Sociology analyses the social determinants of health and utilises a number of concepts and theories in order to understand health and illness.

Task: Students should write a 1500 word essay on the following topic: Sociology analyses the social determinants of health and utilises a number of concepts and theories in order to understand health and illness. Draw on two sociological theories to explain the social determinants of health and discuss how this differs from the medical model. Preparation: Students should read widely prior to completing the essay. This includes all required readings but should move beyond these to include some other sources. Typically a good strategy is to use the set readings to cover the key sociological concepts and ideas and then if you are using an example issue (e.g. eating disorders or the effects of alcohol) do some further reading so that you have evidence relating to your chosen example. Presentation: See details in Unit Outline and Lecture PowerPoint week 4 Assessment Criteria: The essay will be assessed against the following criteria: 1. Demonstrated understanding and application of appropriate sociological theories, concepts and perspectives 2. Critical reflection on the key ideas and concepts 3. Evidence of wide reading 4. Essay reads well and is clear and concise 5. Adherence to academic conventions of essay writing (e.g. APA referencing; writing style) What Feedback can You Expect? It is important the assignments provide you with knowledge and skills that will inform your practice (whether this is in clinical or broader health settings). As such, your lecturer will provide personalised feedback for each of the two essays in this unit. There are two main focus areas for feedback that you can expect to receive feedback around: 6. The quality of the writing. Academic writing is about more than just satisfying some dry conventions on how to express ideas, rather it is good practice for the precision in communication that you will need in many workplace settings. Small errors may lead to a funding application being rejected or the dosage for a patient being incorrectly administered, for example. So, when you receive your essay feedback try to pinpoint ways in which you can be more disciplined and precise in the way you express written ideas. 7. Your ideas, thinking and critical reflection. The difference between a Pass grade and the higher grades like Distinction and High Distinction is much more connected to the way students think (as represented by clear engagement with the topic) than their ability to edit their work. Your ability to connect social issues to health concerns is a powerful way in which you can contribute to the improved health of patients and people you work with. As such, you can expect your lecturer to give you good feedback on how you have made connections between the theories and ideas in the readings and the practice settings that you might work in. The essay will be returned to you within three weeks from the due date (we will aim for a quicker turnaround if we can). NUR210 Assignment One Marking Rubric.doc NUR 210 Health Sociology Module 1 Learning Materials Module One Sociology for Health Professionals 1.1 Content overview 1.2 What is Sociology? 1.3 Definition of health and illness. 1.4 The Biomedical model. 1.5 The sociological approach to the study of health and illness. 1.6 Understanding and explaining social phenomena 1.7 Theories, Discourses and Paradigms 1.8 Sociological concepts and theories 1.9 Historical Origins of Social Health 1.10 Social structural approaches: Societies as objective realities 1.11 The functionalist perspective of health and illness 1.12 The Marxist perspective of health and illness 1.13 Interpretative approaches: Societies as subjective realities 1.14 The Symbolic Interactionist perspective of health and illness 1.15 The Social Constructionist perspective of health and illness – The relativity of social reality 1.16 Feminist Perspectives 1.17 The Structure –Agency Continuum 1.18 The Sociology of health and illness: Defining the field 3 | P a g e 3 Module One Sociology for Health Professionals 1.1- Content overview This first module explores the questions of ‘what is sociology?’ and ‘how is it relevant to the health profession?’ This topic contains: • An overview of Sociology • An introduction to Health Sociology • Online learning activity • A reading list 1.2 -What is Sociology? We begin this module by exploring the concept of sociology. The simplest view of the academic discipline of sociology is that it is somehow concerned with the understanding of human societies. However, this does not take us very far as most people feel they know a good deal about the society in which they live because they experience it every day; this can be described as ‘common-sense’ knowledge. Another approach would be to define sociology as a research based study of society. However, there are other academic disciplines such as history, politics, economics, anthropology and social psychology that also have human society as the object of study. Probably the best way of defining the contribution of sociology is by looking at the key questions that originally stimulated the development of the academic discipline and which continue to underpin sociological research today: What gives social life a sense of stability & order? How does social change & development come about? What is the nature of the relationship between the individual and the society in which they live? To what extent does the society into which people are born shape their beliefs, behaviour, & life chances (including health outcomes)? In other words, sociology looks at the social influences of politics, economy, religion, family, gender roles and so on, and their impact or importance in understanding behaviour (Kellehear, 1990). Sociology tries to understand the underlying patterns in the social world. Although other disciplines do this also, Sociology has its own special way of doing it. Sociologists do not just describe the social world but attempt to theorise, measure, analyse, interpret and test its subject matter. As Waters and Crook (1993, p. 3) state, doing sociology is about approaching the familiar world with new eyes. So why study health Sociology and how is it relevant to working as a health practitioner? Health Sociology analyses the interaction between SOCIETY and HEALTH. Where medical research might gather statistics on a disease, a sociological perspective on an illness can provide insight into what external factors caused the demographics who contacted the illness to become ill. An example of this is if we look at the table below. Life expectancy for both Indigenous men and women is well below the average for non-Indigenous men and women. Health Sociology tries to look at and analyse reasons why this might be so. Understanding some of the underlying factors can help governments, policy makers and other stakeholders to make positive changes. The health industry like any other is embedded with a number of dominant values, assumptions and processes which shape it. Sociology helps provide the language and tools to critically analyse and reflect on these. Hence we will be looking at what the social determinants of health are in the Australian context whilst critiquing the philosophy of primary health care and the dominance of the medical model. 