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Sociology and Public health perspectives for application

Article  in  American Journal of Public Health · March 1972

DOI: 10.2105/AJPH.62.2.147 · Source: PubMed

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This is the first of a series of occasional reviews which
will survey recent research in various fields and endeavor
to indicate their possible usefulness to the public health
practitioner. We begin with a study of sociological analyses
and their practical relationship to public health practice.

Sociology and Public Health:

Perspectives for Application
Introduction
Much of the content of sociology directly con- David Mechanic
cerns man's adaptation to his changing environment and,
thus, this field has important implications for public health
practice. No such review can do justice to the variety of ceptives to unmarried women for the purpose of birth
perspectives and recent research efforts that can be useful control. Many women who do not wish to bear a child
to the public health practitioner, but it is possible to review become pregnant, yet find it difficult to obtain an abortion
briefly some major perspectives and some examples of despite a recent ruling of the Federal District Court to the
research that illustrate how an appreciation of sociological effect that forbidding an abortion is an abridgement of
variables can assist the public health practitioner. women's constitutional rights. The medical profession-
Initially, it is helpful to note how the perspectives including those affiliated with public health-has, at best,
of sociology and public health differ. While public health is sat on its hands, and some organized medical groups and
an applied endeavor that imposes normative criteria which
it then attempts to implement, the sociologist's major hospitals have continued to resist change in traditional
concern is with understanding social phenomena inde- approaches to the problem. Here one might see a variety of
pendently of the immediate value of such understanding. public health problems implicit in the situation depending
This difference in perspective was made clear by Edward on one's perspective. Is the problem one of promiscuity and
Rogers' challenge to sociology' to present its findings in a a growing lack of responsibility among the young, or is it
fashion that allow transformation in the form of public the intransigence of the State Medical Society and the
health programs. But if the sociologist restricted or even physicians in the State? Should our major concern be the
concentrated his efforts on those causes where intervention growing rate of illegitimacy and dependency, or the failure
seems possible, his horizons would be limited indeed. The of the Legislature and the system of medical care to
pervasive belief that all public health problems are dysfunc- respond more expeditiously to people's concerns and self-
tions, which can and must be remedied, rather than part of defined needs? The practice of public health embodies
a complex pattern of adaptation to changing life conditions some system of morality, and part of the sociological effort
and social patterns is in itself a value2 that tells us more must be devoted to examining this morality and its priori-
about the public health practitioner and his priorities than ties relative to competing definitions. It may be that our
about the nature of social life. concept of public health constitutes part of our problem.
The issue of values is fundamental to the entire Despite such issues, there are circumstances where
question of sociological knowledge and application. As considerable consensus exists as to the undesirability of
Elinson and Herr3 suggested in their reply to Rogers' chal- particular conditions prevalent in the community. Although
lenge, much of the difficulty in bringing sociological knowl- values come into play in a wide variety of ways, as I pro-
edge to bear in public health efforts may be the product of ceed in this discussion I shall work on the assumption that
the limited way in which the practitioner poses the issue. It there is substantial agreement on certain basic values
may be the practitioner himself who is part of the relevant to problems of public health; and I will develop
problem-by defining certain relatively "benign" behaviors particular themes that may be of assistance to the practi-
of others as problems, by projecting responsibility to clients tioner.
rather than to the social institutions that serve them, or by
allowing his values to limit considering the real range of Population Distribution and Selection
options for improving the life and health of people.
The general problem can be illustrated by review- Basic to public health is an understanding of the
ing the current ferment concerning abortion reform. In the signifi'cance of the distribution of populations over time
State of Wisconsin, like elsewhere, sexual attitudes and and the various factors affecting fertility, mortality, migra-
patterns have radically changed over the generations, but tion, and social and genetic selection. Public health practi-
the law continues to define contraceptives as lewd and tioners, however, sometimes seem less aware that social
indecent articles, and forbids physicians to prescribe contra- selectivity is a continuing and persistent process that affects
146 A.J.P.H. FEBRUARY, 1972
such varied matters as organizational participation, health serious consequences and a high probability of occurrence.
maintenance behavior, utilization of medical and other He further believes that such behavior emerges from con-
institutional facilities, educational achievement, and almost flicting goals and motives, and that actions will follow those
every other aspect of social and community life. Any prac- motives which are most salient and those goals which are
titioner will tend to observe such selection processes from a perceived as most valuable. Similarly, Zola,26 approaching
