Medical Sociology Research Paper

1. Social Stratification and Health

The single most dominant theme in medical sociological research addresses the way in which stratification by socio-economic status (SES), gender, race, ethnicity, and age affects patterns of health and illness behavior, illness risk, morbidity, disability, mortality, access to health care services, utilization of care, functional health outcomes, subjective well-being, and health-related quality of life (Mechanic 1978). The link between SES and health has been repeatedly documented over the twentieth century and throughout the world (Amick et al. 1995). There is renewed interest in studying economic inequalities in health in many countries and in examining whether inequality itself, independent of income, contributes to poorer health outcomes (Wilkinson 1996). A variety of hypotheses have been suggested, linking inequality to health outcomes at both the community level (social capital and social cohesion) and at the individual level (sense of personal control, perceptions of equity). Ascertaining the role of inequality requires careful specification of types of income inequality and data sources that allow the controls needed to examine causal patterns convincingly.

1.1 Socioeconomic Status and Health

Much effort is given to specify and test pathways through which social stratification indicators affect health, focusing on a wide range of health-related behaviors, environmental risks, and personal traits and dispositions. Link and Phelan (1995), in contrast, building on Durkheim’s (1951) classic analysis of suicide, have presented data in support of the argument that socioeconomic differences are fundamental causes of poor health outcomes because those who are more advantaged in any situation or historical period will have greater knowledge of, or be better able to manipulate, the causal influences in their favor. Thus, while the pathways operative in any situation or historical period are specific to the circumstances, the knowledge, power, and resources characteristic of higher SES that provide advantage are more general and fundamental determinants of health across time and social circumstances.

1.2 Gender and Health

Gender studies in health have also advanced, consistent with their growing importance in sociology more generally. Medical sociologists have a longstanding interest in gender differences in illness, death, and health care utilization. The key challenges have been to explain the female advantage in length of life; the contrasting prevalence of specific disorders among men and women—with particular focus on the high prevalence of depression among women; and different patterns of illness behavior, informal uses of social support, and help-seeking (Mechanic 1978). Studies of mortality generally show that while women may have a biological advantage in longevity, much of the variation in mortality rates can be explained by differential exposure of men and women to the major causes of mortality. These causes are substantially affected by culture, health habits, and exposure to risk.

While the medical sciences define depression as a discrete entity, sociologists have been intrigued by the fact that the female excess of depression tends to be balanced by the male excess of substance abuse, antisocial behavior, and violence. This observation is consistent with a nonmedical conception that views disorders as alternative modes of expressing distress and tension and not simply discrete entities with independent causes. Research on variations in illness behavior tests a range of hypotheses concerning symptom perception and identification, willingness to acknowledge distress and request assistance, and differential barriers and facilitative factors in seeking care for men and women. Patterns of response tend to be specific to disorders and types of services studied, and studies of utilization of care among men and women need to be especially sensitive to the large differences in the use of services related to reproductive health.

1.3 Age and Health

Age, like gender, is a crucial biological and social determinant of many important health outcomes. Aging is associated with increased prevalence of diseases and disability but varying birth cohorts experience different health outcomes at any given age, reflecting changes in social and cultural factors, social developmental processes, lifestyles and behavior, and the availability and effectiveness of medical technology. Debate about the consequences of increased longevity for health is a substantial focus. One view is that the mortality curve increasingly follows a rectangular pattern whereby successive cohorts experience more disability-free years prior to death. A contrasting view focuses on the increasing prevalence of chronic illness and disability with extension of life and increased disability life years among the elderly. The literature provides some support for both perspectives but no clear resolution of the issue. Age is clearly associated with increased prevalence of chronic disease and disability but researchers now more clearly differentiate between the consequences of the aging process itself and the consequences of disease and are less likely to attribute disease-associated impairments to aging.

1.4 Race, Culture, and Ethnicity and Health

There is much interest in differential health patterns by race, culture, and ethnicity. Such research, in contrast to research based on other stratification indicators, is more descriptive of particular groups in time and place and less based on theory. This is inevitable given the diversity of cultural groups and rapid acculturation. Indeed, the categories used to describe race and ethnic groups in most studies and databases (nonwhite, Hispanic origin, etc.) are themselves heterogeneous and their usefulness is in dispute. The literature consistently describes the poorer health outcomes of disadvantaged race ethnic groupings. In the US literature there is much interest in the persistent lower birthweight rates and higher infant mortality among nonwhites (mostly African Americans), as compared with whites, and the extent to which these differences are attributable to socioeconomic differences versus other factors. There is also much interest in why some disadvantaged subgroups achieve relatively good health outcomes despite poverty and many adversities.

