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The Social Patterning of Health and Illness

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1 The Social Patterning of Health and Illness
Week 6.

2 Overview The social patterning of health and illness.
Problems with measuring data on health, illness and disease. Researching health and illness Inequalities in health, mental illness. Gender, ethnicity, age, social class and health. The ‘racialization’ and ‘feminization’ of mental and physiological illness.

3 Problems in researching Health and Illness
relativity of health concepts Concepts and understandings vary enormously from culture to culture. Eg. depression recognized in some cultures and not others Dubos and Pines ‘the meaning of health also varies widely according to all kinds of statuses’.

4 'Good health may mean different things to an athlete and to a road sweeper, to a tree surgeon or an insurance broker, their lifestyles necessitate very different degrees of physical activity, their food requirements and environmental stresses vary, they may have very different understandings and experiences of their own physiology, they may have different levels of access to information about health and disease’.

5 Problems in researching Health and Illness 2
Increased sensitivity to health issues for those who read about it alot Those who do not may over-estimate their own levels of health self assessment questionnaires a poor indicator of actual levels of health due to these wide variations in awareness and understanding. research that uses interview techniques may be problematic for the same reasons. Problems in finding objective measurements of levels of health and illness. health records compiled by doctors and hospitals??? Some suggest patient diagnosis is often distorted by all kinds of prejudices that the doctor or health care professional may not even realize he or she has.

6 Some Problems With Statistics. 1
Under-reporting and Over-reporting of illness. What constitutes illness varies from culture to culture. Depression not recognised in some cultures. Some illnesses not deemed serious enough for medical intervention. Traditional or ‘folk medicine’ or self medication often used first.

7 Certain groups less willing or able to visit the doctor. Why?
Stigmatisation of certain kinds illness. Cultural Taboos. Some illnesses dealt with in the family. Gender issues. Racism and discrimination. Marginal Groups i.e. Gypsies and Travellers Problems with access to services. Language problems.

8 Certain Groups more willing to visit the doctor.
Structural factors. Cultural factors.

9 Some Problems With Statistics. 2
Misdiagnosis and misunderstanding. Can be due to a number of Factors. Subjectivity and self assessment. Subjectivity and diagnosis. Subjectivity and comparative understandings. Time constraints. Patient reporting Influence of gender, social class and ethnicity. Cultural ‘misunderstandings’ and ‘cultural deficit’ models. Cultural Stereotyping- particularly with regard to mental illness. Negative stereotyping, cultural misunderstanding and Marginal Groups i.e. Gypsies and Travellers.

10 Some Problems With Statistics. 3
Problems with how the statistics are compiled. Sample group. Ensuring demographic and geographic representation. Low participation of practices in inner cities Problems with categories- particularly class and ethnicity. Generalisability. Age, gender, ethnicity and social class.

11 Illsley and Le Grand Illsley and Le Grand- Criticised studies based on Under 65’s- proportion of deaths in this age range has changed significantly in last 70 years. Many deaths now take place over age of 65, findings/ results from under 65’s not generalisable to older age groups.

12 Objections to this:- 1. Although deaths under 65 are a minority, they are usually premature deaths, premature death an indicator of disadvantage as it is often preventable. 2. New evidence on health of people over 65 tends to confirm patterns of inequality found among younger people. General problems with ‘Official Statistics’- How? Where? When? Who By? Who For? For What Purpose? No Universalisable Concepts. Problems with comparing studies. a number of problems here, some of them relating to interpretation and detection and the recording of H & I and others relating to access and participation.

13 Problems with disease labels 1
Disease labels not created in a vacuum (Foucault, Turner etc). The interpretation of disease and Disease labels arise within a particular socio-political context different contexts produce different conceptions of causes and what counts as normal and pathological states. Foucault interested in the way that certain kinds of behaviours came to be defined as 'normal' while others came to be defined as Medical struggles around the individual body

14 Problems with disease labels 2
bio-politics of populations in modern societies. Medical knowledge not an objective science for Foucault direct relationship between the discourse of scientific knowledge and the exercise of professional power. Linked to social control

15 Problems with disease labels 3
Link between between knowledge and exercise of power disease entities the product of mediacl discourses Brian Turner uses example of anorexia- depending on the dominant discourse within a society in which anorexic conditions are present it could be viewed as a behavioural disorder of the hormonal system of young women, or a spiritual quest foe perfection etc job of sociology to determine how these socio-historical processes have given rise to certain sets or ideas and perceptions that have been taken to count as knowledge.

16 The Social patterning of Health and Illness Background
Mortality and Morbidity rates vary significantly between societies Also variations between groups within societies. emphasis is usually on social class, gender and ethnicity. also enormous variations between societies

17 Health and Social Class.
Key literature- The Black report (1980) Updated and Republished (1992). The Health divide (1988 37 recomendations ranging from improving information, research and organization so that more effective healthcare planning could be instituted, redressing the balance of health care system so that greater emphasis would be palced on prevention, primary care and community health most importantly recommended improving the material conditions of life for disadvantaged groups, conclusions of the two reports essentially the same.

