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Effort–Reward Imbalance skill discretion (i.e.

, control over the use of

skills by the worker). By replacing job demands
MIKA KIVIMÄKI with efforts and job control with rewards, the
University College London, UK ERI model broadens the view from just work
characteristics to cover aspects of the person
The concept of Effort–Reward Imbalance and the labor market context.
(ERI), describing a source of work-related The ERI model is also linked to several
stress, was developed by Johannes Siegrist of theories that extend beyond the work stress
the University of Dusseldorf (Siegrist 1996, framework. Perhaps the most important of
2010). According to the ERI model, the expe- these is the Equity theory (also known as the
rience of imbalance between high efforts Social Exchange theory), first published in
spent at work and a perception of low reward 1963 by J. S. Adams with the idea that work
received in return is stressful, as this imbal- satisfaction and work motivation are depend-
ance violates core expectations about reci- ent on perceptions of a fair distribution of
procity. According to the ERI model, high resources within interpersonal relationships.
demands at work and heavy obligations in According to this theory, employees seek to
private life (e.g., large debts) may lead to a maintain equity between two components:
high expenditure of effort. The reason for (1) the inputs that they bring to a job and the
high efforts can also be intrinsic, reflecting an outcomes that they receive from it, and
employee’s excessive work-related commit- (2)  the perceived inputs and outcomes of
ment (“overcommitment”). Low rewards others – perceptions of being under- or over-
refer to three factors: insufficient pay, low rewarded result in a feeling of distress. The
esteem (e.g., lack of help or acceptance by input–output ratio in the Equity theory is
supervisors and colleagues), and poor career conceptually close to the term “effort–reward
opportunities (no promotion prospects, job imbalance” in the ERI model.
insecurity, and/or status inconsistency). Siegrist (1996) also lists many other theories
The ERI model, in its comprehensive form, that influenced the development of the ERI
was introduced by Siegrist in 1996 and has model. These include the Job Characteristics
become one of the leading work stress models. model on key determinants of work motiva-
Historically, the ERI model was preceded by tion (Hackman and Oldham 1980), and the
the Job Strain model, which was launched in theories on psychological stress (Lazarus
1979 by Robert Karasek and is the most cited 1991), social support (House 1981), work
work stress model to date. The Job Strain model organization, and democratization (Johnson &
maintains that employees who simultaneously Johansson 1991).
have high job demands (e.g., heavy workload, ERI is typically measured using self-
time pressure, difficult tasks) and low control administered questionnaires. Operationaliz-
over work are in a job strain situation which, if ations based on self-reports are in accordance
prolonged, increases the risk of stress-related with the emphasis on the importance of
disorders. Job control refers to both control perceived psychosocial factors in the ERI
over detailed aspects of task performance model. The short form of the standard
(e.g.,  pace of  work and scheduled hours) and questionnaire instrument includes a total of

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

23 items measured on three scales: Effort A systematic review and meta-analysis,

(6 items, a sample item: “I have constant time published in January 2006 by Kivimäki et al.,
pressure due to a heavy work load”); Reward included four studies examining the ERI
(11 items, a sample item: “My job promotion model and CHD. The summary estimate for
prospects are poor,” affirmative response the ERI model showed a 1.6–2.5-fold age-
refers to low rewards), and Overcommitment and sex-adjusted excess CHD risk for employ-
(6 items, a sample item: “Work rarely lets me ees reporting high effort and low reward. The
go, it is still on my mind when I go to bed”) strength of the association is close to those
(Siegrist et al. 2004). Response to each item observed for other indices of work stress,
is  given on a five-point (effort, reward) or such as Job Strain and Organizational
four-point (overcommitment) Likert-type Injustice (Steptoe and Kivimäki 2012).
scale. The formula for calculating the effort– However, as all these studies were based on a
reward imbalance ratio from the responses is: proxy measure of ERI, further research based
ERI ratio = E/(c * R), where “E” is the sum on the standard validated survey instrument
score of the effort scale, “R” is the sum score is still needed to confirm or refute the asso-
of the reward scale, and “c” is a correction fac- ciation between ERI and CHD.
tor (6/11) for different numbers of items in At least one prospective study has exam-
the numerator and denominator. ined the association between ERI and
In many studies, however, a proxy measure diabetes. Kumari, Head, and Marmot (2004)
of ERI, rather than the standard question- found that high versus low ERI, as indicated
naire, has been used. Proxy measures are by a proxy measure, was associated with an
constructed by utilizing questionnaire items increased 10-year incidence of diabetes in
that were originally included in the survey for men but not in women. The corresponding
other purposes, but also have a reasonable odds ratio, adjusted for age, length of follow-
face validity as indicators of efforts and up, socioeconomic status, ethnic group, and
rewards. Typically, the score used in the anal- baseline abnormalities in an electrocardio-
ysis is obtained by calculating the ratio gram, was 1.7 (95 percent confidence interval
between the effort and reward scales and then 1.0–2.8) in men and 0.9 (95 percent confidence
dividing this ratio into thirds or quartiles; interval 0.4–1.9) in women (note that 95 per-
or  alternatively by cross-tabulating the cent confidence intervals that include unity are
dichotomized scales. not statistically significant at p < 0.05).
ERI has been studied in relation to several Several studies have reported a cross-
disorders with major public health relevance. sectional association between ERI and
This body of evidence includes studies on depressive symptoms or psychological dis-
coronary heart disease (CHD, a leading cause tress, but no large-scale studies are available
of mortality and disability in the industrial- to link ERI with an increased risk of clinically
ized world and the health outcome, which has verified depression (Netterstrom et al. 2008).
been commonly related to work stress); A one-year follow-up of employees from four
depressive disorders (a cause of substantial Belgian enterprises showed no statistically
disease burden, as indicated by disease- significant association between ERI and
adjusted life years); and diabetes mellitus. In subsequent depressive symptoms, but repeat
addition, ERI has been investigated in relation measurement of ERI at baseline and follow-up
to various quality of life measures as well as was associated with depressive symptoms at
work disability, as indexed by long-term follow-up (Godin et al. 2005). Similarly, a
sickness absence. two-year follow-up of young Swiss physicians