particular vantage point, and he tends to form images of the problem from a somewhat different perspective, has
behavior that are constructions from a particular selected delineated five timing "triggers" in patients' decisions to
population.46 By the nature of his position he is more seek medical care. The first pattern he calls "interpersonal
likely to come into contact with people who take advantage crisis," where the situation calls attention to the symptoms
of a particular program or those who seek a service, and and causes the patient to dwell on them. The second
such contacts are likely to influence his perceptions more "trigger"-social interference-comes into play when
than the actual patterns of behavior existing in the popula- symptoms threaten a valued social activity. Similarly, he
tion at large. The constructions the practitioner develops argues, action is precipitated by social pressures of others,
guide him in the options he adopts and those he neglects, perceived threat, and the nature and quality of the symp-
and influence profoundly his perceptions of situations. toms. Zola reports the impression that these "triggers"
The continuing awareness that one's own percep- have different degrees of importance in varying social strata
tions are molded by the context within which one works is and ethnic groups.
nonspecific, but it nevertheless can be helpful because it Both of the above theories of health behavior
alerts the practitioner to preventable errors and promotes focus exclusively on the client, and give little attention to
continuing and serious scrutiny of the important forces in the manner in which characteristics of helping institutions
the environment affecting his work. In dealing with clients, affect the client's behavior and response. But the client's
such awareness facilitates considering not only the manifest behavior may be strongly affected by the nature of services
issue, or the client's presenting complaint, but also the and how they are provided, and such factors as the avail-
larger context within which the problem occurs and how it ability and proximity of treatment resources, psychological
can be dealt with. Such concern with populations and selec- and monetary costs of seeking treatment, stigma, social
tivity within populations has been basic to public health distance, and the like all may affect the client's orientation.
application, and the continuing development of this per- While it is true that people's responses to health and illness
spective will have even more relevance in the future than in are often conditioned responses to prior background and
the past. experience, the health services system has the capacity to
modify such behavior patterns. It can foster dependency or
encourage self-reliance. It can respect and enhance the
Social and Cultural Aspects of Preventive Health and Illness dignity of persons or contribute to stigmatizing and
Behavior humiliating them. As interesting as social and cultural
It is widely appreciated that there are cultural and precursors of health and illness behavior may be, we should
social variations in the manner in which persons define not neglect the fact that considerable potential for making
health problems, participate in health maintenance pro- the delivery of services more congruent with need exists
grams, and utilize medical and other health services.7 For through the proper organization of health care services.
example, there is considerable evidence that socioeconomic Barriers to medical and health care that are a
factors are related to knowledge about disease, use of product of the way health professionals and health care
medical and dental services, acceptance of preventive health services function are more amenable to change than client
practices, purchase of voluntary health insurance, delay in attitudes and behavior. There is evidence that when cost
seeking treatment, and use of folk remedies and self- and other barriers are removed from access to medical care,
medications.823 Such socioeconomic variations encompass and a valuable service is offered, differential utilization of
variations among populations in health values, under- medical services by social class largely disappears. For
standing of disease processes, future and preventive plan- example, socioeconomic differences in the use of medical
ning, cultural expectations, and feelings of social distance services comparable to those traditionally found in the
between oneself and health practitioners.24 The previously United States do not exist in Great Britain, where services
cited research also suggests that impoverished persons feel are provided without cost and on the basis of need.2 7 It is
less at ease in medical settings than more affluent persons, significant that in the United States, when public health
have less understanding of how practitioners operate, and and research programs offer a free service to a particular
are less willing to question their treatment. population such as in the National Health Examination
Underlying these observed relationships are various Survey2 8 or in the Baltimore Morbidity Survey,2 9-3 0
social psychological processes which have yet to be fully persons of lower socioeconomic status and nonwhites (the
examined. In recent years various models have been sug- two groups with the lowest level of utilization of services
gested to explain processes underlying the relationship on a national basis) are usually overrepresented in their
between socioeconomic factors and health and illness participation as compared with other population groups.
behavior. Rosenstock,2 5 for example, giving emphasis to a Finally, more recent data from the National Household
motivational model, has argued that preventive health Morbidity Survey shows that the unfavorable position of
behavior relevant to a given problem is determined by the the lowest socioeconomic groups in respect to physician
extent to which a person sees a problem as having both visits has improved.3 1 These data suggest that government

