1.

Introduction
• In the 19th century death form infectious disease were widespread.
However, today thanks to the improvement of health and standard
of living, such conditions is improved.
• Infectious diseases are being controlled and life expectancy
increases although disparities prevail among developed and
developing countries. However, HIV/AIDS is striking the world; and
toxic wastes are creating illness and death today.
• Communicable diseases are not controlled very well in developing
countries. Health care services are not well expanded. An access to
health service is also out of the pocket of the poor in third world
countries.
• Poor health services, poor sanitation, poor access to health services,
high infant and maternal mortality, low life expectancy, etc. are the
major problems of developing countries even today.
• Medical sociology originated to contribute in improvement in human health.
Medical sociology involves the sociological analysis of medical organizations
and institutions: the production of knowledge and selection of methods, the
actions and interactions of healthcare professionals, and the social or cultural
(rather than clinical or bodily) effects.
• The field commonly interacts with the sociology of knowledge,
science and technology studies, and social epistemology.
• Medical sociologists are also interested in the qualitative experiences of
patients, often working at the boundaries of public health, social work,
demography and gerontology to explore phenomena at the intersection of the
social and clinical sciences.
• Health disparities commonly relate to typical categories such as class and race
. Objective sociological research findings quickly become a normative and
political issue.
• Early work in medical sociology was conducted by Lawrence J. Henderson
whose theoretical interests in the work of Vilifredo Pareto inspired
Talcott Parsons interests in social systems theory.
• Parsons is one of the founding fathers of medical sociology, and applied
social role theory to interactional relations between sick people and others.
• Key contributors to medical sociology since the 1950s include Howard Becker,
Mike Bury, Peter Conrad, Jack Douglas, David Silverman, Phil Strong, Bernice
Pescosolido, Carl May, Jospeh W. Schnieder, Anne Rogers, Anselm Strauss,
Renee Fox, Joseph W. Schneider, and Thomas Szasz
The concept of medical sociology, Health and Medicine
Medical Sociology
• In ancient times, health and illness were interpreted in cosmological and
anthropological perspectives. Medicine was dominated by magical and
religious beliefs. For long time, health care was considered as the
responsibility of individuals and their families.
• Medical sociology is an old conception but relatively young as a field of
endeavor.
• Medical sociology is the study of individual and group behaviors with respect
to health and illness.
• Medical sociology is concerned with individual and group responses directed
toward assessing well-being, maintaining health, acting upon illness (whether
real or perceived), interacting with health care systems, and maximizing
health in the face of physiologic or functional derangement.
• The main focus area of medical sociology is the study of health, health
behavior and medical institutions.
• Medical sociology is the study of individual and group behaviors with respect
to health and illness. It is the application of sociological theories and methods
to questions of health, illness, medicine and healing.
• Medical sociology conducts research on issues of health and healing and
applied research to improve health care systems.
• Medical sociologists do not know the cause of sickness and the process of
healing. Medical sociologists contribute to the growth of human knowledge in
these important areas.
• The health problems facing people in all parts of the world are overwhelming
and complex, there is a good evidence that sociologists can contribute to the
design and implementation of programs to alleviate these problems.
• The main focuses of medical sociology are medical professionals and their
behaviors, and human behavioral responses to health and medicine.
• It is concerned with individual and group responses aimed at assessing
wellbeing, maintain health, acting up in real or perceived illness,
interacting with care systems and maximizing health in the face of
physiologic or functional disagreement.
• It also analyses the impacts of social and psychological condition resulting
from our environment
 1.2 Health
• The notion of Health is difficult to define like the concept of culture. But the most
widely quoted definition is the definition offered by the world health organization .
• WHO defined health as “a state of complete physical, mental and social wellbeing .
• This definition indicated that health has many dimensions: Physical, mental, social,
psychological, spiritual, emotional, cultural, economic and political. This definition is
modified to include the ability to lead “a socially and economically productive life”.
• In the above definition, what is wellbeing is a controversial concept. It is different from
society to society. What is wellbeing in one society may be quite different in another
society.
• For instance, the ideal lean figured body may signal health in the west but may be
quite sickness and malnutrition in sub-Saharan Africa. Any conceptualization of health
therefore depend on understanding of how do called normal states of wellbeing are
constructed within particular social, cultural and historical contexts.
Sociologists, of course, assess people’s health by how well they are able to function
in their daily lives and adapt to a changing environment. Thus, it has different
meanings for peoples of different occupations and cultures.
New philosophy of Health
Recently, new philosophies of health have been acquired. These are
Health is a fundamental human right,
Health is the essence of preclusive life and not the result of over increasing
expenditure on medical care,
Health is intersectional,
Health is an integral part of development,
Health is central to the concept of quality of life,
Health involves individuals, state and international responsibility,
Health and its maintenance is major social investment, and
Health is world-wide social good.
 Dimensions of Health
Health is multidimensional. The definition given above by WHO indicates that
health has physical, mental and social dimensions. Health has also spiritual,
emotional, political, and so on aspects.
1. Physical Dimension
• This is the ability of human body structure to function properly.
• Physical dimension purely refers to the perfect functioning of the body
externally as well as internally.
• Externally having good physique, good appearance, good texture and
complexion, attractive features, well structure and strong body parts and limbs,
well groomed posture, graceful carriage and efficient movement are indicators
of physical health.
• Internally to say healthy, all systems of human body i.e. cells, tissues, organs
and systems functioning at the optimum level.
A person who enjoys good physical health is one who:
i) is energetic
ii) has good posture
iii) weighs normal for age and height
iv) has all body organs functioning normally
v) has a clear and clean skin
vi) has bright eyes
vii) has good textured and shining hair
viii) has a clean breath
ix) has a good appetite
x) gets sound sleep
2. Mental Dimension
• Mental dimension deals with ability to process information and act properly.
• A person is mentally healthy if he or she is relaxed and free from any worries.
Mental health is not merely absence from mental illness.
• Mental health is balanced development of an individual’s personality and
emotional attitudes which enable him to live harmoniously with his fellow
beings. It is influenced by both biological and social factors.
• A good mental health implies that an individual has adjusted satisfactorily
to his environment, home, work place, and other people of the society, so
that he is realizing the maximum amount of happiness from living.
Mental health implies:
i) control on emotions
ii) sensitive to the needs of others
iii) confidence in one’s own abilities
iv) freedom from unnecessary tensions, anxieties and worries
 3. Social Dimension
• The social dimension of health focuses on the ability to interact with other individuals.
• A person is socially healthy if he or she can move in the society confidently with others.
• Social health is the ability to get along with one self and with others, to be independent but at the same
time to realize how dependent one is on others.
• Social health is concerned with helping an individual in making personal adjustment, group adjustment
and adjustment as a member of society.
We are talking here about social well-being.
• Social well-being implies harmony and integration within the individual, between each individual and
other member of his or her society, and between individual and the world in which he/she lives.
• It has been defined as the quantity and quality of individual’s interpersonal ties and the extent of
involvement with the community.
• The social dimension of health generally includes the level of social skill one possesses, social
functioning, and the ability to see oneself as a member of the larger society.
A person with good social health:
i) gets along well with people around
ii) has pleasant manners
iii) helps others
IV) fulfills responsibility towards others
 4. Spiritual Dimension
• It is refers to that part of individual which reaches out and strive for meaning
and purpose of life.
• It is intangible, which means it cannot be seen, or touched, we can only feel it.
This achievement is possible if only an individual has already reached physical,
mental and social dimension of health.
5. Emotional Dimension
• Emotional health deals with the ability to cope, adjust, and adapt to the social
environment.
• Emotions are the feelings which have great role in our life and lead to the
modification of attitude, conducive to personal adjustment and wellbeing.
• The environment we create by our behavior, our attitude, and our actions is
the emotional environment and it greatly influences the personality of an
individual.
• Emotion is an essential element in the adjusted nature of the life process.
 6. Vocational Dimension
• Vocational dimension is the sub-domain of physical, mental and social health.
Livelihood is very serious problem being faced by an individual.
• Vocational health emphasizes upon the problem of livelihood and ensures the
fulfillment of the economic needs of an individual.
• Vocational satisfaction provides him social efficiency, social status, social prestige,
emotional stability and mental relaxation.
• Vocationally satisfied individuals also contribute to the increase in production
and productivity and national wealth.
7. Educational Dimension
• Education brings changes in one’s behavior and attitude enabling him to understand
his responsibility to the society and to the nation.
• Educational Dimension of health i.e. health education has heavy responsibility to
discharge.
• Health education creates awareness regarding health rules, promotes health, builds
up health environment, and shows the path to follow toward the healthful living.
 8. Nutrition Dimension
• Good nutrition is a basic component of health. It is of prime importance in the
attainment of normal growth and development, and in the maintenance of health
throughout life.
• There is a growing realization that adequate nutrition is a necessary step in the
improving the quality of life.
• Malnutrition and under nutrition as an obstacle to social, and economic
development.
9. Environmental Dimension
• The internal environment of man himself (an individual’s internal structure) and
the external environment which surround him (habitat) reflect the health status
of an individual, the society and nation.
• Sanitation is one of the aspects of environmental health.
• It is the quality of living that is expressed in clean home, clean neighborhood and
clean community. Being a way of life, it must come from within the people.
 10. Curative and Preventive Dimension
• This dimension deals with the study and application of curative medicine
and preventive measures for the preservation of health of an individual.
• The Primary objective of curative medicine is the removal of disease.
• Over the years curative medicine has accumulated a vast body of scientific
knowledge, technical skills, and machinery highly organized, not merely to
treat disease, but to preserve life itself as per as it could be possible.
• The main objective of preventive medicine is prevention of diseases,
promotion of health, as it is applied to all healthy people.
• Modern preventive medicine can be defined as “the art and science of
health promotion, disease prevention, disability limitation and
rehabilitation.
 1.3 Medicine
• The word medicine is derived from the Latin word medicina, meaning the art of healing. Thus,
medicine is the art and science of healing. It encompasses a range of health care practices
evolved to maintain and restore health by the prevention and treatment of illness.
• Contemporary medicine applies health science, biomedical research, and medical technology to
diagnose and treat injury and disease, typically through medication, surgery, or some other form
of therapy.
• Though medical technology and clinical expertise are pivotal to contemporary medicine,
successful face-to-face relief of actual suffering continues to require the application of ordinary
human feeling and compassion, known in English as bedside manner.
• For medical sociologists and from sociological point of view, medicine is a social institution
concerned with combating diseases and improving health.
• Through most of human history, health care was the responsibility of individuals and their
families.
• Medicine emerged as a social institution only as societies become more productive, assigning
their members formal, specialized roles.
• As a society industrializes, health care has become the responsibility of specially schooled and
legally licensed healers from anesthesiologists to x-ray technicians.
 1.4 Social Epidemiology
• Social epidemiology is the study of how health and diseases are distributed
throughout a society’s population. Just as early social epidemiologists
examined the origin and spread of epidemic diseases, researchers today find
links between health and physical and social environment. Such analysis rests
on comparing the health of different categories of people, social class, age,
sex, etc.
1.5 Sociology in medicine and Sociology of Medicine
• Sociology in medicine is the label given to the collaborative work between sociologists and medical
or health personnel within medical institutions or health care organizations.
• This distinction represents the applied work of medical sociologists in the pure versus applied
dichotomy of the social sciences.
• In its most extreme form, sociology in medicine encompasses sociological work aimed at the provision
of technical skills and problem solving for the medical community while neglecting contributions to the
parent discipline.
• Medical sociology, like its parent discipline, experienced dual roles early in its institutionalization.
• The distinction between applied and pure work in medical sociology arose in conjunction with the
desire for a communication network that would identify the activities and affiliations of medical
sociologists in the United States.
• Sociology in medicine and sociology of medicine were the names designated for applied and pure
work, respectively, by Robert Straus in 1957.
• Sociology in medicine represents the thrust toward reform, advocacy, and application, with which
medical sociologists responded to the call for inclusion of clinical research in the social components of
health and illness.
• During the 1950s and 1960s, the roles of the social sciences in health care organizations experienced
significant increases due to expansion of medical schools, and so on.
According to Robert Straus, sociology in medicine may be described as the
application of sociological concepts, knowledge and techniques in efforts to
clarify medical and social psychological problems in which the medical
profession and its allied workers are interested.
 In this instance, Sociological knowledge represents medical knowledge in order
to find solutions to medical problems.
Sociology in medicine has been concerned with two distinct but interrelated
topics. These are:
a) Ecology and Etiology of Disease: This deals with the incidence and prevalence
of illness in relation to the location of individuals in the society.
b) Variations in attitude and behavior regarding health and illness: here variation
in response to and behavior regarding problems of health and illness, public
information about illness, definition of who is ill and who is not, conceptions
among different part of the population as to what their health needs are, and
their differential utilization of various kinds of medical facilities.
Sociology of medicine, on the other hand, raises questions about medical workers,
their institutions, and organizations, and their relations with others in their orbit of
activity, in an effort to clarify what are essential sociological questions. In this
instance, application of a sociological perspective to the medical world parallels the
sociological examination of other areas of activity in our society.
Sociology of medicine deals with the following topics:
a. The recruitment of physicians: The demand for physician service has been
increased than ever before. What is/are the criterion/criteria to select students
for physician education? How physicians are selected for employment? These and
others are the concern of sociology of medicine.
b. The training of physicians: Pressure to increase the number of doctors and to
modify the existing pattern of recruitment come, by large, from the outside.
However, pressure to alter the current patterns of training seems to originate
among physician themselves. This focuses on the three aspects of medical
education: reducing length of training time, the new settings in which medical
education can and probably will take place and changes in the content of training.
 Cont’d