2. The Study of Health Care Organization and Provision

It is well established that national systems of health care develop from their unique historical trajectories, national cultures, political systems, and economic status. But medical care, and the systems in which they are embedded, are part of worldwide networks, sharing knowledge, technology, and organizational innovations. In addition, common trends among developed nations in demography, urbanization, epidemiology of disease, medical demand and rising public expectations, and the growing gap between medical possibilities and the ability or will to fund them, pose many common problems for health systems (Mechanic and Rochefort 1996). These problems include means of promoting health, organizing levels of care, expanding health care access, linking health and social services, and cost containment and health care rationing. Most organizational studies on health care systems bear on aspects of each of these problems as they relate to the organization of particular health care systems or subsystems. There have also been efforts to study health care systems comparatively across nations.

2.1 Changing Role of the Physician

Sociological work on the organization of care has focused on the health professions—and particularly the changing role of the physician, the politics of health care dominance and authority, intraorganizational networks and relationships, and integrating levels and sectors of care. There has also been much interest in how incentives and other organizational factors affect processes and quality of care. Much attention has been given to structures and processes of care in particular types of organizations such as hospitals, intensive care units, perinatal units, nursing homes, and health maintenance organizations, and to the role of changing technologies.

Much excellent sociological work has been focused on the development of the medical profession and the means used to achieve dominance over medical work and other health occupations (Freidson 1970). Early work that sought to define the special characteristics of the medical profession has been succeeded by more dynamic analyses of how professions and occupations compete to gain control over varying spheres of work (Abbott 1988). As the authority and control over organizational decisions have devolved from physicians to managers and administrators with the corporatization of medicine (Starr 1982), sociologists have been concerned with whether, and in what ways, the changes in autonomy and control contribute to the proletarianization of physicians.

2.2 Managed Care

In the USA since about 1990 most sociological research on health organization has been focused on the growth of managed care and its variety of new organizational forms. Although organizational forms differ widely, from staff and group model prepaid practices to a variety of network models, they share in common certain strategies that are of great research interest. These strategies include the use of capitation and transfer of risk through organizational levels, the use of utilization review to limit the provision of unneeded care, and new systems of constraint on physicians, including practice guidelines, disease management programs, and physician profiling. With the growth of health care organized by private corporations, there is renewed interest in the consequences of nonprofit versus for profit forms of organization.

Much of the research on managed care relates to the effects of such management on plan and physician choice, access to care, use of inpatient and outpatient services, satisfaction and trust, and health outcomes. Studies are diverse, ranging from how physicians and utilization reviewers communicate and negotiate over care to how physician choice and continuity of care affect patient satisfaction. Methods of study range widely, from conversational analysis and participant observation to experimental studies and surveys. The survey is the most common approach to studying managed care practices but there is increasing use of large administrative data sets to better understand patterns of care and to address specific hypotheses about how insurance coverage, social characteristics, and patterns of illness affect utilization and costs of care.

The most important changes in US health care include the growing corporatization and privatization of health care, the shift from fee-for-service to capitated health insurance plans, and the imposition of rationing devices such as gatekeepers to specialized services, utilization management, and payment incentives for physicians to meet utilization targets. Other central issues involve initiatives to achieve organizational and clinical integration of services, to develop structures more appropriate to treat chronic disease and provide longterm care, and to better coordinate health and other related services for persons with severe and persistent disabilities. Deinstitutionalization trends in developed countries keep clients with mental illness and developmental disabilities, impaired elderly, and other persons with disabilities in their own homes or communities. These trends create profound challenges to the reproduction of, in decentralized community settings, the types and range of services available in total institutions (Mechanic 1999). Although many promising programs and innovations have been developed, most studies report significant barriers to achieving cooperation among service sectors with varying eligibility criteria, bureaucratic cultures, priorities, and reward systems. Seemingly simple in theory, community integration of health services continues as a significant challenge in reality.

3. The Social Psychology of Health and Health Care

The study of stress, coping and social support has been central in medical sociological research and constitutes perhaps the best integrated body of knowledge tied together by common theoretical interests and methodological concerns. This area also interlinks work in medical sociology with efforts in psychosocial epidemiology and health psychology.

3.1 The Stress and Coping Process

The basic paradigm is simple and posits that stressful life events cause negative health outcomes when individuals lack the counterharm resources needed to deal with the challenges embedded in the stress event (Lazarus 1966). Counterharm resources include the ability to deal with the instrumental challenge and to manage the emotions evoked by the situation. Social support is seen as having either a buffering effect on the influence of stress events on outcomes, a more direct positive effect, or both. A measure of sense of personal control (or a related proxy such as low helplessness or mastery) is also often included in these research models and is found to contribute to more positive outcomes. There are a variety of models elucidating the pathways of the stress process and the relative influence of different intervening variables.

