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Contribution of sociology to health:
More than a century ago, Rudolf Virchow noted that medicine is in essence a social science, and politics nothing more than medicine on a larger scale. Virchow and many others over the past two centuries saw the extent to which disease and epidemics derived from the material conditions of living and the social stratification of society. An enormous body of research and analysis has confirmed this observation in more recent years in relation to mortality as a whole and to a wide range of diseases and disabilities. Two important government reports in the 1980s, in England (the Black Report) and in the United States (Report of the Secretary’s Task Force on Black and Minority Health), reviewed the impressive evidence of the effects of socioeconomic status and racial and ethnic differences on health and longevity.
According to the World Health Organization “health promotion is the process of enabling people to increase control over the determinants of health and thus improve their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions.” Since 1984 the promotion of health has become a principal feature of health policy at local, national and international levels, forming part of global health initiatives such as those sanctioned by the World Health Organization. Sociologists have tended to contribute to the development and refinement of health promotion activities rather than analyzing it as an object of inquiry. They have carried out surveys, interviews and observations of people’s lifestyles to provide information for health promotion campaigns. Following are some of the major contribution of sociology regarding health promotion.
· Health promotion is the attention that it gives to the facilitation of healthy lives: the idea that it is not just telling people that they should change their lifestyles but also altering their social, economic and ecological environments health.
· promotion aims to work not only at the level of individuals but also at the level socio‐ economic structures and to encourage the creation and implementation of ‘healthy public policies’ such as those concerned with transport, environment, agriculture and so on.
· The promulgation of healthy lifestyles and the discourse of health promotion and the ‘new public health’ more generally are important and topical subjects which, although retaining some continuities with past health policy, can increasingly be viewed as representing a new paradigm of health care (Nettleton, 1995).
· An etiology and distribution of health and illness which reveal that adequate health policies must take structural and environmental factors has been analyzed and focused.
· political and ideological bases of health education and health promotion activities have also been debated.
· The dominant strand of the sociology of health promotion is its concern to analyze the phenomena as a characteristic of the much wider set of socio‐economic and cultural processes associated with late modernism.
· Sociological analyses of health promotion; develop analyses on matters in relation to health promotion which are of interest to contemporary sociology, including risk, the body, consumption, and processes of surveillance and normalization; and develop critiques of health promotion which are of interest to health and medical practitioners, including issues of gender and race in the implementation of health programmes, cultural dimensions of lifestyles and health behaviors, and the marketing and consumption of health‐related activities.
Sociologists worked on health issues throughout the century, but medical sociology as an institutionalized specialty first developed a strong educational infrastructure in the 1950s and 1960s, largely with the support of the National Institute of Mental Health (NIMH). Unlike the National Institutes of Health (NIH) at that time, NIMH saw the social and behavioral sciences as central to the development of its mission. Thus, the agency broadly invested in fellowships and training programs in sociology, psychology, and anthropology. In the 1950s and 1960s, most medical sociology was focused on mental health issues and contributed many of the concepts and much of the research that helped transform mental health services in the United States from a hospital to a community endeavor. It was NIMH that supported studies in psychiatric epidemiology, stress and coping, public attitudes and stigma, labeling processes, the course of disability, and the study of hospitals. In those years, the emphasis was on mental health broadly conceived, and NIMH contributed importantly to the development of social and behavioral research, including the development of methodologies and analytic techniques. Under pressure during the Reagan years, NIMH very much narrowed its training and research support to focus more specifically on the mentally ill population, in contrast to broader mental health concerns. By the 1980s, however, many of the NIH institutes recognized the importance of social and behavioral research for their missions and helped compensate for NIMH’s more narrow emphasis. The National Institute on Aging, with its broad agenda of studying developmental change across the life cycle, did much to promote improved methodology and high‐quality data and to support substantive research across a wide range of issues affecting health, function, and well‐being. Similarly, the National Institute of Child Health and Human Development supported much sociological effort in the area of population research. While the heart, cancer, and other institutes were more narrowly focused, they increasingly supported epidemiological and behavioral research relevant to their categorical missions. The heart institute was particularly instrumental in developing the field of behavioral medicine.
Medical sociological endeavors tend to follow two streams:
· sociology in medicine and
· Sociology of medicine.
In the sociology in medicine, sociologists work as applied investigators or technicians, seeking to answer questions of interest to their sponsors, whether government agencies, foundations, hospitals, or medical schools. Depending on the ingenuity of the researcher, such work can make broader contributions than the particular task may suggest, but the emphasis is on information and application. This role is familiar, encompassing those who design and execute health surveys and who study such varied topics as access to care, use of services, satisfaction, risk factors in disease, health status determinants, and many more.