SOCIOLOGY AND PUBLIC HEALTH PERSPECTIVES 147

expenditures (particularly Medicare) have contributed The frequently heard complaint of physicians to
toward the reduction of barriers to medical care. the effect that too many of their patients present trivial
The importance of client response is evident, but complaints or that they are hypochondriacs is a manifesta-
such differential client response tends to operate within tion, in part, of the practice of medicine itself. Modern
limits. Various studies show that social and cultural influ- medical practice is characterized by growing demand on
ences have maximal impact on utilization behavior when limited manpower and increasing specialization of medical
the condition has a mild or moderate impact on the person functions. As doctors become more specialized, they are
and when the symptoms are identifiable, familiar, and less interested in and less capable of meeting the more
easily explained. As the impact of the symptoms becomes diffuse needs of patients, particularly those suffering from
more dramatic-and to the extent that the symptoms are psychological distress and those with physical conditions
unfamiliar, unpredictable, and threatening-the effect of vastly complicated by psychological and social factors.
social and cultural factors on help seeking appears to be Such patients are difficult to treat under the best of condi-
very limited.32-34 Social and cultural patterns, as they tions, but there are indications that they do well in a
affect health and illness behavior, are particularly important continuing supporting relationship with a physician who
in the case of serious conditions that do not have a dra- demonstrates concern and interest in their life situations.3 8
matic onset and have early symptoms which are common to However, in accommodating to technological
a wide variety of more familiar and self-limited conditions. change and growing patient demand, medicine is increas-
ingly more bureaucratized, resulting in greater frustration
of such patients' needs. Bureaucratic organization of medi-
Consequences of Medical Labeling and Response cine is essential in insuring a high level of technical care that
is distributed efficiently, but it is a poor instrument for
Practitioners frequently think of their activities as dealing with the psychological needs of difficult patients.
purely medical and sometimes fail to consider the social As doctors continue to become even more specialized and
and other practical consequences of medical decisions and more occupied by growing patient demand for services,
clinical judgments. Although such risks have always been they tend to insist more than ever before that their
evident in the practitioner's work, they are very much patients' illnesses fall within the narrow limits of the medi-
exacerbated as medicine becomes a more highly organized cal disease model.3 9
activity under growing bureaucratic sponsorship. These difficulties in medical care are frequently
Medical judgments and decisions affect the fate of recognized, but one of the major problems we face is how
people by influencing their social opportunities and to rationalize and organize medical services so that they are
potentialities.3 Such influences occur in two ways: more efficiently distributed and, at the same time, respon-
through affecting the patient's attitudes, self-perceptions, sive to the personal needs of particular groups of patients.
confidence in his capacities and, therefore, his degree of Some health organizations have attempted to develop new
activity; or through defining the patient in such a fashion so roles for social workers and nurses who take on important
that he is systematically discriminated against or excluded responsibilities for various aspects of personal care.4O Such
from various community opportunities. Obvious cases such mechanisms, thus far, have been less than fully effective,
as mental patients or epileptics immediately come to mind, for many people wish to have the doctor rather than other
but the relevant processes far transcend these particular protessionals deal with their problems.4" It is likely that
groups of parents and have persistent effects on the attacking this problem will involve not only the transfer of
rehabilitation and community functioning of many kinds of functions' to workers well-trained to deal with specific
patients, including persons with heart disease, renal disease, tasks, but also concerted efforts to legitimize such role
cancer, and other conditions as well. distributions from the perspective of clients. The latter task
In situations where patients have had continuing may turn out to be more difficult than the former.
relationships over time with a personal doctor, such
patients were usually protected from obvious discrimina-
tion because of medical reasons, although they might have
suffered iatrogenic disease as a consequence of the doctor's Interactions, Communication, and Inducements
failure to consider social factors as part of his clinical assess-
ment. But as medical contexts become more bureaucratic, The suggestive powers of the physician are very
and as knowledge of the patient's difficulties is shared by a substantial, and doctors and other health workers are in a
wide variety of people, the possibilities and dangers of position to substantially reduce the stress their patients
communication of medical judgments and their misuse experience by small gestures and behaviors that show an
increase, and the need to develop new protections grows. awareness and concern for the paticnt.
It is essential to appreciate the extensive variation Egbert and his colleagues,42 for example, selected
in disability and community adjustment among patients a random group of patients undergoing surgery and gave
with comparable disease. The patient's definition of his them simple information, encouragement, and instruction
condition and the social resources available to him affect concerning their impending surgery and means of alleviating
the extent of his adjustment to work, social relations, and postoperative pain. The researchers, however, were not
family life, and condition his productivity, life satisfaction, involved in the medical care of the patients studied, and
and the demands he makes on the health care system.3&37 they did not participate in decisions concerning them. An
148 A.J.P.H. FEBRUARY, 1972
independent evaluation of the postoperative period and the Influence of Professionalization and Professional Controls
