Medical Psychology and Sociology: Foundations of Sociology

Sociological influence on health and disease

Behavior models and psychological models bring the individual person to the fore to explain disease and health. Sociological models focus on the influence of social structures on health and disease. The structure of society, the economic system and the organization of health assurance (e.g., the introduction of health insurance structures) all play an important role.

Norms and behavior deviating from the norm

Norms are a society’s systems of rules, which relate to the behavior of its members. Behavior that complies with the norms is reinforced and rewarded; behavior that deviates from the norms is sanctioned. Society places on the individual person a wide range of expectations relating to behavioral norms. If the behavior that deviates from the norms (e.g., quitting a job) is punished, this can have a negative impact on a person’s physical and psychological state of health.

Socio-structural factors

Social classes

A social class is explained as a group of people having similar or equal circumstances, i.e., their living and working conditions are on the same level. Almost all members of society classify their fellow men into specific categories. This first assessment occurs on the basis of outer appearance, language, clothing and occupation. Social classes behave hierarchically in relation to each other and enjoy different reputations within society. In Germany, many studies have shown that those from different social classes behave differently with respect to disease and health.

The concept of social classes is a keyword in sociology. Class-related terms and models are based on education, income and occupational class. This social class index (or meritocratic triad) is seen as an important resource with respect to life chances.

• Educational class: defined by the level of education completed.
• Income class: defined by income.
• Occupational class: defined by occupational prestige.

Attributed and acquired status: origin and personal contribution

A person is given an attributed status on the basis of his or her origin. An acquired status describes the status, which a person can achieve by their own performance, skill and effort.

The meritocratic principle says that positions and rewards should only be distributed on the basis of the performance of the individual person—not on the basis of their attributed status (e.g., gender, origin, parental home or ethnic affiliation).

Social (vertical) mobility

The openness of a society can be perceived by studying the possibility of social mobility.

Under the prevailing circumstances, to what degree can a person influence his or her own social position using his or her own skill and effort?

The medieval estate-based society can be seen as an example of extremely low social mobility. Currently, due to recession, there is a decrease in social mobility in industrial countries.

Social deprivation

Poverty, unemployment, homelessness and belonging to a social fringe group can mean exclusion from society, i.e., social deprivation. Social deprivation has a negative impact on health, independent of a person’s level of education and their occupation.

Important connections between status / class affiliation and health-related behavior

Social class gradients and explanatory hypotheses

Social class gradients describe the reduced levels of, for example, obesity, alcohol and nicotine abuse. Another factor is the prevalence of mental disorders, when it comes to the higher classes within a population. Two theories offer explanations for the origin of these social class gradients: the social causation hypothesis and the social drift hypothesis. The social causation hypothesis has received a greater degree of proof than the drift hypothesis. The latter could primarily be observed in the area of mental disorders, especially in schizophrenic people.

The social causation hypothesis (cause hypothesis)

The cause of the unequal distribution of health and disease is greater exposure to factors that endanger health (higher environmental pollution, worse working conditions, etc.) and risk behavior (nutrition, substance abuse, movement behavior, etc. ), which is accompanied by affiliation to the respective social class.

The social drift hypothesis (selection hypothesis)

The social drift hypothesis argues from the opposite direction. It states that the unequal distribution of health and disease exists because disease forces social relegation or does not allow social advancement. This social drifting away is thus considered a consequence of a disease.

Demographic Structure of Society

Age

Age is a common characteristic that we use to differentiate or sub-group a population. Age cohort is a group of subjects who have shared a particular event together during a particular time period.

“Baby Boomer” age cohort:

• Post-WW II baby boom
• Currently between 52—70 years old
• Widely associated with privilege, as many grew up in a time of widespread government subsidies in post-war housing and education, and increasing affluence

Consider the elderly those over the age of 65 as they typically retire ad are not contributing to the workforce. Resultant shift in quality of life as their reliance on social support increases. In the US, 10 % live below the poverty line. “Silent Generation” and “G.I. Generation” were born during the Great Depression and WW II. By 2025, it is estimated that over 25 % will be over the age of 65.

Dependency ratio examines the proportion of elderly vs. non-elderly and the need for social support.

Age-related decline of physical health can impact:

• Productivity
• Reliance and/ or utilization of health care system
• Loss of autonomy

Social significance of aging includes:

• Increased need of professionals who specialize in this age cohort (care, prevention)
• Age friendly services
• Realignment of societal views (i.we. cultural, social, economic)

Life course theory of aging is a process mediated by:

There is a shift in age-related expectations with increased life expactancy.

Other theories of aging include:

Age stratification: use age as a means to regulate appropriate behavior

Activity theory: certain activities/ jobs are lost with old age, social interactions must be replaced

Disengagement theory: greater divide between both individual and society

Gender

Gender is the range of characteristics pertaining to, and differentiating between and from masculinity and femininity.

