Sociology in Public Health

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SOCIOLOGY IN PUBLIC HEALTH

Sociology as a discipline developed from theoretical writings of the nineteenth century and the first half of the twentieth century. The predominant theories stem from the work of Karl Marx, Emile Durkheim, Max Weber, Talcott Parsons, Robert Merton, and James Coleman. The influence of this rich theoretical foundation has manifested itself in major debates over the role of sociology as a science. European and American perspectives on sociology as a science differ, with the American perspective favoring sociology as a scientific discipline and emphasizing a more quantitative methodological approach than the European approach.

KEY CONCEPTS IN SOCIOLOGY

Several key concepts in sociology relate to its role in public health. Foremost is the emphasis on society rather than the individual. The individual is viewed as an actor within larger social processes. This distinguishes the field from psychology. The emphasis is on units of analysis at the collective level, such as the family, the group, the neighborhood, the city, the organization, the state, and the world. Of key importance is how the social fabric, or social structure, is maintained, and how social processes, such as conflict and resolution, relate to the maintenance and change of social structures. A sociologist studies processes that create, maintain, and sustain a social system, such as a health care system in a particular country. The scientific component of this study would be the concern with the processes regulating and shaping the health care system. Sociology assumes that social structure and social processes are very complex. Therefore its methodology is appropriately complex and often, particularly in American sociology, dominated by multivariate statistical methods of analysis. The advent of the computer in the second half of the twentieth century presented the field with the opportunity to work with very large bodies of data and complex variables.

MEDICAL SOCIOLOGY

Earlier social theorists, such as those noted above, did write on subjects of concern to medicine, health, and illness, but medical sociology, as a subdiscipline of sociology, developed in the post-World War II period. Early debates in medical sociology were concerned with the role of sociology as it relates to medicine: Should the field be critical and analytical, concerning itself with the sociology of medicine (i.e., examining how medicine works); or should it be largely applied, focusing on sociology as a handmaiden for medicine? Like many such formative debates, there could be no conclusive answer. However, the field has developed into two groups: those (largely within academic settings) which focus on the sociology of medicine; and those (primarily in schools of public health and governmental institutions) which focus on the application of sociology to medicine. Later debates related to whether the focus should be on health sociology or medical sociology. This debate has moved the field to a broader, more ecological, view of medicine and health.

SOCIOLOGY IN PUBLIC HEALTH

Public health has been and remains a very applied field. It is also characterized by a population-based approach to health, and statistical methods are deemed the appropriate underlying method for the field. It is viewed as a science that seeks to intervene, control, and prevent large-scale processes that negatively affect the public's health. By these criteria, there is a strong logical fit of sociological principles and practices within public health. Nonetheless, sociology has not been the key social science discipline in public health. That position has gone to psychology, where the emphasis on individual behavior resonates more with a biomedical model. Despite this, many of the primary concerns of present-day public health, with large-scale variables such as social capital, social inequality, social status, and health care organization and financing, remain topics best suited to the sociological perspective and methodology. The emphasis in public health is thus shifting toward a sociological perspective.

SOCIOLOGICAL CONCEPTS IN PUBLIC HEALTH

Sociology in public health is reflected in the myriad of sociological concepts that pervade the practice of public health. More than any other social science, sociology has the discussion of socioeconomic status at its very core. Social-class variation within society is the key explanatory variable in sociology—for everything from variation in social structure to differential life experiences of health and illness. Indeed, there appears to be overwhelming evidence that Western industrialized societies that have little variation in social class experience have far better health outcomes than societies characterized by wide social-class dispersion. In short, inequalities in health are directly related to social and economic inequalities. Much of later-twentieth-century public health is devoted to the reduction of these inequalities.

SOCIOLOGICAL METHODS IN PUBLIC HEALTH

Methodological concerns are critical to sociological research. The great debate in sociology has been on the relative merits and role of quantitative versus qualitative approaches. Both approaches are widely used and play a critical role for public health. Sociology has long recognized that the social world comprises both an objective and a subjective reality. For example, the objective reality of having cancer is accompanied by the subjective reality of the experience of cancer by the patient, and the patient's family and friends. Both realities are relevant to the sociological approach. The subjective, qualitative approach is generally discussed in the theory and methods concerned with illness behavior, but qualitative approaches are equally applicable to the understanding of social policy, world systems, and areas of sociology where statistical measurement is difficult or less relevant.

Within public health, surveillance is seen as a key approach to describing the distribution and dynamics of disease. In sociological approaches to public health, the role of social and behavioral factors in health and illness is central. Survey methodology has occupied a central place in sociological research since the middle of the twentieth century. The concern has been with the collection, management, analysis, interpretation, and use of large quantities of data obtained by direct interview with respondents. Social surveys are characterized by large random samples, complicated questionnaires, and the use of multivariate statistics for analysis. By their very nature, most sociological variables are complex to measure and to analyze. For example, the assessment of socioeconomic status of an individual requires the accurate measurement of several variables that sit within a larger social context. Socioeconomic status (SES) is regarded as a product of several components, including income, residence, education, and occupation. Determining the relative weight of each of these components is a major analytical problem. Thus, when considering the role of socioeconomic status on health care outcomes, there is no easy answer to what mechanism actually works to determine the observed relationship between SES and health.

SOCIOLOGY AND EVALUATION IN PUBLIC HEALTH

Because many sociological variables are at the socalled macro level, there is limited opportunity to intervene rapidly, directly, or simply. For example, the SES of a group is affected by complex components, such as education and occupation, that are part of the total life course of individuals within the group. Thus, to change the SES of a group would require significant redistribution of resources of the larger social structure. A significant period of time and concerted effort is needed to change such macro variables. This is, however, not dissimilar to many other challenges in public health, such as the long-term and time-consuming effort to change lifestyles and reduce behavioral risk factors related to chronic diseases.

The chief role of sociology in public health remains its evaluation of those macro components of society that affect public health at the population level. Such evaluations provide an understanding of why inequalities in health exist, and they help elaborate upon the mechanisms and processes that sustain these inequalities. This relates to the long-standing theoretical concern with social structure among sociologists. Further, sociology reveals the mechanisms for long-term changes that may lead to a reduction in health inequalities. The product of sociological thinking in public health is not immediate nor easily understood by those who seek quick and easy solutions to the suffering of humanity. Nonetheless, the long-term role of sociology in public health is to change and improve the public health.

David V. McQueen

(see also: Community Health; Medical Sociology; Psychology, Health; Social Determinants; Social Health )