Does discourse matter? Using critical inquiry to engage in knowledge development for practice - Cambridge University Press
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Primary Health Care Research and Development 2007; 8: 54–67
doi: 10.1017/S1463423607000072
Does discourse matter? Using critical inquiry to
engage in knowledge development for practice
M. Judith Lynam Associate Professor, Co-Director Culture, Gender and Health Research Unit, University of British
Columbia, School of Nursing, Vancouver, British Columbia, Canada
Recent years have seen an increase in critical analyses of discourses of policy and
practice. However, some argue that this form of scholarship is not central to under-
standing the concerns of day-to-day practice in the health care context. We propose the
converse and contend that critical analyses have particularly important contributions
to make because they challenge us to examine what are largely taken for granted
aspects of practice. One context in which such examinations have been instructive is
primary healthcare. This article is intended to further the dialogue on the ways the culture
concept is taken up in health care. We use the case of culture and health to illustrate the
ways discourses are taken up in local and official contexts and to demonstrate how dif-
ferent discourses and related institutional practices, shape individuals’ relationships
with others in the community context.
Key words: Bourdieu; culture and health; discourse analysis; health inequalities
Received: September 2005; accepted: October 2006
One concern at the forefront of the health care Until relatively recently, much of the research
agenda is to ensure primary health care is access- that has sought to examine issues of culture and
ible and responsive to the health needs of the full health has built upon methods and traditions of
range of the population (Canada, 2002; Britain, anthropology and has generally resulted in descrip-
Department of Health, 2006; US, 2006). For gener- tions ‘of’ the cultures of interest. In recent years,
ations, Britain has welcomed immigrants from however, anthropologists and scholars in cultural
countries throughout the world, most particularly studies have advocated researchers adopt a more
from countries in the Commonwealth. More critical stance. They urged researchers to consider
recently, the formation of the European Union not only how cultures operate but also the conse-
prompted an increase in migration throughout quences of representation for particular cultural
Europe. As a consequence these countries, and a groups (Hall, 1996a; 1996b). Similar positions have
number of others throughout the world (eg also been put forward in health literature (Ahmad,
Australia, Canada and the US), are increasingly 1993; Culley, 1996; Anderson, 2004a; 2004b).
culturally and socially diverse. However, there is However, some practitioners argue that such
evidence that particular groups, notably immi- forms of inquiry are largely academic and not cen-
grants and asylum seekers or refugees, face a num- tral to understanding the concerns of day-to-day
ber of barriers when accessing primary health care practice. We propose the converse and contend
and may receive different levels of care. This is of that critical analyses, including discourse analysis,
particular concern since these same groups are have particularly important contributions to make.
over-represented among those who experience Discourse analysis challenges us to examine what
inequalities in health over the life course. are largely taken for granted aspects of practice
and prompts us to adopt a reflective stance as we
Address of correspondence: M. Judith Lynam, Associate examine our roles and strategies for increasing the
Professor, Co-Director Culture, Gender and Health Research
Unit, University of British Columbia, School of Nursing, T 201- effectiveness of the care we provide.
2211 Wesbrook Mall, Vancouver, British Columbia, Canada In introducing a book on nursing policy in
V6T 2B5. Email: judith.lynam@nursing.ubc.ca Britain,Traynor (1999) observes ‘discourses provide
© 2007 Cambridge University Press
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positions that can be adopted, spaces that can be culture and consider how these discourses have
occupied, categories that can be made available’ contributed to a categorization and representation
(p. 27).Traynor’s statement underscores the import- of the clients with whom we work. As Powers
ance of discourses to the health care enterprise (2001) observes ‘nursing students are taught the
and positions discourses as agents of dialogue. His proper ways to interact with a stereotypical “Black
comment also implies that discourses are dynamic. person” or “Asian person” without letting the
We extend this stance and argue that we must not patient determine the structure and process of the
limit our interest in discourses to the spaces they clinical encounter’ (p. 43). The categorization, evi-
create but also, we must consider the ideological dent in the case Powers refers to, arises out of a
position that underpins the discourses of interest discourse that characterizes culture as static repre-
and the social processes that produce and sustain sentations of groups. We argue that such categor-
them. We argue that such analyses have the poten- ization contributes to unintended and frequently
tial to foster dialogue about, and prompt reflection undesirable consequences. Consequences, that we
on, the ways discourses operate. Our intention in hope to show, can have an impact on health.
this article is to draw attention to potential contri- In beginning this exploration, we are mindful
butions of discourse analysis to practice. We pro- that the categories we draw upon as we navigate
pose to accomplish this aim by: briefly introducing our social world are not neutral. In this regard, we
discourse analysis and the theoretical premises draw upon insights of critical feminist scholars
that underpin it; providing examples of insights for whose analyses have illustrated the ways classifica-
practice obtained from studies that have used dis- tions and categories ‘conceal the fact that social
course analysis; and using discourses of culture and differences always belong to an economic, political,
health to illustrate some of the unintended conse- ideological order’ (Wittig, 1996: 24). Moreover,
quences of categorical representations of culture. such social classifications or categories become
‘institutionalized’ or thought of as ‘natural’ when
they are taken up in and permeate both formal and
Background informal discourses.