5 | P a g e 5 To Van Krieken et al. Some aspects that can be the focus of sociology can include the examination of, social, economic and political influences on the selected area which could be the local, national or global setting (Van Krieken, R, Smith, P, Habibis, D, McDonald, K, Haralambos, M and Holborn, ,M 2000). Over the weeks this will certainly become evident. When we look at health from a sociological perspective we take into account all of the social influences such as politics, the economy, religion, culture, family, gender etc. that influence behaviour and as a consequence health outcomes. Readings The following provide an overview of Sociology and lay the foundation for this unit. I strongly recommend that you read beyond the set text. Set Text Germov, J (2014)Imagining Health Problems as Social Issues. In J. Germov (Ed.), Second Opinion; An Introduction to Health Sociology, Melbourne: Oxford University Press, pp.5-22 Germov, J (2014) Theorising Health: Major Theoretical Perspectives in Health Sociology. In J. Germov (Ed.), Second Opinion; An Introduction to Health Sociology, Melbourne: Oxford University Press, pp.23-39 Heil,D., (2014) Wellbeing and Wellness In J. Germov (Ed.), Second Opinion; An Introduction to Health Sociology, Melbourne: Oxford University Press, pp.23-39 eReserve Kellahear, A. (1990). What is Sociology and why study it? (Chapter One). In A Kellehear (Ed.), Every student’s guide to sociology: A quick and plain speaking introduction. South Melbourne: Thomas Nelson Australia. Van Krieken R. (2000). What is sociology? In Van Krieken,R., Smith,P ,Habibis,D., McDonald,K, Haralambos,M. ,Holborn,M. (2000) Sociology: Themes and Perspectives (pp. 1-35). Frenchs Forest, N.S.W. Pearson Australia. link: http://ereadings.cdu.edu.au/view/cdu:20848 Cockerham, W.C (2007). Medical Sociology. In Medical Sociology (10th ed) (pp. 1-20). Upper Saddle River, New Jersey: Pearson Prentice Hall. Further Readings Schofield, T (2015). A Sociological Approach to Health Determinants Cambridge University Press, Australia, pp16-32 and 53-55, Giddens, A., Sutton,P.(2014),Essential Concepts in Sociology, p 4-26, Polity,UK Jones,P., Bradbury, L. Boutillier,S.(2013) Introducing Sociology Second Edition, Polity, pp1-103 1.3 -Definition of health and illness. There is no uniform definition of health and illness. Definition: Health. “…[S]tate of complete physical, mental, and social well-being and not merely the absence of disease, or infirmity” (WHO, 1946) For example, it is dismissed as “patently absurd and unattainable” and “highly dangerous” given that it is deemed impossible to tell whether individuals or groups have achieved this state, or for such a state to be measured or evaluated (Sax, 1990, p.1). Additionally, the reference to a state of “complete social well-being” is claimed as “so freighted with individual interpretations that it alone renders the definition useless” (Hudson, 1993, p.45) ‘Historically, the word health appeared approximately in the year 1000 A. D. he word originally came from Old English and it meant the state and the condition of being sound or whole. More precisely, health was associated not only with the physiological functioning, but with mental and moral soundness, and spiritual salvation, as well’ (Boruchovitch, E., Mednick, B, 2002). There are a many different definitions of health and illnesses which are often determined by who is doing the defining and what perspective they are coming from. There is a number of cultural perspectives and some of these encompass ideas of the spirit whilst others involve sorcery and/or witchcraft or other non-human sources. In the contemporary Western framework, the dominant perspective of health and illness is the biomedical model. 1.4 -The Biomedical model. The biomedical model is based on the principal of scientific rationality. The body is viewed as a machine and illness in viewed as a defect or malfunction. Illness is the result of the body part involved failing to function properly, or is the result of germs or disease. The biomedical model excludes social, psychological and behavioural aspects of illness. It reduces illness to something that happens to a person’s “parts” rather than to the whole person. In Module 5 looks we will look at the biomedical model in greater depth. 1.5- The sociological approach to the study of health and illness. A sociological approach to health and illness is premised on the belief that health and illness must be analysed in their social context. Health professionals using a sociological approach will recognise that the patient/client is situated within a social context that will construct that person’s experiences, beliefs, knowledge, actions and interactions. Sociology assists health professionals to recognise that membership of a particular group in society (e.g. age, sex, family type etc) can influence experiences 7 | P a g e 7 of illness and wellbeing. Sociologists therefore speak of the social distribution of health and illness. In various sections of this study guide for example, you will note that there exist social patterns of health and illness. A common explanation for health inequalities is based on the belief that individuals are responsible for what happens to them. In attempting to understand and explain health differences, a health worker who uses a sociological approach will look beyond the individualistic explanations. Whilst there is no denying that individual psychology may play an important role in determining an individual’s health status, a sociological approach would lead us to examine the underlying social causes of health and illness. A sociological approach to health and illness will also be concerned with social processes and social relationships. Sociologists are interested in the processes whereby certain groups gain and maintain control over others. They are also interested in the interaction between health professionals and clients/patients. Sociologists may also be concerned with differing beliefs about health and illness. As stated previously, beliefs about the causes of illness vary greatly across cultures. 1.6- Understanding and explaining social phenomena In an effort to answer the questions laid out in the “What is Sociology?” section, sociology pursues an objective scientific approach attempting to explain why social life is not a random series of events, but is structured and shaped by particular sets of rules (both obvious & hidden). This is not to say that social structures determine human behaviour, rather that social structure is both the ever-present condition for, and reproduced outcome of, intentional human agency or actions. Like any other academic discipline, sociology is theory-based. That is, in order to understand how societies work (or why particular bio-chemical processes occur), we must go beyond a simplistic description of the phenomenon under investigation. Also like any other academic discipline which has as its object of study the human and social world, the field of sociology consists of a range of competing explanatory paradigms. Empirical research necessarily involves making assumptions about the nature of social reality. Sociology challenges both naturalistic and individualistic explanations of social phenomena. These understandings arise as a consequence of growing up (`being socialised’) within a particular culture and set of social structures, and can result in people seeing their everyday roles and behaviour as being somehow `natural’. Equally, when looking at other people`s behaviour i.e. `unhealthy lifestyles’ or lack of motivation; for example, the focus is all too often on particular individual characteristics ignoring the social factors that influence such behaviour and beliefs. 