledge diversification within public health. The specific research question is:

What knowledges and understandings of health inequalities do the inter-categorical (studies I and II) and post-categorical (studies III and IV) approaches to intersectionality contribute and how are such contributions made?

Material and methods

The method of the cover story can be understood as a way of studying science or as a retrospective self-reflection based on the four individual studies, making up the material of the thesis. Specifically, the material was reassembled and retold in order to show how certain intersectional approaches generate different types of knowledges and understandings of health inequalities by involving different ways of operationalizing inequalities and managing categories.

In study I, a scoping review of the quantitative international literature was undertaken with the aim of mapping and describing inter-categorical inequalities in mental health. Study II was a quantitative analysis of a population-based survey with the aim of mapping inter-categorical inequalities in mental health in the Swedish adult population. Study III was a policy analysis of a government bill that proposes a national strategy on alcohol, drugs, tobacco and gambling with the study aim to examine the equity-perspective of the bill through an intersectional lens. Study IV was a post-qualitative inquiry based on participatory observations and interviews with the study aim to explore the becoming of social divisions among seniors as they participate in health-promoting activities.

Results

The inter-categorical approach to intersectionality (applied in studies I and II) generated knowledges about health inequalities as quantitative mean differences between population groups, and highlighted unexpected patterns and unpredictable inequalities in mental health. This implies the importance of building responsive systems that regularly monitor inequalities across different intersectional positions and contexts so that services can be directed and adapted to those most in need.

The post-categorical approach to intersectionality (applied in studies III and IV) generated knowledges about health inequalities as processes of marginalization, resistance, exclusion, or inclusion, and highlighted difficult trade-offs with respect to public health policy and practice. This enables a transformative way of thinking by providing the possibility of doing things differently in everyday practices in which marginalization and resistance becomes.

Conclusion

Different approaches to intersectionality contribute diverse knowledges and understandings about health inequalities. This is important since it expands the possibilities for fair decision making and health equity through different outlooks on social justice. Knowledge diversification through intersectionality could be particularly useful to release tension due to the restrictive forces of public health decision making and to increase accountability for the multiple social interests of the population. Thus, it has the potential to make public health decision making more flexible, transparent, reflexive, and democratic.

Abstract [sv]

Bakgrund

Kunskaper om ojämlikheter i hälsa och deras orsaker är centrala inom folkhälsa. Dessa handlar generellt om hur hälsan är fördelad i befolkningen och om de strukturer som utgör förutsättningarna för hälsa i det dagliga livet. System för beslutsfattande inom folkhälsa har dock kritiserats för att utesluta vissa typer av kunskaper med särskild betydelse för jämlik hälsa. Det är en utmaning eftersom kunskaper och förståelser formar vad som anses vara relevanta, rimliga eller ens tänkbara åtgärder. Om vissa kunskaper utelämnas riskerar kunskapsproduktionen och beslutsfattandet att bortse från åtgärder med potential att öka jämlikheten i hälsa. 

Eftersom intersektionalitet är ett mångfacetterat begrepp som inbegriper en rad olika kunskaps-skapande praktiker med fokus på social rättvisa kan det bidra med kunskapsbredd för jämlik hälsa. Begreppet har nyligen vunnit mark inom folkhälsa och bidragit med en förändring i sättet att tänka kring hur dimensioner av ojämlikhet som sexism, klassism, och rasism gemensamt, snarare än var för sig, bidrar till socialt utanförskap och marginalisering.

Syfte

Det övergripande syftet är att utforska möjligheterna att använda intersektionalitet som ett verktyg för kunskapsbreddning inom folkhälsa. Den specifika frågeställningen är: 

Vilka kunskaper och förståelser om ojämlikheter i hälsa bidrar den inter-kategoriska (studie I och II) och post-kategoriska (studie III och IV) ansatsen till intersektionalitet med och hur?

Material och metod

Ramberättelsens metod kan förstås som ett sätt att studera vetenskap eller som en retrospektiv självreflektion baserad på avhandlingens material i form av fyra individuella studier. Mer specifikt har materialet omorganiserats och återberättats för att visa på hur vissa intersektionella ansatser generar olika kunskaper och förståelser om ojämlikheter i hälsa genom olika sätt att operationalisera ojämlikheter och hantera kategorier.

Studie I var en kartläggande översikt baserad på internationell litteratur med syftet att kartlägga och beskriva inter-kategoriska ojämlikheter i psykisk hälsa. Studie II var en kvantitativ analys av en befolkningsbaserad enkätstudie med syftet att kartlägga inter-kategoriska ojämlikheter i psykisk hälsa i den svenska vuxna befolkningen. Studie III var en policyanalys av regeringens proposition om en ny strategi för alkohol, narkotika, dopning, tobak och spel om pengar med syftet att undersöka propositionens jämlikhetsperspektiv utifrån ett intersektionellt ramverk. Studie IV var en post-kvalitativ undersökning baserad på deltagande observationer och intervjuer med syftet att utforska uppförandet av sociala skillnader under hälsofrämjande aktiviteter för seniorer.

Resultat

Den inter-kategoriska ansatsen (studie I och II) generade kunskaper om ojämlikheter i hälsa som kvantitativa medelvärdesskillnader mellan intersektionella grupper vilket belyste oväntade mönster och oförutsedda ojämlikheter i psykisk hälsa. Detta ansågs antyda vikten av att bygga lyhörda system som regelbundet övervakar ojämlikheter mellan olika intersektionella positioner och sammanhang så att åtgärder kan formas och riktas med hänsyn till de med störst behov. 

Den post-kategoriska ansatsen (studie III och IV) genererade kunskaper om intersektionella ojämlikheter i hälsa som processer i termer av marginalisering, motstånd, uteslutning och inkludering vilket belyste svåra avvägningar inom folkhälsopolicy och praktik. Detta ansågs möjliggöra ett transformativt tankesätt genom att bidra med möjligheten att göra saker annorlunda i den dagliga praktiken där marginalisering och motstånd uppstår. 

Slutsats

Olika intersektionella ansatser bidrar med olika kunskaper och förståelser av ojämlikheter i hälsa. Detta är viktigt eftersom det utvidgar möjligheterna till ett välavvägt beslutsfattande och en jämlik hälsa genom olika syn på social rättvisa. Kunskapsbreddning genom intersektionalitet kan vara särskilt användbart för att öka ansvarsskyldigheten gentemot befolkningens olika intressen och behov. På så sätt har intersektionalitet potential att bidra till ett mer flexibelt, transparent, reflexivt och demokratiskt beslutsfattande inom folkhälsa.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2022. p. 46
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2178
Keywords
public health, intersectionality, feminism, health inequalities, health equity, knowledge diversification, decision making
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-193731 (URN)978-91-7855-779-0 (ISBN)978-91-7855-780-6 (ISBN)
Public defence
2022-05-06, Alicante, Byggnad 5B, plan 3, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2022-04-12 Created: 2022-04-12 Last updated: 2022-04-14Bibliographically approved

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Fagrell Trygg, NadjaGustafsson, Per EHurtig, Anna-KarinMånsdotter, Anna

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