showed ERI measured in two study waves to randomized controlled trials allocating
be associated with depressive symptoms at participants with high ERI randomly to ERI-
the latter measurement (Buddeberg-Fischer lowering intervention groups and control
et al. 2008). According to the authors, this groups could eliminate such bias, but such
evidence indicates that the effect on depres- trials are currently not available. Similarly,
sive symptoms becomes apparent only after the exact biological mechanisms that link ERI
prolonged exposure to ERI. with disease at a population level are still
ERI may increase the risk of absence from poorly understood. A group of scientists from
work due to sickness – that is, sickness the University of Bristol, UK, has criticized
absence. In the Whitehall II study of British work stress research, arguing that the associa-
civil servants, for example, ERI predicted tions observed may be attributable to socio-
subsequent long-term (>seven days) sickness economic disadvantage and adverse material
absence in men (odds ratio 1.3, 95 percent conditions rather than causal influences
confidence intervals 1.2–1.5) and women (Macleod et al. 2001).
(odds ratio 1.2, 95 percent confidence inter- New developments in the study of work
vals 1.1–1.4), but no association was found stress deal with integrative concepts, such as
with short-term absences (Head et al. 2007). organizational injustice. While ERI defines
In a study of 16,000 Finnish public sector disproportionate costs for an employee in
employees who had no medically certified terms of gains received – that is, a distributive
sickness absences in the year of the baseline injustice condition – more recent research
survey, ERI predicted future sickness absence widens the perspective to include other
longer than three days (odds ratio 1.4, 95 aspects of injustice (Elovainio et al. 2002;
percent confidence interval 1.3–1.6 in men Kivimäki et al. 2005). Procedural injustice, for
and 1.2, 95 percent confidence interval 1.1–1.3 example, refers to biased decision-making
in women) (Ala-Mursula et al. 2005). procedures which do not include input
The question of whether ERI predicts from  affected parties. Relational injustice
health problems independently of other work refers to a failure in treating individuals with
stress measurements has been examined in fairness, politeness and consideration by
several studies. Most of the evidence suggests supervisors.
that ERI is not redundant for other conceptu-
alizations of work stress, such as job strain or SEE ALSO: Health, Workers’; Medical
organizational injustice (Bosma et al. 1998; Sociology; Occupational Health and Safety;
Calnan et al. 2004; Head et al. 2007; Kivimäki Stress and Work
et al. 2007). However, this is not a universal
observation (Kivimäki et al. 2005), and the
improvement in disease prediction gained by REFERENCES
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Mental Illness, Measuring disorder found in the fourth edition of the
official psychiatric manual of the American
ALLAN V. HORWITZ Psychiatric Association, the DSM-IV-TR
Rutgers University, USA (the DSM-5 was subsequently published in
2013). Mental disorders, according to the
Psychiatrists and other mental health person- DSM, “must not be merely an expectable
nel often claim that mental illness is compa- and culturally sanctioned response to a
rable to other diseases such as diabetes or particular event, for example, the death of a
cancer. When it comes to measurement, how- loved one. Whatever its original cause, it
ever, mental illness is fundamentally different must currently be considered a manifestation
than somatic illnesses. In other areas of medi- of a behavioral, psychological, or biological
cine, biological markers exist that can indi- dysfunction in the individual” (APA 2000,
cate the presence of a disease and confirm or xxxi). First, this definition limits mental
refute a diagnosis: for example, cardiologists disorders to conditions that are dysfunc-
use PET scans to see if a heart has tissue dam- tions in the person – that is, where some
age, nephrologists take x-rays to find the psychological mechanism is not working as
presence of a kidney stone, and oncologists it is designed to function. Therefore, only
employ laboratory tests to detect cancerous dysfunctions within the individual are
cells. Psychiatrists, however, have none of disorders. Second, the definition excludes
these tools. Instead, patient self-reports and, conditions that are proportionate responses
sometimes, clinician observation constitute to social stressors. It uses “the death of a
their sole diagnostic resources. At present, no loved one” as an example of a stressor that
independent criteria exist that might verify expectably leads people to display symp-
the accuracy of any measurement tool’s toms which could otherwise indicate a dis-
assessment of a mental disorder. order if they emerged in the absence of the
Measuring mental illness is especially prob- stressor. The definition’s use of “for exam-
lematic not just because of the lack of ple” indicates that symptoms caused and
independent indicators of disorder, but also sustained by stressors other than bereave-
because normal distressing emotions share the ment – whether the diagnosis of a serious
same symptoms as disordered conditions. For physical illness in oneself or an intimate, the
example, after suffering a loss such as the death loss of one’s home and possessions after a
of an intimate, the breakup of an intense natural disaster, or the failure to achieve
romantic relationship, or the loss of a valued some valued goal – also should not be con-
job, people naturally develop comparable sidered disorders because they do not result
symptoms to ones that characterize depressive from an internal dysfunction but instead
disorders. Therefore, accurate measurements are contextually appropriate responses.
of mental illness require the use of some con- Because psychological dysfunctions and
ceptual criterion beyond symptoms themselves natural responses to stressors commonly
to separate natural from disordered symptoms. share similar symptoms, their separation
A good starting place for the measurement poses an especially challenging problem for
of mental illness is the definition of mental the accurate measurement of mental illness.

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

THREE STAGES IN MEASURING and reflected the theoretical influence of psy-

MENTAL ILLNESS choanalysis. Because analysts were more
concerned with underlying unconscious
The measurement of mental illness has gone mechanisms than with overt symptoms, the
through three major stages. It began in the descriptions of disorders in the DSM were
United States with the census of 1840, which general short, cursory, and difficult to use as
recorded the category of “idiocy/insanity” the basis for precise measurements.
among the households it surveyed. For the At the same time that the DSM-I was devel-
remainder of the century through the first oped, sociologists and psychiatrists became
half of the twentieth century, the conditions interested in measuring mental illness among
of residents of mental institutions comprised community members who were in neither
the raw data for measuring mental illness. inpatient nor outpatient mental health facili-
Because the vast majority of diagnoses found ties. This required them to develop measuring
in these settings were of the most serious dis- tools that could quickly and efficiently esti-
orders, psychotic conditions were of primary mate the amount of mental illness in untreated
concern. For example, the first diagnostic community populations. The most popular
manual for mental disorders, the Statistical measure at the time was the Langner (1962)
Manual for the Use of Institutions for the scale, which was developed for use in a large
Insane divided mental disorders into 22 community study in Midtown Manhattan.
principal groups, only one of which dealt This scale did not reflect particular types of
with less severe, neurotic conditions (Grob mental disorder, but, instead, asked people
1985). This manual served as the primary whether they had experienced a variety
diagnostic manual for mental disorders from of  depressive, anxious, or psychosomatic
its inception in 1918 until its replacement by symptoms such as restlessness, nervousness,
the DSM-I in 1952. worries, low spirits, poor appetite, or trouble
The use of official statistics as a measure of sleeping. This scale, and others that followed
mental illness was an inherently flawed it such as the Center for Epidemiological
method. Many mentally ill people do not Studies – Depression scale (CES-D), pro-
receive treatment and those who do have a duced continuous measures of distress that
wide variety of reasons that have little to do ranged from no to many symptoms, but which
with their mental conditions, such as the were not readily translatable into any particu-
availability of mental institutions, family and lar psychiatric diagnosis (Radloff 1977).
community tolerance for deviant behavior, Generalized symptoms scales such as the
and cultural definitions of what mental ill- Langner scale and the CES-D found remark-
nesses are and how they should be treated. ably high rates of “mental illness.” The
Accurate measures, therefore, cannot rely on Midtown Manhattan survey reported that
counts of treated patients. only 18.5 percent of the population had no
The next stage of measurement began in symptoms of “mental illness”; 36.3 percent
the 1950s. The development of the first edi- had mild symptoms; 21.8 percent had moder-
tion of the Diagnostic and Statistical Manual ate symptoms; and 23.4 percent had severe
of Mental Disorders (APA 1952) reflected the symptoms and were often incapacitated
movement of psychiatric practice from state (Srole et al. 1962). The CES-D found that a
mental hospitals to outpatient treatment. In majority of respondents who had undergone
contrast to the earlier Statistical Manual, the stressful events such as natural disasters,
DSM-I concentrated on neurotic conditions marital separations, or job losses reported