18 The Black report (1980) Summary
1. There remained a marked class gradient in health. 2. That such class differences were more marked in Britain than in many other countries. 3. That in certain respects these class differences were increasing

19 The Black report (1980) cont
gap between the classes had continued to widen. words high mortality rates positively correlated with poverty. lower occupational groups more vulnerable to almost all the killer diseases Peter Townsend ‘mortality rates for working class males were higher in 65 out of 78 disease categories and for working class women in 62 out of 82’. Malignant melanoma rates higher among the higher occupational groups. For women in higher social classes rates of cancer of the brain and the breast were also greater. Accidental death by violence, injury and accident higher among the lower social classes. In 1980's this gap continued to widen as death rates declined faster among the higher occupational groups than the lower

20 The Black report (1980) cont
In 1980's this gap continued to widen as death rates declined faster among the higher occupational groups than the lower lower socio-economic groups also experience more sickness and ill health throughout the life cycle. Poor children more likely to be born with low birth weight their mothers are more likely to suffer complications in pregnancy or childbirth. Poor children more likely to suffer from a range of health problems including obesity, cerebral Palsy, hearing and visual impairment, accidents and higher rates of tooth decay. differences between socio-economic groups become increasingly marked in adulthood Working class people more likely to deem themselves to be in poor health in self-assessment exercises Illness also gendered

21 Gender and Health. Background
Throughout entire industrial world men live shorter lives Men more likely to die at any given age than women of the same age. BUT females are more likely to experience high morbidity rates women are far more likely to visit the doctor than men men generally underepresented in health statistics

22 Gender and Mortality. over the last 100 years, in all contemporary advanced industrial societies, life expectancy has increased for both men and women but higher for women. (1994) average female life expectancy was approximately 78 years compared to 72 years for men. Major causes of death among British men heart disease, lung cancer, bronchitis, accidents and other violent deaths For women cancers of the breast cervix and uterus are major causes of mortality. coronary heart disease now a major cause of female deaths

23 Gender and Morbidity. Women more likely to report both physical and psychological problems to their GP. higher rates of chronic disease such as strokes, rheumatoid arthritis, diabetes and varicose veins for women women also constitute two thirds of those with a disability. Women more likely to have been hospitalized women constitute the majority of those suffering from neurosis, psychosis, dementia and depressive disorders. women also more likely to suffer from Iatrogenic disease

24 Health and Ethnicity. Data seriously inadequate.
Before the 1991 census researchers had to rely on Birth and death certificates to identify ethnicity. comparing the mortality rates of ethnic minorities born in the UK before 1991 is extremely problematic. still comparatively little known about the health and morbidity of British born ethnic minorities. data is extremely limited and must be viewed cautiously.

25 Ethnicity, mortality and Morbidity.
Despite the methodological difficulties a number of studies have provided generally consistent data on the causes of mortality and morbidity among minority ethnic populations. Provisional findings suggest the following. Groups from India, Pakistan and Bangladesh - more likely than white population to die from heart disease. Groups from India, Pakistan and Bangladesh, Africa and the Caribbean - more likely than white population to suffer from a stroke (esp Africans and Afro-Caribbean's). Africans and Afro-Caribbean's suffer from very high rates of hypertension, liver cancer, TB, diabetes and maternal mortality. Afro-Caribbean's and 'Asians' (problematic category) suffer disproportionately from accidental and violent death, and poisonings. Mortality rates for obstructive lung infections such as bronchitis and many types of cancer esp. lung cancer lower among Afro-Caribbean's and 'Asians'.

26 Ethnicity, mortality and Morbidity. 2
All ethnic minorities have higher rates of still births, perinatal moralities (death within 1 week), and neo-natal mortality (within 1 month). Only Afro-Caribbean's and Pakistanis continue to show 'excess mortality throughout infancy' (Whitehead 1992). Children from Asian families have higher rates of rickets. Afro-carribeans more likely to be admitted to mental health units, men more so than women and more likely to be sectioned. Once there they are more likely to receive harsh treatment e.g.- electro-shock therapy, anti psychotics.

27 Explanations. Poverty Stress of migration and racism
Anomic explanations Cultural deficit models

28 Gypsies, Travellers and Health.
not all Travellers are recognized in the eyes of the law as an ethnic nomadic lifestyle compounds and intensifies the problems faced by other minority groups. Britains nomadic population is extremely diverse. Different problems for different groups considerable methodological problems associated with researching Travellers health an invisible minority Gypsy and Traveller health research has usually been conducted separately to that of other minority groups less in the way of funding devoted to research for this group Traveller health needs are very different to those of other disadvantaged groups

29 Research Problems. Researcher Access. Trust. Geographical isolation.
Mobility. Gypsies rejection of officialdom. Truth. Negative stereotyping and cultural insensitivity.

