Sociology of Health Notes
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Date Created: 10/20/15
Framing the Sociology of Health 09162015 The De nition of Medical Sociology o quotThe study of healthcare as it is institutionalized in society and of health or illness and its relationship to social factorsquot 0 Applies the perspectives conceptualizations theories and methodologies of sociology to phenomena having to do with human health and disease Broader than medicine 0 Emphasizes that explanations for health illness and healing practices must go beyond biological and individualistic factors to also focus on the important in uence of social context 0 Lung cancer caused by genetics amp smoking smoking is societal rather than biological Basic insights of the eld can be traced to societies earliest philosophers and physicians 0 Essential interrelationships among social and economic conditions lifestyle and health and illness The Development of Medical Sociology Turn of the century 18801920 heightened awareness about the need for social programs and to address the health crisis 0 Social upheaval because of the effects of the Industrial Revolution and rapid urban growth also in US big in ux of poor unskilled immigrants 0 quotSocial medicinequot coined to refer to efforts to improve public heath 0 But the germ theory of disease was also discovereddeveloped around this time Enabled physicians to better treat acute infectious diseases Reinforced belief that medicine could rely solely on biological science Kept focus on biological science less emphasis on a complementary focus on the importance of social conditions These two factors are very important together l need to address social context that in uences diseaseproblem 0 During rst half of the 19005 growing number of studies on health and medicine 0 Social surveys developed as popular research technique 0 Many focused on health and living conditions 0 0 Social scientists often worked with charity organizations and settlement houses 0 Sociological studies on the medical eld appeared 0 Social work and sociology very closely related Formal sub discipline emerged in the 19505 and 19605 facilitated by 0 Changing patterns of morbidity and mortality Shift from acute infectious diseases tuberculosis to chronic degenerative diseases heart disease which are more interwoven with social patterns 0 Impact of preventative medicine and public health Became clear that protection of public heath required consideration of social factors poverty malnutrition congested living areas 0 Development of modern psychiatry Led to increased interest in psychophysiological basis for many diseases and illnesses 0 Impact of administrative medicine Organizational complexity of the medical eld expanded enormously and so analysis of organizations and structure was necessary Major Topics within Medical Sociology The relationship between the social environment and healthillness 0 Social epidemiology and social stress Health and illness behavior 0 Health behavior and the experience of illness and disability Health care practitioners and their relationship with patients 0 The socializationeducation of physicians and other providers and the profession of medicine 0 Physicianpatient relationship 0 Alternative and complementary healing practices The health care system in US and elsewhere 0 Including health care delivery and the social effects of health care technology 0 How different systems are able to quottalkquot with each other Emerging Areas of Interest Issues related to managed care and health reform o Concerns about high costs of health care and lack of access to health care have led to health care reform in the US 0 Massive shift from traditional health insurance plans to managed care networks eg HMOs throughout the 19905 and early 20005 0 Affordable Care Act was passed in 2010 0 Huge interest in the intended and unintended effects of these changed on the health care system and health care delivery Issues related to medical ethics 0 Understanding values attitudes and behaviors of people relative to new ethical issues in medicine eg human cloning 0 Social policy questions eg new reproductive technologies l trying to get pregnant 0 Social movements that have developed around ethical interests eg prolifepro choice movements Ethics Nuremburg Code Internationally recognized principles regarding the ethics of human experimentation established after the Nazi defeat by the Allies The Code requires researchers to have a medically justi able purpose do all within their power to protect their subjects from harm amp ensure subjects give informed consent After the Nazis under Hitler were voted into power in 1933 in Germany they passed the quotLaw for the Prevention of Congenitally Ill Progenyquot This law required the sterilization of anyone considered likely to give borth to children with diseases that doctors considered genetic Under this law government employed doctors sterilized about 200000 to 300000 people In 1935 the government passed the quotLaw to Proetct Genetic Healthquot prohibiting the marriage of people with certain diseases Both laws were based on eugenics In 1939 the Nazis began killing patients in state mental hospitals Between 80000 to 100000 adults and 5000 children died Then the Nazi government began to kill Jews Gypsies and others whom they considered racially inferior By the end of WWII they had murdered between 510 million people in concentration camps Ethics Tuskegee Syphilis Study This study was begun by the federal Public Health service in 1932 hoping to document the neutral progression of untreated syphilis in African American men 399 very poor and mostly illiterate African American men with untreated latestage syphilis living in Tuskegee Alabama They weren t told they had syphilis nor offered treatment They were told they had quotbad bloodquot a term used locally for a variety of health problems They were told is they participated in the study they would receive free and regular health care transportation to medical clinics free meals on exam days and burial expense payment which were big incentives for extremely poor people Prior to the development of penicillin in the early 19405 treating syphilis was difficult lengthy and costly But this treatment was withheld from the study and they kept from receiving this treatment in other places This study as a collaboration of the PHS state and the county medical associations and doctors and nurses affiliated with the local Tuskegee institute Eventually the study was shut down and now it is something people talk about a lot l in many African American communities today there is a distrust of medical and scienti c communities Ethics Henrietta Lacks Henrietta Lacks 19201951 was an AfricanAmerican woman who was the unwitting donor of cells from her cancerous tumors Cells were used to create an immortal cell line for medical research now known as the HeLa cell line Lacks was diagnosed with cervical cancer in 1951 The appearance of the tumor was unlike anything that had ever been seen by the examining gynecologist Cells were removed for research purposes without her knowledge or her permission standard procedure at that time Lacks died from cancer in 1951 but her ces lived on in medical research In the early 19705 the family learned about the removal of Henrietta s ces 0 Her cells did something strange They could be kept alive and grow 0 As the rst human cells could be grown in a lab and were quotimmortalquot did not die after cell divisions they could be used for conducting many experiments 0 Since they were put into mass production cells have been mailed to scientists around the globe for quotresearch into cancer AIDS the effects of radiation and toxic substances gene mapping nad countless other scienti c pursuits HeLa cells have been used to test human sensitivity to tape glue and many other products 0 Scientists have grown some 20 ton of her cells The Sociological Perspective 0 One of the many perspectives used to acquire knowledge about the world 0 Primary focus to understand social interaction groups and organizations and how social context and the social environment in uences attitudes behaviors and social organization Requires the ability to think about things differently not individualistically quotThe sociological imaginationquot Seeking to see and understandquot how larger social patterns public issues in uence individual behavior personal troubles Major Theoretical Orientations in Sociology Seek to guide the effort to nd explanations Structural Functionalism macro theory 0 Views society as a system with interdependent parts that work together to produce relative stability everyone in society has a function that contributes to the system s functioning or dysfunction 0 Con ict Theory macro theory 0 Views society as a system largely dominated by social inequality and con ict between those in power and those who don t have power Symbolic lnteractionism micro theory 0 Views society as multiple simultaneous interactions between individuals and small groups each day where individual attitudes and behaviors are responses to interpreting social messages along with these interactions Common Data Collection Techniques in Sociology Survey research 0 Systematic collection of information about attitudes and behaviors through personal or telephonic interviews or