length of stay of patients in the experimental and control on Treatment Values
groups showed that this communication and instruction
made a real difference. This is consistent with the research We usually think of professionalization as a vehicle
of Janis,43 which demonstrated that preoperative fear was for improving the quality of health services. We assume
correlated with postoperative reactions among surgical that, as the health worker incorporates the values of his
patients. professional group and subjects himself to the evaluation of
In a similar experimental study by Skipper and his colleagues, he is directed toward worthy goals and in-
Leonard,44 children admitted to a hospital for tonsillec- sulated from improprieties. One of the difficulties with this
tomy were randomized into experimental and control perspective is that professionals often become involved with
groups. These groups differed in that in the experimental their own subcultures which protect professional
group patients and their mothers were admitted to the autonomy, define professional work in terms of the exer-
hospital by a specially trained nurse who "attempted to cise of particular skills, and develop reward structures that
create an atmosphere which would facilitate the communi- tend to accord highest prestige and acclaim to those who
cation of information to the mother, maximize freedom to excel by professional criteria.46 Since medicine as an activ-
verbalize her fear, anxiety and special problems, and to ask ity tends to give high priority to technical and scientific
any and all questions which were on her mind. The infor- skills, and defines tasks associated with such skills as most
mation given to the mother tried to paint an accurate interesting, it is not surprising that doctors develop such
picture of the reality of the situation. Mothers were told orientations.
what routine events to expect and when they were likely to The development of technical skills is extremely
occur-including the actual time schedule for the opera- valuable but, if overemphasized, it may lead to neglect of
tion." The investigators found that the emotional support more important social priorities which doctors may recog-
reduced the mothers' stress and changed their definition of nize, but define as uninteresting opportunities from a pro-
the hospital situation, which in turn had a beneficial effect fessional point of view. While doctors may objectively
on their children. Children in the experimental group recognize that many of the efforts devoted, for example, to
experienced smaller changes in blood pressure, temperature, heart transplantation if rechanneled to other problems,
and other physiological measures; they were less likely to such as differentials in infant mortality, might yield large
suffer from postoperative emesis and made a better adapta- relative benefits, the technical problems in heart trans-
tion to the hospital; and they made a more rapid recovery plantation are defined as professionally exciting, while
following hospitalization, displaying less fears, less crying, routine primary care is seen as mundane and uninteresting.
and less disturbed sleep than children in the control group. Similarly, in psychiatry, rehabilitation is defined as intel-
In short, a little sympathy, support, and instruc- lectually unexciting and routine while psychotherapy,
tion can have great benefits. More frequently than not, which is of questionable efficacy, is seen as interesting, thus
those who endorse the idea that the doctor should provide justifying the tremendous imbalance of resources between
sympathy and support to the patient do so on the belief these two fields.4 7
that this is a noble and human thing to do. It is much less Given the ways doctors and other professionals are
rarely appreciated, however, that establishing such relation- trained, it is not surprising that they seek opportunities that
ships with patients facilitates the informational process allow them to exercise and develop their technical skills and
between doctor and patient, and contributes in an to avoid tasks, no matter how important, that are seen as
important way to the management of the patient and his mundane and unchallenging.4 8 This problem is particularly
progress toward recovery. To neglect, therefore, important exacerbated where primary care functions are not struc-
facts that have bearing on these processes because they are turally differentiated from more specialized medical activi-
of a social or psychological sort increases errors in predic- ties. In countries where such separation is enforced by the
tion on the part of physician and inefficacy in the manage- nature of medical organization, those performing what are
ment of his patients. viewed as lesser skills are often dissatisfied, in part, by their
Another aspect of the same problem concerns the lower status, but the tasks are more likely to be met.4 One
inducements and encouragement provided by health way of approaching this problem would be to functionally
workers and health institutions that facilitate patient separate tasks requiring lower levels of skill and assign them
activity and motivation for mastering their problems. A to other health personnel, but this too raises problems of
substantial literature has accumulated that documents the the segmentation of care, the acceptability of new health
way large impersonal hospitals allow inactivity, encourage workers, coordination of services, licensing difficulties, and
dependency, and lead to various forms of skill deterioration the like.
and hopelessness.4 5 The relationship between a health An important source of professional values is the
worker and patient can serve as a powerful instrument to training experience itself and the models of practice avail-
facilitate or retard the patient's social functioning, his sense able to students within the training context. Practice con-
of potency and potential, and his willingness to struggle sistent with values will depend, of course, on the situational
against his illness. The failure to use these inducements and aspects of the health worker's practice once his training is
supports as a rehabilitative technique is as serious as the completed.5 0 Medical education and the more profes-
failure to prescribe necessary medication or to initiate other sionalized nurses training programs emphasized the acqui-
necessary medical precedures. sition of technical skill and capacities in contrast to giving

