PHC 181 SEU Mental Health in Kingdom of Saudi Arabia Discussion

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College of Health Sciences Department of Public Health ASSIGNMENT COVER SHEET Course name: Sociology of health, illness, and health care Course number: PHC 181 CRN 23070-JM Mental health disorders are a public health issue in Saudi Arabia, like the rest of the world. Obviously, the mentally ill individuals and their families face many challenges in their life journey. Assignment title or task: (You can write a question) Based on this factual statement answer the following questions: 1. Discuss the burden of mental illnesses and those who are at risk in KSA 2. Explore the Saudi society perspective toward mental illness 3. Explain the social lived experience of mentally ill persons in KSA and the available social health services for them Students ID Student name: Submission date: Instructor name: DR. DASARI SREERAMULU Grade: …. Out of 10 College of Health Sciences Department of Public Health Guidelines: • • • • • • • • Written in a Word document (not less than 500 words) divided as introduction, body conclusion and references, PDF is not accepted. Use at least three references (up-to-date and reliable) Assignment must be submitted with properly filled cover sheet (Name, ID, CRN, Submission date). Font should be 12 Times New Roman Heading should be Bold Color should be Black AVOID PLAGIARISM All assignments must carry the references using APA style. Please see below web link about how to cite APA reference style. https://guides.libraries.psu.edu/apaquickguide/intext. Click or tap to follow the link Releasing and due date This paper assignment will be released at the beginning of week 9 (27-03-2022-Sunday 11:59 pm) and due by week 11 (10-04-2022- Sunday 12.00 am). – Grading Criteria Completion and accuracy of response: 0 – 10 points based on the following rubric: Proficiency Some Proficiency Limited Proficiency No Proficiency 2 1.5 1.0 0. 5 Thinking Conte Presentation nt Criteria The purpose and focus are clear and consistent Punctuation, grammar, spelling, and mechanics are appropriate Information and evidence are accurate, appropriate, and integrated effectively Analysis/synthesis/evaluation/interpretation are effective and consistent Connections between and among ideas are made Total / 10 College of Health Sciences Department of Public Health PRINT CMYK PROCESS COLOURS Cyan Magenta Yellow Black 16.5mm (c) “This is a well written, comprehensive text and is a ‘must’ for students in the pursuit of understanding the social aspects of health.” Peggy Murphy, Senior Lecturer (Nursing), Glyndŵr University, UK This core textbook is the ideal companion text for students studying the social aspects of health and illness, whether as part of a health studies degree, nursing course or other professional qualification. Written at an introductory level this book is suitable for students new to this subject and looking for a broad and accessible text for use throughout their studies. The book provides a comprehensive and contemporary exploration of a wide range of topics within the social aspects of health, illness and healthcare. It explores and explains the different relationships between social categories and health, different experiences of illness and the role of the healthcare provider in society. It includes self-contained chapters on: ● ● ● ● ● ● Gender Social class Ethnicity Ageing Physical ill health Mental health and illness ● ● ● ● Disability Death and dying Families, communities and healthcare Healthcare organizations and professions In addition to drawing together many different sources within this subject area, this engaging book is full of case studies, primary sources and activities, all of which will help you get to grips with the core concepts and themes in the study of health, illness and healthcare. Mary Larkin is Principal Lecturer in the Faculty of Health and Life Sciences, at De Montfort University, UK, where she is also Programme Leader for the BA Health Studies and BSc Public and Community Health. ISBN-13: 978-033523662-6 ISBN-10: 033523662-6 SOCIAL ASPECTS OF HEALTH, ILLNESS & HEALTHCARE Mary Larkin UK – PB Cyan Magenta Yellow Black Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. “In short, this is a gentle yet comprehensive introduction which will no doubt become popular with lecturers and students alike.” Dr Sarah Earle, Associate Dean Research, The Open University SOCIAL ASPECTS OF HEALTH, ILLNESS & HEALTHCARE Mary Larkin SOCIAL ASPECTS OF HEALTH, ILLNESS & HEALTHCARE Crown Quarto pb (245 x 189) Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 17/12/2010 11:42 social aspects of health.indb ii 17/12/2010 11:42 social aspects of health.indb i Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Social Aspects of Health, Illness and Healthcare Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 17/12/2010 11:42 social aspects of health.indb ii Mary Larkin Open University Press 17/12/2010 11:42 social aspects of health.indb iii Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Social Aspects of Health, Illness and Healthcare email: [email protected] world wide web: www.openup.co.uk and Two Penn Plaza, New York, NY 10121-2289, USA First published 2011 Copyright © Mary Larkin 2011 All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of Saffron House, 6–10 Kirby Street, London, EC1N 8TS. A catalogue record of this book is available from the British Library ISBN-13: 978-0-33-523662-6 (pb) 978-0-33-523661-9 (hb) ISBN-10: 0-33-523662-6 (pb) 0-33-523661-8 (hb) Library of Congress Cataloging-in-Publication Data CIP data applied for Typeset by RefineCatch Limited, Bungay, Suffolk Printed in the UK by Bell & Bain Ltd, Glasgow Fictitious names of companies, products, people, characters and/or data that may be used herein (in case studies or in examples) are not intended to represent any real individual, company, product or event. social aspects of health.indb iv Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Open University Press McGraw-Hill Education McGraw-Hill House Shoppenhangers Road Maidenhead Berkshire England SL6 2QL 17/12/2010 11:42 Praise for this book viii List of figures and tables ix Acknowledgements xi Introduction: understanding the social aspects of health 1 Chapter 1 Studying the social aspects of health 13 Section 1: The relationship between social categories and health Introduction to Section 1 31 Chapter 2 Gender and health 33 Chapter 3 Social class and health 49 Chapter 4 Ethnicity and health 67 Chapter 5 Ageing and health 81 Section 2: The experience of health and illness Introduction to Section 2 101 Chapter 6 Experiencing illness 103 Chapter 7 Experiencing mental illness 121 Chapter 8 Experiencing disability 137 Chapter 9 Dying, death and grieving 151 Section 3: The delivery of healthcare Introduction to Section 3 169 Chapter 10 Families, communities and healthcare 171 Chapter 11 Healthcare organizations 187 Chapter 12 Health professions 203 Afterword 219 Activity feedback 223 Glossary References Index 237 247 267 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Contents v social aspects of health.indb v 17/12/2010 11:42 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 17/12/2010 11:42 social aspects of health.indb vi 17/12/2010 11:42 social aspects of health.indb vii Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. This book is dedicated to my late grandmother – Alice Rebecca Mayhew (1908–2007) – for being such a source of inspiration to me. vii “This is an easy-to-read introductory text exploring the social aspects of health, illness and healthcare. Key concepts are introduced carefully and there is a helpful glossary of key terms. Activities and discussion points enable students to pace their learning and illustrative case studies bring the text to life. In short, this is a gentle yet comprehensive introduction which will no doubt become popular with lecturers and students alike.” Dr Sarah Earle, Associate Dean Research, The Open University, UK “Larkin’s book provides an excellent and accessible read for students studying health related disciplines . . . a useful resource for those new to the subject area of social aspects of health, health care and illness and a good refresher for those that may not have studied the subject for some time or those returning to study. The reader will be left feeling informed around the key issues and theories.” Sabina Sattar, Senior Lecturer, University of Central Lancashire, UK “I wish to congratulate Mary Larkin for creating such a useful resource. The structure of this book and the writing style employed makes light work of complex subjects. The overview at the beginning of each chapter is useful to signpost the student to the topics covered. Because the book is well explained throughout it would be a useful core text for level 4 5 & 6 modules in pre- and post registration nursing in the UK. Each chapter of this book directs the students reading and the interactive design fosters independent learning. This is a well written comprehensive text and is a ‘must’ for students in the pursuit of understanding the social aspects of health.” Peggy Murphy, Senior Lecturer (Nursing), Glyndwr University, UK “Mary Larkin’s textbook offers the nursing student a lively insight into many applied aspects of the social aspects of health and illness. It uses a variety of theoretical perspectives, and all concepts are clearly extrapolated. A variety of devices are then utilised to facilitate knowledge and understanding. This is an excellent resource, which I would highly recommend.” Siobhan McCullough, School of Nursing and Midwifery, Queen’s University Belfast, UK “Mary Larkin has written a comprehensive survey of contemporary health issues well suited to the needs of students of social aspects of health. Written in an accessible and lively style, the book covers an impressive range of theoretical approaches and substantive material, complemented by summaries, discussion questions and learning activities, to prompt students to reflect on their reading and to engage with the text.” Hannah Bradby, University of Warwick, UK “I find this to be one of the most intuitive texts I have read to date as a student. Mary Larkin has an obvious passion for and belief in what she has written, making this all the more enjoyable and interesting to read.” Roisin Kiernan, Student nurse, Queen’s University Belfast, UK social aspects of health.indb viii Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Praise for this book 17/12/2010 11:42 Figures Figure 1.1 Figure 1.2 Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 4.1 Figure 4.2 Figure 4.3 Figure 5.1 Figure 5.2 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 8.1 Figure 8.2 Figure 11.1 The relationship between the individual and society in sociology Theoretical approaches Gender and morbidity rates – percentage of males and females consulting an NHS GP in the 14 days prior to interview, Great Britain, 1971–2002 Male and female life expectancy at birth, UK, 1981–2056 Prevalence of cigarette smoking, Great Britain, 1974–2007 Prevalence of obesity in adults: by gender, 1993–2005 Life expectancy at birth by social class, a) males, b) females, England and Wales, 1972–2005 Self-reported general health (age standardized) UK, 2001 Prevalence of neurotic disorders by social class Cigarette smoking by socioeconomic classification, adults aged 16 and over, Great Britain, 2006 Percentage