self administered questionnaires 0 Helpful in studying attitudes or values which can t be easily studied in other ways Experimental Research 0 Identifying causeandeffect relationships between speci ed variables in carefully controlled conditions in lab or in natural settings Observational Research 0 Systematic observation of people in their natural environment Use of existing statistics secondary data analysis 0 Drawing on recorded vital and social stats birth and death records for example Studies that involve multiple methods are the best Conceptual Methods Important for theorizing depicting and explaining population distributions of health inequalities Simultaneously organize and spur ideasobservations Illustrate key constructs and causal relationships speci ed by scienti c theories but also provide an important tool for integrating and evaluating rapidly emerging ndings and for guiding new research Contrasting different sets of images is important because doing so shows clearly how social strati cation determinants of population health and determinants of health inequities are portrayed differently Different types of images illuminate or obscure the relevant causal processes that need to be altered to improve population health and reduce health inequities Many models inaccurately depict the distribution of population and resources Models that clearly and unequivocally 1 delineate the social facts of skewed distributions of power and resources and 2 depict the societal processes that generate and maintain these distributions and their embodiment in distributions of health and disease are perhaps most helpful from the sociological perspective What are the SDOH The conditions in which people are born grow life work and age Shaped by the distribution of money power and resources at global national and local levels Mostly responsible for health inequalities the unfair and avoidable differences in health status that are seen within and between countries Why do members of different socioeconomic groups experience varying degrees of health and illness o De nitive work on the social determinants quotClosing the gap in a Generation Health Equity through Action on the SDOHquot The social Determinants of Health focus on factors beyond those of biomedical and behavioral risk Eadyl e Educann Employment and working conditions Food security Gender Health care services Hougng Income amp its distribution Social safety net Social exclusion o Unemployment amp employment security SDOH context 0 quotHealth is a complete state of physical mental and social wellbeing not merely the absence of disease or infirmity Planning services to improve health and well being and reduce the burden of preventable disease you have to be concerned with not only the individual factors but also the broader in uences public policies environmental family etc Why is Policy Important to SDOH Social Policy Health Policy 0 Depoliticized approach only determining the relationship between a SDOH and health status 0 But SDOH do not exist in a vacuum direct result of public policy made by government 0 Health and social policies are interwoven because social policies are the root causes of many health inequalities 0 Most health policy focuses on inadequacies in health care but only 10 of premature mortality 0 000000000 o Preventing the emergence of disease is more a function of conditions that are unequally distributed in society the root causes of unequal health outcomes Policy In uences Population Health Promotes and understanding of the SDOH 0 Educate policy makers and the public Education policies 0 Free food programs at schools sexed curriculums transportation to and from school smaller class sizes better nancing in schools improving teacher compensation improving nutrition in schools improving after school programs and day care 0 Better students better jobs fewer people in low SES healthier people Financial policies 0 Increasing minimum wage tax deductions improved wages and working conditions in developing countries to protect jobs at home Environmental policies 0 More low cost housing air quality traffic safety decreasing crime Workplace policies 0 Reduce exposure to physical hazards reducing psychosocial strains increasing job security Health behavior policies 0 Promote the enhancement of health behavior banning smoking in public areas rehab programs controlling advertisements Also addresses racialage differences quotthe invisibility of successful public health policiesquot when it is working public health doesn t seem like a concern because health concerns aren t prevalent Social Epidemiology The study of the distribution and determinants of health morbidity disability and mortality in populations Social Epidemiology focuses on social and cultural factors related to the distributions and determinants in populations Social Epidemiology is interdisciplinary Combines epidemiology demography sociology history and biologymedicine The Social Epidemiological Domain 0 Social epidemiology examines life expectancy morbidity mortality and disability related to 0 Social class 0 Race and ethnicity 0 Gender 0 Age 0 Life Expectancy and Mortality 0 Life expectancy rates re ect the average number of years that a person born in a given year can expect to live 0 Due to variations and rates among different segments of the population life expectancy is Typically calculated separately for males and females And calculated according to racial and ethnic background 0 Life expectancy and social class 0 O O O The upper class has a distinct advantage On average people with low incomes live 7 years less than the more af uent Level of education and occupational status have been found among important predictors The more af uent also typically use preventative health services are less likely to delay seeking care when they are sick 0 Life expectancy and raceethnicity O O Whites have a much longer life expectancy than do many racial and ethnic minority groups in the US especially African Americans Blacks are much more vulnerable to each of these diseases heart disease cancer etc Hispanics are more likely than nonHispanic whites to be below the poverty level and less likely to have health insurance But they also have the lower death rates Hispanic paradox O O 0 Much research on this hypothesis focus on dietary factors or especially the strong family life and support networks found in many Hispanic families and communities AsianPaci c Islanders are the fastest growing population in the US Japanese Chinese Philippinos As a whole leading causes of death in these groups are the same as other populations but with exception of very new immigrants death rates are lower 0 The RaceClass Relationship 0 O 0 Much scholarly attention has been devoted to this relationship in recent years Both race and class impact mortality Some work eg the Charleston Heart Study has suggested that while race and class both matter the effects of race may be strongly mitigated by class Poverty reduces life expectancy by increasing rates of infant mortality acute and chronic diseases and traumatic death All of the following factors related to race and class or both have been identi ed as SDOH Residential segregation by race Historical and continuing racial discrimination Education occupation income Health insurance Neighborhood in which you live impact health a lot But proximate risk factors at the individuallifestyle level also contribute to health disparities Stress diet exercise etc 0 Life Expectancy and Gender 0 Females have a longer life expectancy than males but there are differences by race White female infants are expected to live 5 years longer than white male infants Black female infants are expected to life 7 years longer than black male infants 0 This trend is changing 0 Females have a slight quotbiological advantagequot at prenatal and neonatal stages 0 But this is not responsible for the sizable gap for mortality it is traceable to interrelationship between biological and cultural in uences 0 There are signi cant differences in the manner in which health services are used by men and women 0 ln agricultural communities rather than industrial ones men typically live longer than women 0 Women have higher rates of debilitating but not life threatening conditions anemia 0 Men are more likely to have life threatening conditions cancer stroke liver disease l men smoke more drink more more exposed to cancer causing agents in work space men are more likely to die in automobile accidents men drive more less cautiously more likely to die in job accidents more likely to commit suicide more likely to be a victim of homicide 0 Women are more likely to receive medical care feel symptoms more more likely to see doctor and often use more preventative measures Morbidity Morbidity refers to the amount of disease impairment and accident in population Socio demographic factors in uencing morbidity rates age SES race and gender Conditions that contribute to morbidity among children and adolescents 0 Poor diet and exercise 0 Use of tobacco alcohol and drugs 0 Sexual activity and pregnancy 0 Violence Morbidity and Social Class 0 Research shows a lot of morbidity and functional limitations in lowers SES groups in American society o The discrepancy between the poor and the non poor was especially great for those between the ages of 35 and 75 o