SOCIOLOGY AND PUBLIC HEALTH PERSPECTIVES 149

 focus to meeting community needs and goals. It would be izing personnel and patients, and the character of profes-
unrealistic to expect educational institutions, which have sional and other work incentives, the basic organizational
very special functions, to forego the development of their problems are very similar from one medical setting to
students' technical skills, but it is essential that such insti- another.5 2 These problems are largely associated with the
tutions provide realistic and acceptable models of practice adjustments demanded by changes in the character of
as part of their training to allow their students to respond medical technology and the need for special skills on the
in meaningful ways to the health care needs of the com- one hand and the human problems inherent in organiza-
munity once they graduate. tional functioning within bureaucratic contexts on the
other.
The Influence of the Medical Care System on the Quality of
Health
Every public health practitioner realizes that the Health and the Environment
medical care system, as more narrowly defined, has only a In the final analysis, the health and vitality of
peripheral role on the quality of health in populations. The populations are dependent on the ability to make successful
quality of a population's health is a response to the overall adaptations to the environments within which man must
nature of the environment, and medical care is only a small survive. Man's ability to adapt depends on his capacities and
part of the larger picture. Much of the vast progress in skills, and his psychological orientations. To a large extent,
health status in the past century is a product of a higher man constructs his own environment depending on the
standard of living, better sanitation, and improved nutri- models and norms that his culture and society provide.53
tion; and many of the risks to health in the present are a His skills and effectiveness depend on the preparatory
product of man's constructed environments. Although good, institutions his community provides for dealing with the
medical care-and in particular good preventive care-can be problems he is likely to face as an individual and as a
brought to bear at particular points in the life cycle so that member of a group. His motivation and the direction of his
it has impact, much of the necessary health action required interests and aspirations will depend on the incentives the
involves larger social and political considerations and the community promotes. His psychological capacities and
development of new patterns of community behavior. strengths are influenced by the human resources and social
The system of medical care in any country reflects supports the environment can provide. Although men can
the traditions of the past and the social priorities for the do a great deal to promote their own health within rather
future. Health care is a vast industry and subsumes many narrow limits, in the larger context life and health are sub-
groups with conflicting perspectives and interests. How stantially dependent on community decisions and social
these interests are weighed, negotiated, and resolved deter- forces which are often outside any single individual's con-
mines, in part, the organization and provision of health trol. It is the appreciation of such facts that should direct
services and the various priorities given to different aspects the profession of public health as it faces the future.
of health care. But certain limits on the nature of medical
activity are also determined by the technical development
of medicine and the character of population demands, and References
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Population, A.J.P.H. 1877-1886 (Nov., 1962). op. cit., 366-385.
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(Apr., 1964), Washington, D.C.: Public Health Service. Ostow, Men, Money and Medicine, New York: Columbia Univer-
29. Roberts, Dean and Wylie, Charles. Multiple Screening in the sity press, 1969.
Baltimore Study of Chronic Illness. J.A.M.A., 161:1442-1446 52. For a discussion of the complex variations in organizing basic
(Aug. 11, 1956). medical services, see William Glaser, Paying the Doctor: Systems
30. Wylie, C. M. Participation in a Multiple Screening Clinic with of Remuneration and their Effects. Baltimore: Johns Hopkins
Five-Year Follow-up. Public Health Reports, 76:596-602 Press, 1970.
(1961). 53. For an elaboration of this framework, see David Mechanic,
31. National Center for Health Statistics. Volume of Physician Some Problems in Developing a Social Psychology of Adapta-
Visits-United States-July 1966-June 1967. Series 10, No. 49 tion to Stress, in J. McGrath (ed.). Social and Psychological
(Nov., 1968), Washington, D.C.: Public Health Service. Factors in Stress, New York: Holt, Rinehart and Winston, 1970,
32. Mechanic, David and Volkart, Edmund. Illness Behavior and 104-1 23.

Mr. Mechanic is Professor, Department of Sociology, University of Wisconsin, Madi-

son, Wisc., 53706. This paper was submitted for publication in June, 1971.

SOCIOLOGY AND PUBLIC HEALTH PERSPECTIVES 151

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