of people with depression, by ethnic group and gender Unemployment by ethnic group and sex, Great Britain, 2004 Income poverty rates Average life satisfaction score by age group Age structure of UK population Average levels of psychological distress Projected change in number of people with depression, 2007–26 The potential influences on prevalence rates of the common mental disorders Brown and Harris’s model (adapted) The medical model of disability The social model of disability Role sets for a female doctor 15 18 36 37 42 43 56 57 58 60 72 74 75 87 95 124 124 128 128 143 144 194 Tables Table 2.1 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 4.1 Table 4.2 Table 5.1 Gender pay gap Weber’s four main classes The Goldthorpe Class Schema, nine-category version Registrar General’s Social Class categories The National Statistics Socio-economic Classification (NS-SEC) system The main non-white, black and minority ethnic groups in the UK Incidence of schizophrenia by ethnic group Self-reported health in Great Britain, by age and sex, 2006 (%) 39 53 54 54 55 70 71 85 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. List of figures and tables ix social aspects of health.indb ix 17/12/2010 11:42 List of figures and tables Table 5.3 Table 5.4 Table 9.1 Table 12.1 Acute sickness: average number of restricted activity days per person per year, by sex and age, 2003–7 Percentage reporting chronic longstanding illness, 2003–7 Percentage reporting chronic limiting longstanding illness, 2003–7 Awareness contexts by Glaser and Strauss Codes of practice in the health professions 85 86 86 161 206 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Table 5.2 x social aspects of health.indb x 17/12/2010 11:42 The publishers would like to thank the copyright holders of the following material for permission to reproduce material in this book: Before I Say Goodbye by Ruth Picardie, 1998, London, p. 38. Copyright © Ruth Picardie, 1997; and Justine Picardie, 1997. Foreword and Afterwords copyright © Matt Seaton, 1998. Reproduced by permission of Penguin Books Ltd. “Observer Life, 22 June 1997” from Before I Say Goodbye by Ruth Picardie. Copyright © 2000 by the Estate of Ruth Picardie and Justine Picardie. Reprinted by arrangement with Henry Holt and Company, LLC. Every effort has been made to trace and acknowledge ownership of copyright and to clear permission for material reproduced in this book. The publishers will be pleased to make suitable arrangements to clear permission with any copyright holders whom it has not been possible to contact. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Acknowledgements xi social aspects of health.indb xi 17/12/2010 11:42 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 17/12/2010 11:42 social aspects of health.indb xii Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Introduction: understanding the social aspects of health Health is a physiological and psychological state but it is also, fundamentally a social state. (Jones 1994: 1) Overview Aims and rationale of the book Contextualizing the ‘social aspects of health’ The rise of biomedicine Challenges to biomedicine The move to a multidimensional view of health The focus on the social aspects of health 2 2 2 4 Content and structure Organization of the content Chapter features Chapter outlines 7 7 7 8 Key points 10 4 Discussion points 10 6 Suggestions for further study 11 1 social aspects of health.indb 1 17/12/2010 11:42 Introduction This is an introductory text to a wide range of topics within the broad subject area of the social aspects of health. It simultaneously addresses the social aspects of illness and healthcare because health, illness and healthcare are intrinsically intertwined. Without assuming prior knowledge, the book will draw on several academic disciplines and theoretical perspectives in order to provide clear explanations of basic concepts and issues within each topic. A further aim is to help students feel more confident with this subject area and increase their chances of greater success in their courses of study. The nature and scope of the book mean that it meets many learning and teaching needs. For instance, it can be used by first- and second-year students on undergraduate courses related to health, social care, youth and community work and social work, as a core/supplementary text, and for reference purposes. It is also for use by students taking pre- and post-registration courses in nursing and midwifery. In addition, lecturers can use relevant chapters as a teaching resource to support and reinforce student learning. This chapter introduces you to the subject of the book, its structure and the topics it covers. Hence careful reading of it will ensure that you know how to maximize its potential benefits for both your current and future study of the ‘social aspects of health’. The introduction to the social aspects of health is twofold. First of all, there is a brief historical contextualization to show how western society’s views of health evolved and the how realization dawned that there are many social aspects to health. This involves a discussion of the biomedical approach to health, the ways in which it was challenged and the ensuing changes that led to multidimensional views of health more generally, and a greater awareness of the social aspects of health more specifically. The second part of the introduction to the social of aspects health comprises an outline of the way that subsequent changes in the study of health have raised the profile of the social aspects of health across many different levels. These include the fact that the increase in research into the social aspects of health has led to the acknowledgement of an extensive number of social influences on health and the development of theoretical perspectives. The main group of social factors that are now recognized as being central to the study of social aspects of health are then outlined. How these are addressed in the book is explained in the final section of the chapter, in which details of the content, organization and features of the book together with summaries of each chapter are also set out. Activity 1.1 List all the factors that you think affect your health. Now compare them with those that are discussed below. Contextualizing the ‘social aspects of health’ The rise of biomedicine Until the middle of the nineteenth century, healthcare was mainly carried out by women within the private domain. If medical problems could not be solved, the services of a variety of health practitioners (with or without medical training!) could be called upon in exchange for payment. Examples of these health practitioners include apothecaries (who offered and produced a range of medicines), barber-surgeons (who carried out limited surgical procedures), village herbalists, bone-setters and midwives. There were few hospitals and it was only the rich who could afford to consult learned physicians. In part, the multiple sources of provision were the consequence of minimal knowledge of illness and disease, due to a lack of understanding of anatomy and physiology and the causes of Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Aims and rationale of the book 2 social aspects of health.indb 2 17/12/2010 11:42 Introduction ■ development of new academic and professional subject areas such as bacteriology, germ theory and microbiology; ■ introduction of aseptic techniques; ■ introduction of anaesthesia; ■ technological developments, such as stethoscopes, thermometers, microscopes and X-rays (Wear 1992; Jones 1994; Loudon 1997). All these developments contributed to the development of biomedicine. This draws heavily on scientific knowledge in general and emphasizes scientific method and objectivity (the hypothecodeductive method). It sees health in terms of biology, attaching supreme importance to learning about anatomy and physiology. Consequently the biomedical approach rests on the assumption that all causes of disease – mental disorders as well as physical conditions – can be understood in biological terms. Disease and sickness are therefore explained in terms of their specific or multiple Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. disease. The reality was that most practitioners offered the same treatment based on the same assumptions and relied on ancient theories without exploring or developing them (Pelling and Harrison 2001; Porter 2002). From the beginning of the sixteenth century onwards, several significant developments laid the foundations for changes in medicine. Amongst these was the Enlightenment, during which geographical exploration and scientific discoveries flourished. For instance, Columbus made his famous voyage to the Americas in 1492 and Copernicus disturbed the received view of the universe in 1507 with his discovery that the Earth revolved around the Sun. In addition, the new ‘art’ of artists such as Leonardo da Vinci (1452–1519) and Michelangelo (1475–1564) reflected a desire to reach a greater understanding of man and nature by using more accurate representations in paintings and sculpture. One of the consequences of these developments was that the laws of nature had to be reinterpreted and applied in a variety of situations. This involved scientific hypothesizing and empirical testing. Another was that people’s knowledge of the human body changed and, more importantly, there was the realization that the only way to find out more about human anatomy and diseases was through the dissection and study of human bodies. These consequences in turn led to new ways of thinking – referred to as discourses – in medicine which emphasized the need to ‘study’ not one sick person, but a group of sick people displaying particular symptoms in order to gain a scientific understanding of disease. As hospitals ensured a plentiful supply of patients for clinical observation and studying anatomy and physiology, these discourses, in combination with the continued growth in ‘scientific’ theories throughout the eighteenth century, resulted in an expansion in the number of hospitals. Simultaneously, medical practice and education began to develop and change significantly, with an increasing requirement to study organized courses in anatomy, surgery and the administration of medicines as well as undertaking hospital and surgical practice. The number of medical schools in London rose from 3 to 12 between 1820 and 1858. With theoretical and practical education and training, medicine not only developed as a powerful profession in its own right (see Chapter 12) but gradually expanded to encompass a growing number of specialisms as well (Loudon 1997; Naidoo and Wills 2008). As the impetus to develop medical theory supported by research through the bringing together of clinical observation and pathological research gained momentum, progress in medical science and technology also accelerated rapidly. Among the most notable were the: 3 social aspects of health.indb 3 17/12/2010 11:42 Introduction Challenges to biomedicine Questions were raised about the effects of medical progress inherent in the biomedical approach from the beginning of the twentieth century, and in the 1960s the level of questioning escalated with the result that direct challenges were made to biomedicine. A main protagonist was Illich (1976) who argued that biomedicine did more harm than good and highlighted its damaging effects. He put forward the theory of iatrogenesis