anxious symptoms (Radloff 1977). These collected from large numbers of people in a
rates reflected the fact that the measures they cost-effective manner. To obtain reliable
used did not distinguish common symptoms prevalence estimates, different interviewers
of distress that developed after stressful life must ask questions in exactly the same way.
events from mental disorders that were dys- Standardization is necessary because even
functions in individuals. minor variations in the wording of questions,
The next stage of measurement of mental ill- interviewer probes, or instructions can lead
ness began in the early 1980s and has persisted to different results. As one study notes: “The
to the present. It reflected the entirely new interviewer reads specific questions and fol-
approach to characterizing mental illness that lows positive responses with additional pre-
marked the DSM-III, the official psychiatric scribed questions. Each step in the sequence
manual that was published in 1980 (APA 1980). of identifying a psychiatric symptom is fully
This manual used the principle that diagnostic specified and does not depend upon the judg-
criteria for mental illness should solely rely on ment of the interviewers” (Leaf et al. 1991, 12).
symptoms and not reflect any theory about The resulting unvarying interview format
what caused these symptoms to develop. For excluded any discussion with the respondent
example, the diagnosis of major depressive dis- about reported symptoms and their context.
order (MDD) required that five symptoms out Computer programs using the DSM criteria
of nine, which must include either depressed then determined whether a disorder was pre-
mood or diminished interest or pleasure, must sent. The rigid equivalence of structured
be present for a two-week period. In contrast to interviews improved the consistency of
symptom scales, which presented continuous symptom assessment across interviewers and
measures, the DSM diagnoses were dichoto- research sites and the consequent reliability
mous: people with five or more symptoms of diagnostic decisions.
received MDD diagnoses, while those with Like the studies using general scales, studies
fewer than five symptoms were not diagnosed using diagnostic measures found extremely
with a disorder. However, similar to continuous high rates of mental disorder in the popula-
measures such as the Langner and CES-D tion. For example, the best-known and most
scales, the dichotomous DSM entities ignored frequently cited study, the National
the context within which symptoms developed Comorbidity Survey (NCS), reported that over
and considered all people who reported enough a quarter of the population (26.2 percent) had
symptoms to have a disorder (for MDD, had some mental illness over the past year and
bereavement was an exception: people who that nearly half (46.4 percent) had experienced
met the criteria after the death of an intimate one over their lifetime (Kessler and Wang
did not receive the diagnosis). 2008). The most frequently occurring catego-
Since the early 1980s to the present, large ries were anxiety disorders (28.8 percent),
epidemiological studies that measure the impulse-control disorders such as ADHD
amount of mental illness in the community (24.8 percent), mood disorders (20.8 percent),
have relied on the symptom-based diagno- and substance abuse and dependence disor-
ses  found in the DSM. Epidemiologists ders (14.6 percent). These findings are compa-
simply  translated the DSM criteria into rable to those of other community surveys
closed-format questions about what symptoms using the DSM criteria. While these findings
respondents had experienced. This yielded a are typically accepted as accurate measures of
questionnaire that non-professionals could the amount of mental illness, they are highly
be trained to administer, allowing data to be problematic indicators of genuine disorders.

PROBLEMS IN MEASURING MENTAL Measuring mental disorders with continu-

ILLNESS ous, as opposed to dichotomous, scales does
not solve this problem, but threatens to make
In recent decades, the measurement of men- it worse. When all points on a continuum are
tal illness has become more standardized viewed as signifying mental illness, then even
and more reliable, so that different people a single symptom can be viewed as disor-
using the same measures will provide the dered. Both continuous and dichotomous
same results. Reliability of measurement is measures treat the natural consequences of
one essential requirement for a truly scien- social stressors and truly disordered condi-
tific study of mental illness. Yet, current tions alike as disorders, thus artificially inflat-
measures of mental illness, while reliable, ing the number of people they consider to be
suffer from a failure of validity. That is, they mentally ill.
do not measure what they’re supposed to What can be done to improve the measure-
measure – mental disorders. Instead, by ask- ment of genuine mental disorders? Researchers
ing about symptoms without regard to the who strive to have valid, as well as reliable,
context within which symptoms develop measures of mental illness could more ade-
and persist, they fail to separate symptoms quately separate normal responses to stressful
that arise and endure because of stressful life situations from mental disorders by including
events or chronically stressful conditions as questions about the context in which symp-
opposed to dysfunctions within the toms develop and persist. They could ask, for
individual. example, if symptoms of depression, anxiety,
For example, respondents answering ques- or substance abuse emerged during periods of
tions about depression might recall symp- intense stress and disappeared as soon as these
toms such as depressed mood or insomnia crises were over. Although the use of such con-
that lasted longer than two weeks after the textualized questions might make it somewhat
breakup of a romantic relationship, a serious more difficult to achieve high reliability, they
illness, or the unexpected loss of a job. should result in more accurate measures of
Although these symptoms might have dissi- genuine mental disorders.
pated as soon as a new relationship devel- Until valid physiological and neurochemi-
oped, the person recovered, or another job cal measures are developed, researchers must
was found, this individual would be counted rely on self-reports for their basic assessments
among the many millions who suffer from of mental disorder. They thus face particular
the presumed disorder of major depression challenges in making sure that their measures
(Horwitz and Wakefield 2006). For example, are actually capturing psychological dysfunc-
the most commonly reported symptoms of tions. Only by incorporating context into their
depression in one large community study measurements will they be able to achieve
were “trouble falling asleep, staying asleep, or the goal of distinguishing mental illness from
waking up early” (33.7 percent); being “tired natural responses to stressful conditions.
out all the time” (22.8 percent); and “thought
a lot about death” (22.6 percent) (Judd et al. SEE ALSO: Diagnostic and Statistical Manual
1994). College students during exam periods, of Mental Disorders (DSM); Medical
people who have to work overtime, or those Knowledge; Mental Illness, Medicalization of;
who take the survey soon after the death of a Mental Illness, Social Construction of; Mental
famous person would all naturally experience Illness, Sociology of; Stress and Mental Illness;
such symptoms. Stress Outcomes, Measuring

Kessler, Ronald C. and Wang, Philip S. 2008.