The disadvantages in health status can be explained by the vulnerability of this group to a number of psychosocial and environmental risk factors 0 Poor have greater risk to hazards increased stress less access to health careinsurance greater participation in harmful behaviors smoking drinking poor eating habits lack of exercise 0 Variation among social class groups and these risk factors appears to be relatively small in early adult hood greater during middle age and early old age and small again in older age Morbidity and RaceEthnicity o Morbidity rates are higher for blacks than whites for most diseases 0 Blacks experience more health problems than white early in life and their health deteriorates more early on o USborn Asian Americans are very similar in their level of health to that of the population as a whole generally healthiest racialethnic group 0 Most Hispanic groups fair worse than whites on morbidity despite the quotHispanic Paradoxquot Morbidity and Gender 0 Reasons offered for gender differences Biological Acquired risks due to differences in social factors Psychological aspects of symptoms and care Health reporting behavior Prior experience with health care Fundamental Causes Proximate Risk Factors and Disease 0 Disease etiology identifying the cause or origins of a disease Fundamental causes typically refers to the social environment 0 These social factors have an in uence on 0 An individuals exposure to multiple risk factors that can affect the onset of a disease 0 Access to or lack of access to important nancial or social resources that can bolster or be a detriment to health Proximate risk factors includes things within an individuals control 6 possible factors for how social structure can determine health status 0 1 Reverse causality health status in uences position in social structure rather than reverse get sick cant work paying big bills so you fall to lower SES 0 2 Differential susceptibility physical traits in uence opportunities for upward social mobility o 3 Individual lifestyle freedom of choice in lifestyles determines differences in health behaviors o 4 Physical environment some people are more likely to be exposed to potentially harmful physical chemical and biological agents 0 5 Social environment effects of living in a stressful vs less stressful lifestyle and have protective social support or not 0 6 Differential access to health care services propensity to use services and bene t from these services for some groups The most complete understanding comes from connecting both FC and PRF Because of this programs designed to help developing countries deal with health problems chronic infectious and parasitic diseases 0 Investing in public and community health FC 0 A more equal income distributions FC 0 Importance of lifestyle and behavioral factors PRF FC amp PRF in Chronic Disease Cardiovascular Diseases leading cause of death in US and the world Etiology focuses on PRF such as smoking exercise and FC such as family history and diabetes Cancer the second leading cause of death in US and mainly due to lung and bronchus prostate and breast and colon and rectum making up a little more than half of cancer deaths in men and women Etiology focuses on FC such as physical environment pollutants and genes and on PRF such as food drug etc HIVAids considered a pandemic disease and the 4th leading cause of death in the world 0 1 killer in Africa but in US is not top 10 leading causes of death o Dif cult to calculate number of HIVpositive people in US Long latency period Most americans have never been tested 0 Etiology through exchange of bodily uids 0 Alzheimer s Disease 0 6th leading cause of death in US o The most common form of dementia o Etiology A protein called beta amyloid forms plague on the brain cells that builds up in the brain over time Molecular tangles inside brains cells can ultimately choke life out of cells 0 While having certain genes increases your risk of developing AD there are environmental triggers to this disease scientists are currently trying to gure these out 0 Mental Illness o 1 in 5 people in the US is estimated to have some type of mental illness each year 0 Measured by the diagnostic and statistical manual of mental disorders 5th edition 0 But the prevalence of mental illness is hard to estimate Due to social stigma many go undiagnosed Society doesn t give as much public attention or funding to mental illness as is given to physical illnesses Many health insurances don t give coverage to mental health services 0 Three approaches to mental illness Biological determinants of mental illness are internal Psychological determinants of mental illness are internal Sociological determinants of mental illness are external in environment or person s social situation 0 Mental Health A Public Health Problem 0 450 million suffer o 1 in every 4 will be effected at some point in their life 0 By 2020 depression will become the second leading cause for disease burden o Preventing mental disorders and promoting mental health is of the immense interest to policy makers o Affect functioning of individual level but also extends further into the community and society Need for care lack of functioning loss of productivity Mental disorders are disabling and often last for many years take huge toll on individuals friends family members 0 Need more attention to prevention of mental illness 0 How can we know how many people suffer Psychiatric epidemiology a type of medical epidemiology Social scientists psychologists sociologists anthropologists Psychiatric Epidemiology o Clinicians can identify mental disorders with interviews and patient histories o How can we know how many people suffer o Interviewers and surveyors are typically nonclinicians who are not adequately trained so data prone to error 0 Creating valid measures to identify mental disorders is a critical challenge hard to get large sample so much variation so expensive to do diagnostic interviews 0 Three examples o Epi Catchment Area Study 0 National Comorbidity Study 0 National Comorbidity Study Replication Results were problematic Differentcon icting results prevalence varied widely True vs Clinical Prevalence 0 Clinical prevalence can be measured by taking surveys of how many people are treated for mental disorders Hospitals psychiatric clinics therapy of ces 0 True prevalence the actual rate of disorders treated or not Direct surveys of community populations have been method of choice Have to interview many people to get suf cient sample Symptom recall is often not good Often hesitance to share sensitive information 0 Problem of Conceptual Validity How to distinguish disordered from the nondisordered Not clear markers for identifying presence of mental iHness Based on rigid rules of how people answer certain questions which may not be a valid measure for some mental disorder Stress is de ned as 0 events or circumstances that cause unease unease felt during events bodily responses to events 0 the mind and body s attempts to deal with unease to recapture a sense of wellness Social Stress Model Stressors social factors or forces that contribute to stress discrete life events or changes chronic strains Stress Theory Holmes amp Rahe 1967 Life events research looked at major life events and people s ability to cope with them Found 43 major life events Discovered the more life events individuals experienced in a given time the more likely they were to experience injury become ill or die HOLMES AND RAHE SCALE OF LIFE EVENTS DEATH OF SPOUSE 100 DIVORCE 73 MARITAL SEPARATION 65 jAIL TERM 63 DEATH OF FAMILY MEMBER 63 PERSONAL ILLNESS 53 MARRIAGE 50 PREGNANCY 4O CHILD LEAVES HOME 29 CHANGE IN SCHOOL 20 MORTGAGE 31 Stress amp Mental Illness Hundreds of studies have associated major life events and onset of anxiety depression schizophrenia and other mental disorders Also discovered that undesirable events were more strongly associated with mental disorders than were desirable ones Brown and Harris 1978 found major negative life events make people vulnerable to clinical depression Other researchers found that certain types of life events are more likely to be associated with development of mental disorders than others events that are quotnonnormative unexpected uncontrollable clustered in timequot Macro Events amp Mental Health Most studies relating adverse life events to psychiatric impairment focus on individuallevel events Childhood abuse and neglect Current interpersonal relationships Financial vocational etc stressors But macrolevel events also very much effect mental health Terrorism natural disasters and wars Richman et al 2008 offer one of the most exciting investigations in this area Examined the impact of one macro event 911 in a sixwave prospective questionnaire study of 2492 Midwest university employees Study had begun in 1996 Analyzed how distress symptoms and fears regarding future terrorist threats affected subsequent mental distress and drinking Followups continued through 2005 Analyses controlling for many demographic variables prior general mental health distress and drinking showed that terrorismrelated negative beliefs and fears in 2003 signi cantly predicted depression anxiety hostility symptoms of PTSD and increased escapist motives for drinking but not quantity of alcohol consumed or binge drinking 0 In men only terrorismrelated fears