In this article, we use discourses of culture, as
To accomplish our aims, we build upon critical the- reflected in professional and policy literature and
orists’ observations of the often overlooked ways day-to-day interactions, to reflect upon the nature
discourses or ‘authorized forms of language’ create of the ‘space’ such discourses create, the ways they
structures that privilege or exclude persons or shape experience and how they guide or inform
groups. Following from this, we argue there is also practice-based interventions.
a need for the analyst to: adopt a critical stance
and consider for whom a ‘space’ is created; consider
whose viewpoints are privileged or masked by a Discourse analysis
particular discourse; and make visible the processes
or practices that sustain or interrupt discourse(s) Discourse analysis is one of a number of analytic
and with what effect. perspectives rooted in critical social theory
In recent years, scholars taking a critical per- (Powers, 2001). In her presentation, Powers (2001)
spective drew attention to the ways professional traces the influences of critical theoretical per-
discourses delineated the mandate of, and strat- spectives and postmodernism on discourse analysis.
egies for, practice. For example, analysts have illus- She contends that a central focus of analysis is on
trated the ways the positioning of practitioners as the nature of scientific knowledge and the assump-
experts has both legitimated and sustained power tions that underpin it. She contrasts this tradition
differentials between different professional discip- with that of ‘foundational science’ in the positivist
lines and their clients (Bartkowski, 1988; Cheek tradition. She argues that while foundational sci-
and Rudge, 1994; Porter, 1998; Powers, 2001). In ence screens out context, history, possibility and
this article, we consider what are largely taken for situatedness, critical theoretical perspectives,
granted aspects of primary health care practice. including discourse analysis, foregrounds them
That is, our focus is on the ways professional and (eg, Powers: 7). Powers also contends that the aims
policy discourses have taken up the concept of of analysis – of foundational science and critical
Primary Health Care Research and Development 2007; 8: 54–67
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https://www.cambridge.org/core/terms. https://doi.org/10.1017/S146342360700007256 M. Judith Lynam
theoretical perspectives – also differ. A principal understandings that recognize the complexity of
difference being that instead of analysing the con- social phenomena.
cept, discourse analysis analyses the process. Foucault (1977; Gordon, 1980) provides a critical
In what follows, we briefly introduce the work of strategy for discourse analysis that is empirically
a selection of theorists in order to draw attention to grounded. His work illustrates the analytic poten-
the nature of contributions critical analyses have tial of shifting the focus of analysis away from cat-
made to health care practice. In so doing, we draw egorization towards processes. For example, his
attention to the issues different critical perspec- highly influential research on prisons and medi-
tives foreground. We then explain why we drew cine draws attention to how such processes as ‘sur-
upon Pierre Bourdieu and Dorothy Smith to illus- veillance’ and the ‘medical gaze’ operate and are
trate the ways discourses of culture and health, the legitimated through discourse. Foucault’s analyses
ideologies that underpin them and the practices illustrate the ways different forms of power influ-
that sustain them, shape experience. ence the nature and structure of interactions such
as those between patient and practitioner. His
analyses also demonstrate how disciplinary dis-
Discourse analysis and health care courses have legitimated particular forms of sur-
veillance as aspects of professional practice and
In his analysis of the theoretical and philosophical defined the nature and forms of knowledge needed
underpinnings of different approaches to dis- in practice.
course analysis and analyses of discourses within Disciplinary knowledge develops over time and
nursing, Traynor (1996; 2004) observes that the is subject to a number of influences. As such, some
nature of knowledge and one’s place in the process use Foucault’s perspective on discourse analysis to
of knowledge generation must take into account examine or trace institutional influences on prac-
the contextual influences of history and culture. In tice knowledge while also making visible the ways
further discussing the ways such influences are such influences supplant other agendas through
manifest, Traynor (1996) notes ‘discourse analysis competing discourses and the authority accorded
attempts to explore the practice of language as it is them. For example, Cowley and colleagues (2004)
used to construct a reality that often serves to sup- drew upon Foucault to illustrate ways structured
port particular institutional ideologies’ (p. 1156, assessment tools shifted the focus of Health Visitor
emphasis added). It can be inferred then, that practice and the nature of relationships estab-
Traynor recognizes the importance of making ideo- lished between clients and Health Visitors. Their
logical positions visible and that he also links dis- analysis shows that the introduction of assessment
course to broader institutional practices and instruments was not a neutral activity. They took
policies. direction from Foucault’s theoretical position to
Like Traynor,Allen, writing in the US, locates his focus attention on the relationships between
stance on discourse and discourse analysis within knowledge and power and the ways these are used
the constructivist paradigm. For example, Allen’s in language and institutional policies and practices –
(1996) analyses of discourses of culture and gen- or discourse – to illustrate how health visitor prac-
der are informed by this position. He argues cul- tice was redefined.Their analysis drew attention to
ture and gender are not ‘objects’ or ‘things’ to be competing discourses in community health practice
discovered, rather, they are ‘constructed through and the ways these played out in interactions
discourse and that such constructions arise from between Health Visitors and clients with a con-
different perspectives and have different purposes’ comitant impact on their relationships and the
(1996: 96). It follows that different constructions nature of practice.