“The Descriptive Epidemiology of Commonly
APA (American Psychiatric Association). 1952. Occurring Mental Disorders in the United
Diagnostic and Statistical Manual of Mental Dis- States.” Annual Review of Public Health 29,
orders. Washington, DC: American Psychiatric 115–129.
Association. Langner, Thomas S. 1962. “A Twenty-Two Item
APA (American Psychiatric Association). 1980. Screening Score of Psychiatric Symptoms Indi-
Diagnostic and Statistical Manual of Mental Dis- cating Impairment.” Journal of Health and Social
orders. 3rd ed. Washington, DC: American Psy- Behavior 3, 269–276.
chiatric Association. Leaf, Philip, J., Myers, Jerome C., and McEvoy,
APA (American Psychiatric Association). 2000. Lawrence T. 1991. “Procedures Used in the
Diagnostic and Statistical Manual of Mental Epidemiological Catchment Area Study.” In
Disorders. 4th ed., text rev. Washington, DC: Psychiatric Disorders in America, edited by Lee
American Psychiatric Association Robins and Darrell Regier, 11–32. New York:
Grob, Gerald. 1985. “The Origins of American Free Press.
Psychiatric Epidemiology.” American Journal of Radloff, Lenore. 1977. “The CES-D Scale: A Self-
Public Health 75, 229–236. Report Depression Scale for Research in the
Horwitz, Allan V., and Wakefield, Jerome C. 2006. General Population.” Applied Psychological
“The Epidemic in Mental Illness: Clinical Fact Measurement 3, 249–265.
or Survey Artifact?” Contexts 5, 19–23. Srole, Leo, Langner, Thomas S., Michael, S. T.,
Judd, L. L., Rapaport, M. H., Paulus, M. P., and Kirkpatrick, P., Opler, Marvin K., and Ren-
Brown, J. L. 1994. “Subsyndromal Symptomatic nie, Thomas A. C. 1962. Mental Health in the
Depression: A New Mood Disorder?” Journal of Metropolis: The Midtown Manhattan Study.
Clinical Psychiatry 55, 18–28. New York: McGraw Hill.
Public Health Issues in local level, there emerged a great need to
produce a new workforce and advanced
Disaster Management surveillance systems at public health depart-
ments across the United States (Brown 2005).
Harvard School of Public Health, USA This entry will address the public health
protections that currently exist and how they
play a daily role in disaster preparedness;
INTRODUCTION define the elements of the disaster cycle and
how this concept is meeting new challenges in
Much has changed since the 1930s and 1940s disaster preparedness, especially at the local
when public health workers were thought of community level; define what determines a
simply as sanitation engineers, placed at public health emergency and the health conse-
the  periphery of the medical profession and quences after a major large-scale natural disaster
rarely ever considered a major factor in disas- or humanitarian crisis; and, lastly, investigate
ter prevention, preparedness, or response. the global health strategies designed to improve
Even in the 1960s and 1970s the perception public health capacity in disasters.
was that public health departments focused
primarily on chronic disease surveillance
and  prevention. World events changed. BASIC PUBLIC HEALTH
Population numbers and densities exploded PROTECTIONS
and infectious disease transmission played
an  increasing role. The inhalational anthrax On a daily basis, all public health systems
scare of 2001 and the 2003 severe acute res- work to protect the population against injury,
piratory syndrome (SARS) epidemic disease, and a variety of environmental and
surprised many in the United States: it was occupational health hazards. This includes
recognized not only that the US Director of establishing priorities and standards, as well
Public Health would assume the major lead- as monitoring systems for water, food, sanita-
ership role in the disaster response when a tion, solid waste removal, shelter, animal and
public health emergency was declared, but vector control, and communicable disease
also that the large majority of state health control and investigation. Public health pro-
departments did not have in their employ fessionals work with emergency response
infectious disease epidemiologists or surveil- agencies to ensure that affected populations
lance expertise relevant to acute onset events. are aware of health and safety risks and how
This led to the rapid development statewide to either avoid or prepare to deal with them
of a syndromic-based surveillance system (WHO 2002; Salinsky 2002). This is imple-
that utilizes case definitions of diseases based mented through a myriad of guidelines for
on clinical features looking for suspicious the diagnosis, care, and reporting of injured
trends (Hope et al. 2008). Given that all and ill persons, as well as guidelines for the
responses to infectious diseases and many distribution of scarce medical resources post-
other population-based crises begin at the disaster that require the execution of surge

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

capacity plans and resource allocation triage Disaster surveillance

As it should be, emphasis is placed on sur-
Society, especially in the developed world,
veillance as a major asset that public health
has come to expect these public health pro-
provides to the health care workforce, to
tections to be present and functioning 24/7
the  citizenry, and to the ultimate decision-
as part of everyday life. Unfortunately, the
makers in disaster prevention and prepared-
degree of public health prevention, prepar-
ness and response. Public health surveillance
edness, response, and recovery is not uniform
is defined as the routine and ongoing collection,
across countries and within their individual
analysis, and dissemination of data (Thacker
communities in every nation-state. This
and Berkelman 1988). The challenge for
includes the United States, where major
public health is to provide “real time” health
gaps in public health preparedness 10 years
data, rather than “trends,” to the Emergency
after 9/11 still exist (Moyer 2011). “Ready or
Operations Center (EOC) (Mignone and
Not 2010,” a report published by the Trust
Davidson 2003) that is part of every Incident
for America’s Health and the Robert Wood
Command System (ICS) (Papagiotas et al.
Johnson Foundation, concluded that “sig-
2012) set up during a disaster. Ideally, poten-
nificant public health improvements were
tial disaster-related data should be received
made following the tragic events of 2001”
on a daily basis before a crisis event is
(see Levi, Segal, and Lang 2011). But today,
declared. Currently, public health agencies
the United States has 50,000 fewer public
are developing more sophisticated surveil-
health workers than it did 20 years ago,
lance systems that will allow the ICS and spe-
mainly because of government budget
cifically the EOC to make timely decisions
cuts tied to the economic recession (Moyer
on surge capacity and resource allocation,
2011). Most critical in departments of
both of which have direct implications on
health are deficiencies in surveillance
triage decisions at every level of care. The
capacity – the basic tool that alerts a state or
types of surveillance systems that can be
local community to a pending or potential
utilized are:
crisis. Among the list of key findings of the
2010 report are that seven states are unable
● Categorical surveillance: an active or
to share data electronically with health care
passive system that focuses on one or
providers, and ten states do not have an
more diseases or behaviors of interest to
electronic syndromic surveillance system
an intervention program (Sayers et al.
that can report and exchange information
2012). An example is following “priority
to rapidly detect disease outbreaks. A year infectious diseases targeted for an
later, “Ready or Not 2011” focused on pro- integrated surveillance and response
tecting the public from diseases, disasters, strategy by WHO” that are a threat to a
and bioterrorism, and found “a decade worth potential influenza pandemic (Perry
of progress eroding in front of our eyes” et al. 2007).
(see Levi et al. 2012). These failures, experi- ● Integrated surveillance: a combination of
enced in every state, were primarily focused active and passive systems using a single
on an inability to identify and contain out- infrastructure that gathers information
breaks, provide vaccines and medications about multiple diseases or behaviors of
during emergencies, and treat people dur- interest to several intervention programs
ing mass traumas” (Levi, Segal, and Lang (Sayers et al. 2012). An example is the
2011). “use of the world’s microbiology

laboratories to upload their reports each ● community preparedness

day to programs that detect events, ● community recovery
trends, and epidemics in communities, ● emergency operations coordination
hospitals, countries, and the world” ● emergency public information and
(O’Brien and Stelling 2011). warning
● Syndromic surveillance: an active or ● fatality management
passive system that uses case definitions ● information sharing
that are based entirely on clinical features ● mass care
without any clinical or laboratory ● medical countermeasure dispensing
diagnosis; for example, cases of diarrhea, ● medical material management and
cough, or rashes (Sayers et al. 2012). distribution
Because it is less expensive, syndromic ● medical surge
surveillance is often the first system to be ● non-pharmaceutical interventions
used in developing countries (Raths 2012). ● public health laboratory testing
It is also a useful tool for following ● public health surveillance and
natural disasters in shelters where limited epidemiological investigation
resources for detection exist (Murray ● responder safety and health
et al. 2009). ● volunteer management