The basic ideas informing the model have been in the literature since the 1960s but much effort has been devoted to refining the model and related hypotheses, developing improved measures, and perfecting the quality of data and analytic approaches. Initial measures of life events were crude and ambiguous. Although the underlying theory was that life events called for psychological and somatic readjustments that strained the organism, and thus positive life changes were significant as well as negative events, the scales combined and confused these items and did not allow a clear test. Moreover, studies treated meaning in a confused way or completely ignored it, did not carefully specify dependent measures of illness, and commonly made incorrect causal inferences from cross-sectional data.

Many important questions persist in the stresscoping literature despite vast improvement in measurement, data quality, and analysis. It is difficult empirically to capture the fact that many stressful life events are not single occurrences but part of a sequence of related stressors. Some researchers have focused on the role of more minor but persistent events such as commonplace daily hassles. Although there has been broad recognition that the meaning of events is central, most investigators have not measured meaning in a manner independent of the phenomena they wish to predict. Brown and Harris (1978) have developed a novel approach to contextual analysis in which detailed descriptions of the event are obtained and trained raters attribute meaning to the event, on the basis of their assessment of how the average person would respond to an event in that context, following a carefully specified protocol.

Focus on the availability of social networks and social support has become increasingly important, with growing sophistication about the complexity of the processes involved. Researchers are now much more aware that persons who attract support are quite different from those who do not, and that selective processes are already evident early in life. Thus, the relative role of social support, as compared with the personal attributes that attract support, is more difficult to assess. Similarly, researchers in the area are beginning to take note of the obligations inherent in support networks and possible deleterious aspects.

The most difficult component of stress and coping research has been the measurement of coping. Most such measures, such as those that focus on taskoriented coping versus denial, are quite limited. However, there is a rich tradition in medical sociology of intensive qualitative study of coping processes in a wide range of illness and disability conditions, including impending death (Fox 1988). Many of these studies proceed on the methodology of grounded theory and seek to understand the stages of illness and how illness trajectories vary. Such studies focus on how people become aware of their illness, the attributions they make, the uses of informal and formal sources of care, how coping changes at different stages of illness, and how persons affected interact with family, friends, and health care providers. Such studies often lack the generality and rigor of large quantitative population studies but they provide a richness of understanding that is not captured in the measurement systems used in the larger studies. Coping is a complex, iterative process, with causal sequences occurring in close temporal proximity, which is almost impossible to capture in the usual survey.

3.2 Disability

The study of disability has become increasingly important as the disability rights movement has advanced in many countries. The ideology of the movement has been built around a sociological conception of disability which maintains that impairments may or may not result in disability, depending on social organization and the physical environment. In essence, whether an impairment becomes a disability depends on physical access to community facilities, social attitudes, and discrimination with respect to employment and other types of social participation, and the types of accommodations the community is willing to make. These, in turn, affect clients’ attitudes, motivation, participation, and productivity. At a macro level, sociologists and economists study the relationship between the economy and use of the formal disability insurance system. Disability status varies as economic conditions and other community characteristics change.

4. Other Areas of Inquiry

Because medicine can be both a source of data to illuminate sociological hypotheses and a basis for addressing applied problems, research in the area ranges very widely across sociological and medical areas. From a broad sociological perspective, illness is a form of deviance and medicine an institution of social control (Parsons 1951). Illness is often manipulated by individuals to seek release from usual obligations and other secondary gains, to excuse failure, and to gain social support. Community agents also seek to control illness definitions to insure societal productivity and protect the public purse from demands that would be too burdensome. In this sense, definitions of illness are differentially constructed by agents who have varying needs, ranging from the individual client seeking certain advantages to government agencies attempting to constrain entitlement payments.

From the standpoint of sociology, medicine has been a basis for studying occupational socialization, professional organization and control, intraorganizational processes, power and influence, demographic processes, political conflict, collective behavior, and much more. From a medical perspective, sociological investigation has contributed to the study of every major disease category, examining etiological and risk factors and other influences on the course of disease and social responses and adaptations. Medicine has also been a context for methodological innovation in experimental approaches, use of surveys, measurement approaches, and analytic methods.

Behavior: Psychosocial Theories; Health Behaviors; Health Care Delivery Services; Health Care Organizations: For-profit and Nonprofit; Health Care, Rationing of; Health Care Technology; Health Economics; Health Policy; Medical Geography; Medical Profession, The; Medicalization: Cultural Concerns; Professions, Sociology of; Public Health; Public Health as a Social Science; Socioeconomic Status and Health; Socioeconomic Status and Health Care; Stress and Health Research

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