create different types or forms of ‘spaces’ and have Smith is a feminist scholar who proposes institu-
the potential to contribute to a dialogic process of tional ethnography as a method to guide critical
knowledge development. Moreover, a number of analyses for a number of purposes, including dis-
authors (eg, Allen, 1996; Anderson, 2004a) argue course analysis. Her position is that the prevailing
that when we take a constructivist position on social order (evident in text and narrative dis-
knowledge development, we are able to move away courses) has historically privileged a ‘male’ per-
from categorical understandings and move towards spective. Moreover, her position is that social
Primary Health Care Research and Development 2007; 8: 54–67
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structures and the practices that sustain them drawn upon this perspective to critically examine
organize individuals’ experiences. perspectives on health inequalities (Lynam, 2005).
In this article we examine particular discourses of
Institutional ethnography takes up a stance
culture and health and explore the nature of the
in people’s experience in the local sites of
‘spaces they create’ and their attendant influences
their bodily being and seeks to discover what
on experience. While Bourdieu does not name
can’t be grasped from within that experience,
power as a central concept in his theoretical work,
namely the social relations that are implicit
he does examine processes and practices that create
in its organization
privilege and disadvantage and does focus attention
(Smith 2001: 161).
on the social processes that assign value to different
As such, she argues that if research begins with the forms of ‘capital’ (Bourdieu, 1990; 2001; Bourdieu
viewpoint of those generally outside of the frame – et al., 1999; Bourdieu and Wacquant, 1992). In his
in her case women – the analyst can then draw conceptualization, it is these processes that are of
upon experiences to identify the disjunctures and interest because they contribute to the creation
points of congruence between prevailing discourses and maintenance of social structures and associated
and women’s experiences. In this way, discourse spaces that shape experience. As such, Bourdieu’s
analysis offers insights into the nature of spaces perspective offers a means of incorporating the
discourses create and whose interests they reflect. perspectives of individuals into discourse analysis.
Analyses informed by Smith’s methodology make But, Bourdieu takes the goal of such analysis fur-
visible the ways prevailing, and often unques- ther. His analytic tools enable the analyst to make
tioned, organizational processes and practices can visible the ways such practices as traditions sup-
serve to privilege some while disadvantaging others, port particular views of what is ‘normal’ or ‘natural’
with concomitant effects on their capacity to access while also reinforcing particular perspectives of
services or mobilize resources for health (Dyck et al., authority (Bourdieu, 1994). His research illustrates
1995; Lynam et al., 2003; Perry et al., 2006). the ways such practices create and sustain social
In keeping with Traynor’s observation that dis- structures that may privilege some at the expense
courses ‘create spaces’ and Anderson’s (2004b) of others and in doing so constrain individual’s
observations that some discourses are historically access to resources or opportunities.
assigned to the margins, focusing attention on For example, Bourdieu’s (2001) analysis of forces
processes and practices that refine or sustain dia- of change in gender relations that have historically
logue and/or effect change becomes particularly privileged men through processes of ‘symbolic vio-
important.We contend that Bourdieu’s perspective lence’, has traced the nature of systemic change that
offers such analytic tools. Moreover, because his has accrued from the introduction of feminist dis-
perspective foregrounds an analysis of processes courses. Bourdieu contends that feminist discourses
influencing the ways relationships are constituted, have been effective in shifting institutionalized
it is particularly useful for understanding individ- practices or traditions, and in introducing alternative
ual’s capacities to develop relationships and to perspectives on women’s abilities in part, because
access and mobilize support to foster health. The they have been pervasive, persistent over time and
analysis that follows is informed by our under- have targeted ‘local’ and institutional policies and
standing of Bourdieu’s theoretical stance as pre- practices (Bourdieu, 2001). However, he cautions
sented in his own writing and others’ critiques of it that prevailing discourses are socially and struc-
(Bourdieu, 1990; 1994; 2001; Bourdieu and turally embedded and, as such, are slow to change.
Wacquant, 1992; Schubert, 2002; Dillabough, 2004; Bourdieu’s work can be seen as aligned with the
Reed-Donahy, 2005). constructivist perspective. In addition however, it
Bourdieu (1990; 2001; Bourdieu et al., 1999) had also requires the analyst adopt a critical perspective.
as a central goal, to make visible the ways broader In the case of culture, this perspective offers a means
societal practices, sanctioned in policy and through for recognizing the ways traditions and practices
tradition, structure relationships and shape experi- accepted as ‘normal’ can be critically examined.