which he used to refer to the harmful and detrimental effects of medical interventions, such as hospital-induced infections and adverse reactions to medical treatment. Such harm does not occur in the absence of medicine and medical practice and hence is medically caused. There are different types of iatrogenesis within Illich’s theory and these are discussed in depth in Chapter 6 (Jones 1994; Naidoo and Wills 2008). There were also those who challenged biomedicine’s view of mental illness as being biologically caused. They disagreed with the way that its focus on normal bodily functioning led biomedicine to see mental illness as being due to biochemical changes in the brain. One of the outcomes of this dissension was the formation of the anti-psychiatry movement which was particularly active in the 1960s and 1970s. This movement criticized traditional theory and practice in psychiatry, arguing that this was incorrect and that mental illness was not a deviation from normal bodily functioning but created by social processes, such as labelling (see Chapter 7) (Szasz 1974; Rogers and Pilgrim 2005). The move to a multidimensional view of health In response to such challenges to ‘scientific’ techniques and drug treatments, the many factors that influence health started to be identified. For instance: ■ psychological factors: the rise of psychology highlighted the role of psychological factors, such as the link between emotional stress and illness, on our health; ■ social divisions: the role of social divisions such as class, income, race, gender and age in shaping health emerged from several reports about health inequalities, such as the Black Report (Black et al. 1980) and The Health Divide (Whitehead 1987); ■ economic and social differences: the World Health Organization (WHO) drew attention to the poorer health experienced by those living in developing countries compared to those living in the developed world, due to economic and social differences; ■ environmental factors: the effects of environmental factors, such as work environments and housing and air quality, were acknowledged from the 1960s, and this was reflected in the public health acts, slum clearance programmes and pollution controls introduced at that time; Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. causes, tracking the cause and the course of disease as it affects particular parts of the human body. In addition, disease and sickness are viewed as deviations from normal functioning. The adoption of biomedicine shaped approaches to health and healthcare until the 1970s. It meant that health was seen largely in mechanical terms, as a state where all parts of the body function ‘normally’ and there is an ‘absence of disease’. Within the biomedical approach, health services are mainly geared to treating sick and disabled people, and their function is remedial or curative. Biomedicine’s pathogenic focus, emphasis on risk factors and establishing abnormality also promoted an interest in the health of the population and influenced the growth of the public health movement in the nineteenth century (see Chapter 6) (Wear 1992; Jones 1994; Loudon 1997; Pelling et al. 2001). 4 social aspects of health.indb 4 17/12/2010 11:42 Introduction healthcare delivery systems: research demonstrated the varying impacts of the different healthcare delivery systems nationally and internationally. As a result of the recognition of the multitude of factors that need to be taken into consideration when talking about health, there has been a move towards a more holistic approach to defining health in the last 50 years. This was encapsulated in the World Health Organization’s definition in 1946: ‘Health is a state of complete physical, mental and social well being, not merely the absence of disease or infirmity’. This definition was significant as it highlighted the importance of a multidimensional view of health for the first time. Subsequent definitions have promoted even broader conceptions of health which also go beyond the narrow focus on ‘scientific’ biological conceptions of health in the biomedical discourse, and emphasize its social and environmental dimensions. For example: to reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and realise aspirations, to satisfy needs, and to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living. Health is a positive concept, emphasising social and personal resources, as well as physical capacities. (World Health Organization 1986: 100) Although there is evidence that western ‘scientific’ biological conceptions of health still dominate, as these definitions testify, there has been a move away from a purely clinical focus. In addition, there has been professional and public acceptance that there are a wide range of influences on health. Furthermore, as indicated in the reference to health as a ‘positive concept’ in the last sentence of the second definition of health above, there are now a variety of conceptualizations of health. Currently there are four main concepts in current use: negative, positive and social health, and quality of life. As demonstrated in the outline of each concept below, their understandings of health range in breadth from narrow to very wide. ■ Negative health: this concept emphasizes the absence of symptoms and regards being healthy as not feeling unwell, and/or not having a diagnosed illness or disease. However, only 15 per cent of the general population in a western society will have chronic physical limitations and only some 10–20 per cent will have a substantive psychiatric impairment. Therefore, using the negative concept of health where the focus is on departure from health means there is no information about the remaining 80–90 per cent of the population. ■ Positive health: the concept of positive health is more than the mere absence of disease or disability and is therefore a broader concept than the narrower disease-based concept of negative health. It refers to a positive state of well-being, ‘equilibrium’ or fitness and energy, all of which are required to function effectively from day to day (often referred to as functional ability). This concept of health has many distinct components which focus on both mental and physical health – it can be described as embracing the ability to cope with stressful situations, the maintenance of a strong social support system, integration into the community, high morale and life satisfaction, psychological well-being and high levels of physical fitness as well as physical health. ■ Social health: the third concept of social health presents a broader view of health again, in that it goes beyond the reporting of symptoms, illness and the ability to meet the demands of everyday life. It focuses on the extent of a person’s social support systems (e.g. the extent of their social interaction and social participation) and argues that these influence mental and physical health. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. ■ 5 social aspects of health.indb 5 17/12/2010 11:42 Introduction ■ Quality of life: this multidimensional concept is the broadest of the four. While it lacks definitional consensus, it generally refers to a range of components relating to satisfaction with life, general levels of physical and mental health, satisfaction with economic and social status, sense of self-worth, social health and functional ability (Currer and Stacey 1986; Blaxter 1990). The focus on the social aspects of health As indicated above, the adoption of a multidimensional view of health from the 1980s meant a general acknowledgment of the fact that there were social aspects to health. Since then, interest in and research into these has burgeoned. The social dimensions of health have been the subject of major government reports, and in 1980 the Black Report (mentioned above) highlighted the persistence of correlations between social class and infant mortality rates, life expectancy and inequalities in the use of medical services. In 1998 the Independent Inquiry into Inequalities in Health Report, headed by Donald Acheson, came to similar conclusions as the Black Report as it also found health inequalities in the UK and that poverty was a significant determinant of health. During the first decade of this century, the number and range of social influences on health that feature in policy documents that address health and health inequalities has increased. Examples are housing, communities, education, level and type of early years support for children and families, access to public services and unemployment (Department of Health 1999, 2003). Moreoever, there has been a growing emphasis on the social determinants of health at local, national and global levels. These are the economic, political and social conditions under which people live and which determine their health. The term ‘social determinants of health’ grew out of the search to identify the specific factors which lead to members of different socioeconomic groups experiencing varying degrees of health and illness. This search gathered momentum and in 2005 the World Health Organization established the Commission on Social Determinants of Health (CSDH) to support countries in addressing the social factors that lead to health inequalities. As part of its remit, the CSDH draws attention to those social determinants of health that are known to be among the worst causes of poor health and inequalities between and within countries. These determinants include unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems. Indeed, the Commission’s recent report embodied principles of action aimed at addressing these in its recommendations (Commission on Social Determinants of Health 2008). Simultaneously, there has also been an emphasis on the social determinants of global health such as pollution, climate change, environmental degradation, conflict between countries, domestic and foreign policies, international trade and the role of international health organizations and development agencies (Marmot and Wilkinson 2006; Department of Health 2008a). One of the consequences of the surge of activity around the social aspects of health is that their identified number and range has increased dramatically. They now include several groups of factors. One is the effect of income, employment, unemployment, social class, gender, race, age, education and culture on health. A second is the impact of social environmental factors such as housing, neighbourhoods and communities, support systems and conditions at work. A third group comprises particular features of a society, such as the distribution of power, money, resources, goods, the strength of its public sector and the accountability of its private sector, and its social and economic policies, which are now regarded as key influences on health. The provision and delivery of healthcare, access to healthcare, and the systems put in place for health protection, health Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Although social health incorporates physical and mental health, it is measured apart from physical and mental health. 