It is crucial that disaster managers and the

health care workforce are aware of the type of THE DISASTER CYCLE
surveillance system being used in the reports
they are receiving and assessing for the public Conceptualizing the internal phases of a disaster
good. from start to finish have been traditionally
Too often, it takes the disaster itself to defined by the disaster cycle. The traditional
expose the public health protection gaps and disaster management cycle contains a four-phase
vulnerabilities that many governments have model to help emergency managers prepare for
neglected because of limited planning and and respond to a disaster (Rosenberg 2012;
financial constraints, and, unfortunately, out Godschalk 2012):
of ignorance (Burkle and Greenough 2008).
Leadership positions in public health at both 1 Prevention (or mitigation) focuses on
the state and national levels are primarily pre-disaster mitigation efforts to reduce
political appointments, as are priorities and vulnerability to disaster impacts such
assets that are made available through the as  injuries, deaths, and property loss.
legislative process. When preventable trage- The most common mitigation efforts
dies fail to be averted, it is not uncommon known to developed countries, all of
for political officials to be voted out of office which lead  to improved community
because of poor public health prevention, resiliency, include: building codes, espe-
preparedness, and citizenry awareness, where cially in  earthquake-prone areas, to
excess or preventable deaths, injuries, fortify buildings; proper zoning and
or  illness occurred. The US Centers for land use management; public health
Disease Control and Prevention (CDC 2011) infrastructure repair and maintenance
public health preparedness capabilities, to ensure safe water, sanitation, adequate
which society expects to be in place today at shelter; access routes to, and availability
state and local levels, are as follows (listed in of, health care (the two As); and public
alphabetical order): education.

2 Preparedness focuses on education, train- these efforts is to mitigate any further pre-
ing, emergency planning and exercises; ventable mortalities and morbidities from
outreach, especially to the most vulnerable occurring. For this to happen, public health
populations, as well as business continuity; departments and authorities must have flexi-
and early warning systems. ble and scalable capacity to respond to both
3 Response focuses on immediate threats to major disaster events (e.g., pandemics and
life and limb and the “essential” public terrorist events) and also more routine events
health protections: search and rescue; (e.g., floods, wildfires, ice storms, chemical
re-establishing clean water, sanitation, spills, and endemic outbreaks of infectious
shelter, food, and energy (heat in cold disease).
weather emergencies and cooling capacity Large-scale disasters (e.g., weather-related
for the increasing number of heat-related hurricanes, cyclones, floods, earthquakes,
deaths). tsunamis, wars/conflicts), while causing
4 Recovery and rehabilitation will focus on significant “direct” mortality and morbidity,
economic and vital infrastructure, which may also result in widespread damage to
may include temporary shelters and Federal essential public health infrastructures (e.g.,
Emergency Management Agency (FEMA) water, sanitation, shelter, food, health access
reconstruction grants. Planners suggest that and availability, energy systems for heat and
the short-term phase of recovery lasts from cooling) and the social protections systems
six months to a year, while the long-term that are routinely available for vulnerable
phase may take decades – as it has in post- populations (e.g., women, children, the
Katrina communities and most of the city elderly and disabled) and the population as a
of Christchurch, New Zealand (McColl whole. The loss or compromise of these pub-
and Burkle 2012). lic health protections may then contribute to
what is referred to as “indirect, preventable,
In developed countries, preparedness and or excess” mortality and morbidity.
response plans are usually in place to monitor Unfortunately, prevention and prepared-
additional increases in physical, mental, and ness phases get the short end of the stick
behavioral problems resulting from disasters when it comes to expenditure of overall
and other traumatic events. Integration of resources. Many communities still remain
public health and the emergency care and focused on short-term emergency response
management systems that include first and planning. The large majority of single
responders, emergency medical services (EMS), event disasters in both developing and
hospital emergency departments, trauma cent- developed countries are managed well by
ers, and volunteers and others are critical to local and regional emergency management
success. All these services have a strong resources. The injuries and deaths that result
public health agenda, especially when opera- from these events, such as multiple casualty
tionalized. Surge capacity elements that are incidents, space-limited localized explo-
mobilized when a disaster worsens contain sions, or building collapses, constitute eve-
major public health resources and leadership ryday examples of “direct” consequences of
authorities. During surge capacity, the the disaster itself. Broader public health
emphasis moves from conventional individ- consequences are rarely realized, other than
ual-based care to population-based care, the the requirements to recover public health
backbone of any public health programs and infrastructure such as water, power, and
decision-making. The common thread of sewage lines that might be damaged or

destroyed by the direct impact of the disas- past three to four decades and support the
ter itself. However, additional public health concept of the traditional disaster cycle.
social protections, such as mental health and These strategic- and tactical-level plans have
psychosocial programs, are often mobilized become standard in most developed coun-
early by public health authorities if not tries and many developing countries, but
absorbed by existing public and private have rarely been challenged by large-scale
health care delivery systems. disaster events. Post-2003 SARS pandemic
It must be emphasized that each phase of studies revealed that strategic- and tactical-
the disaster cycle is dependent on the preced- levels plans in all continents were deemed
ing phase. Recovery will be inadequate and quite adequate, but the local-level operational
may fail if preceding prevention, prepared- responsibility remained unclear, was lacking,
ness, or responses are lacking. With declining or plainly ignored. In the Asia-Pacific region,
public health infrastructure and social pro- the source of the virus, Thailand, China, and
tections worldwide, this statement is more Vietnam decided to double down on what
relevant today than ever. Recovery for most was familiar and focused primarily on
large-scale disasters and humanitarian crises strengthening strategic-level capacity; mean-
consists in rehabilitating the essential public while, in Hong Kong, Australia, and New
health infrastructure: water, sanitation, shel- Zealand, strategic-level approaches aimed at
ter, food, health access and availability, and harnessing available resources such as stock-
energy. Unfortunately, public health recovery piled antiviral agents and vaccines. Even in
still remains incomplete in Haiti, Iraq, parts the best of European national plans, weak-
of New Orleans, and the tsunami-affected nesses were essentially the same. Similarly, an
Indian Ocean nations years after the initiat- analysis of strategic-level national prepared-
ing disaster – to name but a few. ness plans from 53 developing and highly
health-challenged African countries showed
that case management, triage procedures, and
Top-down planning
health facilities lacked “operational clarity”
Slow improvements over the years have been (Ortu, Mounier-Jack, and Coker 2008).
made in support of the overall disaster cycle Important gaps, shortcomings, vulnerabili-
phases. In the hierarchical models that deal ties, and inconsistencies remained at the local
with disasters, strategic-level disaster plan- level that should have been recognized and
ning establishes and examines the implica- addressed by the top-down planning process
tions of long-term goals and objectives; (Canton 2007; Coker and Mounier-Jack
tactical-level plans manage the overall 2006). In 2005, after the SARS pandemic hit
response and public information for a disas- Canada, authors emphasized that “virtually
ter by coordinating the activities of multiple all health care operations, including public
organizational and agency responders, while health, are undertaken only at the local or
anticipating resource needs; operational-level regional level.” Lacking was “local establish-
plans are supposed to achieve results, using ment of a flexible and sustainable emergency
systems and resources to respond directly to management system” and “workable plans
the impacts of the disaster and include all to  deliver health care” (Johnson, Bone, and
first-level responders (Ortu, Mounier-Jack, Predy 2005, 412). During the May 2009 swine
and Coker 2008). flu (H1N1) epidemic in Australia, the role of the
Strategic, tactical, national, and local-level robust primary care general practitioner force
planning documents have emerged over the was made extremely difficult by deficiencies