Sociologists directly contribute to training of medical students in one of the

following two ways:
By helping educators from various departments in the medical school
introduce sociological knowledge and perspective into the courses taught in
these departments, and
By teaching sociological courses that have been tailored to the need of medical
students.
c. Relations of physicians to others in Role-set
The term ‘other’ here used to refer to patients, family, colleagues, and
collaborators.
d. Medical organization- The case of hospitals: Sociology of medicine
investigates the organization of medical organizations.
e. Development of Community health
Basic Approaches to medical sociology
Health, sickness and healing are perceived differently by professional groups like
bio-medical scientists, social scientists, health administrators, ecologists, etc.
1. Bio-medical Approach
• The bio-medical concept is based on the ‘germ theory of diseases causation.’
• According to this model, the medical profession viewed the human body as the
machine and the disease as a result of the breakdown of machine.
• Here the doctor’s role is to repair the machine.
• This approach associates illness with biological change.
2. Ecological Approach
The narrow view of bio-medical concept gave rise to other approaches. Ecologists
viewed health as a dynamic equilibrium between man and his environment.
According to them, disease is maladjustment of the human organism to the
environment.
Cont’d
The ecological approach has three major premises:
i. The interdependent interactions of plants, animals, and natural resources comprise an
ecosystem with characteristics that transcend its component parts.
ii. The common goal of species within an ecosystem is homeostasis a balance between
environmental degradation and the survival of living populations. In this homeostatic
system, infections disease agents (pathogens) and their human hosts are understood to
exist in a dynamic adaptive tension that strives toward a relatively stable balance between
pathogens and human responses.
iii. Modern human adaptations include cultural and technological innovations that can
dramatically alter the homeostatic relationship between host and disease, occasionally
creating severe ecological imbalances. In some cases, these imbalances may benefit
humans in the short term, decreasing the prevalence of a particular disease in a
population and improving human health. In other cases, homeostatic imbalances favor
disease agents, providing opportunity for diseases to reach epidemic proportions and
dramatically increase human morbidity and mortality.
According to ecological approach, human ecological and cultural adoptions determine not only
the occurrence of diseases but also the availability of food and population explosion.
 3. Psychological Approach
• The development in social and behavioral sciences reveal that health is
determined by social, psychological, cultural, economic and political factors of
people concerned.
• These factors must be considered in defining and measuring health and in
treating health problems.
4. Holistic Approach
• The holistic approach is evolved from all the above approaches.
• The holistic approach understands the strength of social, economic, political and
environmental influences on health.
• It is also concerned with the well-being of the whole persons in the context of his
environment.
• This holistic approach views that all sectors of society have an effect on health.
 Importance of Sociology to Health
•

Health includes social components. Most illnesses have social causes and social consequences. By
ignoring the social dimension of health, it is impossible to manage illness effectively. This is because
the hospital environment, culture, the attitude of the group towards illness, social and economic
status, etc. affects the delivery of health service and treatment of the patient.
a) Emotional level: Patients must be given the opportunity to express their emotion. This reduces
their emotional burden that creates conducive environment for effective therapeutic
intervention.
b) Cultural level: patients admitted for the medical examination, surgery, etc. may not be able to
adjust with hospital environment because of the limitation placed by cultural environment. For
instance, a female patient admitted for surgery may not be ready to remove her mangal sutra
because of cultural sentiment. Similarly, female patients who have to undergo medical
examination for gynecological problems feel embarrassed when attended by a male doctor. The
knowledge of sociology helps to deal with such problems created by culture and the social
environment and treat patient.
c) Intellectual level: If the patient is unable to understand the instructions and guidelines given by
the physicians, a close family member can be identified and needed information can be given.
d) Intellectual level: If the patient is unable to understand the instructions and guidelines given by
the physicians, a close family member can be identified and needed information can be given.
Inter relationship between society and Health
• Society and health are too closely interrelated.
• Society has undergone different phases of development.
• Each phases of society is peculiarly associated with health.
• Initially medicine was an art and later it evolved as a science over a long
period of time.
• The development of medicine is related with civilization and advancement
of people in various aspects like philosophy, religion, economic condition,
form of government, education, science and their aspirations.
 I. Primitive society and health
• In primitive society diseases were thought to be associated with sorcery,
magic, breaking a taboo and invasion of evil spirit in the body.
• It was felt necessary to take steps in relieving the body from the influence of
evil spirit.
• Ritual ceremonies are performed in order to remove evil spirits.
• Evil spirit was also allowed to be escape by making holes in specific part of the
body where it was thought to live.
• Later they developed belief that disease was caused by their failure to please
gods and their signs.
• The primitive man attributed disease to the wrath of gods, invasion of evil
spirit in to the body and influence of stars and planets.
• The treatment is based on religion, magic and empiricism.
• Infectious diseases were rampant in primitive societies.
 II. Agricultural society and Health
• Origin of agricultural society denotes development in the history of
society.
• It changed lifestyles of people.
• Cultural development and progress in the field of education including
medicine occurred in agricultural society.
• Development of medical knowledge helped the agricultural society to
control many of the diseases by the locally available herbal plants.
• But disease like plague was not controlled for poor development in
medical sciences.
 III. Industrial society
• With the emergence of industrial societies, life expectancy, production of goods and services
increased.
• Production was carried out by machines powered by fuel.
• Migration of people from rural to urban areas occurred in a large scale because of industrialization.
Social cohesion breaks up.
Industrialization brought many changes in society and the environment caused many health
problems. These are:
a) Social problems and health. Industrialization changed the structure and functions of society
which farther brought changes in the life pattern of people. It increased the magnitude of social
problems such as prostitution, unemployment, poverty, crime, juvenile delinquency, alcoholism,
etc. These problems caused health problems of various kinds.
b) Environment and health. Industrial society is the cause for water, soil and air pollution. Waste
products like industrial effluents are exposed to the environment. These affect the health of
people.
c) Mental health problems. Industrialization changed life patterns of human society. Social
institutions that serve a major role in pre-industrial society break up. Individualism developed in
urban areas. Inability to adapt to the psychological environment created mental problems.
 Cont’d
d) Psychosomatic disorder: physical symptoms like fatigue, pain in the shoulder,
neck and back, hypertension, heart diseases, rapid aging, etc. are referred to as
psychosomatic disorders. The increasing stress on automation, electronic
operations and mechanical energy may create new psychological health
problems. Such hazards often lead to psychosomatic disorders. They are more
damaging than physical or chemical hazards.
e) Accidents: on job accidents, traffic accidents and others injuries cause
physical and mental health problems. Sometimes they lead to death.
f) Culture and health. Industrialization has led to the disintegration of joint
family system that resulted in more burdens and less support which cause
physical and mental illness.
g) Mechanical life and stress. Shift duty disturbs the regular resting time and
night sleep. Such conditions lead to psychosis, neurosis, hypertension, heart
diseases and other health problems.
 Cont’d
h) Occupational health problems: These are disease that arisen of or in the
course of employment. The causes are physical agents, chemical agents,
biological agents, etc.
i. Physical agents: These include heat, cold, light, pressure, noise, radiation
and mechanical factors. Excessive heat causes hyperpyrexia, heat
exhaustion, heat syncope, heat cramps, burns, etc. On the other hand,
heavy pressure causes liaison disease, air embolism and blast. Exposure to
radiation, for instance, workers work in x-ray units may catch up by disease
such as cancer, leukemia, and aplastic anemia.
ii. Chemical agents: gases like Co2, Co, So2, HCL, etc. are expelled from
chemical industries. These create health problems.
iii. Biological agents: Diseases like Encephalitis, tetanus, fungal infection, etc.
are caused by biological agents in the occupational environment.
 Determinants of health

• What makes some people healthy and others unhealthy?

• How can we create a society in which everyone has a chance to live a
long, healthy life?
• Healthy People 2020 is exploring these questions by: Developing
objectives that address the relationship between health status and
biology, individual behavior, health services, social factors, and
policies.
• Health or ill health is the result of a combination of different factors.
There are different perspectives in expressing the determinants of
health of an individual or a community.
• The range of personal, social, economic, and environmental factors
that influence health status are known as determinants of health.
Cont…
• According to the “Health field” concept, there are four major
determinants of health or ill health.