ences of those largely outside of formal institu- Such examinations hold value because they help
tional discourses such as the poor, immigrants, to make sense of taken for granted and often cat-
women and/or youth. In earlier analyses I have egorical or essentializing discourses. ‘Dualisms do
Primary Health Care Research and Development 2007; 8: 54–67
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https://www.cambridge.org/core/terms. https://doi.org/10.1017/S146342360700007258 M. Judith Lynam
not arise from simple namings – rather from his- of the relationships of first generation immigrant
torically constituted, pervasive but unquestioned women and their teenaged daughters with others in
relationships’ (Bourdieu, 2001: 105). Bourdieu their communities and examined their experiences
argues such tacit understandings of ‘normal’ are in accessing supports and resources for health. One
‘embodied’ as cognitive structures and physical dis- of the goals was to understand whether these women
positions over time. Moreover, he notes elsewhere: viewed the informal sector, specifically their rela-
‘The dominated apply categories constructed from tionships with others in it, as a resource. Answering
the point of view of the dominant to the relations this question could provide insight into the role of
of domination, thus making them appear as nat- the informal sector as a resource for health. It could
ural’ (Bourdieu et al., 1999: 50). Using gender as an also help us to understand ways primary health care
example of such unquestioned relationships, interventions could strengthen the resources of the
Bourdieu’s critical analysis demonstrates that the informal sector or foster access to the resources of
introduction of feminist discourses offered an this sector to supplement primary health care inter-
alternative language, point of view on, and analysis ventions.This article builds on this work and focuses
of, the everyday. This, Bourdieu argues, illustrates particular attention on discourses of culture and
the potential impact that can accrue when alterna- health. We undertake an examination of the ideo-
tive discourses or ‘spaces’ are introduced and social logical premises that inform such discourses and
processes are put in place to sustain them. consider their influence.
This brief overview of selected critical perspec- Key theorists drawn upon in conceptualizing
tives on discourse analysis draws attention to their the study were Bourdieu (1990) and Smith (1987).
analytic potential and their potential for establish- The perspectives that informed the study design
ing links between discourse, local experiences and and analysis were chosen because they build from
the processes and practices that sustain them. It also the premise that experiences are socially organized
offers different examples of ways critical analyses and provide direction for analysing individuals’
have drawn attention to tacit understandings and experiences in relation to institutional structures
the ways these can privilege particular viewpoints. and processes. As Bourdieu and Smith both argue,
In what follows, we draw upon a research case to policies and practices that privilege some groups
examine discourses of culture and health. over others (through eg, gender, class or social
location) are so pervasive that they are viewed as
‘normal’. They advanced methodological strat-
Background to the case: discourses of egies that invite examination of the ‘day-to-day’
culture and health and related institutional practices from the view-
point of those outside of the process. In addition,
The study that provides the case for the examination they used these viewpoints as a place from which
of discourse drawn upon in this article, builds from a to examine the assumptions of policy discourse
programme of research that shows the importance and related practices. Giving voice to such per-
of the informal sector as both a source of support for spectives has the potential to ‘interrupt’ prevailing
individuals and a largely unacknowledged resource discourses while prompting reflection on both
drawn upon by the health care system, particularly intended and unintended consequences of such
the primary health care system (Lynam, 1985; discourses, and challenging prevailing discourses
1990; 1995; 2004; 2005). This article builds on this and the assumptions that underpin them.
earlier research to illustrate the ways discourses of The methodological premises of the perspective
policy influence how the client and goals of practice require that the researcher engage with participants
are conceptualized. These impact the nature of while also offering them a mechanism to share their
resources available to families and primary health viewpoint and experiences through the interviews.
care practitioners as they strive to achieve goals in This first stage of data gathering and analysis was
care. We argue it is important for practitioners to followed by a critical examination of policies to
consider what influences individuals’ capacities to explore the ways in which participants’ experiences
access and mobilize support and resources for health were shaped by social and organizational processes.
promotion and illness management. The particular After receiving ethical approval for the study
study drawn upon in this article explored the nature in Britain and Canada parents, teens and key
Primary Health Care Research and Development 2007; 8: 54–67
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informants were invited to participate in a series of relationships they established with others (Lynam,
interviews using a process of third party recruit- 2006; Lynam and Cowley, in press). Moreover,
ment. Potential participants were provided infor- given the evident importance of relationships as
mation about the study by persons in a number of resources for health (Berkman and Breslow, 1983;
community-based organizations, those who Cooper et al., 1999; Berkman and Kawachi, 2000),
expressed interest were invited to participate. The marginalization and the processes of social loca-
parents participated in small group interviews and tion associated with it, has consequences for health.
then a series of follow-up individual interviews. The As the data were analysed, the processes of mar-
teens and key informants participated in one to three ginalization were linked to ‘marginalizing dis-
individual interviews with the investigator.Thirteen courses’. That is, such concepts as ‘exclusion’,
mothers, nine teenaged girls and one boy were ‘minority’ and ‘diversity’ made their way into the
interviewed in Vancouver, Canada.Ten mothers, one day-to-day language of participants and served to
father and six teenaged girls were interviewed in categorize or position them in particular ways. The
London, Britain. Eight key informants from both prevalence of such rhetoric moved individuals to
countries also participated in one to three interviews. ask: How can I see myself as a person of value,
In the study, from which the exemplars are drawn, with a contribution to make, if I am characterized
mothers and their teenaged daughters who were as ‘minor’ and as excluded? In what follows, we
immigrants, refugees or asylum seekers in Britain demonstrate how these views have both intended
or Canada, participated in small group interviews and unintended consequences for individuals and
and a series of individual interviews. Key inform- how policy is articulated.