predicted drinking to intoxication These results indicate an enduring impact of terrorismrelated fears on mental health distress and drinking Macrolevel stressors merit attention in our understanding of populationlevel mental health We don t know the temperamental andor experiential antecedents that increase the vulnerability of some individuals to more pessimistic appraisals of events and in turn to distress symptoms Likely an exciting possibility for genetic researchers 0 Also pessimistic Orjust realistic The Impact Pyramid 0 Individual victims 0 Family and social networks 0 Rescue workers medical care providers their families and social networks Vulnerable populations and impacted businesses 0 Ordinary people and their communities Chronic Stress Chronic stressors are longterm problems con icts and threats that people face in their daily lives 0 What are examples of chronic stressors in your lives 0 Types of chronic stressors o role overload all the role demands placed on an individual exceed that individual s ability to meet them 0 interpersonal con icts within role sets 0 interrole con ict occurs when the demands of 2 or more roles held by a person are incompatible amp the demands cannot be met 0 role captivity describes individuals in unwanted roles where they prefer to do other things 0 role restructuring occurs when longterm roles change or are restructured Stress Theory Selye 1956 Selye studied animals exposed to negative stimuli Found 3 stages of response 0 Flight or ght 0 Resistance 0 Exhaustion At exhaustion stage animal develops illness Demonstrated that prolonged exposure to negative stress produces iHness Social Stress Model Appraisal of Stressors is based on symbolic interactionism where there is a constant process of verbal and nonverbal exchanges interpretations and responses Individuals create their worlds from these interactions ie the social construction of reality Stress outcomes emotional disturbances abnormal behaviors psychosomatic illnesses worsening of other illnesses Stress pathwavs in the body related to disease cerebral cortex through the limbic or emotion center to the HPA axis hypothalamus in the brain which stimulates the pituitary gland which then activates the adrenal and thyroid glands to secrete hormones to trigger a bodily stress response 0 to the reacting But imperfectweak correlation Most studies report a correlation of 03 between stressors and symptoms of mental distress This is modest and so researchers questioned why Found that many individuals have good quotcoping resourcesquot and are not so negatively affected as others 0 Coping buffers negative effects of stress What is coping 0 Using coping resources to handle stressful demands 0 Social resources social networks family and friends 0 Personal resources selfesteem and sense of control or mastery over life 0 Using coping strategies 0 Behavioral or cognitive attempts to manage stressful demands Some groups are more vulnerable to stress than others 0 Negative life events and chronic strains are unequally distributed in the population 0 Some groups have fewer resources and are thus more vulnerable 0 Women 0 The elderly 0 The very young 0 Unmarried people 0 People of low socioeconomic status The Role of Social Class Race amp Gender in Social Stress Social Class People in a lower social class tend to have higher stressrelated mental and physical health problems 0 Two explanations for this include o The exposure hypothesis lower social class people are exposed to more stressors and therefore they have more health problems 0 The vulnerability hypothesis exposure between social class groups may be similar but stressors have a greater impact on health problems for lower class people 0 Race 0 Two beliefs about racial differences in stressrelated health problems 0 They can be attributed to many racial and ethnic minority groups lower social class or SES And once social class is controlled for racial disparities in health problems should disappear 0 They remain prominent after social class is controlled ie other factors account for these differences This research shows that Black vs White adults experience more distress at all income levels GLUE 0 Women tend to have higher rates of psychological distress and depression 0 Explanations for these gender differences include women being exposed to more acute and chronic stressors than men feeling stress when others in their network feel stress being more vulnerable to stress being passive rather than expressive in coping with stressors having less power in societal institutions and more vulnerability to stress Also exaggerated ndings could lead to this gender disparity given that most stress research focuses on depression only Trauma and Stressor Related Disorders in the DSM5 Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Speci ed Trauma and Stressor Related Disorder Unspeci ed Trauma and Stressor Related Disorder Posttraumatic Stress Disorder An anxiety disorder that occurs in response to a traumatic event 0 Eg combat physical assault rape explosion In the event they experienced witnessed or were confronted with actual or potential death serious physical injury or a threat to physical integrity o PTSD is characterized in DSM5 by 1 the persistent reexperience of a trauma 2 efforts to avoid recollecting the trauma 3 persistent negative alterations in cognitions and mood and 4 hyper arousal More speci cally o The traumatic event is reexperienced through repetitive intrusive images or dreams or through recurrent illusions hallucinations or ashbacks of the event 0 To adapt people often try to avoid recollections of the event through psychological mechanisms dissociation numbing or avoidance of circumstances that will evoke recall 0 Substance abuse not uncommon to help numb o Often experience detachment from others and exhibit evidence of autonomic hyperarousal eg difficulty sleeping exaggerated startle response Posttraumatic Stress Disorder Epidemiology and Etiology 0 Prevalence is currently estimated at 05 among men and 12 among women 0 But growing fast because of today s wartime and other traumas May occur at any age from childhood through adulthood May begin hours days or years after the trauma 0 The central etiologic factor is the trauma 0 There may be some necessary predisposition because not all people experiencing the same trauma develop PTSD Imaging studies show altered reduced hippocampal volume Posttraumatic Stress Disorder What Helps Most effective treatment involves m drugs esp SSRls and psychotherapy individual or group Psychotherapy is best when tailored to the nature of the trauma degree of coping skills and the support systems available to the person PTSD in Veterans A Public Health Crisis 0 PTSD is particularly prevalent among the military population given today s multiple wartime deployments By one estimate more than 300000 of the nearly two million US service people deployed since 911 suffer from PTSD 0 Symptoms include ashbacks and nightmares emotional numbness relationship problems trouble sleeping sudden anger and drug and alcohol abuse o The number of cases is expected to climb as the war in Afghanistan continues and could ultimately exceed 500000 PTSD is credited as the primary reason suicides in the military are at an alltime high 0 256 soldiers took their own lives in 2008 the highest number since that data was rst tracked in 1980 PTSD in Veterans Despite the epidemic however PTSD is still not a subject soldiers and veterans are very comfortable discussing Treatment can be a challenge because a strong negative social stigma often prevents soldiers from seeking help 0 Soldiers are socially conditioned not to show weakness to be tough and resilient and not to feel or acknowledge uncomfortable emotions PTSD can and does manifest in many ways 0 Substance abuse in delity spousal abuse divorce rates 0 But in the military these are also taboo subjects soldiers can be dishonorably discharged for some of these 0 Creates additional stigma and makes further problems for treatment PTSD Treatment for Veterans All branches of the military are taking additional steps to address PTSD 0 Now more focused training for clinicians on PTSD in veterans 0 Includes understanding military culture and breaking down the many social barriers to healing 0 Important to remind soldiers they are human with human frailties Counseling them and their families to develop compassion for their human response patterns in the face of extreme conditions can be very effective 0 Many options for PTSD treatment offered by the VA and elsewhere 0 Supportive talk therapy psychoeducation eye movement desensitization and reprocessing EMDR hypnotherapy breath work group therapy 0 Hospitalization may be appropriate in severe cases 0 Community programs eg the Soldiers Project recruit volunteer clinicians to provide services to soldiers and families struggling with reintegration issues Early Life Experiences and the Life Course 0 What happens to people in their early years has consequences for the rest of their lives 0 Many opportunities to intervene and make a difference 0 Most effective time to intervene is early childhood Mechanisms and Pathways 0 Many mechanisms and pathways through which early life conditions affect health in later life 0 Though it s not yet clear precisely how important childhood factors are relative