1.7 -Theories, Discourses and Paradigms Throughout this topic we will be referring to different theories, discourses and paradigms. In order for you to grasp these concepts within the sociological context I have set below some general defintions. ‘A theory is … a system of ideas that uses researched evidence to explain certain events and to show why certain facts are related’ (Germov, 2002, p. 13). A discourse can be viewed as verbal communication and a formal treatment of a subject in written and/or verbal communication. The notion of discourses is critical to our understanding of Sociology and we will talk a bit more about them in later weeks. At this stage it is important to understand the idea bought about by postmodernism that rejected the view that science provides a universal truth. It challenged the notion of the unbiased, impartial writer. Rather, “(C)ritical theory, poststructuralism, and postmodernism expose science’s apparent authorlessness as one possible rhetorical stance among many” ( Agger, B. 1991, p.122). According to Dictionary.com a paradigm is ‘a framework containing the basic assumptions. Ways of thinking, and methodology that are accepted by members of a scientific community’ and a ‘cognitive framework shared by members of a discipline or group’. For many paradigms are viewed as self-perpetuating, Newman for example, views the dominant medical paradigm, a search for causality dominates and all “ non-evidence based” phenomena is ignored and each new health worker is acculturated into the paradigm ( in Picard, 2005). 1.8 -Sociological concepts and theories These perspectives or schools of thought will be discussed in detail further into these study materials but you should try to become familiar with them before you continue. The chapter by Van Krieken et al (2000) is a good place to start exploring these theories in more depth Within sociological theory, there exists a divide between those sociologists who argue that society can be studied in an objective manner through identifying and examining the structures of society, and those who argue for an interpretative or subjective approach to social phenomena more focused on social actors. Structuralist approaches often tend to focus on the macro level (that of 9 | P a g e 9 society) while subjectivist approaches tend to focus on the micro level of interaction (between individuals). However, in more recent time’s a third position has developed which attempts to breakdown this duality between the relative importance attached to social actors versus social structures. These three approaches are explored in the next few pages. 1.9- Historical Origins of Social Health. In the middle of the 19th century, with the industrial revolution came the spread of disease. This was mainly due to huge influxes of people from country into the cities as this was where the work was located. As a result housing became an issue and there was little to no regard for hygiene or sanitation. As a result, preventable diseases like Cholera and Typhoid resulted in thousands of deaths. It was through health sociology and Karl Marx that the linkage between poverty and working class conditions were first articulated. Social legislation based on the principals of sanitation was passed. What this demonstrates for us is that theories are a product of the historical time, place and specificity of the theorist. Within Sociological analysis you need to ask;  Why is this particular question being asked at this time?  What are the structural paradigms that support the current structure?  What cultural paradigms are involved? It is therefore important to critically analyse the phenomena from each of these perspectives. We are now going to look at some of theoretical approaches. 1.10 -Social structural approaches: Societies as objective realities Social structural approaches to exploring social reality include those empiricist sociologists who believe that an objective ‘science of society’ is possible in much the same way as a physical science such as biology or physics. This empirical sociology seeks to explain the norms of social life in terms of various identifiable linear causal influences. Social structural approaches would also include those sociologists who see human society as being shaped by an underlying material social and economic structure. These are structures that may not always be visible, but nevertheless are fundamental in explaining social and individual processes. In relation to health, a predominantly social structural approach would draw upon quantitative data derived from social surveys, epidemiological studies and comparative studies in order to point to the relative influence of societal structures and processes in determining health outcomes for social groups. Within the academic discipline of sociology, two major theoretical perspectives exist which seek to analyse human societies utilising a social structural or systems approach. These perspectives are structural functionalism and Marxism, and their very different organising principles are described in relation to the social determination of health outcomes below. As a brief illustration of the two approaches to structural analysis we will briefly examine the issue of poverty. The functionalist explanation would set poverty in the context of social stratification and the unequal distribution of rewards associated with complex economies where different tasks are performed by different groups within society. Some groups are relatively less well off than others because they have less skills and knowledge and so their contribution to the functioning of society is not as extensive as other groups. Whilst the Marxist explanation would set poverty in the context of the class structure, specifically the relationship of social groups within an capitalist system of economic production in which there are the exploited and the exploiters (with some intermediate groups of managers and supervisors). 1.11- The functionalist perspective of health and illness This theoretical perspective stresses the essential stability and cooperation within modern societies. They believe that the basis of an orderly society is the existence of common value systems that bind its members together. Social events are explained by reference to the functions they perform in enabling continuity within society. Society itself is likened to a biological organism in that the whole is seen to be made up of interconnected and integrated parts; this integration is the result of a general consensus on core values and norms. Through the process of socialisation we learn these rules of society which are translated into roles. Thus, consensus is apparently achieved through the structuring of human behaviour. Within medical sociology, this approach is essentially concerned with the theme of the ‘sick role’, and the associated issue of illness behaviour. Talcott Parsons, the leading figure within this sociological tradition, identified illness as a social phenomenon rather than as a purely physical condition. Health, as against illness, being defined as: ‘The state of optimum capacity of an individual for the effective performance of the roles and tasks for which s/he has been socialised.’ (Parsons, 1951) 11 | P a g e 11 Health within the Functionalist perspective thus becomes a prerequisite for the smooth functioning of society. To be sick is to fail in terms of fulfilling one’s role in society; illness is thus seen as ‘unmotivated deviance’. The regulation of this sickness/deviance comes about through the mechanism of the ‘sick role’ concept and the associated ‘social control’ role of doctors in allowing an individual to take on a sick status 1.12 – The Marxist perspective of health and illness A key assertion of the Marxist perspective is that material production is the most fundamental of all human activities – from the production of the most basic of human necessities such as food, shelter and clothing in a subsistence economy, to the mass production of commodities in modern capitalist societies. Whether this production takes place within a modern or a subsistence economy, it involves some sort of organisation and the use of appropriate tools; this is termed the ‘forces of production’. Production of any type was recognised by Marx as also involving social relations. In modern capitalist societies these ‘relations of production’ lead to the development of a division of labour reflecting in the existence of different social classes. For Marx, it is these forces and relations of production together that