ants in various roles (frontline and administration) While many of the participants in this research
in primary health care delivery were also inter- had difficulties, their difficulties were not grounded
viewed. The nature of these participants’ experi- in their cultural beliefs or values as culturalist per-
ences is reported elsewhere. However, a central spectives would suggest. Rather, their difficulties
concern was that their experiences of intercultural were related to their social positioning – as immi-
relations were characterized by marginalization. grants and asylum seekers or refugees. One parent
In this article, we draw upon this aspect of the par- made the following observations.
ticipants’ experiences to reflect on the nature of
‘spaces’ different policy discourses open up, exam- They (my children) are not really welcome
ine the ideological premises that underpin them, into their society … because they are, um,
and consider the ways discourses shaped experi- why us? Because we are foreigners, because
ence. Using the case of culture and health, we illus- um, we have not the same language, we have
trate ways discourses can, often inadvertently, not the same culture, and especially, especially
contribute to experiences of ‘being on the margins’ because we are refugees, and you know what
and illustrate how processes can be interrupted with that means in this, in this country.
alternative discourses. In this regard, we seek to In this example, the speaker categorizes the children
illustrate the need to move beyond discourses that as foreigners and points out that ‘foreigners’ are
provide what are ostensibly neutral descriptions ‘of’ welcome only with caveats.This tenuous social sta-
culture to consider how culture operates. In particu- tus, perpetuated in part by unchallenged assump-
lar, we seek to illustrate how different discourses tions held and communicated by others about
and the authority accorded them, shape institutional refugees and immigrants, positioned the women,
practices and social relations and influence how their daughters and families on the margins of the
individuals view themselves and those around them. workforce, housing market, neighbourhood or
classroom, even once they became citizens.
In the following quote, a health professional
Does discourse matter? speaks about how she is perceived by others:
The participants’ experiences would suggest that When people look at me they see me as a
yes, it does.As noted in earlier works marginalization Black person and then make assumptions,
was central to the participants’ experiences and that I am not English, not educated.
was an important influence on the nature of the (Health Professional speaking)
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As this woman explained in the interview, the Discourses of culture and health
problematic is that she continually is put in a pos-
ition of defending herself and her credentials. She In what follows, we introduce a number of the-
was educated in Britain, works in her practice field oretical perspectives on ‘culture’ and on ‘culture
in health and sees herself to be on par with her col- and health’ to illustrate the spaces associated dis-
leagues. She also has experience to draw upon in courses open up, the categories they create and the
her work with clients that others in her field do not. assumptions that underpin them. The goal of this
However, this woman’s visible features ‘speak first’. examination is to draw attention to their potential
She is Black, and on this basis people assume she is forms of influence when taken up informally in
‘not English’ and ‘not educated’. As this account conversations or interactions and in more formal
suggests, it is peoples’ (invalid) assumptions that this discourses such as those of policy and practice.
professional must continually confront. Moreover, Theoretical perspectives are not static. Rather,
the above accounts show how day-to-day perspec- by theorists’ own accounts, they are extended or
tives on migration status, social positioning, visibility refined as limits are identified or as the contexts in
and competence merge into categorical appraisals. which they are taken up introduce new theoretical
The discourses of difference could be seen as challenges to be addressed.Theoretical perspectives
contributing to separating out – programmes, on culture and health are no exception. The issues
resources and individuals. However, there was also of culture, diversity and exclusion have received
evidence of competing discourses in the data. considerable attention in scholarship in Britain.
Some of these fostered a view and created struc- This scholarship has been taken up in countries
tures that were (more) inclusive with concomitant throughout the world. A review of this literature
positive effects on experience. identified scholars who take a range of positions
The teens in Britain were more likely to speak and engage in a number of debates including the
of their experiences using terms like racism, or merits and consequences of conceptualizing cul-
exclusion and often, despite citizenship, referred ture as static or dynamic. In what follows a number
to themselves as not ‘British’. Whereas, Canadian of perspectives on culture are considered in light
teens, while acknowledging difference, linked this of study data to draw attention to the ways women’s
to being ‘Canadian’. These latter teens were also experiences of marginalization are socially organ-
more likely to view some of their cultural features ized. In this study popularized, and largely unchal-
or abilities, such as language skills, as assets rather lenged, images of ethnic minorities, immigrants,
than liabilities. Similarly, although all families asylum seekers or refugees influenced how the
were of limited means, the social organization of women viewed themselves and influenced their
community-based resources (such as recreation capacity to participate in society. Moreover, as
and sports programmes) meant programmes were relationships are resources for health (Berkman
much more readily available (affordable and geo- and Kawachi, 2000; Berkman and Breslow, 1983;
graphically accessible) to Canadian teens than their Cooper et al., 1999) marginalization has implica-
British counterparts. In addition, in Canada it was tions for health (Hall, 2004; Lynam, 2005).
much more likely that participants in such pro- Stuart Hall (1990; 1996a; 1996b) traces the ways
grammes reflected the social and cultural diversity changing discourses have influenced representa-
of the region. tions of, and assumptions about, people of colour.
