February 12, 2006
(Re)Examining Health Disparities: Critical Social Theory in Pediatric Nursing
By Mohammed, Selina A
Scientific Inquiry provides a forum to facilitate the ongoing process of questioning and evaluating practice, presents informed practice based on available data, and innovates new practices through research and experimental learning.In recent years, research in health disparities has become an important focus of nursing science. This research explores the relationship between health and social factors such as race/ ethnicity, gender, socioeconomic position, and educational attainment. Research of this nature has significantly enhanced our understanding of the factors that contribute to differences in health among various groups of people. However, researchers are challenged to understand the complexities of how inequalities in health came to be and how we can more comprehensively address them. In particular, we need to avoid ascribing deficits in health to particular characteristics of an individual or group.
In clinical practice, pediatric nurses are faced with similar challenges. They develop and implement interventions to improve health promotion behaviors and thereby reduce health disparities. However, nurses are constrained by the institutional settings and standards within which they practice. In our present healthcare system, interventions tend to focus primarily on the individual or family unit. Locating the individual as the primary site of health in nursing research and practice is limiting, because it sets aside wider social structures that serve to maintain and engender these disparities. These structures may include economic organization, political systems, and societal power relationships that privilege some individuals while marginalizing others. Critical social theory provides a useful approach for capturing these broader contextual perspectives.
Critical Social Theory: A Framework for Nursing Research and Practice
Critical social theory predominantly refers to a series of ideas that emerged during the 1920s and 1930s from the Institute of Social Research at the University of Frankfurt in Germany (Wells, 1995). Expounded and reinterpreted over generations by theorists such as Habermas, the critical social theory does not have a unified definition; however, historical and contemporary versions of this theoretical framework share many fundamental tenets.
As a form of science and inquiry, critical social theory examines relationships of power and the underlying structures in society that produce population inequalities (Grams & Christ, 1992). These societal structures determine, for example, the types of employment and wages that are made available to certain groups of people, distribution of wealth, access to education, and availability of healthcare services (Stevens, 1989). Through the internalization of ideologies such as racism, sexism, and classism, these (mis)representations of social processes are made to appear inevitable, natural, and constant, yet serve to reinforce interests of the dominant group (Alien, 1985).
An assumption of critical social theory is that cultural, political, and economic circumstances in society are not natural and fixed, but are rather historically created and alterable. This theoretical framework advocates for a type of consciousness that regards how these social structures operate to oppress some members of society while systematically privileging others. Therefore, it has an emancipatory intent and seeks to challenge conventional assumptions and social arrangements to move beyond the "what is" to the "what could be" (Thomas, 1993).
Included in this critique is an analysis of how sociocultural, economic, and political conditions inform the development of knowledge. The production of knowledge-including science-is therefore seen not as objective, decontextualized, or ahistorical, but as informed by hierarchical arrangements in society. These arrangements determine what counts as knowledge and whose voices are heard.
Critical social theory is an action-oriented theoretical approach that may be applied to both nursing research and practice (Henderson, 1995). In this approach, research and clinical practice are seen as inherently political in nature because they are shaped by historical, social, cultural, and economic processes (Stevens, 1989). According to Wilson-Thomas (1995), "by analyzing how and why embedded assumptions guide theory development, research, and practice, nurses can begin to describe and explain oppressive environmental effects on health and understand their role in society" (p. 573). Critical social theory can be used to assess how socially derived power structures filter into healthcare practices, both in terms of how deficits in health are assessed and managed, and how they affect communication between nurses and patients.
Using Critical Social Theory in Research: A Case with Diabetes
As the seventh leading cause of death in the United States, diabetes poses a significant public health challenge. One of the goals of Healthy People 2010 is to reduce the economic and disease burden of diabetes and to improve the quality of life for individuals who have diabetes (U.S. Department of Health and Human Services [USDHHS], 2000). The majority of research on diabetes situates it as a disease attributed to genetics, diet, and exercise. Because rates of diabetes are disproportionately higher among non- White ethnic groups and those who are economically disadvantaged (USDHHS, 2000), diabetes is often associated with racialized minorities and people of low socioeconomic status. Critical social theory can be paired with a multitude of research methodologies to explore how social determinants of health contribute to diabetes and particularly how history, ideologies, and societal power imbalances operate in the unequal distribution of this disease.