to adult risk factors or adult educationincome Parental health in utero and as newborn o Infections and in ammation in early years 0 Exposure to poor nutrition and infectious diseases in utero and in early years 0 0 Height is linked to adult mortality especially from CVD Height is indicator of nutritional and disease environment Cthhood Adults who experienced poor health as children have lower outcomes than those who did not experience poor health 0 O O O 0 Lower educational attainment Lower earning Poorer health This is true even when parents incomes educational attainment and social status are controlled for Poor children have worse outcomes l experience circular effects start out with less advantages and then you have poorer health growing up and as an adult Adolescence Adolescence is a time of drastic growth and puberty So diet during adolescence can have long lasting effects 0 Eg 40 of peak bone mass in girls accumulated during adolescence 0 Development of higher peak bone mass during these years protects against bone loss and osteoporosis in postmenopausal women Effects on Development Experiences in early childhood affect children s brain cognitive and behavioral development Social experiences in rst few years of life shape infants and toddlers development Children s development linked to social and economic advantages and disadvantages in home environment Neighborhood conditions have signi cant effects too more on that next time Parents social and economic resources can affect the quality and stability of relationships with infants Parentinfant relationships affect children s emotional development and cognitive development Maternal depression can inhibit motherinfant bonding and is more prevalent in lowincome mothers Higher income and educational attainment are associated with more stimulation of and response to infants and children which is linked to brain development 0 ECLSK shows association between family income and children having the academic and social skills necessary for kindergarten Why 0 Education many increase parent s awareness of early childhood development needs 0 But even more importantly higher income usually means lower levels of chronic stress in the home and great resources to cope with stressors which enables parents to interact more oftenfavorably with children Social Context Matters Childhood health is also affected by macroeconomic conditions and social policies 0 During economic downturns more suffer from poor living conditions leading to greater malnutrition and exposure to disease Early life conditions play out differently in different eras and location 0 Some eras are more likely to expose children to hardship 0 Date and place of birth are persistently associated with risks of adult death 0 Black women in the late 19605 vs in the early 19605 Lower risk factor rates as adults less likely to give birth to an infant with low birth rate Shows the intergenerational health bene ts of social policies that improved infant health eg Title VI of 1964 Civil Rights Act prohibits discrimination on the basis of race color and national origin in programs and activities receiving federal nancial assistance Unresolved Questions about Modern Old Age 0 One of the most important questions we face Can we live longer while still being active and free of disability 0 Other important questions 0 Will the increasing numbers of older people with more education and longer lives contribute to the larger society in what ways 0 Can our health care system handle greater numbers of older adults Seniors in the US 0 During the 20th century the US population under age 65 tripled but those 65 and older increased by a factor of 11 o By the year 2030 about one out of every ve Americans or 20 of our population will be a senior citizen 0 Half of the people 65 or older live in nine states 0 Currently the senior US population is mostly white but the percentage from other races is growing rapidly o This dramatic shift in the number of the elderly in our country means a shift in awareness Changes in the perception of aging o The role of medicine for the elderly 0 The practice of elder care 0 The overall quality of life for the elderly A Shift in Human Health Today s elderly in the US generally do not face immediate health related threats like malnutrition Cardiovascular problems remain the number one cause of morbidity and mortality among the elderly Some ten percent of all elderly now suffer from some form of dementia and this number is expected to triple by the year 2030 People over sixty ve even those with disabling illnesses may live another thirty years What does maintaining quality of life mean in these circumstances Primary family caregivers Females o The typical family caregivers of the elderly are daughters daughtersinlaw and spouses more often wives than husbands 0 Although men also provide assistance females may spend as much as 50 more time providing care Overview of LongTerm Ca re A variety of services which help meet both the medical and non medical need of people with a chronic illness or disability who cannot care for themselves Distinction between medical and non medical care 0 The latter is less likely to be covered by insurance 0 Often referred to as skilled medical vs social non medical By 2020 12 million older Americans will need longterm care Four out of every ten people who reach age 65 will enter a nursing home at some point in their lives About 10 of those who enter a nursing home will stay there 5 years Longterm care is focused on satisfying the expectations of two tiers of customers The resident customer and vs the purchasing customer Funding for Long Term Care Medicaid will pay for certain health servcies and nursing home care for older people o In most states Medicaid also pays for some long term care services at home and in the community Eligibility varies Medicare Generally does not pay for longterm care only for medically necessary skilled nursing facility or home health care 0 However certain conditions must be met for Medicare to pay for even those types of care services must be ordered by a doctor and tend to be rehabilitative in nature 0 Will not pay for custodial and nonskilled care 0 Longterm care can be extremely expensive Nursing Home Care 0 A place of residence for people who require nursing care and have signi cant de ciencies with activities of daily living 0 Required to have licensed practical nurses on duty 24 hours a day 0 Again very expensive Home Health Care 0 Home care and home health care are not the same thing 0 Home care can be provided by informal family or friends 0 Home health care has formal professional providers and can incorporate a wide range of clinical activities 0 Both aim to make it possible for people to remain at home Pressing Policy Questions 0 How will we provide longterm care for growing numbers of the frail elderly 0 How will we pay for long term care in the future 0 How will we maintain the quality of the long term care system 0 Who will provide medical care for the frail elderly people 0 What are the ethical issues surrounding the care of frail elderly people A Broader Understanding of Environment Health can t be fully understood in isolation from its environmental contexts Traditional environmental health approaches focus primarily on toxic substances in air water and soil But more recently environment has been conceptualized in broader terms to include a range of humanmade physical and social features that are affected by public policy Now attracting greater attention because decision makers are recognizing their health implications Environmental Determinants of Health Environmental factors affect large groups that share common living or working spaces They are key candidates as explanatory factors for health differences across geographic areas Major motivation for the research on environmental determinants of health has been the repeated observation that many health outcomes are spatially patterned not individual 0 At all levels across countries across regions within countries across cities across neighborhoods etc o For most outcomes noncommunicable diseases injuries violence etc Explanations for Spatial Patterns A key contender the spatial sorting of people based on their socioeconomic position race or ethnicity But evidence suggests that regional and neighborhood differences in heath persist even after controlling demographic factors This suggests that broad environmental factors also play an important role in health independent of demographic sorting But environmental factors linked to space and place likely do contribute and reinforce SESracialethnic health disparities So individual environmental factors may work together as a reinforcing cycle that creates and persists health differences Important Environmental Aspects Many aspects of the physical and social environment can affect heath Physical environment factors Social environment factors 0 Spatial distribution of environmental factors 0 Other environmental considerations Physical Environmental Factors 0 Factors in the physical environment that are important to health include o Harmful substances eg air pollution proximity to toxic sites these are the focus of classic environmental epidemiology o The effects of the built environment on access to various healthrelated resources eg healthyunhealthy foods