These examples draw attention to the difficul- His theorizing, largely undertaken in the British
ties that can arise when discourses that categorize context, traces the ways history defined groups
people of colour and refugees in particular are evi- and cast them in particular roles through language
dent in general conversation and are unchal- and practices of ‘othering’. Such practices are vis-
lenged. Following the direction of Smith and ible in day-to-day conversation and are also taken
Bourdieu, a central concern is that some dis- up in research and policy. Hall argues against such
courses become part of the day-to-day and are essentializing discourses.
accepted as ‘normal’ or as ‘fact’. To make sense of Writing about studies of ‘race’ and health in the
these different discourses and their influences, we UK, Ahmad (1993) argues that ‘the role of ideo-
turn to an examination of discourses of culture logical considerations has been largely ignored
and health. in health and health service research on black
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populations’ (p. 1). Ahmad, like a number of other they share common experiences or are part of a dis-
analysts, problematizes the culturalist stance crete population group, ignores the complexities
because it can be misused when everyone within a of experience. It also disregards the ways in which
‘group’ is considered to have the same experience. other aspects of one’s life intersect to shape it.
In addition, by focusing attention on health pro- Moreover, the process of categorization that arises
files as associated with a cultural or ethnic group’s out of essentializing discourses can contribute to
beliefs and values, the importance of other factors the negation of the individual and mask the
such as the impact of racialization or social loca- broader social processes at play.
tion on health are eclipsed, thereby masking other Each of these scholars challenges us to be mindful
processes operating. of the nature of the spaces culturalist discourses
Fiona Williams (1989) also writing about cultur- create and, in turn, the assumptions about ‘same-
alist discourses in the British policy context ness’ or commonality of experience that are inher-
observes that: ent in the culturalist view. With recognition that
culturalist discourses shape our thinking about the
Although the step forward taken by ethni-
‘other’, scholars sought to make visible the conse-
city researchers was to examine culture from
quences of practices of ‘othering’ for health. Health
the immigrant’s point of view and in a posi-
inequality researchers in Britain drew attention to
tive light … and to establish the reality of a
associations between social–material circumstances
multi-racial society, nevertheless, looking at
and health, and have shown that some groups are
‘minority–majority’ relationships in a cul-
more likely to be socially excluded (Townsend and
tural framework excludes vital elements in
Davidson, 1992; Shaw et al., 1999; Nazroo and
the relation of ‘race’ to class and power, and
Davey Smith, 2001).
institutionalized racism. This means, how-
ever sympathetic the cultural appreciation, it These struggles for equitable health and
can still skew the analysis and ‘blame the vic- health care are essentially located in the
tim’ (p. 92). wider struggles for equity and dignity which
Williams’ observations resonate with the accounts have been a part of black people’s history.
of the participants in this study and draw attention (Ahmad, 1993: 7)
to the need to recognize the impact of processes of Processes of social location (including marginal-
categorization but also to consider how other cir- ization and social exclusion) that arise out of prac-
cumstances like gender, or material resources inter- tices of ‘othering’ are increasingly being viewed as
sect to create multiple forms of disadvantage. social determinants of health. Such observations
In his appraisal of the health care system’s have important consequences for health services
response to persons of ‘ethnic minorities’ in Britain, delivery and prompt us to consider creating new
Alexander (1999) problematizes the concept of spaces and introducing alternatives to marginalizing
community. He challenges the assumption that discourses – discourses that foster inclusion.
people who are members of ethnic minorities con- Culley (1996) undertook a critical review of the
stitute geographic and/or social communities. He literature to examine the theoretical premises of
argues that programmes must take into account research in culture and health, particularly related
the ways communities are organized and notes to nursing in the Britain. She took up an argument
that this may not coincide with the ways services similar to that of Ahmad and issued a plea to move
are currently organized. That is, he suggests that it the discourse on culture and health forward.
is incorrect to assume that everyone of the same
ethnic background has the same health care needs. (T)he experience of living in a society which
Alexander’s observations reverberate with Fenton is structured by gender, socio-economic and
and Charsley’s (2000) ‘critical interrogation of the racial inequalities and the inter-relation
concept of ethnic groups as populations’ (p. 406). between the living and working conditions
While Alexander points to structural constraints on of minority groups and their health status
the ways in which practice initiatives are undertaken, have been given less prominence than issues
Fenton and Charsley argue that to assume because of ‘cultural’ difference and problems of
people have been categorized in a particular way communication. Not only are very important
Primary Health Care Research and Development 2007; 8: 54–67
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issues largely excluded from the debate, the She draws attention to the persistence of processes
dominant way of conceptualizing issues of and practices of categorization and reminds the
‘race’ and health has many serious flaws reader that people of colour are not all immigrants,
which may serve to obstruct the attainment as many individuals and families arrived in Britain
of equitable health and health care. in the postwar years. She observes that it is not
(Culley, 1996: 564) their ‘culture’ or their status as newcomers that
accounts for their social standing, as popular dis-
Writing in 1996, Culley argues that the discourse courses and related images suggest, but rather, the
in the British health care context is framed within persistence of racializing practices of the broader
a multicultural1 perspective that centres on educa- society. Baxter’s comments align with Williams
tion and changing attitudes. She cites Stubbs (1993) and Williams-Morris (2000) observations in the
in noting ‘within this discourse, the solutions to US that racializing practices have changed slowly
problems facing minority groups are “essentially because assumptions are not challenged and alter-
technical and professional rather than political” native processes are not put in place.