6 social aspects of health.indb 6 17/12/2010 11:42 Introduction Content and structure Organization of the content This book provides a comprehensive and contemporary exploration of the factors mentioned above which are now recognized as being key social aspects of health. The material has been organized in terms of the following three broad themes: ■ The relationship between social categories and health. ■ The experience of health and illness. ■ The delivery of healthcare. These themes will be adopted as headings for the three main sections of the book. The first chapter will furnish the reader with an understanding of the academic and theoretical underpinnings of the social aspects of health required to study this subject area. In order to reinforce and develop students’ understanding further, the theoretical perspectives introduced in Chapter 1 will be revisited during the course of the book and applied to the issues addressed. Although the intention is that the chapters can be read independently, it is strongly suggested that readers familiarize themselves with the material presented in Chapter 1 in order to gain a fundamental intellectual and theoretical knowledge of the social aspects of health before starting any of the other chapters. The chapters within each section of the book present a detailed exploration of a specific topic, drawing on a wide range of literature and documents from many different sources as well as recent statistical data. While the emphasis will be on the contemporary UK, material will also be drawn from historical, European and wider international contexts as the need arises. The nature and extent of the discussions of theoretical perspectives in each chapter will vary according to the topic addressed and be supplemented with other perspectives relevant to specific issues as appropriate. In addition, these theoretical discussions will either be integrated into the individual sections of the chapters or addressed in separate sections. This variation in approach is designed to ensure that the material is organized in a way that makes the presentation of each topic as accessible as possible to the reader. Reference has already been made to the interactions that occur between factors within the social aspects of health. Although the chapters appear as discrete entities, this form of organization is to enable you to gain a comprehensive overview of each topic. Any interactions between the factors addressed in each chapter will be acknowledged where appropriate. Chapter features Every effort has been made to ensure that the text is as readable and interactive as possible. Features include the following. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. improvement and to deal with illness, have also received much attention. Last but not least, as mentioned above, global factors (e.g. globalization and the impact of climate change on health) have more recently featured in research and reports into the social aspects of health. A further consequence is the steady growth of a body of theoretical approaches that acknowledge there are a broad range of social factors that can influence health, and that health is the result of the complex interactions that occur between such factors. Indeed, the concept of the ‘social model of health’ is now used within the field of health (Lupton 1996; Earle 2005). 7 social aspects of health.indb 7 17/12/2010 11:42 Introduction An overview of each chapter. ■ An outline of the content and structure of each chapter. This will include details of the way in which the relevant theoretical perspectives will be addressed. ■ Key concepts will be highlighted in the text the first time they are used and are clearly defined in the glossary at the end of the book. The glossary provides relevant understandings for those with differing levels of social science knowledge. Its comprehensive nature means that it can also be used independently for reference purposes across a range of other modules and/or courses. ■ Activities based on extracts from primary sources (e.g. case studies, historical documents, newspaper articles, policy documents and statistical data). In the ‘Activity feedback’ chapter that precedes the glossary, some suggestions and comments are made to help the reader reflect on their work on the activities and relate issues to relevant theoretical perspectives. Some of the activities can also be used and/or adopted by lecturers and tutors for workshops and classroom discussions. The presentation of these activities is designed to reinforce and support students’ learning as opposed to being essential to the main text in each chapter. They are easily identified as they are presented in boxes and can be omitted by those students who do not require them. ■ Links with other chapters are highlighted. ■ Figures and tables to illustrate key concepts and data. ■ Discussion points for either individual study or teaching purposes. ■ Suggestions for further study and reading, plus web resources. Chapter outlines Section 1: The relationship between social categories and health Chapter 1: Studying the social aspects of health This chapter begins with outlines of the main academic disciplines that inform the study of the social aspects of health. The theoretical perspectives that will be used and referred to in the book are then addressed. Several key concepts and issues that will be frequently discussed are also introduced in this first chapter. Chapter 2: Gender and health The concept of ‘gender’ is defined at the beginning of this chapter. This is followed by an exploration of the differences in men and women’s physical and mental health and the types of factors that shape these differences. The final section of the chapter discusses the theoretical explanations that have been developed about the relationship between gender and health. Chapter 3: Social class and health At the beginning of this chapter is an exploration of the concept of class. This includes class as a form of social stratification and the different conceptualizations of class used in theoretical approaches and social research. The relationship between social class and health is then explored by Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. ■ 8 social aspects of health.indb 8 17/12/2010 11:42 Introduction Chapter 4: Ethnicity and health The concepts of ethnicity and race are distinguished before defining ethnicity and outlining the main minority ethnic groups in the UK. An overview of current findings about the different types of physical and mental illnesses experienced by members of these minority ethnic groups follows. The role of income and poverty levels, housing and healthcare in the health inequalities identified are considered before evaluating the explanations of the relationship between ethnicity and health that have been developed. Chapter 5: Ageing and health This chapter starts by examining the concept of age itself before moving on to discuss the relationship between the life course and our physical and mental health. Given the strength of the relationship between ill health and old age, there is then an in-depth exploration of this phase of the life course. This includes a discussion of the life course perspective and relevant research findings. Section 2: The experience of health and illness Chapter 6: Experiencing illness The emphasis in this chapter is on the experience of illness in general. It starts by explaining the differences between acute and chronic illness, and then examines the theoretical insights into the experience of both these types of illness that have been developed. The last section explores how our experience of illness is shaped by changing definitions of illness and disease, and refers specifically to the medicalization thesis and the rise of health surveillance. Chapter 7: Experiencing mental illness This chapter starts with an overview of mental illness and its incidence. It then outlines the two main types of explanation of mental illness within the study of the social aspects of health. These outlines include discussions of models that have been developed to explain mental illness. This is followed by an in-depth exploration of the experiences of those who live with a mental illness, and how these and the interrelationships between them can lead to their exclusion from many aspects of life in our society. Chapter 8: Experiencing disability As the experience of disability is very much shaped by societal approaches to it, this chapter looks at the changes in definitions and models of disability that have occurred over time. Examples of disabled people’s life experiences in contemporary society are then discussed. These examples illustrate the way that disability still leads to discrimination and inequality, despite the improvements in our approach to those who are disabled in our society. Chapter 9: Dying, death and grieving This chapter considers the contribution that the study of the social aspects of health has made to understandings of dying, death and grieving. In so doing, it explores the evidence and arguments that these experiences are strongly influenced by both the personal and social contexts in which they take place. The social context is the main focus as this is the specific area to which the study Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. examining relevant data on morbidity and mortality rates, the influences on this relationship and the insights provided by key theoretical explanations. 9 social aspects of health.indb 9 17/12/2010 11:42 Introduction Section 3: The delivery of healthcare Chapter 10: Families, communities and healthcare In order to address the policy initiatives that have moved the care of both the acutely and chronically ill out of formal healthcare organizations and into the community, this chapter explores the two concepts which are central to the changes involved: the ‘family’ and ‘community’. It then discusses these policy trends and, more specifically, the increases in informal healthcare they necessitate. The implications for family members providing the additional care and for those receiving it, as well as the issue of the ‘community’ as a source of the informal support required, are also explored. Chapter 11: Healthcare organizations The focus of this chapter is the organization and delivery of formal healthcare. It is divided into three sections. This first explains what the terms ‘organization’ and ‘healthcare organizations’ mean, the second examines examples of theoretical approaches to healthcare organizations and the third evaluates the main changes that have been made to healthcare organization in recent decades. Chapter 12: Health professions This final chapter explores the meaning, the extent and some of the implications of the power of those professionals who deliver healthcare. In order to do this, it explores the concepts of ‘profession’, ‘professional socialization’ and ‘professionalization’ in relation to both the medical profession and other health professions. It then considers the different ways that professional power has been found to operate in healthcare by examining changes in the power of health professions and the challenges to the autonomy of the medical profession. Key points ■ The evolution of western society’s views of health has led to multidimensional views of health. ■ There is now a greater awareness of the social aspects of health and it is widely acknowledged that there is an extensive number of social influences on our health. ■ The range of social influences on our health and theoretical perspectives within the study of the social aspects is constantly changing as further research is undertaken. Discussion points ■ What are the advantages and disadvantages of the biomedical approach to health? ■ What recent examples of iatrogenesis can you think of? ■ To what extent are varying concepts of health useful? Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. of the social aspects of health has made the most contributions. The chapter ends with a discussion of possible theoretical interpretations of the material presented. 10 social aspects of health.indb 10 17/12/2010 11:42 Introduction Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Suggestions for further study ■ Webster (2001) provides a highly readable account of the historical development of healthcare systems if you wish to explore this further. ■ More detailed explanations of the different concepts and models of health can be found in Chapter 1 in Taylor and Hawley (2010). ■ A visit to the World Health Organization website will provide a wealth of information about definitions of health and the factors that influence health. 11 social aspects of health.indb 11 17/12/2010 11:42 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 17/12/2010 11:42 social aspects of health.indb 12 Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. 1 Studying the social aspects of health Theories are lenses through which we investigate the social world. (de Maio 2010: 28) Overview Introduction 14 Health data 26 Academic underpinnings Sociology The sociology of health and illness The sociology of the body 14 14 16 17 Influences on health 26 Conclusions 27 Key points 28 Discussion points 28 Suggestions for further study 28 Theoretical underpinnings Marxist theory Feminism Functionalism Symbolic interactionism Postmodernism 17 18 19 22 23 23 13 social aspects of health.indb 13 17/12/2010 11:42 Chapter 1 Studying the social aspects of health The main aim of this chapter is to provide you with the understandings you require before embarking on your study of the social aspects of health. These understandings will also help you to apply your knowledge of this subject area in any professional roles you undertake. Comprehensive outlines of relevant academic disciplines and theoretical perspectives are provided. These can be used for reference purposes when reading specific chapters in the book and during any future study of the social aspects of health you may undertake. To further assist you with your current and future explorations of the social aspects of health, towards the end of the chapter there is an explanation about how health data are used and a summary of the established influences on health. Academic underpinnings Although several disciplines inform the study of the social aspects of health, it is the sociology of health and illness and the sociology of the body which are most frequently drawn upon. As the discipline of sociology underpins the sociology of health and illness, this section starts with an overview of this subject. The nature and scope of both the sociology of health and illness and the sociology of the body will then be explored, together with their contributions to knowledge about the social aspects of health. Sociology Activity 1.1 Which do you think is the most accurate description of sociology? ■ Social work ■ The study of individuals ■ The study of society ■ The study of the human social world ■ The study of individuals and society Sociology is the systematic study of the human social world or human society, in that it studies human beings in the social world. Although it sees individuals as highly significant, sociology is different from psychology in that it rejects any explanation which just focuses on ‘individuals’, or argues that individuals are autonomous, and challenges the assumption that social behaviour can be reduced to the study of the individual alone. While sociology looks at both individuals and society, it does more than this in that it looks at individuals operating in the social world and their relationship with that world. It maintains there is a two-way relationship between the individual and society, in that individuals are influenced by society and in turn can influence their social environment. This is represented diagrammatically in Figure 1.1. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Introduction 14 social aspects of health.indb 14 17/12/2010 11:42 Chapter 1 Studying the social aspects of health The development of sociology is relatively recent as it originated in the early nineteenth century during industrialization. The rapid industrial change that occurred at this time led to questions being asked about the sources of social change, social order, the relationship between the individual and society, and how the society into which people are born shapes their behaviour as individuals (Earle and Letherby 2008; Naidoo and Wills 2008). Sociology augments and supplements knowledge through a range of perspectives in three ways. ■ By giving us new understandings of society. Sociology tries to understand how the social world ‘works’ – what’s going on in society and the changes in society. It also investigates how the two-way relationship between social structures and individuals shapes the actions of each over time. In order to do this, sociology unravels and interprets the structure of society as well as the actions of individuals in a unique way. Consequently, it helps us to see what is going on in society in a new light. The well-known sociologist C. Wright Mills captured this perfectly when he said that ‘doing’ sociology requires thinking in a particular way. He describes this as thinking beyond our own essentially limited experiences and observations of the human social world, and challenging what appear to be the accepted explanations of social phenomena. The ability to adopt such a critical and questioning approach involves what C. Wright Mills describes as a sociological imagination which is seeing ‘personal troubles [as] public issues of social structure’ (Mills 1959: 8). ■ By providing us with evidence and explanations of an extensive range of facets of our human social world. For instance, how society works in terms of what the different institutions do and how they function together. Sociology can also explain the actions of individuals and groups, and patterns of similarity and difference between people within a single society and between societies. Furthermore, it helps us to understand the distribution of social, political and economic resources and power within society. Consequently, sociology can account for why some groups are more powerful than others. ■ By offering explanations that are distinctive from other subjects. Sociological explanations always look beyond the individual to take into account the wider social causes of individual behaviour. For example, when explaining why someone is unemployed, psychological explanations would perhaps look at personality traits such as lack of self-esteem, motivation or particular abilities. A sociological explanation would look at a number of crucial factors that are ‘beyond’ the individual and out there in society and how they affect individuals. As there is a social class gradient in unemployment, with those from the lower social classes experiencing much higher rates of unemployment than those in the higher social classes, one such factor would be social class. A sociological account would also consider the way that some occupational groups are more able to protect themselves from unemployment: higher occupational Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Figure 1.1 The relationship between the individual and society in sociology 15 social aspects of health.indb 15 17/12/2010 11:42 Chapter 1 Studying the social aspects of health The sociology of health and illness Early sociologists did not discuss health and illness directly. It was not until the 1950s that the value of sociological analysis in this field achieved recognition and even then it did not become established as a sub-discipline until the 1960s and 1970s (Earle and Letherby 2008). Initially it focused on criticizing traditional medical views as being value-laden and highlighted the social control exerted by health professionals through the practice of medicine. During the 1980s, those working within the sociology of health and illness extended its boundaries further and added its voice to the questions that were being raised about the biomedical model’s physiological focus. In doing so, because of its sociological underpinnings, the sociology of health and illness emphasized both the roles of different aspects of our social world beyond the individual and the role of the individual in determining health. The former include social categories, social conditions and social processes. The latter include patients’ own perceptions and knowledge of health. The sociology of health and illness has now achieved professional and academic recognition. As a result of its further development and sociological underpinnings, it is concerned with all aspects of contemporary life that impinge on well-being throughout the life course. Examples of the wide range of issues that the sociology of health and illness currently addresses are: ■ patterns of health and illness in relation to the wider social structure; ■ lay perceptions of health and illness; ■ the experience of health and illness; ■ how certain conditions come to be viewed as illnesses or diseases; ■ globalization and health; ■ the social organization of formal and informal healthcare; ■ the analysis of medical knowledge and professional power; ■ lay-professional interactions in healthcare; ■ the social and cultural aspects of the body. In exploring these issues, the sociology of health and illness adopts an eclectic approach in that it embraces other disciplines, such as epidemiology, public health, social policy and psychology. It also employs many well-established sociological perspectives in its explanations. While the diversity of the content of the sociology of health and illness has been criticized, it has significantly expanded awareness and knowledge of the breadth of social influences on health as Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. groups have more contacts and family ties in business which means they can use these to keep and find employment. In contrast, those in lower occupational groups are often less skilled and less well trained and are consequently more vulnerable to unemployment. Therefore, sociology does not only consider personal characteristics but all those factors in society that could affect an individual’s lack of employment. 