The interplay of structure and agency in health promotion: integrating a concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice.

The recent debate in public health about the "inequality paradox" mirrors a long-standing dispute between proponents of structuralist approaches and advocates of action theory. Both views are genuine perspectives of health promotion, but so far they have not been adequately linked by health promotion theory. Using Anthony Giddens's concepts of structure and agency seems promising, but his theory has a number of shortcomings that need to be amended if it is to be applied successfully to health promotion. After briefly assessing Giddens's theory of structuration, this paper proposes to add to it both the concept of structural change as proposed by William Sewell and the policy dimension as described by Elinor Ostrom in her distinction between "operational" and "collective choice" level. On this basis, a multi-level model of the interaction of structure and agency in health promotion is proposed. This model is then connected to central claims of the Ottawa Charter, i.e. "build healthy public policy", "create supportive environments", "strengthen community actions", and "develop personal skills". A case study from a local-level health promotion project in Germany is used to illustrate the explanatory power of the model, showing how interaction between structure and agency on the operational and on the collective choice level led to the establishment of women-only hours at the municipal indoor swimming pool as well as to increased physical activity levels and improved general self-efficacy among members of the target group.