constitute the economic base (infrastructure) of society. The superstructure of a society – the political, legal, educational, and health systems and so on, are shaped and determined by this economic base. The orientation of this approach as applied within medical sociology is towards the social origins of disease. Health outcomes for the population are seen as being influenced by the operation of the capitalist economic system at two levels. First, at the level of the production process itself, health is affected either directly in terms of industrial diseases and injuries, stress-related ill health, or indirectly through the wider effects of the process of commodity production within modern societies. The production processes produce environmental pollution, whilst the process of consuming the commodities themselves have long term health consequences such as eating processed foods, chemical additives, car accidents and so on. Second, health is influenced at the level of distribution. Income and wealth are major determinants of people’s standard of living – where they live, their access to educational opportunities, their access to health care, their diet, and their recreational opportunities. All of these factors are significant in the social patterning of health Also known as conflict theory, this perspective on health and illness focusses on the role of the medical profession and how working and living conditions in a capitalist society contribute to health outcomes. They would argue for example that dangerous work environments and poor living conditions result in higher morbidity rates in the working classes, hence they make the link between low occupational status, power , income and poor health outcomes. 1.13 -Interpretative approaches: Societies as subjective realities Sociologists within this wide tradition would argue that the social world cannot be studied in the same way as the physical world because people: ‘Engage in conscious intentional activity and, through language, attach meanings to their actions… [therefore] sociologists should be less concerned to explain behaviour than to understand how people come to interpret the world in the way they do.’ (Taylor and Field, 1993, p.15) In attempting to achieve this goal of interpretative understanding, reliance is placed on essentially qualitative research methodologies in order to get as close as possible to the world of the subjects or social actors being studied. In terms of health and illness, this interpretative approach focuses upon the (symbolic) meanings of what it is to be ill in our society, and would not confine its interest in health to what would be perceived as the closed world of clinical biomedicine (this would not rule out the study of the interactions of clinicians themselves both with patients and with colleagues). The following issues in health and illness are examples of the research focus of interpretative sociology: Within this interpretative sociological tradition two distinct perspectives stand out; symbolic interactionism and social constructionism. These approaches will be outlined in relation to health and illness below. 1.14- The Symbolic Interactionist perspective of health and illness This perspective developed from a concern with language and the ways in which it enables us to become self-conscious beings. The basis of any language is the use of symbols that reflect the meanings that we endow physical and social objects with. In any social setting in which communication takes place, there is an exchange of these symbols: that is, we look for clues in interpreting the behaviour and intentions of others. Communication being a two-way process, this interpretative process involves a negotiation between the parties concerned. The negotiated order that develops therefore involves: 13 | P a g e 13 ‘People construct[ing] understandings of themselves and of others out of experiences they have and the situations they find themselves in. These understandings have consequences in turn for the way in which people act, and the manner in which others react to them.’ (Aggleton, 1990, p. 91) Interactionist sociology asserts that the social identities we possess are influenced by the reactions of others. So if we demonstrate some abnormal or ‘deviant’ behaviour it is likely that the particular label that is attached within a society at a particular time to this behaviour will then become attached to us as individuals. This can bring about important changes in our self-identity. A disease diagnosis could be one such label. Within this perspective medicine too would be viewed as a social practice, and its claims to be an objective science would be disputed. In the doctor-patient interaction, patient dissatisfaction can result if the doctor too rigidly superimposes a pre-existing framework (disease categories) upon the subjective illness experience of the patient. Symbolic interactionist focus on agency and how people construct, interpret and give meaning. They contend that health and illness are subjective constructs that vary over time and between cultures. Foucault proposed that communication of any kind is influential in bringing the world into being. He used the word discourse to refer to this social process and argued that it always involved power. Discourses as such make reality. ‘ What is created through text- including and what is left out-creates the truth of reality for people, shaping their behaviours and actions. Formal knowledges, such as the various branches and modalities of science, are especially powerful discourses, but so, to, are religious and political beliefs. Discourses in fact, are critical in bringing us into being as individual subjects with specific identities’ (Schofield, T.,2015,p.54) 1.15 -The Social Constructionist perspective of health and illness – The relativity of social reality This sociological perspective derives from the phenomenological approach of Berger and Luckmann (1967), who argue that everyday knowledge is creatively produced by individuals and is directed towards practical problems. ‘Facts’ are therefore created through social interactions and people’s interpretations of these ‘facts’. This essentially subjectivist approach embraces a number of very different sociological paradigms, but what such paradigms do have in common in relation to health and illness is a focus on the way we make sense of our bodies and bodily disturbances. Social constructionism refuses to draw a distinction between scientific (medical) and social knowledge. Nor would it ignore disease in favour of examining the illness experience; unlike the interactionist perspective. Rather, it maintains that all knowledge is socially constructed. We are seen to come to know the world through the ideas and beliefs we hold about it, so that it is our concepts and categories which are the realities of the world. Foucault (1973,1980,1985,1986) and the work of so-called post-structural social theorists are included within this perspective, though their concerns are frequently different from those researching within the tradition of phenomenology. Foucault is interested in power in itself, not as reduced to an expression of some other conceptual starting point such as class, the state, gender or ethnicity. He seeks to approach the relationship between agency and structure not through an essentialist analysis but by using an ‘interpretative analytics’ of practices and discourses, discerning the workings of power and knowledge in social relations. He tried to define the relationship between language, social institutions, subjectivity and power. In terms of health and illness, this Foucauldian approach to cultural constructionism draws attention to the ways in which we experience ourselves and our bodies not in some naturalistic way, but in what is termed a ‘symbolically mediated fashion’ – the body as a ‘field of discourse’. He looked at how some discourses such as biomedicine for example, created meaning systems and have gained the status of “truth” and hence are able to dominate how we continue to define and organise ourselves as individuals and society as a whole. Other alternative discourses become marginalised as a result. 