16 social aspects of health.indb 16 17/12/2010 11:42 Chapter 1 Studying the social aspects of health The sociology of the body By challenging conventional assumptions about the body and disease, and studying people’s own knowledge of their bodies and perceptions of their bodily experiences, the sociology of health and illness has generated a plethora of studies concerned with the body from a sociological viewpoint. These have been carried out not only within the sociology of health and illness but also in other areas, such as ageing and disability studies. Furthermore, many social changes have increased sociological interest in the body as a social product. For example, the cult of the body in consumer culture means that much modern consumption, such as in the areas of beauty, fashion and leisure, now focuses on goods for body maintenance. Hence the body has become a carrier of commodities which signify particular lifestyles, and create both identity and social status. Medical advances in transplants and cosmetic surgery mean that the concept of a ‘natural body’ is no longer tenable and are further indications of how the body is socially shaped. Demographic changes also mean that there is now a much higher proportion of older people in western societies (see Chapter 5), which has drawn more attention to the physical changes arising from the ageing process and the consequences of living with an ageing body (Shilling 2003; Twigg 2006). As a result, over the past two decades, much sociological attention has turned to the previously neglected study of the body as both a natural phenomenon and a product of factors ‘beyond’ the individual within the social environment. The body now forms an important dimension of the sociological debate. This in turn has led to the development of the sub-discipline of the sociology of the body, which uses sociological perspectives to provide theoretical insights into key social aspects of the body (Williams 2003; Twigg 2006). These include: ■ the impact of environmental, social, political and cultural influences on the body; ■ the way the body is shaped by dominant discourses; ■ lived experiences of health and illness. The sociology of the body therefore adds academic rigour to the analysis of many issues about the social aspects of health addressed in this book, and will be used to add depth and understanding to the explorations of chronic illness and disability in particular. Theoretical underpinnings The discussion of academic disciplines in the first section makes reference to different theoretical perspectives. When social scientists talk about a theory they mean the set of ideas used to explain aspects of the social world in a systematic and consistent way. These explanations are also supported by evidence and extrapolate from this to develop understandings of social phenomena and predict future occurrences. The set of ideas within each theory are referred to as concepts (see Figure 1.2) which can be single words or a phrase. The world view of the proponent(s) of a theory influences their interpretation of the evidence, the nature of their explanation and the concepts they develop. The variation in viewpoints is reflected in the differing theoretical perspectives about our social world. In addition, the sets of Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. well as its social context. In addition, it provides a recognized and dynamic academic base from which to explore, interpret and analyse many social aspects of health. 17 social aspects of health.indb 17 17/12/2010 11:42 Chapter 1 Studying the social aspects of health concepts within each theory are distinctive. For instance, a key concept within Marxist theory is ‘capitalism’ whereas feminist theory uses the phrase ‘inequalities between the sexes’ as one of its main concepts. As many of these theoretical perspectives have both informed, and continue to inform, the study of the social aspects of health, it is therefore essential that the reader is familiar with the main theoretical perspectives. Outlines of the theoretical perspectives that will be used in this book, together with an indication as to which areas of the social aspects of health they will be applied, are set out below. Marxist theory The emphasis in this theory is on the larger, structural elements of society such as the social, economic, legal and political systems. These are known as the macro elements of social structure. However, Marxist theory places most emphasis on the economic structure, as it maintains that the way the economy of a society is run determines the social relationships in that society. More specifically, it argues that the organization of the ownership of the predominant means of production within an economy leads to specific patterns of class relationships which inevitably entail power differentials and lead to social inequalities. For example, when feudalism was the dominant means of production, there were lords and serfs whose relationships were based on unequal rights and obligations, some of which were established in law. According to Marxist theory, such social relationships only change when the economic relationships change within a society. Although Marx himself wrote about different historical epochs he concentrated on modern, western economies. He said that these are based on capitalism; within capitalist societies the means of production is profit-making and produces goods for sale using waged labour. There are those who privately own the means of production and those who have to sell their labour power to make a living. The former are called the bourgeoisie. They are the minority and their livelihood is based on the ownership of capital (hence they are also referred to as capitalists), and on producing and trading in commodities by employing waged or salaried labour. Those who have to sell their labour for wages are called the proletariat. They form the majority of the population in capitalist societies and they neither own capital nor do they have any choice about being workers. The bourgeoisie and the proletariat are the two main classes in capitalist societies. The relationship between them is unequal as the bourgeoisie exploit the proletariat in the pursuit of profit. This is described in the following extract from Marx’s work about how capitalists make a profit from the labour of their workers. In a certain period of time the worker will have performed as much labour as was presented by his weekly wages. Supposing that the weekly wage of a worker represents three workdays, then if the worker begins on Monday, he has by Wednesday evening replaced to the capitalist the full value of Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Figure 1.2 Theoretical approaches 18 social aspects of health.indb 18 17/12/2010 11:42 Chapter 1 Studying the social aspects of health Hence, capitalism produces social divisions based on the ownership and non-ownership of the means of production. According to Marx, another consequence of the exploitation of the proletariat by the bourgeoisie was that the former would experience increasing alienation. He predicted that this would lead to social conflict which would result in the eventual overthrow of capitalism and the emergence of socialism (Marx 1867; Giddens 2009). Marxist theory has been criticized on several counts. One is that it overemphasizes the economic determinants of social relationships and hence class is given primacy in any social analysis using this approach. In addition, Marx’s predictions about such social changes have not been realized and Marxist social analysis has lost some of its pertinence and popularity. Nonetheless, aspects of this theory are frequently referred to in explanations of health and illness. For instance, the sort of inequalities that arise within capitalism, as identified by Marx, have been used to help explain class inequalities in health. Therefore Marxist theory will be returned to in Chapter 3. As it addresses inequalities in power, it is also useful in analyses of experiences of health and illness and the medical profession, and will inform discussions in Sections 2 and 3 of this book. The emphasis in Marxist theory on the structure of society and the way that it constrains and shapes people means that it provides what is referred to as a structuralist view of society. Structural sociologists, conforming to structuralism, focus on how people’s social behaviour, values and attitudes are largely determined by the organization and structure of the society in which they live, and more particularly, the social groups to which they belong in their society. As there is coercion by one class and subordination of another within capitalist society, Marxist theory maintains that there is a fundamental conflict between the two classes. It has therefore been argued that it also offers a conflict theory of society. Conflict theorists argue that conflict is inherent in society and question the possibility of ever achieving social stability and equilibrium. This is because they see the unequal distribution of power and resources between groups in society as inevitably leading to some groups being more dominant than others. As a result, interests clash and there is conflict between dominant and subordinate social groups. The assumption in conflict theory that social order can only be maintained by the dominant social groups coercing the subordinate groups strengthens its assertion that consensus cannot exist in society, particularly as this coercion may involve physical force. However, the operation of informal and formal mechanisms of social control engineered by the dominant social groups is more likely to be used for such purposes in western societies (Dahrendorf 1959; Giddens 1984; Steel and Kidd 2001). Another conflict theory is feminism. This argues that gender conflict is intrinsic to social life and it is to this sociological theory that we now turn. Feminism Feminism is a body of thought and a social movement which sees the equality of the sexes as essential and therefore argues for this equality in all areas of life. It explains the inequalities that exist between the sexes, and links this to the way that women have been historically oppressed and excluded from economic power and politics, and have had restrictions placed on them by society. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. the wage paid. But does he then stop working? Not at all. The capitalist has bought his weeks’ labour and the worker must go on working also during the last three week days. This surplus labour of the worker, over and above the time necessary to replace his wages, is the source of surplus value, of profit, of the [capitalist’s] steadily growing increase in capital. (Marx 1867: 58) 19 social aspects of health.indb 19 17/12/2010 11:42 Chapter 1 Studying the social aspects of health Box 1.1 Well-known feminist theories Marxist feminism This feminist theory says capitalism is the cause of the unequal distribution of power between men and women. It focuses on women’s position within the family in capitalist societies and argues that although women play an important role in the production of capital, they are exploited both in the private domain of the home and family, and the public domain/sphere of paid work within the economy. In terms of the private domain, Marxist feminism sees women as slaves within the family who provide what is called ‘free labour’ which reproduces the workforce that capitalism requires at no cost. The word ‘reproduce’ is used in two senses here. One is in terms of the way that women literally ‘reproduce’ because they produce children who will be future workers. The other relates to the Marxist feminist argument that women also ‘reproduce’ the workforce because the caring work they undertake within the family enables their children and their husbands to function effectively as workers under capitalism. This caring work is not only unpaid but unnoticed and undervalued. In the public sphere, women are exploited in several ways. For instance, they are overrepresented in caring occupations and the aforementioned undervaluing of caring work is reflected in the occupational structure of capitalist societies. They are also viewed as a reserve army of labour to be used in the economy to increase the labour supply when required and therefore reduce wages. Thus, Marxist feminists conclude that within capitalism