The ‘lifeworld’ of health & disease and the design of public health interventions

1. The ‘lifeworld’ of health & disease and
the design of public health interventions
Federica Russo
Philosophy & ILLC, University of Amsterdam
@federicarusso
Joint work with Mike Kelly

2. Overview
 PH interventions
 Examples and challenges
 The evidence base of PH interventions
 Biological and aetiological approaches
 Social determinant approach
 The lifeworld
 Conceptualization and operationalization
 Evidential pluralism
 The lifeworld in design of PH interventions
 Lessons from COVID-19
2

3. What counts as a PH intervention?
3

4.  (Hard) lock down or partial closure/opening
 Smoking cessation programmes, smoking bans, smoking taxation
 Regulation of food labelling
 Vaccination programmes
 …
4

5. What is going wrong in
PH interventions?
5

6.  A lot is achieved, but not enough
 Think of:
 Preventable infectious diseases that nonetheless spread, e.g. measles outbreaks
 Preventable non-infectious diseases on the rise, e.g. obesity
 A third (fourth?) wave of COVID after the summer?!
6

7.  Why is it so?
 Our diagnosis:
 The social dimension of H&D is not sufficiently integrated into the study of the biology
of H&D
 PH interventions do not tackle social factors enough or in an appropriate way
7

8. The evidence base
of PH interventions
8

9. The biological and aetiological approach
 The dominant paradigm: it focuses on the biological causes of H&D
 We opened the opaque box of H&D, down to the molecular level
 Social factors are largely classificatory, not explanatory, or causes in a proper sense
 Social factors are associated with risks, in a classificatory rather than explanatory
way
9

10. The social determinants approach
 Socio-economic factors (and inequalities) map onto health patterning at societal
level
 Social epidemiology
 Quantitative sociology of health
 It establishes that social factors are linked to health, not how-why
 Tendency to go as granular as possible in measuring social factors
10

11. How to integrate
‘social’ and ‘biological’?
11

12. The concept of ‘lifeworld’
 We build on the sociological work of e.g. Schutz, Giddens, Bourdieu
 Each and every one of us inhabits our own lifeworld
 It is constituted of the assumptions, understandings, and taken for granted aspects of our everyday
existence
 It is the seat of our sense of self, and the ideas we have about who and what we are, and who and
what others are
 We anticipate the actions of others and we anticipate the effects that our actions will have on others
in our lifeworld
 It consists of the things we do, the actions we take, the practices in which we engage on a day to day
basis
 It is what we do, and our bodies are like a book in which we inscribe all the many things we do and
we experience
 Any aspect of our life can be described in terms of the lifeworld experience, including health and
disease
12

13. Structures without mechanisms?
 Traditional sociology of health:
 Role of institutions, social support, power structures, communication …
 But:
 Typically at high level of abstraction, not always or necessarily anchored to ‘local’
mechanisms
 Largely theoretical, not supported by quantitative (or qualitative) analyses
 This approach to social structures and health largely misses explanatory power
(and thereby a potential use for the design of PH interventions)
13

14. Lifeworlds and mixed mechanisms
 Lifeworlds need not remain abstract descriptions of (aspects of) life
 In the lifeworld, mixed mechanisms of H&D operate
 Biological and social factors are on a par to explain and intervene on H&D
 How to detail aspects of mixed mechanisms?
 Existing approaches: exposure research, epigenetics, allostatic load, life-coarse approach,
…
 But we can do more
14

15. How to operationalize the lifeworld?
15

16. A question of method
 ‘Lifeworld’ helps with conceptualizing H&D
 But how to study in practice the mixed bio-social nature of H&D?
 This, is a question of method
16

17. More measurement?
 ‘The problem of more measurement’:
 Increasing the granularity of measurement of social factors won’t do
 More measurement doesn’t carry explanatory power on its own
 Not quantity but quality
 Which (social) variables we want to measure
 What we we intend to measure with these variables or proxies
 Theoretical underpinning to measurement provides partial descriptions of the
lifeworlds
17

18. At the extremes of measurement
Age
Very easy to measure
Does it just represent a definite
biological status?
Does it have any explanatory import?
SES
Very controversial how we should
measure it
How can it represent one’s status?
What is its import in explanation of social
or social / health outcomes?
18

19. Measuring socio-economic status
 Theoretical approaches
 Weberian, Marxist, Colemanian, …
 Identification of different indicators, different types of variables
 Procedure: class stratification
 E.g., Goldthorpe Class Schema
 Grouping of types of workers
 Why measuring SES?
 E.g., correlation with health outcomes, or other economic variables, …
19

20. Why measuring SES for H&D?
 Categorise?
 A classificatory variable
 What part of the populations are more exposed, have higher prevalence …
 Explain?
 Active part in the explanation of diseases
 Mixed aetiology!
 What are the active causal pathways from exposure to outcome?
 Social practices / norms / habits to explain (and to prevent) exposure
20

21. Measuring age
 Easy to measure
 Accessibility of data, straightforward question, …
 How to measure it
 Categorically, Continuously
 Using Age
 Control: Adjust results of statistical analyses (control for age)
 Predict: Age structure helps predict results
 Categorise: Grouping and collapsing multiple categories into fewer categories; Care with loss
of information, residual confounding
21

22. Why measuring age for H&D?
 ‘Demographic’ age: Locating individuals in the ‘right’ age group
 Biological age: A typical health status, for that age
 Social age: Social practices that are typical of that age
 Epigenetic age: Our internal clock, possibly different from our chronological age
 …
 [these meanings of age do coincide, possibly they overlap]
 Any explanatory import in using age?
22

23. More description?
 Qualitative, small-scale approaches to H&D can provide the details of the lifeworld
 What happens between actors, why, under what conditions, …
23

24. Complementarity and mutual help
 Methodologically, quantitative and qualitative approaches really are
complementary:
 Detailed qualitative studies may give hints about what to test at large scale, population
level;
 Conversely, quantitative studies may allow unexpected correlations (or lack thereof) to
emerge deserving an in-depth qualitative study
 See Mixed Methods Research
 At the level of policy making, we need to know and understand which mechanisms
are really culture-specific and which mechanisms are instead more general
24

25. Lifeworld and evidential pluralism
25

26. Evidential pluralism for a more solid
evidence base
 In order to establish a causal claim, we typically need evidence of correlation and of
mechanisms
 An epistemological and methodological thesis (not ontological!)
 About mutual support of correlations and mechanisms (reinforced concrete analogy)
 The claim is partly descriptive and partly normative
26

27. Enlarging the evidence base
 What do we take evidence of?
 Both correlations and mechanisms
 About both biological and social factors
27

28. The lifeworld
in the design of PH interventions
28

29. Designing interventions for COVID-19
Aetiology
 The biology of COVID
 The sociology of COVID
 Socializing, touch, sneezing, working
environments and work practices,
shared households, age, ethnicity, …
Prevention
 Vaccination
 Any other interventions would and
should need detailed descriptions of
the mixed-mechanisms on the
aetiology side
29

30. To sum up and conclude
30

31.  Everyone agrees that social factors are important for H&D
 But how we integrate social factors in the explanation of H&D and in PH
interventions does not follow the statement of their importance
 WHY??
 Because we need a concept of lifeworld to account of the mixed aetiology of H&D
 The lifeworld can be studied and operationalized with mixed methodologies
 We can then design PH interventions that target factors at the ‘right’ joints of the
mixed mechanism
31

32. The ‘lifeworld’ of health & disease and
the design of public health interventions
Federica Russo
Philosophy & ILLC, University of Amsterdam
@federicarusso
Joint work with Mike Kelly