• A. Human Biology
• Every Human being is made of genes. In addition, there are factors,
which are genetically transmitted from parents to offspring.
• As a result, there is a chance of transferring defective trait. The modern
medicine does not have a significant role in these cases.
• a. Genetic Counseling: For instance during marriage parents could be
made aware of their genetic component in order to overcome some
risks that could arise.
• b. Genetic Engineering: may have a role in cases like Breast cancer.
Cont…

• B. Environment: is all that which is external to the individual human

host. Those are factors outside the human body. Environmental
factors that could influence health include:
• a. Life support, food, water, air etc
• b. Physical factors, climate, Rain fall
• c. Biological factors: microorganisms, toxins, Biological waste,
• d. Psycho-social and economic e.g. Crowding, income level, access to
health care
• e. Chemical factors: industrial wastes, agricultural wastes, air
pollution, etc
Cont…
• C. Life style (Behavior): is an action that has a specific frequency,
duration, and purpose, whether conscious or unconscious.
• It is associated with practice.
• It is what we do and how we act. Recently life style by itself received
an increased amount of attention as a major determinant of health.
• Life style of individuals affects their health directly or indirectly.
• For example: Cigarette smoking, Unsafe sexual practice, Eating
contaminated food
Cont…
• D. Health care organization
• Health care organizations in terms of their resource in human power,
equipment’s, money and so on determine the health of people.
• It is concerned with
• a. Availability of health service
• People living in areas where there is no access to health service are
affected by health problems and have lower health status than those
with accessible health services.
• b. Scarcity of Health Services leads to inefficient health service and
resulting in poor quality of health status of people.
• c. Acceptability of the service by the community
• d. Accessibility: in terms of physical distance, finance etc e.
Cont…
• Quality of care that mainly focuses on the comprehensiveness, continuity and integration of
the health care.
• The other view of the determinants of health is from the ecological perspective.
Accordingly, there are four different factors affecting health.
• 1. Physical Determinants -The physical factors affecting the health of a community include:
the geography (e.g. high land versus low land), the environment (e.g. manmade or natural
catastrophes) and the industrial development (e.g. pollution occupational hazards)
• 2. Socio – cultural determinants – The socio- cultural factors affecting the health of a
community include the beliefs, traditions, and social customs in the community. It also
involves the economy, politics and religion in the community.
• 3. Community organization - Community organization include the community size,
arrangement and distribution of resources (“relations of productions’).
• 4. Behavioral determinants- The behavioral determinants affecting health include
individual behavior and life style affecting the health of an individual and the community.
E.g. smoking, alcoholism and promiscuity.
Cont…
• Determinants of health fall under several broad categories:
•
• Policymaking
• Social factors
• Health services
• Individual behavior
• Biology and genetics
Cont…
• It is the interrelationships among these factors that determine
individual and population health.
• Because of this, interventions that target multiple determinants of
health are most likely to be effective.
• Determinants of health reach beyond the boundaries of traditional
health care and public health sectors; sectors such as education,
housing, transportation, agriculture, and environment can be
important allies in improving population health.
Cont…

• Policymaking
• Policies at the local, state, and federal level affect individual and
population health.
• Increasing taxes on tobacco sales, for example, can improve population
health by reducing the number of people using tobacco products.
• Some policies affect entire populations over extended periods of time
while simultaneously helping to change individual behavior.
• For example, the 1966 Highway Safety Act and the National Traffic and
Motor Vehicle Safety Act authorized the Federal Government to set and
regulate standards for motor vehicles and highways.
• This led to an increase in safety standards for cars, including seat belts,
which in turn reduced rates of injuries and deaths from motor vehicle
accidents.
Cont…
• Social Factors
• Social determinants of health reflect the social factors and physical
conditions of the environment in which people are born, live, learn,
play, work, and age.
• Also known as social and physical determinants of health, they impact
a wide range of health, functioning, and quality-of-life outcomes.
Cont…
• Don’t miss the Social Determinants of Health topic area and objectives.
• Examples of social determinants include:
• Availability of resources to meet daily needs, such as educational and job opportunities,
living wages, or healthful foods
• Social norms and attitudes, such as discrimination
• Exposure to crime, violence, and social disorder, such as the presence of trash
• Social support and social interactions
• Exposure to mass media and emerging technologies, such as the Internet or cell phones
• Socioeconomic conditions, such as concentrated poverty
• Quality schools
• Transportation options
• Public safety
• Residential segregation
Cont…
• Examples of physical determinants include:
• Natural environment, such as plants, weather, or climate change
• Built environment, such as buildings or transportation
• Worksites, schools, and recreational settings
• Housing, homes, and neighborhoods
• Exposure to toxic substances and other physical hazards
• Physical barriers, especially for people with disabilities
• Aesthetic elements, such as good lighting, trees, or benches
• Poor health outcomes are often made worse by the interaction
between individuals and their social and physical environment.
Cont…
• Health Services
• Both access to health services and the quality of health services can
impact health.
• Healthy People 2020 directly addresses access to health services as a
topic area and incorporates quality of health services throughout a
number of topic areas.
• Lack of access, or limited access, to health services greatly impacts an
individual’s health status.
• For example, when individuals do not have health insurance, they are
less likely to participate in preventive care and are more likely to delay
medical treatment.
Cont…
• Don’t miss the Access to Health Services topic area and objectives.
• Barriers to accessing health services include:
• Lack of availability
• High cost
• Lack of insurance coverage
• Limited language access
• These barriers to accessing health services lead to:
• Unmet health needs
• Delays in receiving appropriate care
• Inability to get preventive services
• Hospitalizations that could have been prevented
Individual Behavior

• Individual behavior also plays a role in health outcomes. For example, if an

individual quits smoking, his or her risk of developing heart disease is greatly
reduced.
• Many public health and health care interventions focus on changing
individual behaviors such as substance abuse, diet, and physical activity.
Positive changes in individual behavior can reduce the rates of chronic
disease in this country.
• Examples of individual behavior determinants of health include:
• Diet
• Physical activity
• Alcohol, cigarette, and other drug use
• Hand washing
Biology and Genetics
• Some biological and genetic factors affect specific populations more than
others.
• For example, older adults are biologically prone to being in poorer health
than adolescents due to the physical and cognitive effects of aging.
• Sickle cell disease is a common example of a genetic determinant of
health.
• Sickle cell is a condition that people inherit when both parents carry the
gene for sickle cell.
• The gene is most common in people with ancestors from West African
countries, Mediterranean countries, South or Central American
countries, Caribbean islands, India, and Saudi Arabia.
Cont…
• Examples of biological and genetic determinants of health include:
• Age
• Sex
• HIV status
• Inherited conditions, such as sickle-cell anemia, hemophilia, and
cystic fibrosis
• Carrying the BRCA1 or BRCA2 gene, which increases risk for breast
and ovarian cancer
• Family history of heart disease
 CHAPTER TWO: Social causes, Distributions and Consequences of illness

• Textbooks of pathology and of clinical medicine are replete with examples

of the particular factors which causes disease i.e. micro-organisms.
• A disease or medical condition is an abnormal condition of an organism
that impairs bodily functions, associated with specific symptoms and signs.
• It may be caused by external factors, such as infectious diseases, or it may
be caused by internal dysfunctions, such as autoimmune diseases.
• In human beings, "disease" is often used more broadly to refer to any
condition that causes pain, dysfunction, distress, social problems, and/or
death to the person afflicted, or similar problems for those in contact with
the person.
• In this broader sense, it sometimes includes injuries, disabilities, disorders,
syndromes, infections, isolated symptoms, deviant behaviors, and atypical
variations of structure and function, while in other contexts and for other
purposes these may be considered distinguishable categories.
These traditional approaches to the causes of illness, however, have been dominated by
the biomedical model which argues that a biological change is brought about by a
preceding biological change.
Sociology offers three challenges to this perspective. These are:
 The presence of many biological causes of illness is strongly influenced by social
factors,
 Because illness is multidimensional, the description of the causes of the biological
lesion alone is not an adequate explanation, in that illness has psychosocial
dimensions which equally need understanding, and
 There is evidence that apparently biologically based diseases, and even death, may be
directly brought about by social factors.
• This indicates that health is affected by the social conditions in which people live and
work.
• Poor social conditions and poverty increase the risks of ill health and disease.
• The social causes include poor sanitation, nutritional deficiencies, violence and
accidents, poor water supply, little or no access to health services, lack of safety at
work, overcrowded or poorly maintained housing, insufficient or poor quality food,
environmental pollution, bad sanitation, stress, lack of exercise due to working, and
traveling patterns etc.
Cont’d