in implementation of the strategic-level “two As” would allow for a formal process to
Australian Health Management Plan for occur that, in effect, purposely placed the
Pandemic Influenza, including resource supply community in the driving seat (Rogers 2011).
failures, time-consuming administrative Anticipation here is defined as “horizon
burdens, delays in receiving laboratory test scanning,” a wide-swath risk calculation
results and approval for provision of antivirals approach to identify potential dangers and
to patients, and lack of clear communication vulnerabilities that recognizes the changing
about policy changes as the situation pro- nature and risks that need to be continually
gressed. Eizenberg, an Australian general identified, reassessed, and documented in a
practitioner, emphasized that “there appears National Risk Register. Assessment, also an
to be endemic failure on the part of health ongoing process, integrates the local exper-
authorities to really understand the impor- tise on different types of disasters, relevant on
tance of implementation issues for commu- a day-to-day basis, and fed back up into the
nity based operations” (Eizenberg 2009, 152). regional and national planning process. This
process has the potential to ensure that
change is “local practitioner-led” based on a
Decade of community-centric
number of anticipated local-level vulnera-
bottom-up planning
bilities and assets being transferred into the
In many areas of the world since the early larger regional planning documents. The
2000s there has been a considerable growth in focus is placed in the lap of the community
interest in the meaning and use of the “com- itself, ensuring that the information is
munity” in disaster recovery and resilience, purposely drawn into proactive national-,
and in inventive ways in which this can be regional-, and community-level preparation
accomplished. In Australia, where disasters, and prevention measures that are unique to
especially natural disasters and climate each community’s characteristics and vulner-
changes, are becoming more frequent and abilities (Rogers 2011).
aggressive, a holistic view of the disaster While local organizational and hazard
cycle  has been formalized in “The Prepared practices have been improved dramatically,
Community” approach, which favors bottom- research suggests that community engage-
up rather than top-down planning (Common- ment strategies, policies, and practices are
wealth of Australia 2004, 5–6). Rogers (2011) still caught up in economic issues. For exam-
observed that practice experiences of local- ple, developing better insurance for disasters
level experts remained stuck in the institutional helps cut the cost of recovery and reconstruc-
memory of the local branch of the emergency tion; and improvements in public education
services in each town or city. In addition, it have shown that individuals can take more
was observed that the disaster event at the responsibility for preparedness and recovery
community level is “discreet” and “must be instead of relying entirely on the government.
understood in its totality” in isolation from the Admittedly, direct engagement and participa-
top-down process, and recognized, based on a tion are always costly and difficult, so that
number of factors and vulnerabilities that the  anticipation and assessment inclusion
make every community uniquely different may not happen. “What ‘community’ means
(Rogers 2011, 54). The recommendation was in rhetoric and reality seem to differ.”
made that two phases, “anticipation and However, whether it be the United Kingdom,
assessment,” be clearly articulated and added Australia, or the United States, “there are
to the disaster cycle. The addition of these signs that ‘community’ is being rethought in

new ways, as this concept is increasingly major disasters (Burkle 2012b). In the early
moving to the center of thinking – if not 2000s, those who called themselves disaster
action” (Rogers 2012). professionals numbered 100,000. In 2010,
Other commonly made mistakes are that there were more than 250,000, and the num-
planners fail to incorporate the constructive ber is growing at a rate of 6 percent per year
cooperation of citizens into emergency and (Walker et al. 2010). Many make up the
recovery plans. Planners should not assume burgeoning numbers of community-level
that citizens lack the expertise; they should volunteers. Some of the most talented profes-
recognize the myriad of interlinked networks sionals emerging in the discipline are those
to which people belong (ethnic, religious, in recovery, and include social scientists,
business, and institutional), which they rely engineers, attorneys, economists, and many
on for information and meaning in a crisis; civilian volunteers at the community level.
and they should recognize that a large num- Schools of public health are increasingly
ber of non-critical victims and challenging admitting civil engineers, attorneys, economists,
problems can best be dealt with within a and other professions to joint degree pro-
familiar environment by “capable, non-expert, grams, graduates knowing that their produc-
caregivers and community organizers” (Burkle tive years will be spent in improving global
2006). The more the community is supported health and mitigating the impact of war and
and becomes part of the solution, the stronger conflict in terms of scarcity of water, food,
and more focused the strategic and tactical and energy. As such, disaster management in
outcomes will be. For many federal agencies, the search for solutions has become multi-
this involves more than just delegating duties disciplinary in nature as well as in research.
to the community. What matters is how
effective those interactions continue to be
over the long term when communities become PUBLIC HEALTH EMERGENCIES:
a greater and trusted partner, how each THROUGH 2020
constituent views the recovery process, the
attention they receive, and how widely When public health resources and protec-
the  defining of the needs differs among the tions are not recovered or rehabilitated in
fortunate and not so fortunate within the a timely manner, or are destroyed or denied
same community (Burkle 2012a). to vulnerable populations as they are during
There is currently a strong movement modern-day wars, a major and sustained
afoot to professionalize assistance in both “public health emergency” may occur. In a
domestic and international disasters. Contained short time, indirect mortalities and morbidi-
in this mandate is an emphasis on public ties such as preventable illnesses, injuries, and
health instruction (Walker et al. 2010). Focus mental health and behavioral emergencies
is being placed on existing academic, non- may surpass direct mortality and morbidity
governmental, and governmental education rates (Burkle and Greenough 2008). For
and training centers to provide a compe- example, in some post-conflict environ-
tency-based curriculum and certification that ments, where the public health resources
will eventually lead to a multidisciplinary (primarily public health protective infra-
registry of certified providers (Walker et al. structure) are less than 10 percent of what
2010). This multidisciplinary movement was available before the war began and no
suggests that entry-, mid-, and higher-level resources are made available for recovery and
professionals are crucial in all phases of rehabilitation, the indirect morbidity and