Sociology of medicine, in contrast, focuses on testing sociological hypotheses, using medicine as an arena for studying basic issues in social stratification, power and influence, social organization, socialization, and the broad context of social values. Work within this tradition explores such themes as how physicians control the work of other health occupations; how lower social status and gender affect health interactions; and how political and economic interests influence the structure of care, reimbursement, and the uses of technology. At the organizational level, such studies commonly contrast rhetoric with reality, seeking to identify the motivations, incentives, and group interests that result in departures from public declarations and stated goals.8 Medical sociology has little theory of its own, depending on its parent discipline for its broader perspectives. Thus, the major points of emphasis that define sociology in general help focus the way generic questions about health and medicine are formulated.
Medical sociology, for example, has had long involvement in the study of medical education, dating from the 1950s. Educators sought assistance from sociologists in improving curricula and in understanding better how to structure education to deal with the stresses of training, reduce unethical behavior, improve selection processes, and induce more thoughtful inquiring behavior on the part of physicians in training–in short, how to transform students into better medical professionals. Many sociologists sharing these goals with medical educators did excellent studies on such issues as coping with uncertainty, specialty selection, factors affecting professional socialization, and the like Other studies, however, examined medical education in terms of its values and contradictions. They focused on the incompatibility between educational rhetoric and the behavior of the faculty; they described the economic and prestige incentives that deterred faculty from their professed goals and values; and they viewed some of the less commendable behavior of medical students as adaptive to many of the contradictory challenges and incentives to which they were exposed. They questioned whether the ethical problem was simply a matter of more careful selection to avoid a few “bad apples” as physicians often saw the issue, the lack of a course in ethics, or the result of fundamental problems concerning the incentives and rewards within medicine. In short, they saw the problem not as one of simple remedies. In addition, critics of medical education were less impressed by the claims and status of the profession.
Work in medical sociology, more closely tied to disciplinary interests, finds less acceptance among physicians and administrators because it looks at issues of health and medicine from the outside, commonly operating on premises that reject basic assumptions of the medical profession. Thus, in response to one study that described the deceptions used by house officers under pressure from their medical chief to gain autopsy permissions, one prominent physician lamented the preoccupation with “learning in its most ghoulish aspects” and warned that it just opened “new veins of muck for those who make it their business to rake the medical profession.” An eminent physician, stung by a highly critical study of his service, lamented, “The authors’ combination of smugness and naivete is hard to bear by someone who has been dealing with the realities.” This is just one of many instances in which sociology from the outside was hard to take by those being studied.
Robert Petersdorf and Alvin Feinstein, in commenting on the field, note that such work “has been a troublesome domain for many clinicians, who believe their distinctive concerns for individual people are lost in collectivist beliefs about society, and whose generally conservative political views have clashed with the strongly liberal, often radical positions of many sociologists.”It seems clear that these commentators–and probably most of their colleagues–prefer a sociology that is adjunct to medical activity and accepting of its basic premises. Such a sociology would simply be a servant to medicine, not fulfilling its larger responsibility to understand medicine as a social, political, and legal endeavor; to challenge its curative and technological imperatives; to examine equity of care in relation to class, race, gender, age, character of illness, and geographic area; and to study the appropriate goals and objectives for health care in the context of an aging society with an illness trajectory dominated by chronic disease.
Although the critical perspective accounts for only a part of sociological effort, it is an indispensable component. This is not to argue that such analyses are not occasionally overstated or that their failure to show understanding for the constraints under which health professionals and policymakers work sometimes undermines receptivity of the audience. Perhaps most grating to the practitioner is a tendency to view necessary restructuring less in terms of small adjustments and more in terms of major changes that, if not politically repugnant, may seem far‐fetched or impractical. Yet such work and the perspectives underlying it have been enriching and over time have been accepted as part of conventional wisdom.
