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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.Thus, you cannot be healthier without involving the society and interaction with others and the environment. The commonest association of sociological influence on health is the direct effect of poor socio-economic background on morbidity and mortality. Poor people in every society are associated with multiple diseases and limited access to healthcare.
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
| In lower social classes | In higher social classes |
| Generally an instrumental attitude towards the body: “As long as everything works, I do not need to see a doctor.” | The body has symbolic value; health is seen as a value in and of itself. |
| Higher tolerance of symptoms and more frequent non-compliance | Better access to health-related information |
| Workers make less frequent use of cancer screening and have a higher risk of early disability as employees. | Population groups with higher status more frequently experience allergic and atopic diseases. |
| People in socially weaker classes make less frequent use of prenatal care and screening for diseases. | Anorexia nervosa is a disease of the middle and high classes. |
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)
This hypothesis puts forward that being in a lower class in society is a cause/ risk for developing certain diseases.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.The hypothesis puts forward that mental illness causes one to drift further downwards of the social class.
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: it is the hierarchical ranking of people into groups based on their ages. It is used to regulate appropriate behavior. It exists so that society ensures people of different ages have access to different society rewards, powers, and privileges.
- Activity theory: it is also known as the implicit theory of ageing. Thistheory holds that ageing is considered successful when older adults engage into activities such as social interactions as opposed to the disengagement theory where ageing is associated with inactivity. Certain activities/ jobs are lost with old age, social interactions must be replaced
- Disengagement theory: the theory states that ageing is unavoidable and associated with mutual withdrawal from members of the society and thus social isolation.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:
| Sex | Biological factors | The sex someone was born with | |
| i.e. chromosomes XX vs. XY vs. intersex (genotype does not align with phenotype) | |||
| Gender | Identity | The gender you “identify” with | |
| Female | Male | ||
| Expression | The gender you “express” to the outside world | ||
| Trans-gender | Cis-gender | ||
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:
| Those who have an overlap of gender identity | Have no gender (i.e. androgynous) | Those who move between genders |
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:
| Psychological components | Behavioral components |
| Who are you attracted to? | Who are you having sex with? |
| Erotic desires | Sex of partner |
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:
| Male | Female |
| Strong, dominant, aggressive | Submissive, emotional, “soft” |
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:
| Common language, ancestral, social, cultural, or national factors | Is primarily an inherited status | Less statistically or concretely defined than racial groups |
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
| Social | Work situation, social class, family relations, housing situation, social network |
| Cultural | The cultural understanding of health and disease play an important role, which has to be taken into consideration when dealing with foreign patients! Symbolism, religion and moral concepts have a great influence on the understanding of health and disease and their progress. |
| Natural | Biological, chemical and physical circumstances are basic influencing factors on health and disease, especially if diseases accumulate following a long period of latency (e.g. radioactivity, chemical poisoning). |
| Technical | Risks and injuries, which result from technical devices, e.g., car accidents, electric smog. On the other hand, many technical achievements impact the progress of disease (e.g., modern medical devices). |
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
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 28th 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:
- a linear or classic pyramid shape (isosceles triangular shape)
- a widened or modified pyramid shape (pagoda shape)
- a beehive shape
- a bell shape
- an onion or urn (exaggerated onion)-shape
- 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
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High birth rates, high death rates, slight growth with a high ‘population turnover’ |
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Slow decrease in death rates, continuing high birth rates, the population grows |
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Death rates decrease further, birth rates slowly decrease, population growth reaches its peak |
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Birth rates decrease further, population growth also decreases |
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Birth and death rates decrease further, population growth is roughly constant |
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?
- The job demand-control model
- The model of occupational gratification crises
- The model of precarious occupation
- The model of relative deprivation
- The model of the process of social comparison
2. Epidemiological transition is…
- …the transition of a pandemic to an epidemic.
- …the change in population structure dependent on social vertical mobility.
- …the change in the way people within an entire population relate to health at a certain phase in the development of a society.
- …the changes in a pathogen during the process of the spread of an infectious disease.
- …the trans-continental spread of epidemics.
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