1.16- Feminist Perspectives Feminist perspectives in Sociology first emerged in the 1960s in response to the neglect of gender issues and the sexist nature of many traditional sociological theories. There are many different perspectives placed under the feminist banner. Despite this diversity they all emphasise the importance of patriarchy and challenge biological assumptions about the nature of women. They have made a major contribution to Health. 1.17 -The Structure –Agency Continuum As you can see one of the key debates across sociology is between structure and agency that is what is the degree in which human behaviour is determines or influenced by the structures, institutions, systems and groups that surround them as compared with the ability of the individual to direct their 15 | P a g e 15 own experience. This is not an either or phenomena but rather they are interdependent that is, humans shape and at the same time are shaped by society. 1.18 -The Sociology of health and illness: Defining the field Sociology brings two distinct focuses of analysis to the study of health and illness. At one level it tries to ‘make sense of illness’, by applying sociological perspectives both to an analysis of the experience of illness, and to the social structuring of health and disease. At this level, sociology makes an important contribution to multi-disciplinary research into issues of interest to clinicians and other health professionals, the development of health policy, and epidemiological studies. At a second level, sociological enquiry can open doors to an understanding of the impact of wider social processes upon the health of individuals and social groups. Such processes include social inequalities, professional relationships, change and self-identity, knowledge and power, and consumption and risk. 2.2 What is Epidemiology? Epidemiology is defined as the study of the incidence and distribution of morbidity and mortality in order to identify the role of nonbiological factors in sickness and health ( Jary & Jary, 1991, Collins Dictionary of Sociology, Harper Collins, Glasgow) Epidemiology is concerned with the distribution of disease in society. Epidemiologists are concerned with patterns of disease and are therefore interested in identifying groups that are at risk of disease. Epidemiologists are also interested in analysing the effect of certain interventions. Epidemiology usually relies on the collection and analysis of large bodies of statistical data. Data is available from a number of sources including medical records, surveys, census data etc. According to Abdel Omran (1974 in Haralambos, van Krieken, Smith and Holborn, 1998, p. 183) there are three significant stages in social development that affect the kinds of diseases experienced by people. Stage 1:The age of pestilence and famine is characterised by frequent epidemics and famines. It is associated with pre-industrial, agricultural societies with high rates of mortality. 4 | P a g e 4 Stage 2:The age of receding pandemics is characterised by transition. With social and economic development as well as improvements in health care and sanitation, epidemics and famine receded in importance as major health risks, while industrial diseases, malignancies and cardiovascular diseases increased. Most western societies went through this stage during the 18 th and 19 th centuries but most third world nations are still in this transition stage. Stage 3: The age of degenerative and man-made (sic) diseases is characterised by the prevalence of cardiovascular disease, stroke, cancers, occupational hazards, drug addiction, mental illness and geriatric conditions. It is associated with advanced social and economic development. There has been a marked reduction in the modern world of communicable diseases with a corresponding increase in what many refer to as lifestyle diseases. 2.3 – Modern Medicine and Epidemiology Morbidity refers to the state of being diseased or unhealthy within a population whilst mortality is the term used for the number of people who died within a population. The status of modern medicine rests, in part, on claims to have reduced mortality rates. A closer examination of mortality rates throughout the history of the modern world reveals that the eradication of many communicable diseases was a result of improved sanitation, better water supplies, increased knowledge of basic hygiene, better nutrition and knowledge of nutrition, and reduced family size. Infectious or communicable diseases do remain a serious problem in the developing world and among certain disadvantaged groups within developed or first world societies. The major causes of death in the developed world (e.g. Australia) are related to modern living. Causes of death however vary among age groups (e.g. the major cause of death in young Australians aged 15 to 24 in 2011-13 was suicide), gender groups (i.e. women continue to outlive men), ethnic and cultural groups (Australian Aboriginals have a much higher mortality rate than non-Indigenous Australians) and social classes (i.e. those of the lowest socio-economic groups in Australia have higher standardised death rates). With decreased mortality rates there is a corresponding increase in morbidity rates. 5 | P a g e 5 Morbidity rates do vary across and between social/population groups but in general in the modern world, the level of affluence of a particular society also influences these rates. While these materials provide an overview on this issue, the readings for this module explore this topic in much more detail. 2.4- Social Stratification Stratification refers to the ranking of social groups. To Macionis, ‘Sociologists use the term social stratification to refer to a system by which categories of people in a society are ranked in hierarchy’ (1991, p.234). All known societies have some form of stratification system. In capitalist societies such as Australia, one form of stratification is class. In Australia we may hear the terms upper class, middle class, working class and underclass. An individual’s social position will often determine their educational background. A person’s educational background will often determine their occupation. Their occupation will determine, partially at least, their income levels and standard of living. An example of an exception to this theory is the mining industry in Australia. When mining was booming the demand for labour outstripped the market hence wages were raised to meet demand. There is much evidence to suggest that the social class of a person will determine their health status. Both males and females of low-income households have poorer health (higher morbidity rates) than those from more affluent households. Mortality rates differ between occupational groupings. In general, manual labourers have higher mortality rates than members of professional groups. 