• Many causes of diseases and ill health are related to the

social conditions of our lives because everything, including
health, is dependent of social conditions we live in.
• If the social conditions are not good, then both physical and
mental health gets badly affected.
• In general, social, cultural, psychological, etc. factors affect
the health of an individual.
2.1 Theories of Disease causation
• Prior to the rise of modern medicine, disease was attributed to a variety of spiritual or
mechanical forces.
• It was interpreted as a punishment by god for sinful behavior or the result of an
imbalance in body elements.
• Ideas about disease emerging during the nineteenth century were influenced by two
developments which provided a philosophical and empirical basis for the biomechanical
approach characteristics of modern medical practice.
These developments were:
a) the Cartesian revolution which gave rise to the idea that the mind and body were
independent.
b) The doctrine of specific etiology which flowed from the discovery of the micro
biological origins of infectious diseases.
• These effectively denied the influences of social and psychological factors in disease
onset.
• Rather, the body was viewed as a machine to be corrected when things go wrong by
procedures designed to neutralize specific agents or modify the physical processes
causing disease.
• These ideas have been progressively challenged as the mono causal view of disease has
been modified by multi-causal models of disease onset.
 2.1.1 The Germ theory of disease
• The germ theory of disease, also called the pathogenic theory of
medicine, is a theory that proposes that microorganisms are the
cause of many diseases.
• Although highly controversial when first proposed, it is now a
cornerstone of modern medicine and clinical microbiology,
leading to such important innovations as antibiotics and
hygienic practices.
2.1.2 Multi-causal model of diseases
• Germ theory suffered the weakness of being a single cause
theory. All diseases were presumed to be caused by germs and
by germs alone -- one species of germ per disease.
• When infection with, for instance, the cholera germ occurred,
then the disease cholera should surely follow.
• The argument is that there is no direct relationship between the
presence of microorganisms and the existence of disease, not all
these exposed to pathogens became ill.
• Clearly, an organism or other noxious agent is a necessary, but
not a sufficient cause of disease.
• The epidemiological triangle approach sees disease as the
product of an interaction between an agent, a host and the
environment.
• Host and environmental factors determine exposure and/or
susceptibility to the noxious agent in question. In this respect, all
diseases, including infections, are multi-factorial and have
multiple causes.
• In the triad model, the single element of the agent is represented
as if it were equal in importance to the variety of relevant factors
in the host and the multitude of environmental influences.
• The actual findings of epidemiology in the study of a vast array of
diseases have not supported this exaggerated weight given to the
agent as a cause at disease.
• One of the benefits of this broader view is that the health of a
population may be promoted by procedures which modify
susceptibility and exposure as well as by procedure which attack
the agent involved in the disease. That is, disease can be
prevented as well as cured.
• The epidemiology triangle is useful in understanding infectious
disorders, but is less useful with respect to chronic, degenerative
disorders such as heart disease, stroke, arthritis, for here no
specific agent can be identified against which individuals and
population may be protected.
• Many contemporary medical problems are better understood in
terms of a web of causation or chain of causation.
• According to this concept, disorders such as heart disease develop
through complex interactions of many factors which form interlocking
chains.
• These factors may be biophysical, social or psychological and may
promote or inhibit the disease at more than are point in the causal
process.
• For example, some of the factors implicated in heart disease are high
blood pressure, blood cholesterol levels, diet, smoking, physical
activity, a type of personality and stress.
• Since many of these factors can be modified, prevention offers better
prospects for health than cure.
• It is also important to note that many of the factors implicated in heart
disease have been identified as increasing the risk of other disorders,
such as stroke and cancer.
• It should be apparent that both these models accord some significance
to the physical and social environment and/or the patterns of behavior
they may engender.
 2.1.3 The theory of general susceptibility
• The theory of general susceptibility has emerged over the past 20 years and
departs in important ways from mono-causal and multi-causal model of
disease.
• It is not concerned with identifying single or multiple risk factors associated
with specific disorders, but it seeks to understand why some social groups
seem to be more susceptible to disease and death in general.
• For example numerous studies have shown that social class, measured by
occupation, education, income or area of residence, is closely related to health.
• These four theories of the causes of disease have been presented in a more or
less historical sequence.
• From the brief descriptions offered it is clear that the role ascribed to the
physical, social and psychological environment increases as we have progress
from the germ theory to the theory of general susceptibility.
• The latter completely overturns the doctrine of specific etiology central to the
former, for broad nonspecific social and psychological factors are seen to be
associated.
 2.2 Social construction of illness and the social production of health
1. Taken- for – granted realities, like disease categories, are socially
constructed within the contest of each particular culture.
• Things and ideas are considered real in our everyday lives only when there is
a social agreement that they are real.
• In our everyday lives only when there is a social agreement that they are real.
• Things and concepts are labeled through language; they are the subject of
discussion, and people act on the knowledge that they exist.
• Reality is a bit like the emperor’s new clothes in that the reality derives from
the social agreement that a thing exists, not from physical evidence per se.
• People gain cultural knowledge-including such categories and the cognitive
models through which people learn to think from the socialization process of
childhood.
• In this sense, illness exists because people put a label on them. In turn, when
an illness category or label exists, then people pay attention to particular sets
of symptoms and therefore decide that they have the illness.
Cont’d
2. Culture defines normality: what is considered normal-in behavior,
thinking, or even physical attributes-is cultural, that is, we learn it as
children, and when share these assumptions with others in our social
group.
3. Illness categories may have important symbolic dimensions medical
anthropologists have shown that there is considerable cultural variation in
the type and severity of symptoms regarded as important by different
social groups.
• Some illness has important symbolic dimensions. Susan Sontag (1978)
describes illness as cultural metaphor and claims that particular illness
(such as tuberculosis, cancer, AIDS) can have powerful social meanings in
specific social contexts.
• The symbolic dimensions of illness most often have negative valuations
and result in social stigma and ostracism (for example, leprosy).
• The cultural meanings of an illness like leprosy can be maintained even
when they are no longer scientifically justified. The cultural meanings vary
from culture to culture.
4. Medical systems reflect social reality:
• Issues of socio economic class, gender hierarchies and ethnic
relations often play out in the context of a medical system.
• The epidemiological distribution of disease is not equitable
from one social group to another.
• In general, the poor have higher rates of morbidity and
mortality for all causes. Men and women generally have
different rates of illness.
• Social stratification is the most important variable in
determining both health status and access to medical care.
• Medical systems can be seen as socio-cultural systems. There
are particular social roles for practitioners and patients, and
there is hierarchy of power and prestige among practitioners.
5. Illness behavior can be considered a hierarchy of resort:
• When people perceive that they are ill, they act on this
perception and seek medical care. This is called illness
behavior.
• The primary components of illness behavior include acceptance
of the sick role and seeking therapeutic interventions.
• Studies of illness behavior center on patterns of seeking health
care; these patterns are called a hierarchy of resort.
• In general, people’s hierarchies of resort begin with seeking
solutions at home, usually from a female figure, mom/mana.
• If household remedies do not work, the patient and his or her
family move up the hierarchy of resort to health care specialists.
6. The sick role is an important concept:
• In event of sickness our culture provides us with particular
social roles the sick patient, the healer, the supportive friend or
family member. That way, everyone is expected to know what
to do. Otherwise problem may encounters in helping the sick.
• Because people live in households and as part of families,
important characteristics of both health status and medical
care seeking are determined by these social groups.
• Individual’s health status is affected by access to adequate
nutrition; clean water, hygienic conditions, and medical care.
• People in a household have many of these elements in
common with a variety of disease outcomes.
 Society and health
Society shapes people’s health in five major ways. These are:
1) Cultural patterns define health. Standard of health vary from society to
society. For example, lean figured body is an indicator of healthy in western
society, but sign of illness and malnutrition in some African countries.
2) People define as “healthy” what they should hold to be morally good.
Ideas about good health constitute a type of social control that encourages
conformity to cultural norms.
3) Cultural standard of health changes over time. Early in the 20th century,
some physicians condemned women for enrolling in college or university,
claiming that higher education placed unhealthy strain on the female brain.
But today, we know it differently.
4) A society’s technology affects people’s health. In poor societies, infectious
diseases are rampant because of malnutrition and poor sanitation. As
industrialization raises living standards, people become healthier. But
industrial technology also creates new threats to health.
5) Social inequality affects people’s health. Every society on earth unequally
distributes the resources that promote personal wellbeing.
 2.3 Social and psychological factors and health
• The role of social factors in the causes of illness can be seen in
two ways. These are direct and indirect effects.
• Sometimes something in the social environment triggers an illness
without any apparent physical intimidator. In this case we can say
that the social environment directly affects health and illness.
• On the other hand, social factors indirectly bring the individual
and harmful physical or biological factor together in some way, for
example, custom of drinking a water from stream or a well that
will help determine their disease pattern.
• Thus, it is possible to say that social and psychological factors
have direct and indirect relations with health.
• Life style is the way people live. It includes cultural and behavioral factors and
lifelong personal habits like smoking, alcoholism, drug addiction, etc.
• There is an association between health and life style of individuals. People in
developed countries suffer from certain diseases frequently such as coronary
heart disease, obesity, lung cancer, drug addition, etc.
• In developing countries, health problems are related to lack of sanitation, poor
nutrition, personal hygiene, elementary human habits, customs and cultural
patterns.
Health problems related to some of the life style factors are discussed below:
Alcoholism and drug addition
Alcoholism
• The term “alcoholism” refers to a disease known as alcohol dependence
syndrome; the most sever stage of a group of drinking problems which begins
with binge drinking and alcohol abuse.
• Binge drinking is the officially set standard of drinking per session for men and
women. Binge drinking turns into alcohol abuse when someone’s drinking
begins to cause problems and the drinking continues anyway.
Alcoholism is drinking alcohol beverages at a level that interferes with physical health,
mental health, and social, family, or jobs responsibilities. It is a type of drug addiction.
It has four main characteristics:
Craving: a strong need to drink
Loss of control: not being able to stop drinking once you have began
Physical dependence: withdrawal symptoms, such as nausea, sweating, or
shakiness after stopping drinking
Tolerance: to need to drink greater amounts of alcohol in order to get high.
Alcoholism carries many serious dangers. These are:
increase risk of certain cancers,
it can cause damage to liver, brain and other organs,
it cause birth defects,
it affects central nervous system,
it produces mild to severe psychic dependence,
it causes suicide, automobile and other accidents and injuries and death due to
violence,
 it leads to individual and family disorganization.
Drug: Drug addiction such as cocaine, cannabis, heroin, etc. causes
various physical and mental health problems.
• Drug abuse, also known as substance abuse, involves the repeated
and excessive use of chemical substances to achieve a certain effect.
• These substances may be “street” or “illicit” drugs, illegal due to their
high potential for addiction and abuse.
• They also may be drugs obtained with a prescription, use for pleasure
than for medical reasons.
• Different drugs have different effects. For instance cocaine or
methamphetamine may produce intense rush and initial feelings of
boundless energy.
• Heroin, benzodiazepines or the prescription of oxycontin may result
in excessive feelings of relaxation and calm.
• Generally, all drugs have the tendency of over stimulation of the
pleasure center of the brain.
What causes drug addiction and abuse? Most persons abuse drugs to
the point they loss their home, their family, and their job. Why? There
is no simple reason for this.
Drug abuse and addiction is due to many factors. These are:
Inability to self-soothe or get relief from untreated mental or
physical pain: Without the self-resilience and support to handle
stress, loneliness or depression, drugs can be a tempting way to deal
with the situation.
Family history of addiction: if you have a family history of addiction,
you are at higher risk for abusing drugs.
History of Mental illness: Drug abuse can worsen mental illness or
even create new symptoms.
Peer pressure: If people around you are doing drugs, it can difficult
to resist the pressure to try them, especially if you are a teenager.
Smoking and Health
• Smoking is the inhalation and exhalation of fumes from burning
tobacco in cigars, cigarettes, and pipes.
• It is a practice where a substance, most commonly tobacco, is burned
and the smoke tasted or inhaled.
• This is primarily practiced as a route of administering for recreational
drug use, as combustion releases the active substances in drugs such as
nicotine and makes them available for abortion through lungs.
• It can be done as a part of rituals, to induce trances and spiritual
enlightenments.
• The most common method of smoking today is through cigarettes,
primarily industrially manufactured but also hand-rolled from loose
tobacco and rolling paper. Other smoking includes pipes, cigars,
hookahs and bangs.
• Tobacco smoking is today by far the most popular form of smoking and
is practiced by over one billion people in the majority of all human
societies. Less common drugs from smoking include cannabis and opium.
Some of the substances are classified as hard narcotics, like heroin and
crack cocaine, but the use of these is very limited as they are often not
commercially available.
• The health impacts of tobacco are the circumstances, mechanism, and
factors of tobacco consumption on human health.
• Epidemiological researches have been focused primarily on tobacco
smoking, which has been studied more extensively than any other form
of consumption.
• Tobacco smoke contains nicotine, a poisonous alkaloid, and other
harmful substances like carbon monoxide, acrolein, ammonia prussic
acid, and a number of aldehydes and tars.
• Tobacco use leads most commonly to diseases affecting the heart and
lungs , with smoking being a major risk factor for heart attacks, strokes,
chronic obstructive pulmonary disease (COPD), emphysema, and cancer
(particularly lung cancer of the larynx and mouth, and pancreatic), and
threat to male potency.
Education and Health
• Education increases in literacy ratio helps to improve health status of individuals.

