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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