2.5- Social Inequity Social inequity is characterised by the existence of unequal opportunities and rewards for different people in society dependent upon their social position and/or status. It contains structured and recurrent patterns of unequal distribution of goods, services, opportunities, rewards and punishments. To Germov (2014), social class is a position in a system or structural inequality based on the unequal distribution of power, wealth, income and status. People who share a class position typically share similar life chances. There are also several explanations for social inequity in health which Germov describes in Chapter 5 of your set text Second Opinion (2014) 6 | P a g e 6 2.6 -The Social Gradient of Health The social gradient of health is a continuum of health inequity from high to low, where the poorest people experience the worst health outcomes and as the gradient of wealth rises, so does the health status. This is also the case when looking globally at health outcomes. The Australian Institute of Health and Welfare (AIHW) is a major national agency, which provides reliable, and relevant information and statistics on Australia’s health and welfare. Much of the information is available on line. http://www.aihw.gov.au 2.7- Gender and Health and Illness According to Waters and Cook (1993) Gender is the social interpretation of assumed biological sex differences. Unquestionably, there are differences in the health and illness experiences of males and females. Sex specific health problems do exist and some of these may be related to differing reproductive functions and others to differences in lifestyles. Biological explanations of health differences have often historically been used as justification for unequal treatment. Biological differences were evoked historically as the rationale for exclusion of women from higher education for example. The theory that biology made women unfit for education was most eloquently put in relation to higher education, since this occupied the period of women’s lives when their biology ‘ought’ to have precedence. One book published in America in 1873 by an ‘expert’, Dr Edward H. Clarke, went rapidly through seventeen editions and set forth the argument that education directly caused the uterus to atrophy (Oakley, 1981, p. 121). Although this may appear to us an outmoded belief, contemporary ideas do little to dispel the myth that women’s biology determines their psyche. Such as the following ‘joke’ from South Park: “I’m sorry, Wendy, but I just don’t trust anything that bleeds for five days and doesn’t die”. The obvious implication is that anyone who bleeds for five days each month and doesn’t die, i.e. a woman, must have something wrong with them. Women’s menstrual cycle continues to be the justification for women’s exclusion from certain roles and particular spheres. The image of women as the weaker sex is reproduced in contemporary portrayal of ‘real life’, as witnessed in the half hourly soap operas we are socialised into accepting as our modern guides to the good life. 7 | P a g e 7 Sociological studies have revealed the sexualised pathways relegated to individuals labelled criminally deviant. Males are more likely to be channelled through the criminal justice path whereas females labelled criminally deviant are exited via the medical justice exit point. In other words the bad man is bad, but the bad woman is mad. Often, the selection of treatment or discipline modalities is directly related to beliefs about women’s biology. She must have been experiencing some hormonal difficulties at the time. Male biology has also been used to justify certain behaviours. Uncontrollable sexual desire has been cited repeatedly in defence of rape. Stratification by gender is common to many societies. The roles expected of males and females are often clearly prescribed. These roles reflect beliefs about femininity and masculinity. Despite attempts to gain equality, women, in contemporary Australian society, remain primarily responsible for unpaid labour. They remain the primary child carers and continue to be marginalised in the workforce. Women continue to dominate the nurturing professions (e.g. childcare, nursing, primary school teaching etc.) whereas men are predominant in the traditional masculine occupations (e.g. science based occupations). Gender is one determinant of health status. In advanced capitalist societies, including Australia, women continue to have a higher life expectancy than men. There is some evidence to suggest that the differences between male and female life expectancy is lessening. This graph sourced from the UN 2010 plots hours per day of housework performed on average by sex and region. Haralambos (1998) argues that women are subject to greater medicalisation of their lives than men. Medicalisation refers to the process through which aspects of your life become defined as medical issues requiring medical intervention by experts. Menopause is an example of this. To Schofield (2015), the health toll on women and children in regards to men’s violence is critically important. ‘According to the Australian Human Rights Commission ( 2012,p.7), ‘domestic and family violence is the leading contributor to death, disability and illness in women aged 15-44 years. It is responsible for more of the disease burden than….smoking and obesity’. Worldwide. Men’s violence 8 | P a g e 8 has affected at least one out of every three women from beatings, sexual coercion and physical abuse’ (Schofield, 2015,p.77) Feminist commentators have also expressed concern at the male monopolisation of contraception. The increasing medicalisation of all aspects of female existence has further alienated women from their own bodies, it is argued. The medicalisation of menopause and menstruation are just two examples. Both of these female experiences have become pathologised and as such, require medical intervention. This increasing medicalisation of all aspects of social existence is highlighted in feminist analyses of female sexuality. Lupton reports on a study undertaken of general gynaecology texts (Scully and Bart, 1981 in Lupton, p. 138) that found a pattern of concern for the patient’s husband that was greater than concern expressed for the female patient. Textbooks continued to claim the vaginal orgasm as the norm with the consequential labelling of women not experiencing it as sexually deficient. Globally women bear a disproportionate burden of the world’s poverty, many have little to no access to education or health care. Generally women outlive men, and in western society visit the doctor more regularly, take over the counter and prescription drugs more regularly and are over represented in hospital admission rates. Some theorists argue that the difference in doctor visitation rates may be explained as a response of women’s enhanced willingness to report illness. Others argue that this data is reflective of genuine differences in illness rates for women. Still others argue that the best explanation lies in the way the medical system treats and defines the two sexes. As Dorothy Broom (2002, p. 104, in Germov, J (ed.) 2002) reports, there is evidence to indicate that the male body has been viewed within scientific medicine as the normal body. An alternative view is that the higher rates of illness reported by women are a reflection of their different and unequal social roles and social positions. Psychosomatic illnesses, for example, may simply reflect a response by women to a patriarchal society and the poor social status related to being relegated to repetitious, menial and alienating labour. 9 | P a g e 9 Feminist concern with the monopolisation of women’s health by a profession dominated by males has been commonly expressed in the last three decades of the twentieth century. The issue of the control of women’s bodies has dominated feminist health literature for well over two decades. While women have historically articulated discontent at what they believed was encroachment by males in the women’s health arena, this protest has become increasingly commonplace and acceptable in the 20th century. The male control over women’s bodies is particularly notable in childbirth. Prior to World War II, the majority of women gave birth at home. Hospital births were rare. By the mid-1980s, 99% of all births in Britain occurred in hospitals (Stanworth, 1987, in Lupton, 1994, p. 148). Childbirth became increasingly medicalised and technological intervention in birth (e.g. anaesthesia, forceps, caesarean sections) became commonplace. Although the World Health organisation in the 1980s saw no justification for a Caesarean section rate of 10 to 15%, the Australian average was 20% of all live births. 