Economic status and Health

• The economic conditions of people determine purchasing power, standard of
living, quality of life, family size and the pattern of disease and deviant behavior
in the community.
• Poor economy is linked to deficiency in health /health problem due to lack of
fulfillment of basic needs. On the other hand, upper class groups enjoy better
health. They also suffer from granary heart disease, diabetes and obesity which
are related to their life style.
• Thus it is possible to say that improve in economic status reduces morbidity and
increase life expectancy and improve quality of life
Poverty /unemployment and Health
• unemployment causes for malnutrition.
• Unemployed people are Vulnerable to not only malnutrition but also emotional
problems that cause mental problem such as depressive psychosis, and psycho-
somatic disorders (gastritis, eczema, etc.)
Occupational status and Health
• This is the major determinant of health. White collar jobs do have healthy life styles and
their work environment is safe.
• They have relatively high awareness on health. Since their work environment is safe or
with low risk, they enjoy better health than other industrial workers. However, they are
vulnerable to neurotic mental disorders.
• Industrial workers (blue collars), on the other hand, are exposed to major health risks in
their environment. They are exposed to physical, chemical and biological agents that
cause disease. Industrial accident is common. Generally, their environment is not safe.
• People working in agriculture suffer from malnutrition, anemia, and other problems
Juvenile delinquency and Health
• Juvenile delinquents are those children involved in criminal activities. Children involved in
juvenile delinquency are isolated from the normal social life. The basic needs of these
children are not fulfilled. They develop the habit of taking alcohol, drugs, etc. All these
cause physical and psychological health problems.
Beggary and Health
• social negligence, poor quality and quantity of food got by begging, etc. are not
conductive for health. They are deprived of proper home conditions. .
Prostitution and Health
• prostitution is associated with various health problems, for instance, STDs.
Syphilis is a STD which leads to paralysis of the limbs, blindness and heart
disease
Population Explosion and Health
• population explosion creates competition over resources. This has an
impact on food crop production or supply of food. It causes poor
environmental sanitation.
Political system and Health
• political system plays a major role in determining the health status of the
people. Problems in implementing health services are not the result of
technical problems but due to political system.
• Political system is responsible for making decisions regarding resource
allocation, manpower policy, choice of technology and the degree of
medical services make available and accessible to different sections of
people.
 2.4 The Distribution of illness in a society
• The study of social conditions and how these influence and
determine the health situation of populations has always been a
subject of interest and importance for public health in general.
• This is because the determinants of health are both biological and
social factors. The concerns of social factors as the cause of illness
give to social epidemiology.
• Social Epidemiology is the study of how society and different forms
of social organization influence the health and well-being of
individuals and population.
• In particular, it studies the frequency, distribution and the social
determinants of the states of health in a population.
• Thus, social epidemiology goes beyond the analysis of individual risk
factors to include the study of the social context in which the
health- disease phenomena occur.
 Social class, sex and age
• Within any given society, social and cultural factors influence who is in greatest
danger of becoming ill and dying
Social class
• social class is categorization of a society based on such criteria as income,
education, occupation in a society etc.
• The relation between social class and health is clear. Those who are lower on
such things as income, educational achievement, and occupational status
generally have higher disease and death rates than do their more affluent
counterparts.
• High infant mortality, low life expectancy and high prevalence of disease related
to poverty are the major problems of lower social classes.
• One of the major reasons for the substandard health status of the poor is that
they live in situations that substantially increase their general susceptibility to
disease.
• They live under less sanitary conditions, have less nutritious diets, and are less
likely to take preventive health actions such as obtaining routine physical
examinations.
Generally, the major reasons for high morbidity and mortality among the poor are:
 They live in situations that substantially increase their susceptibility to disease, e.g. Poor
housing, poor sanitation, poor nutrition, poor access to health services, etc.,
 poor women are less likely to have prenatal checkups and more likely to have poor diets,
 many poor people are not covered by the advancement and expansion of Medicare and
Medicaid, and some health care still depends on-out-of pocket costs, and
 The medical care that the poor do receive is likely to be of lower quality.
Sex
• women appear to be healthier than men, especially if we consider longevity as the key
measure of health. The life expectancy of women is greater than men.
• Women also have lower rates of most serious chronic illness. What accounts for these
differences?
 women may be biologically more capable of survival than are men,
 it may be due to gender-role definitions that encourage males to be aggressive and to seek
more stressful and dangerous occupations,
 Lifestyle of men is less healthy than those of women. For instance, men drink more alcohol
and smoke more tobacco, and
 Cultural definitions of women as “the weaker sex” may lead women to respond more
quickly to symptoms and to seek medical care earlier in an illness episode. If so, this
treatment may enhance the likelihood of effective medical intervention for women.
 Age
• There is a relation between mortality and age. The relation is a lopsided U-
curve. This is because mortality is still, despite major improvements since
the 19th century, relatively high in infants under year one old, mortality then
declines rapidly before picking up again in middle age and rising steeply in
the elderly. Many specific causes of mortality are related with age at later
life.
Early age
infections disease cause death (in developing countries)
leukemia cause death (in western society)
non- age factors are generally the cause of death
Old age
age factors cause death
cancer and ischemic heart disease
more illness
Elders visit doctors more frequently.
 Chapter 3: Doctor-patient Relationship
Introduction
• Doctors and patients regularly or frequently meet.
• The rules that apply in doctor-patient relationships are different.
• These two people have just met, but within seconds one has begun to tell the
other intimate personal details about his health.
• What is more, it is likely that, in a few minutes, he/she will be prepared to remove
some of his/her clothes and submit to a physical examination.
• The interaction is shaped by their differing social roles and their different needs.
• The patient is seeking expert knowledge and access to treatment.
• The doctor is acting as the gatekeeper of the scarce social resources that is
health-care and so is seeking information about the patient in order to assess his
needs.
• The success of medical intervention is influenced by the nature of doctor-
patient relationships. For example, central to medical diagnosis and treatment
is the exchange of information between doctor and patient.
• However, unless patient feel at ease and are encouraged talking freely they
may not disclose the real problems that are troubling them or express their
worries and concerns which thus remain hidden.
• Thus it is possible to say that the doctor-patient relationship is central to
medicine and is essential for the delivery of high quality health care in the
diagnosis of disease.
• A patient must have confidence in the competence of their doctor and must
feel that they can confide in him/her.
 Cont’d
• Creating an atmosphere which allows a sensitive discussion not only assists
the doctor in diagnosing a patient’ problem but also influences the patients’
responses.
• The nature of relationship between doctor and patient plays a vital role in
diagnosis and treatment decisions, as well as contributing more generally to
patients’ feelings of well-being and satisfaction with the consultation.
• Some sociologists have depicted the general social expectation which
surrounds the behavior of doctors and patients and emphasized their shared
values.
• Others have examined the ways in which doctors and patients may differ in
their beliefs and expectations and have shown how each may seek to
influence the process and outcome of the consultation.
 Approaches to Doctor-Patient Relationship