(Culley, 1996: 565). Culley’s analysis supports the These perspectives draw attention to the social
view that a culturalist stance, while of some rele- processes and social structural relations that are
vance to understanding individuals’ perspectives, associated with different discourses on culture and
is problematic. This occurs when the culturalist health.As noted at the outset of this article,Traynor
stance shifts attention away from addressing struc- argues that discourses of policy and practice can
tural conditions that show evidence of sustaining support a particular institutional agenda.Therefore,
inequities and evidence such conditions have per- it is important to consider the perspectives that
sistent negative effects upon health and health underpin policy. With this in mind, we turn now to
services delivery. a brief examination of ways the British policy con-
In the same era, Baxter makes the case for the text has taken up and/or contributed to the main-
education of health professionals about issues of tenance of particular discourses of culture and
equality in ‘multiracial Britain’ of the 1990s.As well health. In light of the preceding analysis, we reflect
as outlining the poorer health profiles of people of upon the nature of spaces these policies create while
colour, she argues that their social location has roots considering the assumptions that underpin them.
in these population groups’ migration history.
A substantial number of those who immigrated
from the Caribbean or Africa settled in neighbour- Shifting discourses: culture, health and
hoods surrounding London, ‘where there was a health inequalities are new spaces being
demand for labour’ (Baxter, 1997: 16). She observes: created?
A much higher proportion of black and eth-
nic minority people than white people are Despite considerable research in many countries,
concentrated in areas with a high level of documenting the systemic nature of health
material and social deprivation, such as poor inequalities and linking them to such social condi-
housing conditions and underemployment, tions as poverty, education, racializing practices
and therefore they suffer from poor social and poor working conditions, governments have
and environmental and economic conditions. not, historically, made a commitment to broaden-
The pattern of social and economic inequal- ing the health agenda to include restructuring and
ities is closely related to social class. financing to address these issues.
(Baxter, 1997: 20) At the time this study was being completed
however, Britain had moved away from an era of
policies of restraint and had made a commitment
to redressing health inequalities and mitigating
1
The term multicultural, like other terms holds different mean- social exclusion. A key initiative was the establish-
ings. Culley’s use of the term I interpret to be what Ahmad ment of the Social Exclusion Unit (SEU) (Britain,
refers to as the culturalist approach. That is, a view of culture
that focuses on beliefs, values shared by a ‘cultural’ group and SEU, 1998).Also in this time period the government
one that does not direct attention towards the analysis of the made a commitment to modernize the public ser-
social and institutional processes that influence action. vices, redress inequities faced by racialized groups
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(Britain, HO, 2000, March) and amend the Race extracurricular sports and arts programmes in
Relations Act (Britain, HO, 2001a; 2001b; 2001c; schools in disadvantaged neighbourhoods.
2001d). These initiatives suggest that the govern- Introducing these as health initiatives suggests the
ment is attentive to inequities and recognizes the government is concerned with addressing the
structures (including social processes) that sustain social conditions that undermine capacity building
them. They therefore proposed to put in place of youth thereby contributing to health inequalities.
mechanisms to ensure inequities and their conse- It can be argued that such initiatives represent
quences are at the centre of the policy agenda. policies of inclusion by making resources available
Such initiatives suggest a shift in the ideological across all social sectors and creating opportunities
premises underpinning the broader policy agenda. for youth.
In what follows, I trace the steps that suggest the In these British documents, there is evident
social roots of health inequalities are being recog- recognition of the social roots of health inequalities
nized and describe a number of initiatives that and how they have been taken up as health issues.
seek to consider the consequences of marginalizing The central concepts evident in this policy discourse
discourses. In the brief review that follows, I draw include recognizing: the ways different social con-
attention to ways this shifting ideological stance ditions intersect to create disadvantage; the char-
competes with racializing and marginalizing dis- acteristics of the social (particularly neighbourhood)
courses inherent in some conceptions of culture environment as a resource for health; education as
and health. a resource for health; and community involvement
The language of policy has taken up and pro- through representation and partnerships as con-
posed to address the experiences of being on the tributing to health. Fostering social cohesion as a
margins.That is, it seems policy makers have recog- feature of the community that can contribute to
nized that marginalization and exclusion are experi- health is also an evident interest. An ideological
enced at the local level, in neighbourhoods, and shift can also be identified in that by seeking to
that opportunities to develop capital are not readily ensure all initiatives are mainstreamed and seen as
available to those of limited means. The policy ini- central to the NHS mandate (Britain, Department
tiative ‘Tackling Health Inequalities: A Programme of Health, 2003, July), discourses of inclusion are
for Action’ (Britain, Department of Health, 2003, being taken up in British health policy.This suggests
July) for example, elaborates on these initiatives and movement beyond rhetoric to structure and process.
delineates in detail the nature of community based These health initiatives are to be further rein-
strategies for remedying structural inequities in forced by concurrent initiatives within the SEU.
service delivery by working in partnership with This unit has an overarching mandate. A review of
community and voluntary organizations while also the extent of initiatives under their purview draws
building community capacity (Britain, Department attention to efforts to recognize that inequalities
of Health, 2003, July). The premises of this policy are the result of a range of conditions and that some
era align with the ideologies underpinning the sectors of the population are particularly vulnerable.
work of key researchers in health inequalities. It
Ethnic minority people are more likely than
can be argued that these policy initiatives seek to
the rest of the population to live in poor
foster social cohesion (Wilkinson, 1996; 1999),
areas, be unemployed, have low incomes, live
address inequalities in health experienced by ethnic
in poor housing, have poor health and be the
communities through structural change (Nazroo,
victims of crime.
