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By Gretel H. Pelto
Anke Niehof has contributed a welcome, lively and thoughtful analysis to the on-going discussion of conceptual models that can be used to link individual health and socio-cultural conditions. The significance of the household as the essential lynchpin between health and society still fails to receive central attention, either from scientists and scholars or from program planners and implementers. The lack of serious attention to household dynamics and conditions is difficult to explain. The inclusion of household demographic and economic characteristics in epidemiological, sociological and econometric studies is evidence of tacit recognition, but these are typically treated as “control” variables, rather than being seen as central to understanding social-health relationships. Implicit in Niehof’s paper is the idea that at least part of the neglect of the household, as a fundamental locus or unit of analysis, is due to a lack of strong conceptual models that can serve to guide both research and program activities.
Niehof’s skillful introduction of “care” into the conceptual model for health-society linkages is an important contribution. In nutrition there is a growing literature on the role of care for understanding the determinants of malnutrition in children in developing countries. UNICEF (1990) published and widely disseminated “The UNICEF Conceptual Framework for Determinants of Nutritional Status” in which the underlying causes of childhood malnutrition were categorized as “insufficient household food security,” “inadequate health services and unhealthy environments,” and “inadequate maternal and child care.” These, in turn, are seen as the result of basic causes, which rest on fundamental economic, social and political structures. The framework is now so widely cited and accepted in nutrition that it has taken on iconic status. More recent work on care and caregiving has ranged from efforts to synthesize the methodological and theoretical support for the concept (Engle et al. 1996), to examination of its role in young child feeding (Pelto et al. 2003), to empirical studies (Leroy 2005). To reach out to the public health nutrition audience, it will be useful if Niehof explicitly links her model to the nutrition and care framework so that the value of the household focus can be more directed highlighted for that audience.
Niehof’s model draws attention to the range of societal-household-individual dynamics that can be subsumed under the general heading of ‘macro-level/micro-level linkages.’ In the present version of her model these are implicit, but they are not actually specified with the same level of attention that she gives to intra-household dynamics. Empirical studies to trace macro-level/micro-level relationships in health have been surprisingly slow to develop, particularly given the clear recognition of such relationships in the theoretical perspectives of critical medical anthropologists. Susan Scrimshaw’s paper on induced abortion in Ecuador, prepared for a conference on “Micro and Macro Levels of Analysis in Anthropology” provides an example of the insights that can be gained by explicit attention to these linkages (Scrimshaw 1985). I hope that in the next iteration of her model, Niehof will develop her discussion of macro-micro linkages more fully.
I fully agree with Niehof’s decision to make explicit the role of gender in all of the processes of concern in a micro-ecological analysis. Without in any way diminishing its significance I think it is also useful to conceptualize it at a more fundamental level, which can be characterized as the analysis of “power.” Introducing the concept of power into the micro-ecological model has the advantage of calling attention to its role at all levels from the household to the broadest levels of global political economy. In a recent discussion, designed to reach a multi-disciplinary nutrition audience, Jeffrey Backstrand and I used the concept of power ” as a proxy for a large set of factors that reflect material, economic and political factors in human behavior.…” We suggest that power-related features need to be examined together with belief-related factors, which we defined as including “ideational, cultural and psychological features of human experience” (Pelto & Backstrand 2003: 297S). A central theme of our paper is that the tendency to focus exclusively on one or the other of these two broad domains has been a major barrier to collaborative research, within and across disciplines that are concerned with understanding the determinants and consequences of health and nutrition for individuals and societies. We strongly agree with Niehof’s contention that “…traditional disciplinary boundaries, such as those between medical anthropology, medical sociology, public health and nutrition sciences, not only stand in the way of understanding the processes involved, but also obstruct finding comprehensive solutions to major health problems.” In addition to building better conceptual models, for which Niehof’s presentation of a micro-ecological focus is a thoughtful contribution, integrating power-related and belief-related constructs into our research designs and careful attention to operationalizing them in our studies will also further the goal of breaking down barriers that constrain the applicability of our research.
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Previously published on medanthrotheory.org and is republished here under a Creative Commons license.
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