A. The Parsonian Formulations (Parsons’ Model of Doctor-Patient Relations)

• Talcott Parsons was one of the earliest sociologists to examine the relationship
between doctors and patients.
• His interest is in this area arisen from a concern with the question of how society is
able to function smoothly.
• This is partly achieved as he said because people act out social roles which are
associated with socially prescribed patterns of behavior.
• Parsons began with the assumptions that illness was a form of dysfunctional deviance
that required reintegration with the social organism.
• Illness, or feigned illness, exempted people from work and other responsibilities, and
thus was potentially detrimental to the social order if uncontrolled.
• Maintaining the social order required the development of a legitimated sick role to
control this deviance, and make illness a transitional state back to normal role
performance.
Parsons saw four general expectations or norms governing the functional sick
role:
i. the individual is not responsible for their illness,
ii. exemptions of the sick from normal obligations until they are well,
iii. illness is undesirable, and
iv. The ill should seek professional help and cooperate with doctors.
• The physician role or the doctors’ role is to represent and communicate these
norms to the patient to control their deviance.
• The role of the doctor is supplementary to the patient, whereas the patient is
expected to cooperate fully with the doctor; doctors are expected to apply
their specialist knowledge and skills for the benefit of the patient.
• In order to carry out the tasks of diagnosis and treatment, doctors often
need to know intimate details about the patient that are not usually known
between strangers.
• It may, for example, be necessary to carry out intimate physical
examinations and to ask information about the patient’s personal affairs.
• The potential tension arises from this (personal nature of medical care).
However, this can be reduced by the obligation on the doctor to remain
objective and emotionally detached, and to use this privileged position for
the benefit of the patient and not for personal advantage.
• Medical education and social role expectations impart normative
socialization to physicians to act in the interests of the patient rather than
their own material interests, and to be guided by an egalitarian universalism
rather than a personalized particularism.
Patient:
Table Parson’s analysis of the roles of patientsDoctor:
sick1.role professional role
and doctors
Obligations and privileges Expected to
1. must want to get well as quickly as 1. apply a high degree of skill and knowledge to the
possible problems of illness
2. should seek professional medical advice 2. Act for welfare of patient and community rather
than for own self-interest, desire for money,
and cooperate with the doctor advancement, etc.
3. allowed (and may be expected) to shed 3. be objective and emotionally detached (i.e.,
some normal activities and should not judge patients’ behavior in terms of
responsibilities (eg employment and personal value system or become emotionally
involved with them)
household tasks 4. be guided by rules of professional practice
4. regard as being in need of care and Rights
unable to get better by his or her own decisions 5. granted right to examine patients physically and
and will
to enquire into intimate areas of physical and
personal life
6. granted considerable autonomy in professional
practice
7. occupies position of authority in relation to the
patient
Critics argue that Parsons Analysis is important in identifying the general social expectations which
guide the behavior of doctors and patients. But following are indicated as the weaknesses of the
model:
i. The model overlooks conflict and tension that may be experienced by doctors and patients, as
well as the differing forms of this relationship may take. The source of conflict can be the
obligation of doctors’ to act in the best interest of individual patients’ and his/her duty to serve
the interest of the state. Doctors pass decisions on who is ill or not. Patient may seek time off
work but doctors may decide that the patient is not ill. This may lead to conflict. The other conflict
for doctors arises from the competing interests of individual patients and the larger patient
population. This is because doctors are responsible in distributing scare resources. In the absence
of criteria on deciding, for example, which patient should be given a transplant or prioritizing of
different patients, is based on the judgment of individual clinicians. Doctors may also experience
conflicts between maintaining the confidentiality of the doctor-patient relationship and disclosing
information to patients’ parent or spouse. For instance, take the case of HIV/AIDS.
ii. Doctors and society may consider some disease such as HIV/AIDS, Obesity, lung cancer, etc. as the
responsibility of the ill and physicians react less favorably to those patients.
iii. Critics argue that Parsons has been overly optimistic about physicians’ socialization to
universalism and affective neutrality. Physicians’ often react negatively to dying patients, patients
they do not like, and patients they believe are complainers. They are also subject to personal
financial and personal interests in the patient care.
 Cont’d
iv. Critics argue that Parsons’ Model is specify to acute illness, and did
not speak to the increasing prevalent chronic illnesses and
disabilities, a sick role which is permanent and not transitional.
v. Critics have also shown that there is a great deal of inter-cultural and
inter-personal variations in sick roles and norms. There is also a
cross-class variation. Some of the poor adapt to their lack of access
to medical care by becoming fatalistic, rejecting the necessity of
medical treatment, and coming to see illness and death as inevitable.
On the other hand, the educated classes become more assertive in
the relationship, rejecting the norm of passivity in the favor of self-
diagnosis or negotiated diagnosis.
 B. Marxist and Feminist Approaches
• Marxist sociologists interpreted the doctor-patient relationship within the
context of capitalism.
• The doctor-patient relationship is conditioned by medical-industrial capitalism,
profit maximization drive the innovation of technologies and drugs and
constrains physician decision making.
• Physicians are both agents and victims of capitalist exploitation.
• They are engineers required to fix up the workers and send them back into
community and work environment is made dangerous and toxic by capitalism.
• Physicians who own the means of production are supposed to accrue
occupational autonomy and great wealth. This anomaly has led Marxist
medical sociologists to propose the thesis of physician proletarianization.
• Theorists of physician proletarianization point to the rising numbers of salaried
physicians, the deskilling of physicians to less skilled technical personnel.
• Feminists have focused on the patriarchal nature of the male-physician-
female-patient relationship documenting the history of medical pseudo-
science that has portrayed women as congenitally weak and in need of
dubious treatment.
• It stated the exclusion of women from medicine.
 C. Economic Approaches
• The growth of studies on cost-containment, and the economic trend of 1980s
social sciences, led to the rise of methodologically individualistic ‘rational
choice’ studies of the doctor-patient relationship.
• These studies usually ignored the functionalists’ interest in norms, as well as
the critical theorists’ interest in power and exploitation. Instead, the
economists’ model starts from the assumption of a mutual ‘utility-
maximizing’ agency contract between the doctor and the patient.
• The patient is interested in maximizing consumption of health, and the
physician is interested in maximizing income.
• The studies then focus on the effects of ignorance, reimbursement, and
utilization control structures on doctor behavior, the doctor-patient
relationship and the success of medical agency.
• Different payment structures affect physician behavior.
 Types of Doctor-Patient Relationship
• Parsons identified four types of doctor patient relationship based on the degree of control
exercised by both doctors and patients.
A. Paternalistic Doctor-patient relationship
• Paternalistic relationship is a relationship which involves high physicians control and low
patient control.
• The doctor is the dominant and acts as a ‘parent’ figure that is trusted by the patient and
decides what he or she believes to be in the patient’s best interest.
• Patients rely on doctors.
• The patient is submissive.
• The doctor is the expert and the patient is expected to cooperate.
• The doctor relies on closed questions designed to elicit yes or no answers.
• The doctor uses a disease centered model and be on reaching a diagnosis, rather than the
patients’ unique experience of illness.
• Generally, paternalism is a doctor centered style of doctor-patient relationship. It is
common traditionally.
 B. Mutuality Doctor-patient relationship
• In this consultation style, both doctors and patients bring knowledge; the
doctor brings clinical skills and knowledge and patients bring their own
theories, experiences, expectations and feelings.
• Both parties participate as joint venture on a relatively equal footing and
engage in an exchange of ideas and a sharing of belief systems.
• The doctor uses open questions to encourage the patients to talk about his
or her complaint.
• This approach relies on taking time to listen and trying to understand the
patient’s point of view.
 C. Consumerist Doctor-patient relationship
• This describes the situation in which power relationship is reversed and the
patient takes active role, whereas the doctor adopts a fairly passive role and
accedes to the patient’s request for a second opinion, referred to hospital, a
sick note, etc.
• Such a relationship mainly occurs in a competitive market situation where
doctors are dependent on patient’s good will for their business and financial
security.
• Here the patient knows exactly what they want and forces the doctor into a
patient centered approach.
 D. Default Doctor-patient relationship:
• This may occur if patients continue to adopt a passive role, even though doctors reduce some of their
control of consultation.
• This may occur because patients are not aware of the alternatives and are timid in negotiating a more
participative relationship.
• This is where the patient centered style fails. The doctor is trying to relinquish control but the patient is
unwilling to accept it. The result is impasse.
• Different types of relationship, and particularly those characterized by paternalism and mutuality, can be
viewed as appropriate to different conditions and stage of illness.
• For example, at an acute stage of illness it may be necessary or desirable for the doctor to be dominant,
whereas at later stages it may be beneficial for patient to be more actively involved and to engage in an
adult-adult relationship rather than the adult-child relationship which underlies a paternalistic approach.
• For example, patients with diabetes mellitus rely episodically on the doctor’s expertise, but are required
to assume considerable responsibility for their condition and to monitor their own blood sugar level and
alter the dose of insulin or tablets accordingly.
• However, the nature of doctor-patient relationship and the interaction that occurs in the consultation
often cannot be explained solely in terms of the patients’ medical condition.
• Other important influences are the beliefs and expectations of patients, the doctor’s clinical-practice
style and the setting within which the consultation takes place.
 Patients Beliefs and Experience of Illness
• Patients coming to medical consultation have generally been through a process of
evaluating and assessing the seriousness of their symptoms, and may have
developed their own explanations of the possible causes of their problems and the
actions required of the doctor. Their explanations can be derived from:
previous contact with medical professionals (experience),
from popular literature,
mass media, and
Advice and experience of family and friends.
• In some case patients’ beliefs and assessments differ from clinical scientific views but
can nevertheless be seen as rational when viewed in terms of the patients’ context
and experiences.
• For example, a man may be very anxious about a slight chest pain if his father died at
a young age from a heart attack and perhaps expect to be referred to hospital for a
specialist opinion.
• Patients’ concerns and assessments of the seriousness of a condition may
also be influenced by cultural values.
• Other differences may arise from the importance attached to the social
significance of medical problems in terms of their impact on patients’
everyday life.
• For example, although acne is clinically trivial and fairly common among
adolescents, it has important implications for the individual’s self-concept
and social relationships, and can thus be viewed as serious when judged in
social terms.
• Similarly, for more serious medical condition, such as epilepsy, the negative
social meanings and feelings of stigma may have a greater impact on the
patient’s life than do the medical problems directly associate with the
disease or disorder.
• Patients’ social context and experiences not only influence the meanings
attributed to symptoms but may also increase risks of illness.
• For example family problems, job problems and other adverse life events have
been shown to increase the risk of depression, abdominal pain, heart disease
and other medical problems.
• Patients who are grieving or worried may also sometimes feel ill and benefit
from the affective quality of the doctor-patient relationship, although they have
no detectable disease.
• Patients’ experiences of illness thus often have important social dimensions
and individual meanings. These feelings and concerns in turn influence their
expectations of the medical consultation and their needs for information and
reassurance.
• However, whether patients’ beliefs and feelings are made known and
responded to depend both on the doctor’s clinical-practice style and the
patients’ ability to influence the consultation.
 Doctors’ Orientation and Practice Styles
• According to Parsons, doctors’ behavior in the medical consultation is guided
by the general social and professional expectations.
• However, there are important differences between doctors in terms of
whether they define their task in fairly narrow clinical terms or are
concerned more broadly with the patients’ experience of illness.
• The difference in doctors’ orientations and practice style has important
implications for the nature of the relationship they seek to create with
patients and hence for the opportunities available for patients to participate
in the consultation rather than merely cooperate with the doctor.
Byrne and Long (1976) identified two ways of consultation styles:
‘doctor-centered’ and
‘patient-centered’.
• Doctor-centered style was characterized by the traditional paternalistic approach,