women are exploited as reproducers and producers. It is this emphasis on capitalism within Marxist feminism that has led to criticisms of its analyses for prioritizing capitalism over patriarchy and not attributing relevant significance to the latter (Barker 1997; Steel and Kidd 2001). Radical feminism Radical feminists emphasize that men, as opposed to the economic system, are the primary exploiters of women. For them, patriarchy is based on the fundamental biological differences Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. The impossibility of developing ‘a holistic feminist account that speaks for all women’(Ramazanoglu and Holland 2002: 5) has been a constant theme within feminism. Although there are indeed striking differences between feminists in their values and perspectives (as discussed below), a central theme running through them is that it is men who have oppressed and excluded women because our social system is based on patriarchy. As a result, it is assumed that men can and should dominate and have most of the power because they are superior and that women should be subordinate to them. Feminists argue that patriarchy and the power it gives to men results in men being in control of the key institutions that shape our society, such as the judiciary. Our patriarchal social system is also embedded in and reinforced by social institutions. Commonly cited examples of these are the family and the education system. With regards to the former, feminists point to the way that girls, unlike boys, are socialized within the family into thinking that their primary responsibilities are to the home and family. They blame the education system for the gender stereotyping in the careers that girls and boys are trained for and encouraged to pursue (Barker 1997). Therefore, the main thrust of feminist argument is that the inequalities between men and women are due to the way that patriarchy works in our society, as this means that female inequality and subordination to men is seen as ‘natural’. The most well-known feminist theories are Marxist, radical and liberal feminism. These are discussed in Box 1.1 below. 20 social aspects of health.indb 20 17/12/2010 11:42 Chapter 1 Studying the social aspects of health Liberal feminism In line with the thinking of liberalism – that individuals should be treated in accordance with their efforts as opposed to their birth or heredity – liberal feminists argue that men and women should have equal rights. Such gender equality should be achieved through the existing legal structures in society. Hence, rather than advocating a radical transformation of gender relationships, liberal feminists believe in campaigning to remove all social, political, economic and legal obstacles that prevent women having the same rights and opportunities as their male counterparts. While many liberal feminists maintain that there have been moves to greater equality between the sexes as a result of campaigning, the extent to which this has occurred in both the public and private spheres is much debated. Critics of liberal feminism also point to the evidence that although the gender pay gap is decreasing, women are still primarily responsible for the day-to-day running of the home (Sullivan 2000; Abbott 2006; National Statistics 2007; Gatrell 2008). The development of these different strands has led to feminism in general being accused of lacking internal coherence as a social theory. However, it has had substantial impacts both intellectually and as a social movement. It challenged earlier sociological theories because of the way they focused on a narrow range of topics and ignored gender. Indeed, feminism’s greatest contribution is probably its attack on the ‘malestream’ tradition of mainstream sociology which renders women invisible. Hence it not only forced an intellectual reconsideration of established thinking and theories but also stimulated research into gender issues nationally and internationally. As a social movement it has helped women to achieve greater economic, political, legal and social equality and still strives for improvements in women’s lives. In relation to the study of the social aspects of health specifically, it has drawn attention to many important, yet previously unrecognized, issues about women’s health. These include the social causes of women’s illness which were ignored because women were defined within medicine soley by their biology and reproductive capacity. By offering varying analyses, the broad tendencies within feminist theory enhance understanding and help to shape effective action aimed at addressing such issues (Barker 1997; Abbott et al. 2005). Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. between men and women and hence women’s oppression by men is inherent in patriarchal societies. Patriarchy is ‘transhistorical’ and ‘transcultural’ in that whatever the historical period or culture, men systematically dominate and shape society to meet their needs rather than the needs of both males and females. Such domination is both physical and sexual (Firestone 1979). According to radical feminists, women can achieve freedom by wresting control of their bodies and fertility from men. They also argue that new technology can help eliminate some of the obstacles to achieving this freedom. Criticisms of this feminist theory include its lack of recognition of the variations in the interpretation of biological differences between men and women across time and between cultures. For instance, during the First and Second World Wars, women’s biological inferiorities were overlooked in the need to fill gaps in the workforce created by the absence of men from traditional ‘masculine’ jobs (Oakley 1972, 1984). Another flaw in radical feminism that has been highlighted is that not all gender relationships are characterized by oppression and exploitation. Furthermore, despite all the changes in women’s position in society over the past 50 years, there is no evidence to suggest that a matriarchal society would be preferable. 21 social aspects of health.indb 21 17/12/2010 11:42 Chapter 1 Studying the social aspects of health The different types of feminism can be confusing when you first come across them. Read through them once again and complete the following table. This activity will help to consolidate your understanding. Some suggestions about what you could have included in each box can be found in the ‘Activity feedback’ chapter on page 223. FEMINIST THEORY CAUSE(S) OF INEQUALITIES BETWEEN MEN AND WOMEN SOLUTIONS CRITICISMS Marxist feminism Radical feminism Liberal feminism Functionalism In contrast to the preceding theories, functionalism focuses on those factors that bind society together to make it stable. This theory sees society as a biological organism (such as the body), made up of different integrated social structures which have to work together (as the different parts of the body do) in order for society to function properly and for social order to be maintained. These social structures comprise sub-systems and social institutions. Within these, individuals are allocated to social roles. Correct performance of social roles is essential for the maintenance of social stability. A central value system ensures that there are shared cultural and social expectations about the way each role should be carried out and the way others should respond. These social expectations are called role relationships, each of which carries with it a specific set of rights and obligations. For instance, in a classroom, a teacher has the right to control the class and is expected to teach the class effectively. The children in that classroom have a right to the education being provided and are expected to behave in a responsive manner. Social institutions themselves also have to perform specific functions that are necessary to maintain social order and for the continuation of social life. Using the family as an example, this social institution uses the process of socialization to ensure that the next generation continues to perform social roles. Returning to the analogy of the body, according to functionalism, malfunction occurs when individuals within their sub-systems and social institutions solely pursue their own interests and do not adhere to the central value system in fulfilling their roles and relationships. Such malfunction can cause damage across the whole social system in the same way that disease does when it affects a part of the human body. Similarly, if the malfunction is not addressed, society cannot operate effectively and loses its order and solidarity (Parsons 1964; Jones 1994). Functionalism presents an essentially ‘consensual’ representation of society; the consensus is based on an agreement to sustain society and shared norms and beliefs. When change occurs, a state Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Activity 1.2 22 social aspects of health.indb 22 17/12/2010 11:42 Chapter 1 Studying the social aspects of health Symbolic interactionism As indicated above, functionalism is concerned with how individual motivations and actions are in alignment with the central value system of society rather than an individual’s own aims, beliefs and consciousness. Symbolic interactionism puts forward a different view of the role of the individual in social life. This theory is interested in people as active social actors; it focuses on how they make and define their own reality through their perceptions and interpretations of the social world that arise from their interactions with each other. Furthermore, social roles and norms are learned through these interactions. Indeed, symbolic interactionism developed as a reaction against perspectives such as functionalism which presented individuals as passively responding in a puppet-like way to the social system. Another point of distinction between functionalism and symbolic interactionism is the views they adopt about the nature of the social world. We have seen how functionalism makes use of analogies associated with the natural world, such as the human body. This means that it sees the social world as objective and observable. In contrast, symbolic interactionism sees the social world as being made up of its individual participants motivated by human consciousness. Consequently, symbolic interactionism argues that the meaning of human action is not observable but is subjective and has to be interpreted by studying the meanings that people attach to their behaviour. Hence, this theoretical perspective focuses on micro elements of society which are the small-scale aspects of human behaviour such as the face-to-face interactions between individuals and between individuals and groups. Research adopting a symbolic interactionist approach begins with the individual and focuses on explaining the social world from the point of view of the subjective individual as a social actor. Criticisms of symbolic interactionism have centred around the way it ignores structural factors, does not place individuals and groups within a wider social context and offers depth at the expense of breadth. Despite these criticisms, this perspective has generated invaluable understandings of meanings and their fluidity. It has also produced many insights into the social aspects of health, and work carried out within a symbolic interactionist theoretical framework will be referred to in Section 2 of this book when discussing experiences of