recreational resources medical care 0 Community design eg land use mix street connectivity transportation systems 0 The quotbuilt environmentquot the presence of and proximity to healthrelevant resources as well as to aspects of the ways in which neighborhoods are designed and built Harmful Substances A large body of work has documented the effects of exposure to particular matter on cardiovascular and respiratory mortality and morbidity o Particulate matter solid particles and liquid droplets found in the air 0 Research has identi ed speci c physiologic mechanisms by which these exposures affect in ammatory and vascular processes 0 The effects of particulate matter are consistent across countries 0 Lead exposures linked to cognitive development problems in children 0 Consistent inverse relationship between airborne particulate matter and birth weight 0 In Australia Brazil Canada France Italy the Netherlands South Korea UK and US known to be consistent across countries 0 Because of evidence legislation has been directed at reducing levels of air pollutants and lead in the environment Access to Resources 0 Evidence links proximity to healthy or unhealthy food stores with dietary behaviors and related chronic disease outcomes food deserts Food availability and food advertising in uence energy intake and the nutritional value of foods consumed Physical activity levels are strongly affected by presence of and access to recreational facilities Community Design Walking and physical activity levels are also affected by land use mix transportation systems and urban planning and design quotWalkabilityquot measured by proxies like building density land use mix and street connectivity predicts walking patterns some streets are designed to make you walk more Physical activity by children is strongly associated with features of the built environment and physical activity resources The importance of residential environments to obesity and related conditions was shown in a 2011 randomized housing intervention 0 Lowincome participants who were randomly assigned to move into lowpoverty areas with more walkability experienced signi cant improvements in weight and diabetes indicators Physical Exposure in the US Few available data to make crossnational comparisons of exposure to harmful physical or chemical environmental hazards But little evidence that air pollution is a more severe problem in the US than in other highincome countries 0 US is a major emitter of carbon which contributes to air poHqun 0 Heavy reliance on automobile transportation is linked to traffic levels which contributes to air pollution and its health consequences 0 Concentration of particulate matter less than 10 micrometers in diameter is one available measure of air pollution In US concentration levels is 194 micrograms per cubic meter lower than the OECD average of 22 micrograms But our reliance on private automobile transportation has promoted automobiledependent development patterns with consequences for population density land use mix and walkability In 2008 the US had 800 motor vehicles per 1000 people 0 Vs 598 in France 554 in Germany 526 in UK and 521 in Sweden Compared to cities in other highincome countries US cities tend to 0 Be less compact 0 Have fewer public transportation and nonmotorized travel oonns 0 Have longer commuting distances Social Environmental Factors Factors in the social environment that are important to health include 0 Factors related to safety violence and social disorder 0 Factors related to the type quality and stability of social connections eg social participation social cohesion social capital and the collective efficacy of the neighborhood The Shape and Structure of Social Relationships Neighborhood conditions can create stress that has biological consequences Features of the social environment that operate as stressors eg perceptions of safety and social disorder have been linked to mental health problems Social participation and integration in the immediate social environment eg school work neighborhood are important to both mental and physical health The stability of social connections is also very important eg the composition and stability of households the existence of stable and supportive local environments in which to live and work people are coming in the neighborhood and leaving neighborhood this has a disruptive effect so people s health suffers Social Support One mechanism through which the social environment can enhance heath Buffers the effects of stress 0 By in uencing how one perceives a situation threat vs challenge l with more social support people tend to view things more as a challenge because it seems more possible for them to overcome it o By in uencing how one responds to stressors Remember the hypothesis about the quotHispanic Paradoxquot The reason that many Hispanic groups appear to have better health outcomes than might be predicted by their incomes and education may be because of their strong social support networks Social Capital Social capital quotFeatures of social organization such as trust norms and networks that can improve the efficiency of society by facilitating coordinated actionsquot an expression in how much you feel integrated or a part of your given organization Consistently strong relationships between social capital and self reported health status and to some measures of mortality Social capital depends on the ability of people to form and maintain relationships and networks with their neighbors Characteristics of communities that foster distrust among neighbors eg neglected properties and criminal activity can affect both the cohesiveness of neighbors and the frequency of poor health outcomes Social Environmental Factors in the US International comparisons of social environments are complicated by difficulties in obtaining comparable measures But we know eg that homicide rates particularly those involving rearms are markedly higher in the US than in other rich nations Social cohesion capital and participation measures in the US 0 Greater organizational memberships reported a country of joiners belong to a lot of clubs 0 High prevalence of quotprosocial behaviorquot volunteering time donating to charities 0 Intermediate levels of interpersonal trust US does not have a lot of trust in government 0 Much less likely to have trust in social institutions 0 Lowest voting participation rates of all OECD countries Spatial Distribution of Environmental Factors Levels of residential segregation shape environmental differences across neighborhoods Neighborhoods with residents who are mostly lowincome or minorities may be less able to advocate for resources and services The location of healthrelevant resources are also in uenced by 0 Perceptions and stereotypes about area reputation o Perceived local demand for products and services 0 The purchasing power of residents Physical environmental threats eg proximity to hazardous sites are typically more prevalent in lowincome or minority neighborhoods These neighborhoods also often lack the social connections and political power that could help to remedy adverse conditions Spatial Distribution in the US Low SES people are much more likely to experience residential segregation in the US Residential segregation by income and neighborhood disadvantage has been increasing over time in the US Spatial variation in healthrelated consequences appear to have very different distributions in the US than in other countries 0 Healthy food access issues Food deserts are more prevalent in US O 0 Large geographic disparities in toxic exposures to environmental hazards Levels of safety and violence are also more strongly spatially segregated Other Environmental Considerations 0 Other contexts like school and work environments are also important to health 0 School environments of children adolescents and college students affect O 0 Diet Physical activity 0 The use of alcohol tobacco and other drugs 0 Dietary options on cafeteria menus and in vending machines opportunities for physical activity and health education curricula have all been found to be important to children s health 0 Workplaces are important determinants of health inequalities occupational safety and access to preventive services Strongly linked to illhealth and adverse mental health outcomes 0 Physical working conditions eg exposures to dangerous substances like lead asbestos mercury O O O 0 Physical demands eg carrying heavy loads Ergonomic problems eg sitting too long in unsupportive chairs Stressful psychosocial work environments eg workplace bullying Job strain ie high external demand on a worker with low levels of control or rewards Workplace Conditions and Policies in the US 0 US employees work substantially longer hours than their counterparts in many other highincome countries 0 Annual working hours in US are 15 higher than EU average 0 Other working conditions and workrelated policies also differ in US 0 US workers have a larger gender gap in earnings affects women s health O O 0 US workers spend more time to commuting to work decreases cardiorespiratory tness and increases stress US workers often have weaker employment protection US workers often have fewer unemployment bene ts US workers often experience less generous family and sickness leave policies Sociological vs Biomedical Perspective on Health 0 