30 Nomadism, Mortality and Morbidity.
Poor dental health. Increased susceptability to tetanus, polio, TB, whooping cough M, M, R, Diptheria. Low birth weight. High rates of infant mortality, miscarriage Spread of infectious diseases, respirartory infections, impetogo, other skin infections, lice, scabies, threadworm, gastroenteritis, (Link to environment and large families living in close proximity). High rates of diabetes (Gypsies and trad Travellers) High rates of alcohol related illness. Limb deformity form fractures (low rates of follow up treatment). High rates of cardiovascular disease particularly among men. High rates of mortality among males as a result of Drug use and overdose ( 'New-Age' Travellers) High rates of drug induced mental illness ( 'New-Age' Travellers)

31 Explanations. 1 Cultural erosion (Gypsies and trad Travellers)
Dangerous environments. Poor uptake of preventative care, (smear tests, breast screening, health checks, child developmental screening, dental services, health education, Poor uptake of immunisations. Links to Poor access to health services (Temporary residents). Poor ante-natal and post-natal care. Lowuse of contraception (Esp Gypsies and trad Travellers) Short birth intervals (Gypsies and trad Travellers)

32 Explanations. 2 Poverty. Illiteracy (excepting New-Age Travellers).
Discrimination. Illness often dealt with within group (Folk remedies) Suspicion of conventional medicine (esp 'New-Age' travellers). Poor sanitation. Large families living in close proximity Low uptake of immunisation. Poor hygiene re dogs and food prep. Drug use ( 'New-Age' travellers)

33 Explaining Health Inequalities .1
1 Social constructionist approaches. take issue with the nature of the data and evidence upon which studies of health inequalities are based. Labelling theorists ‘disease labels are not always applied in the same way to all groups in society’. doctors apply specific disease labels more readily to some groups than others. Variations in morbidity rates a product of differential labelling

34 Explaining Health Inequalities . 2
2. Natural and social selection approaches. evidence essentially valid. often used to explain the health differentials among gender and ethnic groups, differences rest upon supposed biological or physiological differences. ill-health a major cause of low social position rather than a consequence of it. social mobility can be explained by reference to good health. Based on false suppositions about ‘natural’ difference. Surprisingly feminist accounts of the ‘natural’ body have been influenced by selectionist approaches.

35 Explaining Health Inequalities 3
3. Materialist-Struturalist approaches. rates of morbidity and mortality linked to individual or group’s location in the social structure This approach accused of being overly deterministic fails to take into account the meanings of the social actors themselves fails to acknowledge that health and illness labels are negotiated on an ongoing basis.

36 Explaining Health Inequalities 4
4. Cultural- behavioural approaches. differentials in health status linked to individual or group norms, values, attitudes, knowledge and behaviours. cultural deficit models deficit in knowledge or inappropraite behaviours or cultural practices are said to be the cause of unequal patterns of ill health. Eg high incidence of rickets, caused by vitamin D deficiency, among some Asian cultures is a result of cultural norms and values which dictate that ‘Asian’ women must cover their bodies in public (the body produces vitamin D upon exposure to sunlight).

37 Global Inequalities Life expectancy at global level, continues to improve – UK insurers just had to make new calculations In Africa average age of death around early 40s – same level as UK was at in 1900 Russian males around 59 years of age BUT outliers pull figures down WHO report details the global gap Many health issues the result of undernutrition among the poor and overnutrition amongst the wealthy

38 The AIDS Pandemic AIDS now fourth biggest cause of death
70% of the 40 million with HIV/AIDS concentrated in Africa Life expectancy at birth in sub-Saharan Africa is currently estimated at 47 years without AIDS it would be around 62 treatment not available to those who suffer most

39 Environment. Poverty and Health
In both Africa and Asia, unsafe water, sanitation and hygiene, iron deficiency and indoor smoke from solid fuels 10 leading causes of disease. All much more common in poor countries Link back to Gypsies and health 1.7 million deaths a year are attributed to unsafe water, sanitation and hygiene mainly through infectious diarrhoea. Nine of ten such deaths among children Many of diseases suffered by those in poverty strongly related to patterns of living, and particularly to consumption – too much or too little

40 Disease in the West Overweight and obesity are important determinants of health Increases in blood pressure Unfavourable cholesterol levels Increased resistance to insulin Raises the risk of coronary heart disease, stroke, diabetes, and many forms of cancer WHO say killing about 220,000 people in the US and Canada alone, and 320,000 in 20 countries of Western Europe Tobacco – nearly 5 million attributable deaths in 2000, mostly in West Alcohol – worldwide 1.8 million deaths, 4% of global disease burden, much of this in the West (growing) Physical inactivity causes about 15% of come cancers, heart disease an diabetes lack of fruit and vegetables they say responsible for 3 million death globalization of Western diseases of affluence In developing those countries that are more urbanized see ‘Western diseases’

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