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Whose theory is it anyway?
  1. Jennie Popay
  1. Correspondence to:
 Professor J Popay
 Lancaster University, Alexandra Square, Lancaster LA1 4YT, UK; j.popay{at}lancaster.ac.uk

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Investigations into the role of theory in enhancing our knowledge of the factors that shape levels of and patterns in population health should not be restricted to the domain of researchers.

All journal editors welcome debates but it is perhaps surprising that debate should emerge from the planned publication of a glossary rather than a research paper or opinion piece. But then again this is a glossary (and guide) to “postpositivist theory building for population health”. There’s a lot in here to generate debate. Take the notion of “postpositivism” for example. Arguably it is words like this that have got social science a bad name but whole books have been written about postpositivism and its relation, often tense, with positivism. Then there is that term “population health”. As Dunn notes this is a vague term and therefore leaves lots of room for differing interpretations about what it is and what its primary purpose should be. Finally, and for some most fascinating there is the term “theory”. As the glossary and other commentators highlight there are many differing understandings of the role of theory in relation to population health. But implicit in the glossary and comments is the idea that the relevance of theory to population health is confined to the domain of researchers—and quantitative ones at that! So my contribution to this debate is to suggest that the role of theory in enhancing our knowledge of the factors that shape levels of and patterns in population health is much wider than this.

Firstly, there is the important question of the role of theory in qualitative research. I know that some JECH readers might be asking themselves what qualitative research has got to do with population health but that is a debate for another day. For now, let’s accept qualitative research is part of the population health research “tool kit”. If it is then much of what is written in this glossary has little relevance to the role of theory in qualitative research other than to emphasise the need for it. Theory is the core element of qualitative research, it derives from it (grounded theory), is tested in it, and most importantly is the mechanism through which qualitative research can claim more general relevance. Take the case of Hilary Graham’s work on smoking among poor women.1 The link that Graham makes between the women’s accounts of when and why they smoke with theories about the nature of women’s caring role allowed her to generalise from a small sample to the larger group of (white) women bringing up children in the face of severe material disadvantage. Similarly, in his study of the experience of patients on one ward in a mental hospital Goffman built theory about the nature and impact of “total institutions” on behaviour that transformed mental health policy and practice for ever.2

My second point concerns the role of lay theories in population health. I would raise two somewhat different issues here: the role of lay theories for the people involved and the challenge lay theories pose for academic theories.

There is at least one important difference between theories in research and those developed in ordinary life. In quantitative population health research theories are typically multifactorial involving the addition of more and more variables into putative models. In contrast the theories we all develop as lay people as we seek to make sense of our experience of health and illness are interpretations and elaborations of the meaning of causal factors in the context of everyday life. In Max Weber’s terms they provide understanding in terms of both cause and meanings. Qualitative research exploring lay theories about the causes of health inequalities, for example, has highlighted a number of “purposes” served by such theories. As Mildred Blaxter has argued for example, they are a means for people to re-assert their moral worth: “To acknowledge inequality would be to admit an inferior moral status for oneself and one’s peers: hence perhaps the emphasis on ‘not giving in’ to illness.3 This can be seen to be a claim to moral equality even in the face of clear economic inequality”. Lay theories about the causes of health inequalities have also been argued to be a means for people to re-assert individual control through an emphasis on indirect rather than direct mechanisms particularly an emphasis on stress as a key factor mediating the relation between material circumstances and ill health.4 From this perspective a more sophisticated understanding of lay theories about the causes of health and illness has much to offer public health.

Lay theories also challenge formal codified theories in population health research although these challenges remains largely implicit, emerging perhaps only in the high rates of non-compliance to be found in patients’ responses to medical directives5 or, more dramatically and less frequently, where individual patients take grievances to court. Increasingly, however, some of these “theories” are developing into organised protest. Remember the case of the women of the Bristol Survey Support Group who engaged in a battle against the medical researchers whose subjects they had been in a clinical trial.6 Not only did they take exception to the results of the trial but they challenged the theory underpinning this work. And more salient from a population health perspective is the increasing visibility of what Brown has called popular epidemiology.7 In the UK one of the most important examples of this is the case of people of Camelford in Cornwall who persisted in their challenge to the expert opinion that the 20 tonnes of aluminum sulphate accidentally tipped into their water supply in July 1988 had had no lasting impact on their health.8 The nature of the challenge posed by lay theories about the causes of health problems is twofold. Firstly, they represent a challenge to the “objectivity” of expert “theories”. They both contest the impartiality of expert knowledge compared with other forms of knowledge, and raise questions about the extent to which the process of objectification—upon which the truth-claims of scientific knowledge depend—permits a proper understanding of health problems. Secondly, they challenge the authority of professionals to determine the way in which problems are defined in the policy arena. Lay theories in the realm of population health therefore represent both an epistemological challenge and a political challenge to the institutional power of expert theories and it is a challenge that we in population health research have so far failed to face up to.9,10

Investigations into the role of theory in enhancing our knowledge of the factors that shape levels of and patterns in population health should not be restricted to the domain of researchers.

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