Considerations for determining gender of an individual include:

Genderqueer, also referred to as non-binary, is when an individual is not exclusively masculine or feminine.

This is a catch-all category which can include:

Sexual orientation

Sexual orientation refers to a person´s sense of identity based on attractions, related behaviors, and membership in a community of others who share those attractions.

Sexual orientation is composed of:

Sexual orientation is traditionally defined as including:

• Heterosexuality: attraction and sex with opposite gender (i.e. male with female)
• Bisexuality: attraction and sex with either gender (i.e. male with either male/female)
• Homosexuality: attraction and sex with same gender (i.e. male with male)
• Asexuality: lack of sexual attraction to anyone

The social construction of gender refers to social norms, expectations and roles assigned to each gender many times even before they are born. The gender roles can shape the expectations of “proper” behavior.

Society tends to predefine the characteristics of each gender:

These predefinitions are propagated by media and society, and disapproved upon when broken. Societal views are more biased towards men than women (i.e. men shouldn´t have female roles). Men´s roles are perceived as having more value (i.e. home-maker vs. professional).

Society also assigns unequal value to jobs and education based on gender

• Men; higher pay for same job with same qualifications, at school considered smart
• Women: less relative pay and responsibility, at school considered hard-working

There is a socially difference in biological vs. psychological difference in health.

Gender segregation

Gender segregation is the separation of people according to social constructions of gender.

Race and Ethnicity

Race is a socially defined category that is based on physical differences between groups of people. The racial formation theory looks at race as a socially constructed identity, where the content and importance of racial categories are determined by: social, economic and political factors. Many times the racial difference may be perceived or based from a historical perspective (i.e. color of your skin vs. color of your hair or eyes).

Ethnicity is a category of people who identify with each other based on cultural differences:

Ethnicity is a dynamic process and can change across generations.

Social constructs of race and ethnicity can impact:

• Level of and access to education, employment (disparity in pay and opportunity)
• Life expactancy, overall health, access to health care, health behaviors

Racialization or ethnicization is the processes of assigning ethnic or racial identities to a group that did not identify itself as such:

• Usually ascribed by the dominant group or population
• The racialized group often gradually identifies with and eben embraces the ascribed identity

Immigration status

Immigration is the movement of people into a country of which they are not natives in order to settle or reside there. Immigrants tend to move to more industrialized, economically sound, and politically stable countries. Immigration can have both positive and negative effects for the donor and recipient countries:

• Can alleviate labor shortages in recipient country, lighten social load in donor country
• Exploitation of immigrants to optimize economic gain
• Social support and services cannot handle “herding” or mass movement of immigrants
• “Brain-drain” of donor country

Occupation and disease

In the long term, high workloads have a negative influence on health. Workers are more often affected by physically hard labor and shift work, which foster physical diseases. Doctors, for example, are exposed to very high psychological loads, in terms of high responsibility, high level of time pressure and high expectations from many sides (e.g., from patients, relatives, colleagues, family, etc.)

A person’s subjective impression of job insecurity is a stress factor!

Two models have been developed concerning the influence of stress in professional life. They describe the connection between stress factors in professional life and the risk of cardiovascular diseases.

The job demand-control model

A person’s workload can be described in the demand-control model in terms of two dimensions:

• The amount and character of the demand;
• The controllability of the tasks;
• A new third dimension: social support.

Strong social support can serve as a stress buffer and compensate high workloads.

Model of occupational gratification crises

As the name suggests, the model of occupational gratification crises brings into focus the relationship between occupational exertion and earned rewards (e.g., payment, social recognition, etc.). Social support and attitude (goals in life, psychological stability, etc.) are buffers.

Ecological factors and health

Economic factors and health

The economic and financial situation of a country has a great impact on the health of an individual. The structure of the health system is also very important: statutory or private? While in Germany every person has to have health insurance, in the USA, for example, a lot of people in lower social classes have no access to medical care. However, the tendency for people in higher social classes to receive better medical care is also present in Germany (private vs. statutory health insurance patients). The enormous impact of economic factors on health can be seen in terms of life expectancy as seen when comparing highly-industrialized countries and threshold countries.

Average life expectancy for men 2005 – 2010:

• Germany: 77 years
• Central Africa: 45 years

Social demography in medicine

Demography: The science of population combines elements from sociology, geography, medicine and economics, and it examines the life, growth and decay of human populations.