mortality rates may continue to rise and not crucial biodiversity areas destroyed, and
return to the pre-war baseline for over a major scarcities of water and food – result in
decade (Burkle and Greenough 2008). In significant public health emergencies. For
these catastrophic situations the indirect example, in 2010 climate change for the first
deaths and morbidities have been massive time resulted in more than 300,000 fatalities
in  both number and severity. Every major and additional excess deaths and morbidities.
war essentially becomes a public health As populations flee to already densely packed
emergency in a matter of weeks, as the vital urban conclaves, the internally displaced gravi-
infrastructure is destroyed. The Vietnam tate to dense settlements (e.g., more than
War, the 2003 war with Iraq, and the ongoing 473,000 outside Nairobi, Kenya) or coastal
war in Afghanistan between them have disaster-prone areas where sanitation is
resulted in the death of 60–70 percent or ignored, infectious diseases are prevalent,
more civilians and have become catastrophic and potable water is scarce. Rapid urbaniza-
public health emergencies, with severe tion of megacities, especially in Africa, Asia,
declines in health indices, such as infant and Latin America, now contain the highest
mortality rates, under age 5 mortality rates, mortality and morbidity rates among the
and maternal mortality rates. Eighty percent most vulnerable populations, especially infants,
of major conflicts occur in 23 out of the 34 children, and women. In many areas, public
most fragile biodiversity areas around the health infrastructures and social protec-
world, containing the majority of our plants tions are either absent, ad hoc, or poorly
and vertebrates. As the “biological oxygen” of maintained. In reality, these areas lack basic
the world, these biodiversity areas are respon- human securities and outside humanitarian
sible for the production of food, fresh water, representation and the true nature of the
enriched soil, balanced bacterial, and other public health emergency may not be fully
microorganism growth and pollination of known (Burkle 2010).
vital plants. Following a major conflict, ecolo- Emerging and re-emerging infectious dis-
gists struggle for years to restore the fragile eases are increasing at an alarming rate. Most
ecosystem, but are increasingly unable to arise from Southeast Asia, where the highest
return them to their original state (Burkle density of human populations live side by
2010). With declining public health infra- side with water fowl and other animals known
structure and the marginalization of social to harbor diseases such as avian influenza. As
protections worldwide, public health emer- a result of the 2003 SARS pandemic, nation-
gencies are more common than ever. Disasters states signed up to an International Health
may catalyze or be a chronic symptom of Regulations Treaty (IHR) in 2005, which
fragile nation-states that suffer long-term grants the World Health Organization
extreme poverty. Unfortunately, since the (WHO) unprecedented powers to provide
mid-twentieth century 47 percent of wars public health interventions in the future
reignite within 10 years; in Africa this amounts (WHO 2011). Coordinated public health
to 60 percent or more. Without attention to measures, such as isolation, quarantine, epi-
basic public health protections, including demiological investigations, and mandated
both protected land and marine areas/sanctu- reporting by sovereign countries, finally
aries, human security cannot be guaranteed contained the transmission of the virus.
(Burkle and Greenough 2008; Burkle 2010). This  was  the first time that public health,
The crises of this century – such as climate infectious disease, and ethics and legal pro-
change, rapid unsustainable urbanization, fessionals assisted the Incident Command

System’s Emergency Operations Center in 2005 IHR Treaty, other disasters lack a simi-
Canada to provide needed consultation and lar global authority for crisis coordination
advice; and it was the prelude to the health and accountability (Burkle, Redmond, and
emergency operations center concept that McArdle 2012). Many of the documented
may be needed in large-scale disasters where problems surrounding disaster and public
health consequences are the major threat health recovery will remain until such an
(Burkle et al. 2007). authority emerges.
Although there is much to learn about the
operationalization of public health science, Hurricane Katrina, 2005 Hurricane Katrina
tasks, skills, leadership, and authority in pop- devastated the public health system in New
ulation-based emergencies, especially at the Orleans. Mississippi was better prepared for
community level, the IHR Treaty provides an the public health consequences and recovered
unprecedented model, and the only existing more rapidly. New Orleans, however, lost
model, for global cooperation among nation- public health personnel, and epidemiological
states in public health. The coordinated data banks were flooded and turned into
response to the 2009 H1N1 outbreak showed pulp. The Times-Picayune newspaper, despite
a great improvement in the public health losing its physical facility, continued to
response efforts in the United States and else- provide vital information on public health
where in the world. State and local public status during the recovery period. Interestingly,
health departments are “first responders” in a the publication of obituaries was noted by
wide variety of health threats, many of which the  population to have markedly increased
the public is unaware of. The public health over the following year. The Department of
responsibilities and skills, enhanced since the Health, without the personnel and resources
implementation of the IHR Treaty, include to investigate traditional ongoing data
tracking the source, spread, and severity of collection and surveillance, relied on help
health threats; assessing the impact of these from outside resources to complete the
threats and how the public health can be pro- investigation. This study showed a 47 percent
tected; testing laboratory samples to identify increase in excess and preventable mortality
the cause of infectious and non-infectious one year after the hurricane. Lack of access
threats; educating the public on how to safe- to,  and availability of, health and mental
guard their health; and working with elected health care led to these  findings. Katrina
officials and others to implement measures to emerged as a major laboratory, welcomed
protect the citizenry (WHO 2011). or  not, for the study of vulnerability and
resiliency. Homegrown partnerships essential
to community-based resilience that usually
Public health emergencies arising from
emerge from households, friends, family,
large-scale natural disasters
neighborhoods, non-governmental and volun-
The following brief examples are provided tary organizations, businesses, and industry
to illustrate some of the complexities of pre- were repeatedly ignored. When the disaster
sent day public health emergencies, com- struck, these “shadow responders,” who
plexities that are not often considered or provided most of the initial evacuation
dealt with  in  short-term single event dis- capacity, shelter, food, and health care, and
asters. Furthermore, whereas pandemic who rebuilt much of the search and rescue
prevention, preparedness response, and capacity and cleanup, were denied post-
recovery have benefited greatly from the Katrina funding, which was instead poorly