2.8- Aboriginal Health Aboriginal Australians have the worst health outcomes of any other group. Mortality rates are the highest of any group. ‘For the Aboriginal and Torres Strait Islander population born in 2010–2012, life expectancy was estimated to be 10.6 years lower than that of the non-Indigenous population for males (69.1 years compared with 79.7) and 9.5 years for females (73.7 compared with 83.1)’ ( ABS, 2014). The Australian Institute of Health and Welfare provides the following summary of Aboriginal health status. They had higher age–specific death rates at virtually every age than other Australians, especially between 25–54 years, when Aboriginal death rates are five to seven times higher. Between 1988–94 Aboriginal men, but not women, experienced decreases in mortality rates from circulatory diseases, infections, injuries and mental illness. Death rates from diabetes in 1997–2010 were 5.4 times higher for Aboriginal people as compared with other Australians. Infant mortality was three to five times higher than that for the overall population. 10 | P a g e 10 Aboriginal women were twice as likely to have low birth weight babies. Aboriginal women remain at 3 times the risk of maternal death with sepsis specific cause of death , although their childbirth rates are 3% of the total births in Australia. Aboriginal Australians are admitted to hospitals at a greater rate than are non-Aboriginal Australians. According to Territory Health Services Annual Report 1999–2000, the gap in life expectancy between Aboriginal and non-Aboriginal people has widened over the past twenty years. The gap over this period increased from 16 to 18 years and 18 and 19 years respectively (Territory Health Services 2000, p. 99). The most common reason for hospitalisation of Indigenous patients in the same period was dialysis. The second major reason for admission to hospital was, for males, injury and for females, pregnancy and childbirth. Respiratory diseases, digestive diseases, circulatory diseases, mental disorders and diseases of the skin and subcutaneous tissues, were other important causes of hospitalisation for Indigenous Australians. Non-insulin dependent diabetes mellitus (NIDDM) is also a significant health problem for Indigenous people. The likely prevalence of NIDDM among Indigenous people is between 10 to 30%, which is about 2 to 4 times that among non-Indigenous Australians. Alcohol consumption and family violence are also significant issues with consequences for the health and well-being of Indigenous Australians. Locational disadvantage can also have an impact on an individual’s ability to seek assistance and resources when necessary. A large proportion of the Northern Territory’s Aboriginal population resides on remote communities. Access to specialised medical services may mean travelling long distances and relocating to alien environments, further contributing to the social isolation already resulting from membership of a marginalised group. We will be taking a further look into Aboriginal health in the next module. 2.9 –Health and Age Age is another determinant of health and cuts across other social variables such as social class, ethnicity and gender. In the discussion on social class and gender it was noted that major cause of death varied across age groups. 11 | P a g e 11 The impact of age upon health status will be mediated by other social variables, such as gender, social class and ethnicity. Across all age groups, the most socially disadvantaged experience the worst health. Ageism according to Grbich ( 2004,p. 120), refers to the systematic stereotyping of older people because of their age. To some extent an analysis of the health of Australia’s aged population reflects the status of the elderly. In many cultures social status increases with age but Australia, similarly to other western highly industrialised nations, attaches greater status to youth. The elderly are perceived to be unproductive and a burden on society. The labelling of the elderly as senile and dependent has serious implications for the way the elderly view themselves and are viewed by others. The grouping together of the elderly in this fashion conceals the diversity among Australia’s aged population. Like other industrialised nations, Australia’s population is an ageing population. The challenges of an increasingly aged population for Australian society have been thoroughly documented. Increased longevity (life expectancy) coupled with higher rates of morbidity is noted trends throughout the developed world. The health and illness experiences of Australia’s aged population are not homogenous however and must be viewed in the context of the interrelationship between age, gender, socio-economic status, race and ethnicity. Although most elderly people manage to remain at home rather than enter institutional care, the need for institutional care has increased significantly and is likely to continue to do so. This of course has economic implications for governments and there is some evidence to suggest that governments, including the Australian government, are leaning more toward increasing the provision of home care services than increasing spending on institutional care. Whilst this may appear an attractive approach, the ideology of community embedded within these policies is questionable. Notions of community care carry connotations of neighbourhoods in which people have the time and motivation to help one another, and especially to be willing to care for the sick and needy in their midst. Instead, modern suburbia can be isolating, with people being divided by traffic, urban developments and poor public transport . 12 | P a g e 12 Quite often, home care demands that family members assume the caring role. Historically this role has been undertaken primarily be women. With increasing numbers of women entering the paid labour force, the likelihood that women can continue to assume the caring role for the elderly is questionable. Health service delivery to the elderly rural and remote population is hampered by what some theorists refer to as urban bias. This bias ignores key dynamics of lifestyle and community characteristics. Such problems are compounded by insufficient critical mass, distance and dispersed demand (Dunn and Williams, 1997). There is some evidence to suggest that people leave the Northern Territory when they retire to move to urban areas where services are available and accessible. In fact, the vast majority of older Australians live in large inland cities or reside on Australia’s coastal regions. Older Australians who remain residing in rural and remote regions may benefit from ageing in place but may be disadvantaged in that their needs in terms of service provision are rarely met (Knapman, p. 131 in Grbich). In rural areas, older people share with younger people the disadvantages that result from a centralised, hospital based and technology oriented health system (Knapman, p. 131). Health service delivery to the elderly rural and remote population is hampered by what some theorists refer to as urban bias. This bias ignores key dynamics of lifestyle and community characteristics. Such problems are compounded by insufficient critical mass, distance and dispersed demand (Dunn and Williams, 1997). Although the majority of young people in Australia experience relatively good health, some significant health issues have been identified. Injury is the leading cause of death for 12 to 24 year olds with two-thirds of all deaths attributed to some form of injury, including accidents and suicide. There are about three male deaths to every one female death among young Australians. Rates of depressive disorders are three times higher for young females than for young males. Males have a higher rate of substance use disorders. According to AIHW (2013, p.Vi), ‘There were 52 deaths per 100,000 males aged 0–24, nearly twice that among females of the same age (30 per 100,000). Males were nearly 3 times as likely to die from land transport accidents, the major cause of death for males aged 1–24. 