Place-focused physical activity research, human agency, and social justice in public health: Taking agency seriously in studies of the built environment
Highlights
► Place-focused activity research can potentially improve health and social justice. ► Any activity resource or barrier must influence the mind before shaping health. ► People are perceptive, critical, and deliberative in their behavioral responses. ► Attention to human agency can improve the science and ethics of ongoing research. ► Taking agency seriously is a powerful expression of respect for persons.
Introduction
In the past decade, studies increasingly have looked to the built environment as an opportunity to prevent disease and support human health (Dannenberg et al., 2003, Sallis et al., 2009). The built environment includes the buildings, transportation systems, and landscape patterns that are human made or modified over the course of years or decades (Lovasi, in press, Papas et al., 2007). One line of inquiry, labeled here as “place-focused physical activity research,” has investigated the effects of the local physical environment on transportation choices and on physical activity (Gutman et al., 2009, Ottoson et al., 2009, Sallis, 2009, Transportation Research Board, 2005). These studies have identified numerous area-based characteristics that may be implicated in health outcomes and potentially modified to facilitate healthy behaviors and to reduce the burden of chronic disease (Srinivasan et al., 2003, York, 2010).
Place-focused physical activity research is part of a broader movement in epidemiology toward studies to identify and explain the causative properties of social structures in the production and distribution of health. This research trend, referred to as social determinants of health or eco-epidemiology, among other labels (Forde and Raine, 2008; March and Susser, 2006; Syme, 2004; Venkatapuram and Marmot, 2009), represents a reaction against the individual-centered biomedical paradigm of preceding decades and harkens back to the inception of public health when regulation of land uses and hygiene practices was used to protect against communicable diseases (Hirschhorn, 2004, Perdue et al., 2003). This social determinants of health agenda aims not only to improve overall health but also to reduce the disproportionate incidence of poor health among economically disadvantaged and minority groups and to shift some of the responsibility for health from the individual to society (Link and Phelan, 1995). For many, the turn toward a social determinants paradigm represents a return to public health's historic commitment to social justice (Robertson, 1998).
As this agenda has gained momentum among health leaders (Commission on Social Determinants of Health, 2008, Commission to Build a Healthier America, 2009), there have been increasing calls to integrate the individual within the social determinants of health framework (Forde and Raine., 2008). On practical, conceptual, and ethical grounds, the case has been made for taking human agency seriously in health equity studies (Blacksher, 2010, Forde and Raine, 2008, Minkler, 1999, Schmidt, 2009b). Place-focused physical activity research in particular should heed this call. Unlike studies focused on environmental exposures to toxic substances, the harmful effects of which are assumed to be inevitable once predisposing conditions like nutritional status are taken into account, physical activity facilitators and barriers must influence the mind before having an effect on health. Yet, many of the hypotheses and conceptual models put forth to date ignore this fact. Structural environmental variables are conceptualized as constraints with little if any account of what is being constrained. Sometimes identified explicitly as “environmental determinism” (Ewing, 2005, Macintyre et al., 2002) but more often implicit, the supposition is that changing the built environment inevitably will produce more active behavior patterns and thus result in better health. Moreover, once an environmental characteristic has been linked to health in this way, policy interventions are assumed to be justified (Venkatapuram and Marmot, 2009).
Yet, built environment interventions, like so many health promotion interventions, have often proven ineffective (Simoes et al., 2009, Tudor-Locke et al., 2008, Wells and Yang, 2008). Education campaigns have been proposed to complement environmental change efforts (Saelens and Glanz, 2009), but this dual intervention strategy still rests on the decision power of some agenda-setting institutions or individuals. Disappointing results may not represent a failure of any particular study, but rather shortcomings of the research paradigm and, in particular we argue, inadequate attention to people's understandings of, historical and current relation to, and ideas for the future of their neighborhoods. Certainly, there are studies that acknowledge the complexities entailed in promoting health through environmental change, and some exemplary studies have developed creative strategies to involve community residents directly in research and planning for environmental change (Farhang et al., 2008, Lewis et al., 2005, Macintyre, 2007, Mensah, 2005, Mujahid et al., 2007, Schulz et al., 2005, Srinivasan et al., 2003, Transportation Research Board, 2005, Vasquez et al., 2006). Still, the field's treatment of human agency in the published literature has been sporadic and sometimes dismissive.
We maintain that the promise of place-focused physical activity research and by implication the broader movement toward a rich eco-epidemiology cannot be fully realized in the absence of systematic attention to human agency and its interaction with structure. More specifically, we argue that taking agency seriously in place-focused physical activity research is essential to the pursuit of health equity and the broader demands of social justice in public health, an important consideration as studies of the built environment and physical activity increasingly focus on socially disadvantaged communities (Floyd et al., 2008, Lovasi et al., 2009a). Our critique is aimed at the published literature to date1 rather than any particular research or advocacy initiative, and this critique is intended to bolster rather than dismiss new directions that integrate attention to individual and collective agency. The ecological models influencing place-focused physical activity research highlight the importance of physical activity determinants at multiple levels including the individual level (Sallis et al., 2006). Yet the recent advancement of place-focused physical activity research (Gutman et al., 2009, Story et al., 2009) presents renewed opportunity for more thorough attention to human agency.
We begin with a brief discussion of our working conception of human agency and its relation to structure in the context of health. We then identify and describe four categories of human agency pertinent to place-focused physical activity research and discuss how accounting for each may yield more effective research and reforms and more equitable health outcomes (Table 1). Both problematic and positive examples from the published literature are discussed, and our selection of papers is intended to be illustrative rather than representative. Finally, we discuss how this research and reform agenda can deliver on the demand to express respect for persons, a core principle in public health ethics and social justice in public health.
Section snippets
Human agency in the context of place-focused physical activity research
Recent efforts to articulate a theory of health lifestyles aim to correct individualistic interpretations of health-related behaviors (Cockerham, 2005, Frohlich et al., 2001). Drawing on Weber's notions of life choices and life chances, Cockerham defines health lifestyles as “collective patterns of health-related behavior based on choices from options available to people according to their life chances” (Cockerham, 2005, p. 55). Life chances refer to the structures and social norms that
Discussion
In sum, we have argued that attending to human agency in the forms and ways we describe above may result in more accurate research and, when applied in contexts of social disadvantage and vulnerability, more equitable health outcomes (Table 1). But there is another reason to take people's agency seriously in studies of the built environment and physical activity: it is a powerful expression of respect for persons.
Respect for persons is a core principle of public health ethics (Childress et al.,
Conclusion
Place-focused physical activity research has significant potential for informing urban policy and improving population health. But the promise of this field turns on taking human agency seriously. Built environments are the product of human imagination and invention and their impact on health is subject to human perception, deliberation, and participation. Yet, too often this research marginalizes or attempts to “control for” human subjectivity and, in doing so, ignores the histories, stories,
Acknowledgments
The authors thank the Robert Wood Johnson Foundation's Health and Society Scholars Program at Columbia University for funding the early research stages of this publication. We also wish to thank Carolyn Cannuscio, Kim Hopper, Michael Gusmano, and David Takeuchi for their reviews and helpful suggestions. Finally, we would like to thank Jacob Moses, Ross White, and Molly Jung for their meticulous assistance with manuscript preparation.
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