Journal of Public Health Advance Access originally published online on October 18, 2005
Journal of Public Health 2005 27(4):315; doi:10.1093/pubmed/fdi061
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Editorial |
More public health theory please – but make it adequate
Jim Connelly
Member, Editorial Board, Journal of Public Health
(Editors note: Our stated aim is to focus on public health practice. In this editorial, a member of our Editorial Board argues the case for adequate theory.)
Why for instance, why does self-perceived degree of relative economic inequality lead to increased risk of cardiovascular disease?1 Is it because people who think themselves as poor and marginalized lead their lives in a state of chronic psychological and bodily stress arousal. 2 Or is it due to a cognitive-behavioural maladaptation where unhealthy behaviours are experienced as ineluctable ways of getting by? 3 Or is it that these and other mechanisms4 interact with each other? Basing public health activities on a poor or meagre theoretical understanding – such as the dominance of rationality in personal decision-making about health5 – is itself evidentially ungrounded4 but may be politically expedient. What should we do with theories?
In answering this question, I suggest we need to articulate public health theories of disease causation, 6 we need empirical observations informed by strong theories and we need to establish better means to change, improve or drop theories. 7 More than this, we need to tackle head-on the acceptability and adequacy in public health science of retaining the conceptual and methodological distinctions between facts and values (philosopher David Hume’s ‘you can’t get an ought from an is’) and subjective and objective knowledge. These distinctions underlie the tension between describing the world and changing it. Renewing and expanding the paradigm for the scientific practice of public health will require open debate on such matters. 8
To restate the last point, do we wish to describe in increasingly accurate terms the underlying causes that produce, sustain and increase poverty, injustice and misery – the project of a pure objective scientific practice – or do we want theoretically and empirically grounded resources to transcend fact-value distinctions and guide a public health practice that seeks human emancipation?9
Whatever we do with theory we ought to be respectful of a number of thoroughly non-postmodern principles of theory adequacy:
- Theories should be described, whenever possible, simply and should be open to refutation by testing;
- Authors of theories should acquaint themselves with and acknowledge the prior origination and uses of concepts they use to build their theories;
- Theorists should explain how their theory encompasses and, in particular, expands upon established theories.
My tip for the top theoretical framework for public health is critical realism, 10–12 which I believe offers a comprehensive and compelling explanation of the way public health as a human science has and might progress. The challenge for critical realists is the same for adherents of other theories, it is to accurately and insightfully redescribe other contender theories – such as Marxism, Biomedicine, Behaviouralism, Social Constructivism – in its own terms and then to demonstrate that the stated theory meets all of the principles of adequacy. So more theory is required in public health – but adequate theory please.
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References |
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 TOP References |
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- Wilkinson R. Unhealthy societies: the afflictions of inequality. London: Routledge, 1996.
- Carroll D, Davey Smith G, Smith G, Sheffield D, Shipley MJ, Marmot MG. The relationship between socio-economic status, hostility and blood pressure reactions to mental stress in men: data from the Whitehall II study. Health Psychol 1997; 16: 131–136.[CrossRef][Web of Science][Medline]
- Bartley M. Social Ecology. In: Health inequality: an introduction to theories, concepts and methods. Cambridge: Polity, 2004: 126–127.
- Bartley M. The life-course approach. In: Health inequality: an introduction to theories, concepts and methods. Cambridge: Polity, 2004: 103–115.
- Choosing health; making healthy choices easier. London: The Stationery Office, 2004.
- Potvin L, Gendron S, Bilodeau A, Chabot P. Integrating social theory into public health practice. Am J Publ Hlth 2005; 95: 591–595.
[Abstract/Free Full Text] - Berkman LF, Kawachi I. Social epidemiology. NewYork: Oxford University Press, 2000.
- Kuhn T. The structure of scientific revolutions, 2nd edn. Chicago: Chicago University Press, 1970.
- Connelly J, Emmel N. Preventing disease or contributing to the struggle for emancipation. Does professional public health have a future? Policy Polit 2003; 31: 565–576.[CrossRef]
- Bhasker R. The possibility of naturalism: a philosophical critique of the contemporary human sciences, 3rd edn. London: Routledge, 1998.
- Archer M, Bhaskar R, Collier A, Lawson T, Norrie A, eds. Critical realism: essential readings. London: Routledge, 1998.
- Connelly J. Realism and health promotion: effective practice needs an effective theory. Health Educ Res 2001; 16: 115–120.
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