based on the assumption that the doctor is the expert and the patient is required to
cooperate.
• Doctors in this category employed tightly controlled interviewing methods aimed at
reaching an organic diagnosis as quickly as possible.
• Questions were mainly of a closed nature, such as ‘how long have you had the
pain?’ it is sharp or dull? And there was little opportunity for patients to express
their own beliefs and concerns.
• Doctors characterized by a patient-centered approach adopted a much less
authoritarian style and encouraged patients to participate in the consultation and to
express their own feelings and concerns.
• They therefore made considerable use of ‘open’ questions, such as ‘tell me about
the pain’, how do you feel? What do you think is the cause of the problem?
• They also spent more time listening to patients’ problems, picking up cues,
encouraging patients’ expressions of their ideas or feelings and clarifying and
interpreting their statements.
• Byrne and Long found that individual general practitioners could be fairly
consistently classified as holding either doctor-centered or patient-centered
consultations.
• This suggests that doctors develop a particular consulting style which they then
employ fairly consistently, and often do not vary their behavior significantly in
relation to the patient’s presenting problem, although doctors classified as
patient-centered showed the greatest flexibility.
• These different consulting styles can be linked to differences in doctors’
orientation and perception of the nature of the medical task.
• A doctor-centered approach is concerned with identifying and treating disease
through the traditional diagnostic framework and knowledge of disease
processes.
• Doctors adopting this approach thus ascertain the patient’s complaint and seek
information that will enable them to interpret the patient’s illness within their
own biomedical framework.
• Doctors adopting a more patient-centered also use these clinical skills and knowledge, but at the
same time they acknowledge that patients may have specific ideas about the causes of their
illness and expectations of the consultation, and that people may respond in different ways to
similar disease rates.
• They therefore attach greater importance to eliciting patients’ ideas, feelings, and expectations
and integrating this with their own disease-centered concerns.
• Doctors adopting a patient-oriented approach also frequently pay greater attention to the
psycho-social aspects of illness in terms of its possible social origins and to patients’ experience
of anxiety, depression and other emotional problems.
• These differences in practice style and the differing opportunities they afford for patient
participation not only characterized the clinical interview but also influence the broader
relationship between doctors and patients.
• For example, treatment decisions may be controlled by the doctor based on the belief that the
doctor as the medical expert is in the best position to act in the patients’ interests, thus giving rise
to a paternalistic relationship.
• Alternatively, doctors may adopt a more participative style, recognizing that the benefits of
different forms of treatment may depend on the patient’s own evaluations and life circumstances,
or may require that the patients assume considerable responsibility for their own treatment.
 Structural influences on the Consultation
• General practitioners frequently identify a shortage of time as the major constrain on
adopting a patient-oriented approach, with consultations averaging about 6 min
(although this obscures wide variations in the actual length of consultations, which
range from about 2 min to over 20 min).
• Pressure of time encourages a more tightly controlled doctor-centered (or paternalistic)
consultation, with the aim of reaching a diagnosis as quickly as possible. As a result,
shorter consultations have been shown to be associated with more prescriptions being
issued and fewer psychological problems identified.
• However, doctors’ practice styles probably exert a more important influence on the
content of consultations than the time available.
• Thus general practitioners with a disease-oriented approach often do not change their
practice style as a result of increased consultation time, but merely do more of the
same.
• Similarly, general practitioners with a more patient-oriented approach often prefer to
run over time, and possibly keep other patients waiting, if they feel that it is necessary to
spend more time with a particular patient.
• They may also deliberately restrict their list size, so that they are able to
provide what they regard as good-quality care. As a result, the length of time
available for consultation is itself partly a function of a practice style, as well
as serving to constrain patterns of interaction in the consultation.
• Committing sufficient time to listen and respond to patients’ worries and
concerns may also reduce the number of return visits, and hence the total
length of consultation time for an episode of illness.
• The length of consultations tends to be greater and the practice style of
doctors more patient-oriented where medical care is financed on a fee-for-
service basis.
• This is because of a fee-service-payment is often associated with a greater
availability of resources and greater priority being given to pleasing the
patient, and hence the development of a more consumerist approach.
 Patients Influence on the Consultation
• Whereas two major determinants of the nature of the doctor-patient relationship and the
interaction that occurs in the consultation are the doctors’ clinical practice style and the
structural constraints on the consultation, a third influence the patient’s ability to exercise
control and participate in the consultation.
• This active involvement in the consultation is most likely to occur when patients possess
considerable knowledge and familiarity with their condition.
• Personal characteristics of patients associated with greater participation in the consultation
include being of a high social and educational level, being a male, and not belonging to an
ethnic minority group.
• The involvement of patients has relations with the flow of information between the two
actors and satisfaction obtained from consultation.
• Doctor-patient relationships, although surrounded by general social expectations, are thus
characterized by differing degrees of control by both doctors and patients.
• The type of relationship which best promotes positive outcomes depends on the nature of
the patient’s medical conditions, and their general expectations of the consultations, and
thus requires that doctors are sensitive to the patient’s needs and concerns.
 Conflict and Control
• Medical consultations are rarely characterized by overt conflict between doctor and
patient. Nevertheless, differences in the interests, expectations and knowledge of the
lay person and the professional may give rise to tension.
• Doctors are trained to diagnosis and treat disease, whereas patients are concerned
with their personal experiences of illness and may bring to the consultation ideas and
expectations that differ from professional medical views.
• A failure to reconcile these perspectives may thus give rise to tension and
dissatisfaction.
• For example, a patient’s condition may be dismissed by the doctor as ‘trivial’, reflecting
a failure to identify the underlying reason for the consultation or the significance of the
condition for the patient.
• Patients may also have expectations for the outcome of the consultation, such as a
prescription or referral to a specialist, which may not be judged necessary by the
general practitioner. However, the doctor’s reasons for his or her chosen cause of
action may not be fully explained or accepted by patients.
• Except in situations characterized by a strong consumerist relationship, doctors retain ultimate
control of the consultation as a result of their professional status and specialist knowledge, and
their greater experience in managing the encounter.
• Nevertheless, patients may be successful in influencing the outcome of the consultation and
achieving their desired end through persuasion and negotiating with the doctor. This may involve
patients in trying to persuade the doctor that a particular type of treatment is appropriate by
presenting information in the form which they believe is likely to lead the doctor to the desired
course of actions.
• Doctors, rather than accepting patients’ requested or suggested course of action, may in turn try to
convince patients that their approach is best.
• This may involve overwhelming patients with evidence in the form of laboratory tests, or their own
previous experience in treating patients with similar types of conditions, in support of their chosen
course of action, perhaps accompanied by a warning of the likely consequences of neglecting their
advice.
• In some situations either the doctor or patient manages to achieve their desired outcome, but
often a compromise or temporary agreement is reached.
• For example, a patient may agree to try a course of tablets on the understanding that if they do not
achieve a beneficial effect within a specified time they will then be referred for a specialist opinion.
• Control of the consultation may be exercised not only through verbal techniques but also
through non-verbal behaviors.
• It is estimated that in a two-person conversation, the verbal component carries less than 35%
of the social meaning of the situation, and 65% or more is carried by the non-verbal
component.
• Nonverbal cues in the consultation, as in other forms of interaction, contribute to the rapport
between doctor and patient and influence the amount of information exchanged.
• For example, by looking interested, nodding encouragingly and other gestures doctors can
provide positive feedback to patients, whereas by continued rifling through notes, twiddling
with pens, or failing to look directly at patients, they may convey disinterest and result in
patients failing to describe their problems.
• Interaction is also influenced by the seating and relative positions of doctors and patient in
the consulting room.
• Carrying out certain diagnostic tests which require the doctor’s attention and concentration is
also in itself an effective way of silencing a patient.
• Non-verbal techniques may also be used to serve as a signal that the consultation has ended,
as for example when doctors write out a prescription, rise to their feet or hold open the door.
 Communication and Satisfaction with the Consultation
• A major critics of medical care by both general-practice and hospital patients
concerns the lack of information and explanation. It affects understanding
prescription and dissatisfaction.
• Many studies also show that doctors have communication problems. These
problems of communication have resulted in greater priority being given to
teaching doctors communication skills, with the aim of making their
communication clearer and better organized so that patients will comprehend
it, remember it and feel satisfied that they have been informed.
• Successful, communication, however, also depends on the perceived relevance
and importance of what is being communicated and whether it makes sense in
terms of patients’ own beliefs and concerns.
• This requires that an exchange of views takes place, so that doctors are aware of
and can respond more directly to patients’ expectations, ideas and concerns.
• Doctors are often not aware of whether or not patients are satisfied with
the consultation since, whatever their views, patients may retain a
deferential attitude reflecting the traditional expectations of the patient
role.
• Thus they rarely express their dissatisfaction or tell the doctor when they
disagree with his or her advice or have no intention of following it.
• Indeed, some patients regularly attend for repeat prescription even if they
do not take the medication or take it only irregularly, in order to keep up the
appearance of being a good patient.
 Changes in the Doctor-Patient Relationship
• A number of changes are encouraging greater patient control and participation
in medical care.
• One change is that people are becoming more knowledgeable about health
matters. This partly reflects the greater emphasis on individual responsibility for
health and the increasing attention to health issues given by the media.
• A number of general practices and hospital clinics also now make case notes
available to patients, which promote patients’ knowledge and confidence in
asking questions and contribute to a more equal relationship with the doctor.
• More generally, medicine like other areas of life is increasingly characterized by a
questioning of professional authority.
• Maternity care forms one area in which a consumerist approach has been
particularly strong and has resulted in more account being given to individual
women’s needs and choices in decisions regarding pain control and other
aspects of their care.
• Another source of change arises from doctors’ changing perception of their
role.
• This is seen in the greater readiness of doctors to disclose a terminal illness
and trend, especially in the USA, for patients to be increasingly involved in
decisions regarding treatment, especially in situations where the benefits and
risks of different therapies and procedures are uncertain.
• This change reflects a greater acceptance of a participative approach to
medical care, as well as increased fears of malpractice claims which
emphasize the importance of joint responsibility and promoting patients’
feelings of confidence and trust in the doctor.
• Many general practitioners are also extending their role beyond the
traditional disease model to engage in counseling, health education and other
activities requiring more active involvement by patients, while homeopathy,
acupuncture and other forms of alternative medicine are gaining acceptance.
• Structural changes which have implications for the doctor-patient relationship include
the growth of private medicine, which forms a small but expanding component of
medical care in many countries.
• The introduction of private health care and its expansion lead to competition between
hospitals both in terms of both price and quality, with one indicator of quality being
patients’ evaluations and satisfaction with the organization and process of care.
• Change in general practitioners’ income, the wide availability of information about
practices which will enable patients to be more selective in their choice of doctor.
• These trends suggest the patients will continue to become increasingly better
informed about health and medical matters and that doctors working at both general-
practice and hospital level will attach greater importance to the patient’s perspective
and to the broader social context of disease.
• This is likely to produce a greater participation of patients in the consultation and in
medical decision-making and thus in relationships characterized as mutual, as well as
a greater concern in the health service with patients’ evaluations and satisfaction with
health care.
 Chapter Four: Health care system