Sociologists have for decades studied organized forms of group practice, including health maintenance organizations (HMOs), making efforts to understand how alternative organization and payment arrangements affect access to and use of care and its costs. Researchers have inquired how patients’ social class, race, gender, and geography affect the quality of communication with health professionals and access to specialized care and how interaction and communication processes relate to adherence with medical advice, patient satisfaction, and issues of equity. Seemingly esoteric concerns of sociology have now become commonplace, such as the rights of patients in human experimentation, choices in pregnancy and childbirth, the right to be informed about the nature of one’s treatment, protection against the uses of medicine for social control purposes, the excessive use of medical technology, the importance of primary care, the role of social behavior in disease and disability, and the potential of prevention. Disability as an example. Because the scope of sociology is so broad, it is more useful to convey how sociologists think than to attempt to summarize the range of their concerns. The area of disability and rehabilitation offers one important example. From the early work of Talcott Parsons, it was clear that sickness and disability were, in part, social role definitions evolving from a system of expectations and social relationships. Expectations are seen as powerful influences in society, conditioning not only what is permitted but also the human possibilities of adaptation. Social norms and social arrangements commonly result in the unnecessary exclusion of persons with disabilities from many social settings and often indirectly undermine their subsequent motivations and efforts. Sociologists have often noted that the social definition of a chronic disease or impairment and the processes of adaptation that relate to it shape future opportunities and constraints. In such instances as myocardial infarction, spinal injury, loss of hearing or sight, and other chronic disease and impairment, persons with comparable conditions adapt in varying ways to varying degrees. Whether the condition becomes the core of the person’s identity and totally incapacitates function or whether it is more peripheral depends not only on personality and motivation but also on social arrangements and public attitudes. Whether a person with impairment becomes disabled thus depends in large part on how rehabilitation efforts are organized and the extent to which physical access, attitudes, and social reactions make jobs, recreation, and other forms of social participation feasible. Such thinking is the basis of the Americans with Disabilities Act, supported by a strong bipartisan coalition and pending action in Congress. These views are only now becoming commonplace. Yet their foundation and philosophy have been developing for decades by studies that established the deleterious ways in which people with disabilities were socially defined and dealt with.
· On the social psychological level, Mechanic has extended the early work on the sick role to consider illness behavior and what constitutes trust. Parsons (1951) made a major contribution in identifying the components of the sick role in terms of what was expected of the patient. Over the years, others criticized and expanded this model to include expectations of those with chronic illnesses and disabilities.
· Mechanic (1962) made contributions in considering what it meant to be ill and how one experienced and expressed illness. This work led him to reconsider the doctor–patient relationship and, on a more macro level, what illness meant in society. This stream of research has laid conceptual building blocks and theoretical foundations that make discussions of trust and social justice more sophisticated. As Mechanic (1989) points out, trust is the social glue that makes diagnosis and treatment possible on the individual level and social policy possible on the community and societal levels.
· On the organizational level, studies of national health care services, multiple hospital systems, assisted care facilities, hospices, support groups for those with HIV/AIDS and the environment within which these organizations operate have led to important findings about how the organization of health care directly impacts the cost, access and quality of care. This work is now expanding to important sets of cross‐national studies that are examining the essentials of effective health care systems, how different organizational models may produce similar results and how the mix of populations served interact with the organizational structures of the delivery system to yield variable results. In other words, the organization of health care needs to be tailored to the needs of the population and local culture and environment. That is why there is persistent interest in comparative health care system.
· Inequality in health has also been a dominant theme of the sociology of health and illness which has evolved from a consideration of differences in behavior and material circumstances to a complex consideration of how health behaviors and material and social resources interact to produce differences in health outcomes both on the individual and community levels. Researchers in this area have illustrated the importance of social capital in dealing with health issues.
· Social capital refers to the social resources and networks available to individuals that help them define and cope with health problems. Consistent findings show that larger amounts of social capital are predictive of less disability, more support and a higher quality of life.
· Research on social equity has also highlighted the need to do multi‐level analysis; to consider individuals in their environments and as members of a community and nation. Each layer of relationships is likely to explain some of the health outcomes and considering individuals in context permits a more fine‐grained analysis of health and disease realities.
· Health‐related quality of life research has directed attention beyond issues of mortality and morbidity to how people are living (Levine, 1987, 1995). This concept is applicable across the lifespan and groups of individuals.
· Investigations into quality of life have led to important distinctions between objective and subjective indicators of well‐being. AlbrechtandDevlieger (1999) discovered, for example, that there was a disability paradox raised by the apparent discrepancies between the quality of life of disabled people as perceived by the general public and those living with the disability. About 50 per cent of the people with serious and persistent disabilities in the study reported that they had a good or very good quality of life even though outside observers might deem otherwise. This type of result suggests that clinical and policy decision‐makers need multiple sources of data to understand the desires, wants and experiences of vulnerable and disable people. As a consequence, quality of life is being incorporated into most judgments of treatment outcomes. Much progress is being made in this area.
· The work on health‐related quality of life has also drawn renewed attention to the concepts of normalcy and deviancy (Phelan et al., 2000).
· The women’s movement and interest in international health have illustrated how white male norms established at one point in history in postindustrial countries do not serve as useful reference points for the behavior of all people
· .Most research has been traditionally done on men by men and for men. Yet, recent research clearly demonstrates that women’s health experiences and issues are different from those of men, requiring considerable changes in the conceptualization and delivery of health care for women and children. In fact, one of the major factors in improving the health of a nation is to educate women and make health resources available to them, for women are usually the people who care for children, older parents and disabled people.
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