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Health Capability

Advancing the potential to flourish and thrive

JENNIFER J. PRAH, PHD, MSC, MA, MSL

Health capability is an emerging paradigm that addresses these concerns and reexamines some of our most basic assumptions about health in ways that allow us to understand what health means in a wider and fuller context. As a health care delivery system, from a regional, national and global perspective, it is necessary for us to rethink how we approach health care.

What is Health Capability?

Health capability is the ability to be healthy; it is a power to perform with the potential for achieving desired ends, as was cited in an article entitled “Health Capability: Conceptualization and Operationalization” by Prah Ruger in a 2010 edition of American Journal of Public Health. It entails individual aptitude and is a cradle to grave concept which requires life-long abilities and aptitudes that enable optimal health. Health capabilities are key strengths resulting from individual and societal commitment of human, financial and physical resources with the goal of helping people thrive.

There are inherent differences in individual health capabilities and by looking at them empirically we can begin to understand why personal skills and health benefits alone are not enough to be as healthy as possible and that a narrow biomedical model for disease is also insufficient. We can see that even people in the best external conditions can still have poor health.

The health capability model captures the dynamic, interactive, multidimensionality of both health and flourishing. It considers the overlap of biology and genetic predispositions with macro, social, political and economic environments, public health, health care systems and intermediate social contexts such as economic status and political empowerment.

Health capability presents a dynamic, flexible, detailed, multi-dimensional topology.

Health capability employs a more flexible approach to health care than linear approaches that are limited to one-to-one associations among variables. This kind of reductionist approach looks at basic relationships first and then the sum of the principal subcomponents, producing a data set that can be difficult to interpret and to comprehensively represent a person’s lived experience. Health capability accounts for both internal and external factors on an individual level and allows for contemporaneous multiple relationships among factors. This overlapping feature offers a nuanced, sequentially interactive, dynamic and multidimensional understanding of individual ability to be healthy. It reveals heterogeneity in the influence of irreducibly social experiences.

A valuable element of this model is how, over time, it allows multi-sectional, longitudinal, inter-sectorial and institutional analysis and design. It considers heterogeneous relations among individual and societal level variables (e.g., income, education, race and racism, sexism and gender discrimination, hetero-normativity and LGBTQIA2S+). By measuring and using a different construct we can better address problems around lack of information on the direct health impact of external factors. Rather than drawing inferences about individual health based on group or macro level characteristics (e.g., race, gender, or socioeconomic status), health capability incorporates external factors into the individual level and considers impacts of the individual on society.

The Health Capability Profile

To understand this more clearly, we have created a health capability profile comprised of 15 different health capabilities which encompass 49 separate health functionings and agencies. The goal is for each and every person to reach their highest health potential, their full health capability. The profile provides a full picture of a person’s lived experience and of their journey toward reaching their healthiest and most flourishing potential. The capabilities are internal and external and include:



• Internal Capability 1: Health Status and Health Functioning – Your state of health.
• Internal Capability 2: Health Knowledge – Knowing about your health and knowing how to be healthy.
• Internal Capability 3: Health-seeking Skills and Beliefs, Self-efficacy – Believing in yourself and your health.
• Internal Capability 4: Health Values and Goals – Valuing health.
• Internal Capability 5: Self-governance and Self-management and Perceived Self-governance and Management to Achieve Health Outcomes – Managing your health, achieving health from within.
• Internal Capability 6: Effective Health Decision-Making – Making good decisions in health.
• Internal Capability 7: Intrinsic Motivation – Being self-motivated toward health.
• Internal Capability 8: Positive Expectations – Having positive expectations about one’s health and flourishing.
• External Capability 9: Social Norms – Cultures of health and expected behaviors in society.
• External Capability 10: Social Networks and Social Capital for Achieving Positive Health Outcomes – Connecting to others for health.
• External Capability 11: Group Membership Influences – Health norms of your social groups.
• External Capability 12: Material Circumstances – Having material circumstances that support health.
• External Capability 13: Economic, Political, and Social Security – General feelings of security.
• External Capability 14: Utilization and Access to Health Services – Receiving health care when needed.
• External Capability 15: Enabling Public Health and Health Care Systems – Effectiveness of health systems.

Examples  

To look at the structured thinking behind these capabilities let’s examine #4, an internal capability, Health Values and Goals. Within this capability is a sense of agency and valuing setting health-related goals such as managing cholesterol levels. It includes valuing lifestyle choices such as moderate vs. excessive drinking and the ability to recognize and counter damaging social norms. Health values and goals is the internal capability of valuing ones health, including health-related goals and health-promoting behaviors. Examples of this are regular exercise, a healthy diet, and an active lifestyle. Importantly, it also includes the ability to recognize and counter social norms that undermine the value of health and to persist in these values despite negative social messaging.

When we adapt these capabilities, encourage them in ourselves, in others and in our communities, it is important to consider three questions: (1) why are they important, (2) what do they look like and (3) how do I do it.

Valuing health is important because we live in a world of finite resources, including one’s own resources of time, attention, and energy. Health will be compromised if it is not prioritized and understood to be central to a good life.