There are usually 6 dimensions considered to belong to the concept of health 0 O O O O 1 Physical functioning Can you take care of yourself Are you mobile 2 Mental health How is your psychological wellbeing Do you have control of your emotions and behaviors 3 Social wellbeing Do you participate in a social network 4 Role functioning Are you able to perform your daily roles in life 5 General health perceptions How would you selfrate you heath 6 Symptoms Do you have any physical or psychological symptoms of sickness Sociological de nition of health considers the 6 dimensions of health emphasizing social and cultural aspects of health and illness 0 Biomedical de nition of health focuses on the individual s physiology and the absence of disease Sociologists argue that the biomedical perspective is a limited perspective for fully understanding health because 0 O O O The presence of disease a doctor s diagnosis and treatment are not always objective phenomena Physicians are not the only ones de ning health and illness State of health is also in uenced by psychological and social heath A focus on a malfunctioning or diseased body part doesn t consider the rest of the positively functioning individual How Should Health be De ned Talcott Parsons Health should be seen as the ability to meet social norms within your everyday roles and tasks 0 Andrew Twaddle Health should be viewed on a continuum between perfect health and death perfect illness with normal health falling in between 0 World Health Organization Health is a state of complete physical social and mental wellbeing What are Health Behaviors No longer considered just activities quotundertakenfor the purpose of preventing health problemsquot 0 Health behaviors are de ned by 4 dimensions 0 Prevention preventive health behavior doing activities to minimize the risk of disease injury and disability 0 Detection doing activities that can detect disease injury or disability before symptoms appear 0 Promotion efforts to encourage and persuade individuals to engage in healthpromoting behaviors and avoiddisengage from health harming behaviors 0 Protection focuses on making the environment that people live in as healthy as possible Positive and Negative Health Behaviors But health behaviors can be both positive and negative 0 Negative also often referred to as quotrisk behaviorsquot UnHealthy Lifestyle Patterns in the US Behavioral Risk Factor Surveillance System BRFSS Data 2011 o 212 of American adults smoke decreasing over time 635 are overweightobese increasing over time 766 consume too few fruits and vegetables 792 engage in too little exercise 66 are heavy drinkers for women more than 2 drinks in a given sitting o 183 are binge drinkers binge drinking more than 5 drinks in a given sitting Damaging Health Behaviors OOOO o The most damaging negative health behaviors related to deaths include o 1 tobacco use particularly cigarette smoking responsible for 19 of US deaths annually 0 2 dietary factors and inadequate exercise responsible for 14 of US deaths annually 0 3 alcohol responsible for 5 of US deaths annually 0 About 40 of deaths in the US are attributable to 4 behaviors that can be changed Macro Micro Factors 0 Both macro and micro factors in uence lifestyle choices 0 Macro socialstructural conditions 0 Micro personal choices within that structural context Macro factors impacting individual health behaviors The availability of protective or harmful consumer products 0 Physical structures or physical characteristics of products 0 Social structures and policies 0 Media and cultural messages Why not more regulation 0 Using social policy and the force of laws to regulate individual behavior contradicts the culture of individualism in the US o By ignoring research showing a direct relationship between macro level factors and health society doesn t have to x difficult problems it s on the individual Individual Health Behavior ModelsTheories Health Belief Model 0 Theory of Reasoned Action 0 Stages of Change Model Health Belief Model One of the rst models which adapted theories from the behavioral sciences to examine health problems Still one of the most widely recognized and used models in health behavior applications Helps to understand why some people engage in healthprotective behaviors and some do not Argues that people consider both healthrelated and nonhealth related consequences of behavior 0 Eg why don t people stop smoking immediately given widespread public health warnings People will take preventive health action only when certain conditions exist Four constructs re the perceived threat and net bene ts 0 Perceived susceptibility opinion of the chances of getting a certain condition 0 Perceived severity opinion of seriousness of condition 0 Perceived bene ts opinion of the effectiveness of some advised action to reduce the risk of the impact 0 Perceived barriers opinion of the concrete and psychological costs of the advised action Perceptions can be shaped by non health demographic socio psychological structural factors Cues to action Events internal or external which can activate a person39s quotreadiness to actquot 0 Eg media attention advice from doctor a friend s illness etc Theory of Reasoned Action lntention precedes performance of a speci c behavior Intention to perform a speci c behavior is a function of two factors 0 1 attitude positive or negative toward the behavior determined by the person39s belief that a given outcome will occur if she performs the behavior and by an evaluation of the outcome 0 2 the in uence of the social environment general subjective norms on the behavior determined by a person39s normative belief about what important or quotsigni cantquot others think she should do and by hisher motivation to comply with those other people39s wishes or desires Behavioral beliefs beliefs that form the foundation of a person s attitude toward a behavior Normative beliefs beliefs which underlie a person s subjective norms Stages of Change Model 1 Precontemplation the person is unaware of the problem or has not thought seriously about change 2 Contemplation the person is seriously thinking about a change in the near future 3 Preparation the person is planning to take action and is making nal adjustments before changing behavior 4 Action the person implements some speci c action plan to overtly modify behavior and surroundings 5 Maintenance the person continues with desirable actions repeating the periodic recommended steps while struggling to prevent lapses and relapse 6 Termination the person has zero temptation and the ability to resist relapse Interpersonal Theories Individuals engaged in ongoing interpersonal relationships with family members friends and coworkers are more likely to participate in healthprotective behaviors Among adults this often occurs as signi cant others attempt to in uence and persuade the individual to practice a healthy lifestyle Social Networks 0 Structural characteristics 0 lnteractional characteristics 0 Functional characteristics Social support 0 Emotional support 0 Instrumental support 0 Informational support 0 Appraisal support Community Level Theories Community organization Method of intervention whereby individuals groups and organizations engage in planned action to in uence social problems 3 models of practice 0 Locality development eg Peace Corps 0 Social planning eg United Way 0 Social action eg civil rights movement Diffusion of Innovations Theory Explains how new ideas and practices spread within or between societies Five adopter categories 0 Innovators early adopters early majority late majority and laggards how early on you join in on a trend Organizational change theories health education strategies directed at several levels of organizations at once may see most durable results Stage theory of organizational change 0 Explains how organizations plan and implement new ideas and information Organizational development theory 0 Focuses on underlying dynamics of change and what activities health educators would use to make sure change is successful Ecolodical models system models can t look at them in isolation and have to target multiple levels Focus attention on the individual and the social environment as the targets for any intervention Suggest a quotreciprocal causationquot between the individual AND the environment interrelationship Ecological models look at the dynamics between 0 intrapersonal factors 0 interpersonal relationships 0 organizationalfactors 0 community factors 0 public policies What is Health Promotion The process of enabling people to increase control over and to improve their health 0 Sources The Ottawa Charter for Health Promotion WHO Geneva 1986 and the Bangkok Charter for Health Promotion in a Globalized World WHO Bangkok 2005 lnvolves strengthening the skills and capabilities of individuals AND changing social environmental and economic conditions in order to alleviate their impact on public and individual health Strategies of Health Promotion Advocacy for health to create the essential conditions for health Enabling all people to achieve their full health potential Mediating between the different interests in society in the pursuit of heath Priority Action Areas according to WHO Build healthy public policy Create supportive environments for health Strengthen community action for health Develop personal