health and illness (Hochschild 1983; Cuff et al. 2006). Postmodernism The term postmodernism itself is broad and is used in a range of academic disciplines when describing the profound social changes that occurred at the end of the twentieth century in what Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. of equilibrium is restored through the establishment and acceptance of new consensual agreements. Some everyday activities can also have a latent consensual function in maintaining the system as a whole. For example, in addition to the nutritional function of food, this perspective would also point to the way it reinforces social groupings and cultural practices within a society (Lupton 1996). Therefore, functionalism is viewed as a consensus theory. Such theories use organic analogies and argue that society survives and remains stable because of the broad acceptance by the majority of its citizens of consensual beliefs. They also assert that the natural state of society is one of dynamic equilibrium which copes with change by restoring balance and harmony. However, functionalism has been criticized for assuming that all those within the sub-systems do actually share the same understandings about situations to such an extent. In addition, criticisms have been levied at its prescribed and static notions about social roles and the way that individuals passively carry out those roles. Nonetheless, this perspective has made significant contributions to the understanding of key areas of the social aspects of health, such as the experience of illness and healthcare systems. One of the most influential theorists within functionalism is Parsons, and we will be referring to his work when these issues are discussed in Chapters 6 and 11 respectively. 23 social aspects of health.indb 23 17/12/2010 11:42 Chapter 1 Studying the social aspects of health Our world is being remade. Mass production, the mass consumer, the big city, big brother state, the sprawling housing estate, and the nation state are in decline: flexibility, diversity, differentiation, and mobility, communication, decentralization and internationalization are in the ascendant. In the process our own identities, our sense of self, our own subjectivities are being transformed. We are in transition to a new era. (Hall 1988: 24) As this book will demonstrate, many existing sociological theories, such as Marxism and functionalism, have become unsustainable in their original form and have required adaptation because they are historically and culturally relative. Postmodernism is the most recent sociological theory and challenges the all-embracing nature and expressions of certainty about the social world of its theoretical predecessors. It searches for new ways of explaining our changed social world with its decline in absolutes and the collapse of meaning. In doing so, it emphasizes that we can never uncover the truth, be objective or have a theory about the social world. This is because social life is continually constructed and reconstructed through our everyday interpretations and actions, and therefore knowledge about the social world is constantly changing. Indeed, postmodernism argues that we are ‘agents’ who can make an increasing number of choices about how we shape our lives and identity, rather than having our behaviour and roles prescribed by the society in which we live. This focus on human subjects and human action has also led sociologists to direct their attentions to agency as opposed to structure. Postmodernism has several strands. One of these is social constructionism, which refers to how social reality is actively viewed or ‘constructed’ in a particular way by individuals and groups as a result of social relations and human agency rather than being ‘natural’ or biological in origin. Social constructions of different aspects of society or behaviour vary historically, socially and culturally. Thus, there is no obdurate reality because we make our own and social reality is essentially contestable (Giddens 1992; Cuff et al. 2006). Postmodernism has been accused of not being a unified theory and overemphasizing choice in its conceptualization of human beings as ‘agents’. Nonetheless, this theory has been credited with extending the boundaries of sociological enquiry and challenging analyses proffered across a range of theoretical bases. Using feminism as an example, postmodernism has questioned whether patriarchy is so pervasive throughout society and in women’s lives, and consequently has raised awareness of the variations in the experiences of womanhood. It has also contributed to the study of the social aspects of health. An example is the way it shows how medical knowledge is a product of those engaged in its practice in particular societies and historical periods. This has in turn highlighted the fluid and dynamic nature of medicine and the extent to which it lacks neutrality. Therefore, postmodernism has challenged the ‘truth’ of medical knowledge, and we will draw on this work throughout the book. Furthermore, many of the societal changes it refers to have been used in the exploration of new areas in the study of health. For instance, the growth in individualization and reflexivity that postmodernists assert are features of post-industrial society has been used in relation to lifestyles and risks to health (Giddens 1992). Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. sociologists refer to as the move from industrial to post-industrial society. These changes not only include the transformation of industrial organization but also of class structure, religious allegiances and political life. As a result, contemporary life is less certain, identities are more fluid and society has become more diverse, pluralistic and fragmented. Stuart Hall, a leading sociologist, summarized this phenomenon in the following quotation from an article written in the 1980s: 24 social aspects of health.indb 24 17/12/2010 11:42 Chapter 1 Studying the social aspects of health Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Activity 1.3 The following concepts are all referred to in the discussions of the theoretical perspectives above. Using the table below, place them under the correct perspective. When you have finished, compare them with the list of key concepts within each perspective that are set out in the answer to this activity in the ‘Activity feedback’ chapter on page 224. Concepts Active social actors Agency Alienation Analysis should begin with the individual Bourgeoisie Capitalism Central value system Consensual representation of society Cultural and social expectations Women’s subordination to men is ‘natural’ Proletariat Economy of a society Education system Equality of the sexes Equilibrium Exploitation Human consciousness Impossibility of uncovering the truth Individuals make their own reality Knowledge about the social world is constantly changing Society is like a biological organism Lack of objectivity Means of production Oppression and exclusion of women Patriarchy Post-industrial society Social construction Social order Social roles Socialization Understand and interpret human action Sub-systems Focus on the individual rather than society Marxist theory Feminism Functionalism Symbolic interactionism Postmodernism 25 social aspects of health.indb 25 17/12/2010 11:42 Chapter 1 Studying the social aspects of health An important issue in the study of the social aspects of health is the use of data about variations in health in our society. Differences in health between various groups in society are usually measured in terms of morbidity and mortality rates. The former refer to the numbers and patterns of physical and mental illnesses within a designated group at a given time, while the latter refer to numbers and causes of deaths within a designated group at a given time. Both are expressed as a rate per 100,000 of the population and reductions in either or both are equated with improved health. Mortality rates are also used to calculate the most widely used indicator of population health in general – life expectancy at birth. This provides an estimate of the average number of years a newborn baby can expect to live if patterns of mortality at the time of their birth were to stay the same throughout their life. The measurement of health is controversial. One area of controversy has been the indicators used, which have been accused of lacking objectivity. Taking morbidity rates first, these are compiled using self-reported health, and yet such self-reports have been found to consistently underestimate disease which is clinically identified and people inevitability define their health in different ways. Service utilization rates (such as visits to GPs and number of inpatient hospital stays) have also been used as indicators of morbidity but these can be inaccurate because the extent of a patient’s use of health services can be influenced by a variety of individual and social factors. These factors include changes in policies on service provision and length of utilization – for instance, policy initiatives over the past two decades have resulted in considerable increases in day surgery and reductions in the length of inpatient hospital stays. With reference to mortality rates, a key indicator used is occupation. As we shall see in Chapter 3, the way occupations are classified is regularly revised and also varies between studies. Therefore, comparisons of findings can be questionable. Furthermore, important information has been omitted because married women have typically been classified according to their husband’s occupation (Bowling 2005; Steel et al. 2008; Graham 2009). More generally, concern has been expressed about the way that the social processes involved in measuring health introduce varying degrees of bias and subjectivity. Hence, refinements to the methods and models used for measuring health differences are continually being made. Although it is important to be aware of the problems associated with measuring morbidity and mortality rates, it is equally important to realize the full potential of such data in increasing knowledge about the social aspects of health. The patterns that emerge from careful analyses of morbidity and mortality data have been invaluable in showing how health and illness are produced by social relationships and inequalities, as opposed to random biological events. These insights are often further enhanced by the use of data from other indicators, such as smoking rates, obesity levels and data about specific illnesses. Therefore, in order to develop your understanding of the social aspects of health as much as possible, morbidity and mortality figures will feature in several chapters of this book, and, where necessary, they will be used in conjunction with other health indicators. Influences on health During the course of the discussions in this book, reference will also be made to many of the influences on health. Those that are most frequently discussed in the study of the social aspects of health, plus a summary of their specific impacts on health, are set out below. The reader will be referred back to this list as appropriate. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.156.86] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Health data 26 social aspects of health.indb 26 17/12/2010 11:42 Chapter 1 Studying the social aspects of h…

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