We can recognize when a person sets these priorities through their words and actions. They will speak positively about health and work to explicitly counter social norms that damage health. How they structure their daily schedules, their free time, their plans and both short and long term priorities will also speak to the value they place on health.

It is important to note that health values and goals are continuously developed. Part of how one values health is through asking some core questions such as: why is my health important to me? What resources am I committing to my health? What goals can I set to become healthier? How might I change some of my unhealthy lifestyle habits and what social norms may be detracting from my health?

To continue this analysis, let’s look at an external capability, #9, Social Norms.

Social norms may vary based on culture however they are to be evidence-based and scientifically valid.

Health capability incorporates external factors into the individual level.

They include the extent to which health seeking behaviors and health-seeking skills are viewed favorably (e.g., minimal use of alcohol, abstinence from drugs, safe sex practices) or unfavorably (e.g., alcohol abuse, obesity within the family). They also include the extent to which healthy behaviors are adopted by the majority or minority of the individual’s societal population and by whom within this population. They include the extent to which discrimination or anti-discrimination is the dominant social norm and how this impacts the provision of health care and public health services. How do these factors lead to disparities in access? How do social norms ameliorate disparities in health care access and how do they provide decisional latitude or power in familial contexts that are conducive to each person’s health agency?

Social norms are particularly important as an external capability because they shape our beliefs and actions. They provide guidance to what is acceptable, normal, valuable and important, and to what is expected in order to belong to society. Living in society that encourages and sustains people to be active agents of their own health is a critical capability. When society includes positive scientifically accurate norms such as childhood vaccines, influenza immunizations, respectful and anti-discriminatory expectations about behavior and empathy and care towards helping its members thrive, everyone benefits. It is important that health care and public health providers ensure that underserved populations and communities are not put at risk by power imbalances in either the parent-child relationship or by unscientific beliefs of the parents.

We can develop the health capability of social norms with the promotion of positive public moral norms through individuals as well as institutions such as the media, academia, governmental agencies, and popular culture.

Applying the Health Capability Profile 

Practical applications of the health capability profile consist in a three-step process.

The first step is to adapt the profile to the health condition and to the setting under consideration.



The second step is to document the adapted profile through both quantitative and qualitative data collection. Surveys are created that incorporate response from all stakeholders of the health care process, including nurses, physicians, community resource centers, and patients themselves. The analysis of the data draws from a synergistic approach that adopts a position of equal value for quantitative and qualitative data creating mixed methods results. This analysis uses 1-100 health capability scores and the creation of flow diagrams at the individual level. In utilizing these steps and creating a data analysis plan, there are multiple layers. First, the individual level through the documentation of individual health capability profiles. Profiles are unique to each individual at the point in time they are created. They offer multi-level analysis and show strengths vs. vulnerabilities at a glance, as well as highly granular data. Individual profiles are intrinsically dynamic and nuanced and allow for optimal circumstances (e.g., absence of symptoms) as well as enabling conditions. Profiles can reveal multiple causes and thereby better describe people’s complex experiences. In the analysis plan, there is also a cross cutting level of investigating each of the 15 health capabilities and a regional/community level.

The final step in applying the profile is to employ the results to foster policy change and improved health capability for all. Indeed, the individual profiles identify cumulative and heterogeneous effects, which help address equity concerns. They also showcase underlying vulnerabilities and illustrate how to build collective resilience. Finally, they highlight strengths and present positive examples on how to achieve optimal health capability. Health capabilities can be promoted in many ways, including community-wide sensitization that improves knowledge and fosters evidence-based social norms around health care, or through motivational interviews and community outreach, which can be implemented alongside institutional reform in a more comprehensive approach to health policy.

Case Studies 

As discussed, health capability is a flexible model and can be applied to each and every situation that involves health. The health capability profile is adapted to specific conditions and settings, for example, in addressing chronic hepatitis B virus in rural Senegal.  Details about the methodology of this study are available in an article entitled “Applying the Health Capability Profile to Empirically Study Chronic Hepatitis B in Rural Senegal: A Social Justice Mixed-Methods Study Protocol.” by Coste, Marion, Mohammed A. Badji, Aldiouma Diallo, Marion Mora, Sylvie Boyer, and Jennifer J. Prah that is in press for 2022 publication in the protocol journal BMJ Open.

Conclusions

To summarize, health capability presents a dynamic, flexible, detailed, multi-dimensional topology. It includes individual factors, socio-cultural aspects and institutional features that together create health and flourishing. It accounts for and captures interactions among individuals and their environment. It can be applied to empirical studies using a mixed methods social justice design. Its implementation science identifies gaps among observed health capabilities and the optimal health capability level. The health capability profile demonstrates how individuals and societies can work together for each and every person to reach their highest potential, their full health capability and ultimately flourishing.

Jennifer J. Prah, PhD, MSC, MA, MSL, is Amartya Senior Professor of Health Equity, Economics and Policy, at the University of Pennsylvania’s School of Social Policy and Practice and the Perelman School of Medicine. She is also the founder and director of the Health Equity and Policy Lab (HEPL.