13 | P a g e 13 About 6% of males aged 14–19 smoke tobacco daily and are less likely than females of the same age to do so. More than 2 in 5 (43%) males aged 14–19 were at risk of injury resulting from a single occasion of drinking alcohol. Males aged 0–24 were more likely to be hospitalised for injury, and more likely to die from injury, than females of the same age. Chlamydia is the most commonly notified infectious disease among young males. More than half (53%) of chlamydia notifications among males were for those aged 15–24. 1 in 4 (23%) males aged 16–24 had experienced symptoms of a mental disorder, and 4 in every ,1000 males aged 18–24 had been diagnosed with a psychotic disorder. In spite of this, rates of help seeking among young males are low (13%). About 193,400 males aged 0–24 (8%) have a disability, and about 78,000 accessed selected disability services. Youth from lower socio-economic groups were more likely to die younger and more likely to be hospitalised than those from higher socio-economic groups. Young people living in rural and remote areas have generally poorer health compared with those living in metropolitan areas. Both death rates and hospitalisation rates increase with increasing remoteness. 1.10 Socio-economic status, inequality, health and education A significant indicator of the existence of social class is the distribution of wealth. In Australia for example, there exists big differences in the income levels of the population. A very small proportion of the population owns a very large proportion of the wealth. Poverty and the accompanying social disadvantage is strongly correlated to ill health and early mortality. Poor social and economic circumstances affect health throughout life and people who are closer to the poverty line are at twice the risk of serious illness and premature death. The social gradient of health aligns material disadvantage with other areas that affect health such as insecurity, anxiety and social disadvantage (Wilkinson and Marmott, (eds.),1999). In every social category, the healths of the poor are significantly worse than that of their more affluent neighbours. Within the Australian context, the association between the health of Indigenous Australians and their comparable disadvantage cannot be overestimated. Likewise, wealthier overseas born Australians experience significantly greater health than their poorer counterparts. Workplace injury is a significant problem in Australian society with over two-thirds of a million Australians suffering a work-related injury or illness each year (Industry Commission 1995, cited in Burdess, 1995, in Grbich, 1999). Workplace injuries primarily occur in working class occupations. 14 | P a g e 14 Moreover workplace deaths occur primarily among blue collar or working class occupational groups. Working class or manual jobs are generally more hazardous than professional or managerial occupations. Manual workers are often exposed to environmental hazards (e.g. chemicals, excessive exposure to natural environmental hazards such as sun exposure), poor working conditions, tedious repetitive tasks, stresses related to the disproportionate reward to the workload ratio, increased risk of accident and injury, and to the alienation caused through a workplace organisation that is disempowering and alienating. It is not uncommon to attribute the health status of a population group to some deficit shared by its members. This victim blaming is often perpetuated in the popular media. The circumstances of the individual or group are attributed to some failing on their behalf. Individualistic explanations ignore the structural determinant of people’s existence. Instead, the reasons for ill health or premature death are attributed to either a flaw in the individual’s personality, or a result of some biological deficiency. These explanations do little in the way of explaining why significant differences in health and illness experiences are evident across different groups in society. In other words, they fail to adequately explain why the poor in general, as a whole suffer greater ill health and earlier death than those who are not poor. Globally, vast differences in health are evident between the third world or underdeveloped nations and those belonging to the first world or the developed nations. These patterns cannot adequately nor simply be contributed to biological, behavioural or psychological differences. Sociologists writing from a consensus perspective tend to share some aspects of the victim-blaming. These sociologists do not necessarily believe that inequality cannot be eradicated but their beliefs about how best to achieve equality may differ sharply to sociologists who theorise from the conflict perspective. The consensus view often focuses upon the need to educate the poor, to promote health through campaigns aimed at raising awareness and changing behaviours. Health education campaigns are increasingly common, and from a cynical viewpoint could be said to further perpetuate the myth that individuals are solely responsible for their life experiences. By way of contrast, Conflict theorists argue that the health of an individual or group is primarily determined by their social position. The structural determinants of health override individual psychology in determining health and illness experiences. Workplace injury is a significant problem in Australian society with over two-thirds of a million Australians suffering a work-related injury or illness each year (Industry Commission 1995, cited in 15 | P a g e 15 Burdess, 1995, in Grbich, 1999). Workplace injuries primarily occur in working class occupations. Moreover workplace deaths occur primarily among blue collar or working class occupational groups. Working class or manual jobs are generally more hazardous than professional or managerial occupations. Manual workers are often exposed to environmental hazards (e.g. chemicals, excessive exposure to natural environmental hazards such as sun exposure), poor working conditions, tedious repetitive tasks, stresses related to the disproportionate reward to the workload ratio, increased risk of accident and injury, and to the alienation caused through a workplace organisation that is disempowering and alienating. From an individualistic perspective, we may ask why it is that people remain in occupations that have little reward and high-risk health implications. Why don’t these people just get a better, less risky job? A sociological perspective will remind us of the relationship between income and status, education and occupation, occupation and wellbeing. In our society, the occupation of an individual is largely determined by their educational attainment. Professions that reap the greatest rewards generally also demand the greatest educational commitment. To become a nurse in the Northern Territory, for example, one must commit to university study for either a two year (accelerated) program or the standard three years of study. To become a medical professional one must commit to the education system for a significantly longer period. To become a labourer on a building site, or operate a checkout at the local supermarket, little education is often required. Longer years of education and training usually translate into greater income levels on workplace entry. Sociologists from a conflict perspective would argue that entry into and participation in, educational institutions is not distributed equally. Inequalities are socially reproduced across generations. A child from a working class family will generally find it more difficult to achieve the e