Abstract
Introduction: An alternative approach to health systems research is discourse analysis. Objective: to describe the scientific production that investigates health systems using discourse analysis as a theoretical-methodological perspective. Methodology: Systematic review. The search was conducted in five databases (SciELO, MEDLINE, PubMed, EBSCO and Science Direct), in both Spanish and English. The descriptors used were “sistema OR salud” AND “análisis OR discurso”, and their English equivalents. Qualitative studies, scoping reviews, essays and PhD theses, published between January 1994 and December 2019, were included; in all cases their subject was described clearly as discourse analysis of health systems, their functions or organizative structure. Results: A total of 27 texts were included in the revision; four categories describe how discourse analysis can be used in the study of health systems as well, the concept of the health-disease process, subject autonomy, management discourses, and health systems as public policy. Discussion: Health systems are fields for the exercise of power relations that construct subjects, configure the autonomy of the subject, and determine the interventions of the health-disease process. Conclusions: This review identifies that discourse is used as a device of power that configures subjects and the way in which the health-disease process is intervened.
References
Rajan D. Situation analysis of the health sector. Strategizing national health in the 21st century: A handbook. Geneva: World Health Organization, 2016.
Giovanella L, Feo O, Faria M, Tobar S. Sistemas de salud en Suramérica: desafíos para la universalidad la integralidad y la equidad. Río de Janeiro: ISAGS, 2012; p.21
Iriart C, Merhy EE. Disputas inter-capitalistas, biomedicalización y modelo médico hegemónico. Interface (Botucatu). 2017(21): 1005-1016. doi: https://doi.org/10.1590/1807-57622016.0808
López O, Jarillo EC. A health system’s neoliberal reform: evidence from the Mexican case. Cad Saude Publica. 2017(33). doi: 10.15090/0102-311X00087416
Fischer F. Reframing public policy: Discursive politics and deliberative practices. New York: University Press, 2003.
Hajer MA. The living institutions of the EU: Analysing governance as performance. Perspect Eur politics soc. 2006; 7(1): 41-55. doi: https://doi.org/10.1080/15705850600839546
Howarth D. Power, discourse, and policy: articulating a hegemony approach to critical policy studies. Crit Pol Stud. 2010; 3(3-4): 309-335. doi: https://doi.org/10.1080/19460171003619725
Urra E, Muñoz A, Peña J. El análisis del discurso como perspectiva metodológica para investigadores de salud. Enferm Univ. 2013; 10(2): 50-57. doi: https://doi.org/10.1016/S1665-7063(13)72629-0
Frawley W, Fairclough N. Discourse and social change. 7. Cambridge: Polity, Language in Society university Press 1993; 421-424
Aitken G, Alldred P, Allwood R, Billington T, Burman E, Goldberg B, et al. Psychology, Discourse and Social Practice: From Regulation to Resistance: Taylor & Francis; 2005.
Hollway W. Subjectivity and method in psychology: Gender, meaning and science: Sage Publications: 1989.
Jaworski A, Coupland N. The discourse reader. Third edition. London; New York: Routledge; 2014.
Korobov N. Reconciling theory with method: From conversation analysis and critical discourse analysis to positioning analysis. Forum Qual Soc Res. 2001; 2(3). doi: https://doi.org/10.17169/fqs-2.3.906
Wodak R, Meyer M. Methods of critical discourse analysis. London, England: Sage; 2001.
Kendall, G, Wickham G. Using Foucault’s Methods. London: Sage; 1999.
CASP, UK. CASP checklists. Critical Appraisal Skills Programme (CASP). Oxford: 2018; 33(1): 121-131.
Molina J, Peter E, Gallo J, Perelló C. Instrumentalisation of the health system: An examination of the impact on nursing practice and patient autonomy. Nurs Inq. 2018; 25(1): doi: http://dx.doi.org/10.1111/nin.12201
Rodríguez PG, Universidad de Buenos Aires. La producción de enfermedad en el paradigma de la salud del siglo XXI. Anagramas Rumbos sentidos comun. 2013; 12(22): 37–52.
Avni S, Filc D, Davidovitch N. The Israeli Medical Association’s discourse on health inequity. Soc Sci Med. 2015; 144: 119-126. doi: https://doi.org/10.1016/j.socscimed.2015.09.015
Molina J. Saber, poder y cultura de sí en la construcción de la autonomía del paciente en la toma de decisiones. Relación de la enfermera con el paciente, familia, equipo de salud y sistema sanitario. Palma: Universitat de les Illes Balears; 2013.