4.1 Introduction
• Health care is the prevention, treatment, and management of illness and the
preservation of mental and physical wellbeing through the services offered
by the medical, nursing and allied health professions.
• Health care embraces all the goods and services designed to promote health,
including preventive, curative and palliative interventions, whether directed
to individuals or to populations”.
• The organized provision of such services may constitute a health care system.
• Before the term “health care” became popular, English-speakers referred to
medicine or to the health sector and spoke of the treatment and prevention
of illness and disease.
• In most developed countries and many developing countries health care is
provided to everyone regardless of their ability to pay.
 4.2 Types of Health care
• There are different types of health care. This ranges from self-care (dealing with the symptoms by
oneself) to obtaining professional help.
A. Self-care
• Sometimes patients treat their illness by themselves. Most patients have knowledge of how to treat
common conditions: a bruise, a cut, a headache, a bad cold, etc.
• Self-care is important in prevention than care.
• In prevention, it focuses in awareness creation of people to take responsibility in preventing disease.
• It helps to reduce morbidity, and costs of individual and health service providing organizations for
therapeutic intervention.
• However, it has its own problems:
First, if people are persuaded to take responsibility for their health, there can be unforeseen cost if it
fails, because in a sense they are then responsible for their illness. This out-come has been called
“victim-blaming”.
Secondly, many individual measures are ineffective in the face of socio-structural causes of ill-health
such as social class, poverty, unemployment, etc. Moreover, an emphasis on the supposed value of
individual measures deflects attention from both wider social deprivation and other problems on to
the individual.
 B. Family care
• Relatives, household members and friends can offer support and advice and a
form of lay nursing if required. A child treatment in times of illness can be
good example.
• Family care is obtaining help and support from family. It is available for family
members. Industrialization reduced strong family sentiment and some groups
like elderly are not receiving adequate help from family in western society.
• The main problem of family care is increase in costs of family, especially
women (burden on family, especially women). But the role of women has
been changing rapidly and it is becoming increasingly unreasonable to expect
wives and daughters to devote themselves full-time to the care of other
members of the family units.
 C. Community care:
• Family and household care for many illnesses place a great burden on the
family. The idea of community care emerged in the 1950s particularly in
response to the discharge of patients from large mental hospitals.
• Community care is care in the Community in contrast to care in an institution.
The resources of the Community are mobilized to help patients.
• With adequate resources, general practitioners can manage more health
problems in the community without the patient being hospitalized.
• The community or district nurse can treat problems in the patient’s own
home which would otherwise have required hospital nursing care.
• These increase the power of cares to look after more people in the
community.
 However community care suffers from the following limitations:
i. Community care is often underfunded. The resources going to community
care are wholly inadequate and it is left to the family and individuals to pick
up the pieces.
ii. Community care requires coordination and collaboration between various
health and welfare agencies. Liaisons are not available between general
practitioners and social workers. Thus who should be responsible to organize
it is another problem of community care.
iii. Professional interest tends to support the status quo, especially the pre-
eminence of hospital funding. Encouraging community care usually means
the reallocation of resources away from the hospital sector, and for this
reason is often resisted.
iv. Community care, by the community, depends on the willingness and ability
of the community to cope. The burden usually falls on families, particularly
their women members.
 D. Self-Help Groups
Some disease and illnesses pose particular problems for care.
These problems may be of a material nature, for example the illness may be physically
disabling, or psychological.
Self-help groups help patients in especial need and fill the gap of health service
deficiencies. It is the most successful one.
E. Professional Care
• Professional care might be defined as health care delivered by people in part or full
time employment in a health care capacity.
• It is a care given by trained professionals.
• Professional care can be primary Vs. secondary.
Primary care is a care provided for patients as a point of first contact with the health
service. It is general that help to cope with present problem.
On the other hand, secondary care is a care provided based on hospitals by
specialized person.
 4.3 Access to health care
Not all members of human society have an equal entitlement to health care.
There are inequalities in access to health care. Three forms of inequalities have
been identified. These are:
i. Geographical inequality
ii. Social class inequality
iii. Specialty inequality
i. Geographical inequality
a) Hospitals or health service centers are not distributed fairly in urban and
rural area
b) Disparity in distribution of health centers
 Developing countries – poor access to health care
Developed countries – better access to health care
 ii. Social class inequalities
Lower Social classes have poor health conditions.
The poor have greater health need.
They have less consult with health service.
They have fewer health resources, and
They under use the health service relative to their need.
iii. Specialty inequality
• absence of specialty and lack of basic amenities such as reasonable food and
living conditions in some areas such as mental and physical handicap,
geriatrics and parts of psychiatry results in a distortion of priorities in the
provision of care.
 4.4 Health care systems
• Human beings have come up with a variety of explanations for what causes
disease and how to care it.
• In fact, because it is complicated, unpredictable, and frightening, societies
often have a number of disease theories in order to increase their chance of
finding a cure.
• In this part, the health care beliefs and practices of personalistic, naturalistic
and scientific health-care systems as well as those of Chinese and Holistic
medicine are presented.
 4.4.1 Personalistic Health Care Systems
• Small hunting and gathering bonds often had animistic religions, meaning that
they believed souls or spirits lived in the world and did good or bad things to
people.
• Hunters and gathers applied this animistic conception to disease and
concluded that disease was an unnatural condition sometimes caused by
spirit intrusion, that is, invasion by an outside force such as a spirit, agent, or
ancestor’s soul that still roamed the world.
• According to personalistic health care systems, disease is believed to be
caused by the active, purposeful intervention of a sensate being.
• In some cases, the evil agent was believed to be directed by a human being
such as a witch or a sorcerer.
• Another cause of disease, in the view of hunter- gathers, was improper
behavior on the part of the patient, a break of taboo, which displeased a
spirit or ancestor’s soul.
• Healers in these personalistic systems are shamans, a combination of
doctor and religious leaders, or diviners, people knowledgeable about the
spirit world.
• In their healing capacity they can serve as agents of social control by
defining illness as a sign that people have not been behaving properly.
• Their medical recommendation might be for people to behave according to
the accepted moral code of their society in order to cure or prevent
disease.
 4.4.2 Naturalistic Health Care Systems
• In the pre-industrial, agricultural societies of china, Greek, and India, health-care systems
developed that relied much more heavily on natural forces as explanations of illness.
• Naturalistic medicine considers disease as largely the result of the impersonal working of forces
in nature or the body.
• Supernatural processes work, but disease is basically a natural process that human beings can
understand and influence. In such belief systems, the body is seen as made up of a number of
elements; health results when these elements are all in the proper balance, or equilibrium.
• Disease occurs when the elements fall out of balance.
• Depending on this health system, the elements in the body might be heat, Cold, humors (fluids),
or something else.
• These elements fall out of balance because of excessive heat or cold in the person’s
environment, a poor diet, or excessive emotion.
• The healers in naturalistic health care systems are physicians or herbalists who are trained in the
remedies that can restore the body equilibrium.
• The healers are skilled practitioners who learn their art through training and apprenticeship.
• Surgery is not common. The healers focus on treatment by changing diet, bleeding or purging.
 4.4.3 Chinese Medicine
• Present-day Chinese medicine is a good example of a medical system that has incorporated a lot of scientific
medicine while retaining many traditional Chinese beliefs about health and disease.
• It is a mixture of naturalistic health care systems and scientific medicine.
• Traditional Chinese medicine is a good example of naturalistic health care system.
• According to health philosophy of china, the universe evolved from basic elements or forces. These elements are
yin and yang.
• These two forces lie behind all natural phenomena including the human body.
• Yang is heat and can cause fever, whereas yin is cold and cause chills.
• But yin and yang constitute a single entity in an individual, and the proper balance of each is essential to health.
• Another important concept is the notion of chi, or vital energy that flows through the body.
Healers in china have a number of procedures to influence the balance of the yin and the yang. These are:
 Acupuncture – fine needles are inserted into the body at key points to influence the flew of chi in the body,
 Acupressure – uses finger tops on the same points to apply pressure, and
 Moxibustion – sticks made of rolled leaves burned over points of the body for varying periods of time. The heat
produced is thought to influence the flow of chi in the body.
In modern china, scientific medicine and traditional Chinese medicine are used together to diagnose and treat
disease.
 4.4.4 Scientific health care systems
• Scientific health care systems view disease as a natural process caused by
specific biological factors responsible for each disease.
• Medical knowledge is based on scientific research rather than religious
tradition.
• Unlike naturalistic medicine, scientific medicine admits of no spiritual or
super natural role in the diseases process.
• Disease is caused by natural biological forces, and social and emotion forces
as seen as secondary or unimportant.
• Healers in scientific medicine are extensively trained physicians with a
thorough knowledge of anatomy, physiology and biology.
• The physicians have responsibility for diagnosis and cure, and the patient is
in a relatively passive role.
 4.4.5 Holistic Medicine
• Holistic medicine is an effort to provide for the whole needs of sick people by
using not only scientific medicine but also any other healing systems that devote
attention to people’s emotional, social and spiritual needs.
• Holistic healing assumes that a person constitutes a single biological,
psychological, and social unit and that disease can be effectively treated only if all
three aspects are considered.
• In holistic medicine, the unique needs of each individual are addressed, and
there is an emphasis on educating the patient in order to encourage people to
take care of themselves rather than become overly dependent on scientific
healers.
• Holistic healing does not shy away from using healing techniques that have not
been accepted by scientific medicine.
• It might use chiropractic, homeopathy, naturopathy, spiritual healing, herbal
therapy or a range of other interventions that scientific medicine believes to have
little therapeutic value.
 4.5 Public Health
The term “public health” came into general use around 1840. It arose from the
need to protect the public from the spread of Communicable diseases.
In 1920, C.E.A. Winslow, former professor of public health at University, gave
the most quoted definition of public health:
“ the science and art of preventing disease, prolonging life, and promoting
health and efficiency through organized community efforts for the sanitation of
the environment, the control of communicable infections, the education of the
individual in personal hygiene, the organization of medical and nursing services
for early diagnosis and preventive treatment of diseases, and the development
of social machinery to ensure for every individual a standard of living adequate
for the maintenance of health, to organize these benefit as to enable every
citizen to realize his birth bright of health and longevity.
There are two distinctive characteristics of public health. These are:
i. It deals with preventive rather than curative aspects of health, and
ii. It deals with population-level health issues, rather than individual-level
health issues.
• Public health has not made headway in terms of sanitary reforms and
control of communicable disease in developing countries such as Asia and
Africa.
• But it has made tremendous strides in the industrialized western countries
resulting in longer expectation of life and significant decline in death rates.
• As a result of improvements in public health during the past 50 or 60 years,
public health moved from sanitation and control of communicable disease
(which have been largely controlled) to preventive, therapeutic and
rehabilitative aspects of chronic diseases and behavioral disorders.
• A EURO symposium in 1966(8) suggested that the definition of public health
should be expanded to include the organization of medical care services. This
was endorsed by another expert committee of WHO in 1973(9).
• Thus modern public health also includes organization of medical care, as a
means of protecting and improving the health of people.
• Since the organization of public health tends to be determined by cultural,
political and administrative patterns of the countries, there is a wide mosaic
of organizational arrangements.
• Public health, in its present form, is a combination of scientific disciplines (eg
epidemiology, biostatistics, laboratory sciences, social sciences, demography)
and skills and strategies (eg. Epidemiological investigation, planning and
management, intervention, surveillance, evaluation) that are directed to the
maintenance and improvement of the health of the people.
• With the adoption of the goal of “Health for All”, a new public health is now
evident world-wide, which may be defined as: “the organized application of
local, state, national, and international resources to achieve “Health for All”,
i.e., attainment by all people of the world by the year 200 of a level of health
that will permit them to lead a socially and economically productive life.”
• Although the term “public health’ has its original meaning, the term is still
widely used.
• The like preventive medicine, social medicine and community medicine are
used as synonyms for public health.
• Public health is not only a discipline but has become a “social institution”
created and maintained by society to do something about the death rate and
sanitary conditions and many other matters relating to life and death.
• In this sense public health is both a body of knowledge and also a means to
apply the knowledge.
 Community Health
• The term “community health” has replaced in some countries, the terms
public health, preventive medicine and social medicine.
• A EURE symposium in 1966 defined community health as including, “All the
personal health and environmental services in any human community,
irrespective of whether such services were public or private ones”.
• In some instances, community health is used as a synonym for
“environmental health.
• It also used to refer to community health care; therefore, a WHO expert
committee in 1973 observed that without farther qualification, the term
community health is ambiguous and suggested caution in the use of the
term.
 Changing Concepts in Public Health
In the history of public health, four distinctive phases may be demarked:
a. Disease Control Phase (1880-1920)
• Public health during 19th century was largely a matter of sanitary legislation and sanitary
reforms aimed at the control of man’s physical environment, eg water supply, sewage
disposal, etc; clearly these measures were not aimed at the needed technical knowledge.
However, these measures vastly improved the health of due to disease and health.
b. Health Promotion Phase (1920-1960)
• At the beginning of the 20th century, a new concept, the concept of health promotion
began to take shape. In addition to disease control activities, one more general goal was
added to public health, that is, health promotion of individuals. It was initiated as personal
health services such as mother and child health services, school health services, industrial
health services, and mental health and rehabilitation services.
• Since the state has assumed direct responsibility for the health of the individual, two great
movements were initiated for human development during the first half of the present
century. The movements are provision of basic health services through the medium of
primary health centers and subentries for rural and urban areas.
 c. Social Engineering Phase (1960-1980)
• The advancement of preventive medicine in developed countries helped them
to control acute disease and acute illness problems have been brought under
control.
• However, new forms of health problems in the form of chronic diseases began
to emerge, for example, Cancer, diabetes, cardiovascular diseases, alcoholism,
and drug addiction, particularly among affluent societies.
• These problems could not be tackled by the traditional approaches to public
health such as isolation, immunization and disinfection nor could these be
explained on the basis of the germ theory of disease.
• A new concept, the concept of ‘risk factors’ as determinants of these disease
came into existence.
• The consequence of these diseases, unlike the swift death brought by the acute
infectious diseases, was to place a chronic burden on the society that created
them.
• These problems brought new challenges to public health which needed reorientation
more towards social objectives.
• Public health entered a new phases in the 1960s, described as the ‘social engineering’
phase. Social and behavioral aspects of chronic disease and health were given a new
priority.
• Public health moved into the preventive and rehabilitative aspects of chronic diseases
and behavioral problems.
d. Health For All Phase (1981-2000)
• As the centuries have unfolded, the glaring contrasts in the picture of health in the
developed and developing countries came into sharper focus, despite advances in
medicine.
• Most people in the developed countries and the elite of developing countries enjoy all
the determinants of good health, adequate income, nutrition, education, sanitation,
safety drinking water and comprehensive health care.
• In contrast, only 10-to-20% of the population of developing countries enjoys better
access to health services of any kind.
• Death claims 60-250 per 1000 live births. Life expectance is low in
developing countries.
• There is a health gap between the rich and the poor within countries and
between countries.
• Understanding these health gap, in 1981 the members of WHO pledged
themselves to an ambitious target to provide Health for all by the year 200,
that is attainment of a level of health that will permit all peoples to lead a
socially and economically productive life.