Marginalisation and Health: Lecture Notes

Introduction to Marginalisation and Health

Marginalisation

  • Marginalisation is defined as the social process of being made marginal, separated from the rest of society, forced to occupy the fringes, not considered to be the centre of things, and having a lower social standing.
  • It affects equity in the disbursement of resources such as food, housing, and wealth, as well as access to services, programs, and policies.
  • Marginalised individuals, families, communities, and countries experience poor health.

Difference and Deviance

  • Difference: The idea that an individual possesses characteristics that are dissimilar to or behaves differently from the majority of people within society.
  • Deviance: Behavior that transgresses social expectations and is likely to attract sanctions from other members of society (Liamuttong & Kitisriworapan, 2019, p.84).

Stigma

  • Stigma is an attribute or characteristic that separates people from one another.
  • It is used by individuals to interpret specific attributes of others as ‘discreditable or unworthy’ and this results in the stigmatised person becoming devalued (Liamuttong & Kitisriworapan, 2019, p. 88).
  • Stigma is socially constructed and is attributable to cultural, social, historical, and situational factors.
  • Stigma is culturally-derived, therefore, like culture, it:
    • Stems from values, attitudes, beliefs, norms
    • Changes over time
    • Is not held by all members of a society
    • Is expressed in language
    • Is affected by other structural factors, such as gender, class and ‘race’

Discrimination

  • Discrimination involves acting upon the idea that someone is of less value and should be excluded from social networks and the benefits of society.

Stigmatised Groups

  • Groups who are stigmatised often include those with:
    • Compromised physical ability
    • Mental health issues
    • Physical appearance differences
    • Specific sexual identities
    • Social deviance
    • Economic disadvantage
    • Particular racial identity

Layered Stigma

  • Layered stigma refers to a person holding more than one stigmatised identity.
  • Experiencing one stigmatising condition can increase the risk of other stigmatised conditions; for example, medication for psychosis may lead to obesity and subsequently type 2 diabetes.

Effect of Stigma on Health

  • Stigma leads to:
    • Reduced access to the social determinants of health
    • Increased morbidity and mortality

Case Study: The Stigmatisation of Obesity

  • Obesity is defined as excess body fat accumulation with multiple organ-specific pathological consequences.
  • Overweight and obesity are at ‘crisis’ levels globally, concerning health and financial levels for individuals and countries.
  • Recent global estimates:
    • Worldwide obesity has nearly tripled since 1975.
    • In 2016, 39% of adults aged 18 years and over were overweight.
    • 39 million children under the age of 5 were overweight or obese in 2020 (World Health Organization, 2021).
  • Body Mass Index (BMI) classifications: obesity is a BMI => 30; overweight is a BMI =>25.
  • BMI has its limits as it can either overestimate body fat in muscular athletes or underestimate body fat in older people who have lost muscle mass.
  • Waist circumference is a better assessor of metabolic risk than BMI because it is proportional to total body fat and metabolically active visceral fat (Haslam et al. 2006)
  • "Poor diet is the leading cause of death and biggest contributor to non-communicable disease burden in all six World Health Organization regions" (Branca et al. 2019 p, 3).
  • Interventions to prevent and treat obesity are mostly ineffective and potentially harmful.
  • BMI is not an accurate predictor of disease risk for individuals.
  • Interventions should focus on improving diet quality and physical activity, instead of weight.

Obesity in the ASEAN

  • The prevalence of obesity and being overweight among ASEAN’s citizens is increasing due to rising incomes and urbanisation (The Asian Post, 2020).
  • It is placing a strain on the region’s healthcare systems and government budgets.

Historical Factors

  • Traditional pre-industrial societies tend to value moderate to large amounts of body fat.
    • A sign of health and wealth.
    • Causal links are made between fertility and health.
  • Post-Industrial societies:
    • Thin ideal started to become more accepted in 20th Century.
    • Most concern about body weight is motivated by appearance, not health.
    • Some cultures have adapted thin body to include accentuated hips and breast.

Cultural and Structural Factors

Factors include:

  • Serving sizes
  • Transport
  • Cost
  • Urbanisation
  • Nutrition education
  • Labelling laws
  • Sedentary lifestyle
  • Economy / Employment
  • Global food systems
  • Food and water insecurity
  • Family
  • Socio-economic status
  • Government
  • Education

Sources of Weight Stigma

  • Health professionals contribute to stigma, ranging from student health professionals to experienced specialists.
  • Negative attitudes and beliefs affect the provision of health care services, such as diagnosis and treatment.

Structure-Agency Debate

  • Individual and collective agency does play an important role – we should be able to take responsibility for aspects of life over which we have some control.
  • However, an over-emphasis on individual and responsibility (agency) can result in victim-blaming.
  • The general orientation in contemporary society is to hold obese individuals personally accountable for their size and to discredit and reject them as personal failures (Sobal, 2008, p. 364).
  • This results in marginalisation and poorer health outcomes and ignores structural factors.
  • We need to re-frame this discussion to focus on food security

Food Security

  • Food security is defined as the availability of affordable, nutritious, and culturally acceptable food.

Implications for Health and Professional Practice

  • Marginalisation results in higher rates of morbidity and mortality.
  • Stigma is culturally-informed and therefore is present in society and in the health system, which worsens health outcomes.
  • Epidemiology has changed: more people are carrying more weight, especially children and youth.
  • The health risks of obesity are similar to many other modifiable risk factors such as poor diet, physical inactivity, and excess alcohol.
  • People’s understanding of the ‘normal’ size, function, and health of the human body stems from culture.
  • Forgetting that stigma is constructed and changes over time and from place to place, people judge, dismiss, and exclude the ‘other’.
  • Thinking that focuses on obesity more than other aspects of health is flawed.
  • The stigma surrounding obesity stems from cultural values relating to beauty, what constitutes a ‘normal’ body and a limited view of ‘health’.
  • Why is obesity not discussed as a human rights issue? Do obese people have a right to be treated fairly and with respect?
  • The debate needs to be re-constructed to one that focuses on health, wellness, and food security.
  • Obesity is causing a strain on the health system, but health research and health promotion tend not to focus on other aspects of the food/health connection, so we do not have a complete understanding – this leads to health interventions that make stigma worse and that ignore other health problems.
  • Health professionals who stigmatise obese people and who assume ‘thin’ people are healthy, contribute to the disease burden.
  • The health system is affected by factors outside of the system, such as food and water security, the built environment, transport, housing, leisure pursuits, and the media. While Biomedicine can help individuals, health problems will continue and may grow without associated structural and cultural change.

Conclusion

  • Marginalisation has a negative impact on health because marginalised people have poor access to social determinants of health.
  • Culturally-informed norms can lead to the stigmatisation and marginalisation of people defined as ‘deviant.’ A variety of conditions, diseases, and body presentations have been stigmatised, although the focus of stigma changes from place to place and through time.
  • Stigma is based on judgments and assumptions which may be inaccurate, negative, and incomplete, but in all cases are unhelpful.
  • Increasingly, obesity is stigmatized in Western countries, and weight-related stigma leads to poor health outcomes.
  • The focus of the weight debate is on agency rather than structure, disease rather than wellness, and food rather than quality of life and wellness when all play a role in this health issue.