Generative behavior and its determinants

These are some terms you should memorize:

• Fertility: the number of live births, with respect to women.
• Birth rate: the number of live births in a given period of time, divided by the average population in the same period of time.
• Fertility rate: the number of live births per 1,000 women of a certain age interval at a given point in time.
• Nuptiality: marriage and divorce behavior within a population.
• Mortality: part of deaths in the population.
• m (death rate): the proportion of deaths in a given period of time, divided by the average population in the same period of time.
• Perinatal mortality: the number of deaths between the 28^th week of pregnancy and the first week of life, per 1,000 live and still births.
• Lethality: a measurement of the deadliness of a given disease.
• L (lethality rate): the number of people who have died in a given period of time, divided by the number of sick people in the same period of time.
• Gender proportion: this describes the numerical relationship of the male population to the female population.
• Share of the Elderly / Old-Age Dependency Ratio: the number of people over 60 years per 1,000 persons in the age bracket 15-59.
• DALY: Disease-adjusted Life Years: this concept aims to measure the importance of diseases on a society. The DALY-measure describes the length of time in years spent in ill-health or which is lost due to premature death.

Demographic aging

Population pyramids illustrate all age groups within a given population at a given time, in graphic form. Note the following when it comes to interpretation of a population pyramid:

• left: male, right: female
• vertical axis: people’s age in years
• horizontal axis: the actual number of people per age group (mostly in thousands)
• ‘ bulges’: wars, natural disasters, changes to family policy

The ideal basic forms are presented in the following graphic:

Explanation:

1. a linear or classic pyramid shape (isosceles triangular shape)
2. a widened or modified pyramid shape (pagoda shape)
3. a beehive shape
4. a bell shape
5. an onion or urn (exaggerated onion)-shape
6. a Christmas tree or droplet shape

Theory of demographic shift

During nation-wide industrialization, shifts in the generative structure of the population occur. Although this theory originates from the 1920s, it still influences epidemiological thinking. The five stages describe the transformation of aspiring societies: initially, high birth and death rates dominate. In the course of industrialization and modernization, the birth rates stagnate, the population shrinks, and life expectancy increases. Germany and most other industrial countries are at stage five.

The five phases of demographic transformation

Changes in the disease spectrum: epidemiological transition

The epidemiological transition describes the changes in the frequency of diseases and the causes of death. In modern societies, chronic-degenerative diseases now dominate, rather than infectious diseases.

This has (had) the following consequences for medical practice:

Primarily, medical treatment no longer aims to cure the patient, but rather to preserve quality of life. This entails implementing rehabilitative measures rather than curative practice. Demographic aging impacts both health and social politics. One of the goals is compression of morbidity, i.e., seeking to ‘compress’ diseases and disabilities into the shortest possible period immediately before death. Thus, good health should be preserved during old age, in order to keep the enormous costs for chronic diseases at the lowest possible level.

Society in change: the law of contraction and the consequences for medicine

The Law of Contraction describes the historical tendency towards smaller and smaller families, with the consequence that solidarity between individuals only relates to smaller and smaller groups of people.

This sociological thesis was developed in the context of a background where the state is taking over more and more tasks relating to social security, thereby taking over the function of the family nucleus. Certain changes can indeed be explained by the law of contraction, however, in most cases, the nuclear family still forms the most important social and financial network.

Yet, it is an undeniable fact that the number of one and two-person households is continuously increasing in Germany and very few multi-generational households now exist. Furthermore, both partners within a family work. One consequence for the health system is the changing way that things are being organized for sick and elderly people. There is an increasing need for hospital beds, nursing and retirement homes as well as provision of childcare.

Review Questions

The answers can be found below the references.

1. A patient who suffers from symptoms of severe stress comes to your practice. In your social case history you specifically ask for his occupational background. He relates that he has to deal with constantly high levels of time pressure at work, and that he has very little room for recreation. Which of the following models best describes the development of the symptoms, which result from this situation of psychosocial strain?

1. The job demand-control model
2. The model of occupational gratification crises
3. The model of precarious occupation
4. The model of relative deprivation
5. The model of the process of social comparison

2. Epidemiological transition is…

1. …the transition of a pandemic to an epidemic.
2. …the change in population structure dependent on social vertical mobility.
3. …the change in the way people within an entire population relate to health at a certain phase in the development of a society.
4. …the changes in a pathogen during the process of the spread of an infectious disease.
5. …the trans-continental spread of epidemics.

References

M. Schön (2007): GK1 Medizinische Psychologie und Soziologie. Springer Verlag.

K. Buser, T. Schneller, K. Wildgrube (2007): Kurzlehrbuch Medizinische Psychologie und Medizinische Soziologie. Elsevier Verlag.

S. Rothgangel (2010): Kurzlehrbuch Medizinische Psychologie und Soziologie. Thieme Verlag.

Altersstruktur der Bevölkerung in Deutschland via Demografieportal

Correct answers: 1A, 2C