skills Reorient health services Relevant for all countries including developing nations Evidence shows that Comprehensive approaches rather than singletrack approaches are most effective Settings for health offer practical opportunities for implementing strategies Participation is essential to sustain efforts Health literacy and learning fosters participation access to education and information is key Five Priorities for Health Promotion in the 21st Century Promote social responsibility for health lncrease investments for health development Expand partnerships for health promotion lncrease community capacity and empower the individual Secure an infrastructure for health promotion What is Disease Prevention Covers measures not only to prevent the occurrence of disease such as risk factor reduction but also to arrest its progress and reduce its consequences once established Primary secondary and tertiary levels of prevention Lots of overlap with health promotion but Disease prevention is usually seen as emanating from the health sector which deals with individuals and populations identi ed to have particular risk factors andor behaviors Health Promotion in the Ottawa Charter WHO1986 Not just the responsibility of the health sector Goes beyond healthy lifestyles to wellbeing Aims at making political economic social etc factors favorable through health advocacy Focuses on achieving equity in health Demands coordinated action by all concerned including all social institutions and each individual Should be adapted to local needs and systems US Agencies Concerned with Health Promotion and Disease Prevention The Centers for Disease Control and Prevention CDC The US Army Center for Health Promotion and Preventive Medicine The Public Health Education and Health Promotion Section of the APHA The Wellness Council of America And many others Health Promotion at All Levels Needs to include actions directed at determinants of health that are 0 Outside of the immediate control of individuals ie social economic environmental conditions 0 Within the immediate control of individuals ie individual health behaviors Tendency in US to focus only on changing individuallevel behavioral risk factors Challenge for all societies is to reduce inequalities in health Reducing poverty and increasing opportunities are key to improving health and wellbeing for all ness Behavior Behavior undertaken to 1 relieve the experience of illness andor 2 better de ne the meaning of it Usually mediated by strong subjective interpretations of the meaning of symptoms Differences by age gender ethnicity education family structure social networks health insurance and SES Patients and providers may have different perspectives and both matter Refers to the way we process perceive evaluate and act on pain discomfort or other signs of organic malfunction The experience of illness is a social experience 0 Social factors play a role in our de nition of it our response to it and our experience of it The social construction of illness lllness behavior is in uenced by social and cultural factors in addition to and sometimes instead of physiological conditions Five Stages of the lllness Experience Stage 1 Symptom Experience Begins with the sensation that something is wrong How does this process take place David Mechanic 1968 developed a theory of helpseeking behavior to help us understand this assessment process and how individuals act prior to seeking a health care provider Mechanic s 10 Factors Mechanic identi es 10 factors that determine how individuals respond to symptoms of illness 1 How noticeable is the symptom 2 How serious does the symptom seem to be 3 How much does the symptom interfere with your ability to ful ll your roles 4 How frequent persistent or reoccurring is the symptom 5 How tolerant of pain and discomfort are you 6 How knowledgeable about medical matters are you 7 How frightening are the symptoms 8 Is there anything that interferes with your ability to focus on the symptom 9 Are there other things going on in your life that you might attribute the symptoms to 10 Are there practical reasons why you cannot seek treatment Five Stages of the lllness Experience Stage 2 Assumption of the Sick Role lllness as Deviance Do you agree with the following statements Sick people have an obligation to try to get well A person who has an illness cannot be held responsible for hisher iHness A person who is sick should go to a doctor in order to nd out what is wrong with them A person who has pneumonia should not have to go to work A person who has pneumonia should not have to cook meals or clean the house The Sick Role Talcott Parsons 1948 wrote about illness not just being a biological or psychological condition or an unstructured state free of social norms and regulations When a person is ill they substitute a new role the sick role for the old normal role The sick role is a social role characterized by certain exemptions rights and obligations and shaped by the society groups and cultural traditions to which the sick person belongs Parsons argued that our industrialized society would have certain expectations for sick people Exemption from normal role obligations Exemption from personal responsibility The sick person must want to get well and not show signs of enjoying the sick role The sick person must seek and cooperate with technically competent help Criticisms of the Sick Role The sick role does not account for variations in behavior among sick people It ts with serious acute illness but not with less serious acute iHnesses It ts for acute illness not chronic illness It does not adequately account for the variety of settings in which physicians and patients interact It is more applicable to middleclass patients and middleclass values than it is for people in lower SES groups Stage 3 Medical careself care Seeking care by using medical care services or selfcare practices Rational choice theory People will decide how to respond to sickness by identifying possible options Andersen and Aday suggest that seeking care is a matter of considering o the physical political and economic environments 0 characteristics of the health care system 0 characteristics of the person seeking care predisoosind enabling and need Trends in Utilization of Medical Services The poor esp the working poor who make too much to qualify for Medicaid but cannot afford health insurance are less likely to use services The homeless are less likely to use services though many suffer from psychiatric disorders African Americans and Latinos vs Whites are less likely to have adequate access to care Older adults have greater medical care utilization than other age groups Women have greater medical care utilization than men The poor esp the working poor who make too much to qualify for Medicaid but cannot afford health insurance are less likely to use services The homeless are less likely to use services though many suffer from psychiatric disorders African Americans and Latinos vs Whites are less likely to have adequate access to care Older adults have greater medical care utilization than other age groups Women have greater medical care utilization than men Stage 4 Dependentpatient role A person accepts that treatment for their illness is necessary Patient is expected to make an effort to get well Stage 5 Recovery and rehabilitation As recovery occurs personpatient is expected to relinquish the sick role and move back to hisher normal role obligations Note Some chronically ill patients are able to move away from the sick role but others are never able to resume their normal roles RECAP Five Stages of the Illness Experience 1 Symptom Experience 2 Assumption of the Sick Role 3 Medical CareSelf Care 4 DependentPatient Role 5 Recovery and Rehabilitation Chronic Illness Impairment amp Disability A chronic illness is an ongoing or reoccurring objective condition that people usually live with the rest of their lives 0 An acute illness is shortterm and people usually are able to fully recover Impairment is the loss of some anatomical or physiological function Disability is a consequence of impairment where a person transitions from a state of having dif culty doing a task to being unable to do it when they try Stages after diagnosis of a chronic illness impacts sense ofsef O O O O Hoping for the best Fear that life will change drastically Bargaining Intrusion Feelings of control loss amp lower selfesteem Immersion Social isolation Stigma An attribute behavior or reputation which is socially discrediting in a particular way 0 Causes one to be mentally classi ed by others in an undesirable rejected stereotype Impacts how people view the affected person which has an effect on hisher sense of self Erving Goffman identi ed two different types of stigma o Discreditable When a stigma is hidden or has yet to be revealed The revelation of the stigma may be either within or outside of the person s control 0 Discredited When a stigma has been revealed or can t be hidden The stigma affects not only person s behavior but the behavior of others 0 Passing When stigma is successfully concealed Four Dimensions of Stigma 0 Social rejection 0 Financial insecurity o Internalized shame 0 Social isolation Is stigma an acute or a chronic stressor How might stigma affect health andor medical care
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