In my own work, for example, I used a methodology informed by critical social theory to explore how urban American Indians described diabetes. I found that historical and present-day relationships with dominant society framed how participants constructed their representations of diabetes. Participants went beyond the biomedical disease model to define diabetes and demonstrated how systemic racism and economic oppression affected their access to healthcare services and their ability to manage diabetes (Mohammed, 2004).
Implementing Critical Social Theory in Clinical Practice with Adolescents Who Have Diabetes
Critical social theory can be applied in a similar manner in practice with adolescents who have diabetes. Although diabetes is not a principal cause of mortality for adolescents, improving leading health indicators of physical activity and nutrition/ obesity (risk factors for diabetes) are two primary objectives for this group in the Healthy People 2010 initiative (USDHHS, 2000). Pediatric nurses are trained to educate adolescents about the need for proper nutrition, increased vigorous physical activity, and, for those adolescents who have diabetes, compliance with insulin or oral medication regimens.
However, within a medical system that restricts our attention to individuals, the social context in which patients live can be regularly overlooked. Pdiatrie nurses can use critical social theory to examine how oppressive arrangements in society (e.g., poverty, housing, food scarcity, discrimination, etc.) operate to hinder the health of their patients. For example, they can assess whether or not adolescents can readily obtain certain types of foods, participate in school programs that provide nutritious lunches and physical education classes, or live in neighborhoods with adequate street lighting and affordable fitness centers to facilitate exercise. Pediatric nurses also can assess whether their patients experience discrimination or have access to adequate healthcare services.
Within this framework, nurses can consider how they themselves participate in reproducing social structures. These structures determine how they define, assess, prioritize, and respond to health and illness. Utilizing critical social theory, nurses can expand their scope of practice in ways that address their patient's health challenges on a societal level, rather than on an individual level.
Critical social theory can also be used to examine how power relations in healthcare interactions affect communication between nurses and adolescent patients with diabetes. The emancipatory dimension of critical social theory and the commonly identified ideals of partnership with patients propose that adolescents be equal partners in healthcare decisionmaking processes. This, however, can be a difficult goal to achieve. Although there are many institutional, sociocultural, and political factors that constrain this equal partnership, two are particularly prominent. The first is the uneven distribution of health-related knowledge between nurses and adolescents. By virtue of having this knowledge, nurses are cast in an authority role in a nurse-patient interaction (Alien, 1987). The second factor is the prevailing stereotype of adolescents as irresponsible, noncompliant, or unable to make "good" decisions (Stevens, 2004). As a result of this stereotype, adolescents are often excluded from conversations and decisions regarding their own diabetes care (Dickinson, 1999). Solutions to this power imbalance can only be accomplished by attending to wider societal forces (e.g., debunking adoles\cent stereotypes or de-emphasizing the priority of "expert knowledge"). However, nurses can start to dismantle this hierarchy by using a dialogic approach with adolescents in healthcare encounters (Dickinson) and by considering adolescents to be "knowledgeable actors" of their own lives (Stevens).
Critical social theory is a useful alternative paradigm for research and practice, providing a framework to address the fundamental causes of health disparities and social injustices. Nursing has a long tradition of championing the needs and rights of the poor, the underserved, and the disenfranchised (Bekemeier & Butterfield, 2005). If we, as a profession and as individual practitioners, are interested in substantially influencing the health outcomes for our patients, we need a variety of tools. Critical social theory offers a model of science and an approach to clinical practice that helps us to analyze existing problems and form partnerships with patients and communities to create social change.
Column Editor: Diane Hudson-Barr
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Selina A. Mohammed, PhD, RN
Postdoctoral Research Fellow
Women's Health Disparities Interdisciplinary Training Grant
University of Michigan School of Nursing
Ann Arbor, MI
Search terms: Critical theory, healthcare disparities
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