1999) and enhance the accessibility of services
(Britain, SEU, 1998, Cm 4045: 8)
(Benzeval and Donald, 1999).
The intersections of family poverty and parental These British policy initiatives represent a new
unemployment on children’s wellbeing has also era in social and health policy discourse and
been recognized in this policy era. ‘The vicious announce the intention to recognize the ways a
cycle of poverty, social exclusion, educational fail- number of social conditions intersect to contribute
ure and ill health is mutually reinforcing. It needs to health inequalities. This necessarily brief review
to be broken. It can be broken’ (Hutton, 2000: 8). suggests that the British policy discourse has moved
The recent action plan (Britain, Department of towards a vision of inclusion and in the process,
Health, 2003, July) proposed the introduction of has proposed a number of initiatives to address the
Primary Health Care Research and Development 2007; 8: 54–67
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structural issues (such as low income and poor examine assumptions inherent in theory and pol-
housing) that contribute to health inequalities. icy discourses. More importantly, they also offer a
However, drawing upon Bourdieu’s perspec- way of drawing upon different viewpoints to trace
tive, we must be mindful that these shifts need to the impact of different discourses on experience.
be accompanied by a critical vigilance. For, as evalu- In such analyses, a key consideration is the perva-
ations of previous policy have shown, if resources siveness of discourse and whether there is evidence
are not committed to implement policy shifts, that dissenting views are considered as forces for
then goals are not always achieved (Britain, change at the organizational or policy level.We posit
Department of Health, 1999). Moreover, formal that such change may rectify existing inequalities
policy discourses need to find their way into for- or take these into account as programmes are being
mal and informal domains if they are to challenge developed or care is being provided. By critically
historically constituted practices. Discourses co-exist analysing the assumptions that underpin conclu-
and those that continue to single out people as sions about health inequalities, space can be created
vulnerable on the basis of particular features for broader understandings of social determinants
continue to reinforce stereotypical-categorical of health and the ways they contribute to health
images. Such categorization will continue unless inequalities. Such analyses are in line with research
efforts are made to focus attention on, and change, that has helped to shift the balance away from indi-
the processes that assign groups to the margins. vidual responsibility for health inequalities towards
a view that such responsibilities are shared with
society (Butterfield, 1991; Graham, 1993; Wilkinson,
Summary 1994, 1996; MacIntyre, 1997; Cooper, 2002).
Does discourse matter to professional practice
In this brief analysis of policy, we sought to offer and the people we work with? We would argue yes
insights into ways discourses of policies and the they do, in that they have the ability to exert an
ideological premises that underpin them create impact on many levels. For these reasons discourse
the contexts that shape individuals’ experience. As analyses have much to offer in knowledge devel-
such, they have the potential to create, or erode, opment for professional practice. The analytic
community contexts for health. We drew upon approaches employed here offer a means for show-
exemplars from a study that began by describing ing that when discourses are taken up on the ground,
women’s experiences and then, taking direction when their impact is pervasive and when discourse
from Bourdieu and Smith, proceeded to consider is supported by institutional policies, they ‘make a
the extra-local conditions that shaped them. In this difference’. If however, discourse remains ‘on the
article, we sought to demonstrate that considering books’ or while espoused, if challenges are not acted
ideological premises of policy and other discourses upon, disjunctures become evident. Such contradic-
and how these are enacted in practice, in relation tions are noted by those who are, or are not, served.
to viewpoints of those outside the policy process, can Such contradictions are evident in data or accounts
offer guidance for change or serve as hallmarks of as ‘disjunctures’ between policy and practice, or
success while drawing attention to the complexities evident in voices whose views are denied, eclipsed
of the policy and practice arenas.We also illustrated or minimized with their attendant effects. Such
the importance of recognizing competing discourses insights prompt us to attend to the ways broader
and of noting disjunctures or congruence between institutional practices shape the relationships we
formal policy and implementation plans. are able to establish with others and influence our
Bourdieu’s perspective offers the possibility of actions as practitioners.
analysing peoples’ experiences not solely as indi-
vidual experiences, but also as experiences that
accrue from the ways in which society is organ- Acknowledgements
ized. The significance of this for research in culture
and health is that we gain insights into ways of The research that this article builds upon was sup-
understanding and working with individuals. Such ported by a Canadian Health Services Research
insights could create the spaces needed to foster Foundation and Canadian Nurses Foundation
dialogue and could enable us to more critically Fellowship.
Primary Health Care Research and Development 2007; 8: 54–67
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