Echeverría G, Maturana JM. Análisis crítico del discurso de políticas públicas en diversidad sexual en Chile. Univ Psychol. 2015; 14(4): 1485-1498. doi: http://dx.doi.org/10.11144/Javeriana.up14-4.acdp
Breheny M, Stephens C. Irreconcilable differences: Health professionals’ constructions of adolescence and motherhood. Soc Sci Med. 2007; 64(1): 112-124. doi: https://doi.org/10.1016/j.socscimed.2006.08.026
Trigg LJ. Reproducing social inequality and unequal treatment in the national health information infrastructure: A discourse analysis of institute of medicine executive summaries. Ans Adv Nurs Sci. 2009; 32(3): 188-199. doi: 10.1097/ANS.0b013e3181b0d70a
Schofield I, Tolson D, Fleming V. How nurses understand and care for older people with delirium in the acute hospital: A critical discourse analysis. Nurs Inq. 2012; 19(2): 165-176. doi. https://doi.org/10.1111/j.1440-1800.2011.00554.x
Dahlborg E, Pennbrant S, Boman Å. “The Emperor’s new clothes”: discourse analysis on how the patient is constructed in the new Swedish Patient Act. Nurs Inq. 2017; 24(2). doi. http://dx.doi.org/10.1111/nin.12162
Cole M. A discourse analysis of hand hygiene policy in NHS Trusts. J Infect Prev. 2015; 16(4): 156–161. doi: http://dx.doi.org/10.1177/1757177415575412
Fealy G, Hegarty J, McNamara M, Casey M, O’Leary D, Kennedy C, et al. Discursive constructions of professional identity in policy and regulatory discourse. J Adv Nurs. 2018; 74(9): 2157-2166. doi. http://dx.doi.org/10.1111/jan.13723
Apker J, Eggly S. Communicating professional identity in medical socialization: Considering the ideological discourse of morning report. Qual Health Res. 2004; 14(3): 411-429. doi. http://dx.doi.org/10.1177/1049732303260577
Horsfall J, Cleary M. Discourse analysis of an ‘observation levels’ nursing policy. J Adv Nurs. 2000; 32(5): 1291-1297. doi. http://dx.doi. org/10.1046/j.1365-2648.2000.01601.x
Bermúdez I, Ramos NM. La efectividad, estrategias y estructuras en el análisis del discurso político y su influencia en los Servicios Estatales de Salud en Quintana Roo. Sal Quintana Roo. 2022; 8(30): 8-14.
Mitchell PF. A discourse analysis on how service providers in non-medical primary health and social care services understand their roles in mental health care. Soc Sci Med. 2009; 68(7): 1213–1220. doi. https://doi.org/10.1016/j.socscimed.2009.01.001
Irestig M, Timpka T. Towards responsible system development in health services: A discourse analysis study of design conflict resolution tactics. J Biomed Inform. 2010; 43(1): 137-143. doi. https://doi.org/10.1016/j.jbi.2009.08.005
Dickinson H, Glasby J, Nicholds A, Sullivan H. Making sense of joint commissioning: three discourses of prevention, empowerment and efficiency. BMC Health Serv Res. 2013; 13 Suppl 1: S6. doi. http://dx.doi.org/10.1186/1472-6963-13-S1-S6
Kacen L, Bakshy I. Institutional narratives in the discourse between oncology social workers and cancer patients’ self-help organization. Qual Health Res. 2005; 15(7): 861–880. doi: http://dx.doi.org/10.1177/1049732305277908
McKinlay E, Plumridge L, McBain L, McLeod D, Pullon S, Brown S. What sort of health promotion are you talking about?: a discourse analysis of the talk of general practitioners. Soc Sci Med. 2005; 60(5): 1099-1106. doi: https://doi.org/10.1016/j.socscimed.2004.06.041
Evans RA, Johnson S, Liu F, Boutain DM. Applying critical discourse analysis in health policy research: Case studies in regional, organizational, and global health. Policy Polit Nurs Pract. 2016; 17(3): 136-146. doi. http://dx.doi.org/10.1177/1527154416669355
Walton JA, Lazzaro M. Othering the chronically ill: A discourse analysis of New Zealand health policy documents. Health Commun. 2016; 31(4): 460-467. doi. http://dx.doi.org/10.1080/10410236.2014.966289
Baum F, Lawless A, MacDougall C, Delany T, McDermott D, Harris E, et al. New norms new policies: Did the Adelaide thinkers in residence scheme encourage new thinking about promoting well-being and Health in All Policies? Soc Sci Med. 2015; 147: 1–9. doi. https://doi.org/10.1016/j.socscimed.2015.10.031
Baum F, Friel S. Politics, policies and processes: a multidisciplinary and multimethods research programme on policies on the social determinants of health inequity in Australia. BMJ Open. 2017; 7(12). doi.10.1136/bmjopen-2017-017772
Trigg LJ. Social construction of the patient through problems of safety, uninsurance, and unequal treatment. Adv Nurs Sci. 2009; 32(3): 17-27. doi: 10.1097/ANS.0b013e3181b0d721
Harper DJ. Discourse analysis and mental health. J Mental Health. 1995; 4(4): 347-358. doi: https://doi.org/10.1080/09638239550037406
Irestig M, Timpka T. Politics and technology in health information systems development: A discourse analysis of conflicts addressed in a systems design group. J Biomed Inform. 2008; 41(1): 82-94. doi: https://doi.org/10.1016/j.jbi.2007.05.009
Huzzard T, Hellström A, Lifvergren S. Whole system in the room: toward systems integration in healthcare. Health Commun. 2018; 33(7): 800-808. doi. http://dx.doi.org/10.1080/10410236.2017.1314854
Foucault M. El sujeto y el poder-por qué estudiar el poder: la cuestión del sujeto. 1998.
Foucault M, Rabinow P. Space, knowledge, and power. Material Culture 1982: 107-120.
Foucault M. La política de la salud en el siglo XVIII. Estrategias de poder. Barcelona: Paidos; 1999.
Foucault M. La ética del cuidado de sí como práctica de la libertad. Nombres. 1999; 15.
Laurell AC. Revisando las políticas y discursos en salud en América Latina. Medicina social 2010; 5(1): 79-88.
Águila C, Sicilia Á, Segovia L. El ideal de cuerpo delgado y la formación del sujeto neoliberal: Un estudio de caso. Movimento. 2021; 26. doi. https://doi.org/10.22456/1982-8918.104124
Houghton E. Becoming a neoliberal subject. Ephemera. 2019; 19(3): 615-626.
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