used by government officials. For many to health care, energy for heating and
communities, Katrina exposed the fact that cooling, and unprecedented challenges to
science, governance, and politics are difficult resiliency. Large swathes of destroyed
to disentangle – a problem that can be buildings, land damage, and liquefaction
endemic (Burkle 2010; 2011). made the idea of rebuilding impossible for
many. Populations have moved or report
Haitian Earthquake, 2010 Haiti has always they either wish to or plan to do so. For
lacked adequate public health infrastructure those who remain, a “new normal” mindset
and social protections. The 2010 Haiti has taken hold and serves as an objective
earthquake showed that the majority of those measure for the process that defines a new
immediately killed and severely injured were daily life and future decisions for survivors.
in two of the most densely populated of five Many still await the slow and painful
population zones. These areas lacked basic categorization and recategorization of
public health protections such as adequate their  homes by government agencies as
shelter, water, and sanitation before the viable to  live in – or for demolition – and
debacle, and survivors had to be evacuated the frustrations of an even slower process
to  areas where these protections existed. by  insurance companies to determine
This was not an easy task. Whereas the efforts coverage of costs or whether insurance will
of  the humanitarian aid community were even be offered to those who have decided
directed toward saving lives during the emer- to stay and rebuild (McColl and Burkle
gency phase, progress was slow in the 2012).
recovery and rehabilitation of the public The capacity to speed up the recovery pro-
health infrastructure, which was massively cess by taking action in advance to identify
destroyed. Once the emergency phase ended, and reduce vulnerabilities is known as resil-
the presence of relief agencies and donors ience (Burkle 2011). Whereas this mindset
declined. It is not surprising therefore that drives the response-to-recovery process,
the subsequent cholera epidemic devastated planners must be cognizant of what elements
an already severely compromised public are behind it when there is a  “pause” in
health system. It is crucial that emergency recovery and when a “new normal” mindset
phase providers of care be educated in the is an expected outcome – especially when
basic skills needed to seek, during the actual events on the ground are constantly
emergency phase, those declining heath evolving as the volatility of the crisis and risk
indices that forebode the onset of an exposure escalates. This requires high com-
emerging public health collapse (Burkle munity vigilance and commitment.
2010; 2012a). Disturbingly, not long after the earthquake,
newspapers in New Zealand reported com-
Christchurch, New Zealand earthquake, ments from outside Christchurch that the
2011 This has been one of the most population was sick and tired of reading only
challenging of major disasters, the effects about people who were trying to cope, assert-
of which are still being felt. The series of ing that it was time for people to “just get on
earthquakes and aftershocks that hit with living and stop whining.” For the people
Christchurch, New Zealand were severe of Christchurch, recovery became an indi-
and sustained, resulting in major damage vidual and community-centric effort that
to homes, buildings, essential services and ended at its borders (McColl and Burkle
resources in water, sewerage, food, access 2012).

GLOBAL HEALTH STRATEGIES TO education and communications guide-

IMPROVE PUBLIC HEALTH lines, especially in water, hygiene, and
4 Agreements between all international
A WHO conference following the 2004 health organizations on benchmarks,
Indian Ocean tsunami yielded a summary standards, and codes of practice for health
statement document of consensus agree- preparedness, response, and recovery,
ments designed to develop the public health and mechanisms to ensure that aid groups
capacity within disaster management sys- adhere to these standards.
tems worldwide, emphasizing that enhanced 5 Implementation of concrete steps to
public health capacities will result in less improve management and coordination
suffering and death when disasters strike. of disaster responses, especially when
The 12 elements to this agreement (WHO large numbers of expatriate groups com-
2005; Nabarro 2005) are: mit to assistance, and to have the assis-
tance managed through a participatory
1 National capacity for risk management structure made up of recipient and
and vulnerability reduction in nation- donor communities and internationally
states can be accomplished by implemen- recognized standing committees.
tation of updated policies and legislation, 6 Capacity building in supply systems,
restructuring of disaster management communications, and logistics, with
authorities, and financial commitments management support from United
and support for response and health ele- Nations systems agencies and the WHO.
ments of disaster preparedness. 7 Voluntary bodies, for example the Red
2 The prompt assessment of health situa- Cross Movement, and non-governmen-
tions and needs when a disaster strikes. tal organizations (NGOs) that provide
Population-based information measured professionals should be at the center, and
as rates, not absolute numbers, is essen- not marginal to preparedness and
tial, as are worldwide consensus on tech- response efforts, and must include coor-
niques for obtaining this information, dination of needs-based deployment of
including GIS-based data, and enhanced available resources.
logistical support capacity leading to con- 8 Good donorship must be practiced and
solidated multisectoral population-based includes requirements for timely, sus-
health needs assessments well within two tained, appropriate, and flexible funding
weeks of the disaster, especially for vul- that can be applied to emerging needs of
nerable populations. all disasters, not just those that com-
3 Recognition that evidence-based guid- mand international attention.
ance occurs in psychological threats and 9 Improve capacities for potential contri-
losses and mental health; gender equity, butions of government military and
in particular health, reproductive health, commercial private sector resources for
and nutritional threats faced by women; disaster response and coordination
food, health, and nutrition needs of chil- alongside local and national govern-
dren; standard approaches for identifying ment, civil society, and NGOs.
and managing the dead; involvement of 10 Establish effective working relationships
volunteer health workers and manage- with local, national, and international
ment of in-kind donations; and health medical agencies during disaster response.

11 Transparent accountability and profes- Burkle, F. M., Jr. 2012a. “Preparedness, Response,
sional ethics of all humanitarian health and Recovery in the Decade of the Commu-
actors. nity.” Keynote address presented at the Disaster
12 Local communities must be enabled to Roundtable 34, National Academies of Science,
Washington, DC, March 21.
develop cross-sectoral capacity for vul-
Burkle, F. M., Jr. 2012b. “The Development of
nerability reduction and effective disas-
Multidisciplinary Core Competencies: The
ter responses, and receive financial and First Step in the Professionalization of Disaster
technical backing to do so. Medicine and Public Health Preparedness on
a Global Scale.” Disaster Medicine and Public
Many lessons need to be relearned with Health Preparedness 6(1): 10–12.
every generation. The International Committee Burkle, F. M., Jr., and Greenough, P. G. 2008.
of the Red Cross (ICRC) many decades ago “Impact of Public Health Emergencies on
recognized that in war the occupying power Modern Disaster Taxonomy, Planning, and
had the obligation under the 4th Geneva Response.” Disaster Medicine and Public Health
Convention, Articles 55 and 56 to restore the Preparedness 2(3): 192–199.
public health infrastructure and protections Burkle, F. M., Jr., Hsu, E. B., Loehr, M., Christian,
M. D., Markenson, D., Rubinson, L., and Archer,
to what they were before the conflict (ICRC
F. L. 2007. “Definition and Functions of Health
1949). Even in the late 1800s, the importance
Unified Command and Emergency Operations
of public health was well understood by those Centers for Large-Scale Bioevent Disasters
who carried the burden of crisis recovery. within the Existing ICS.” Disaster Medicine and
Public Health Preparedness 1(2): 135–141.
SEE ALSO: Disease Surveillance and Burkle, F. M., Jr., Redmond, A. D., and McArdle,
Global Health Security; Emerging and D, F. 2012. “An Authority for Crisis Coordina-
Re-Emerging Infectious Diseases; Pandemic tion and Accountability”, Lancet, 379(9833):
Preparedness and Response 2223–2225.
Canton, L. G. 2007. “Emergency Management: A
Social Science Perspective.” In Emergency Man-
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Eizenberg, P. 2009. “The General Practice Expe- Moyer, C. S. 2011. “US Still Faces Public Health
rience of the Swine Flu Epidemic in Victoria: Preparedness Gaps 10 Years after 9/11.” Ameri-
Lessons from the Front Line.” Medical Journal of can Medical News.
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Walker, P., Hein, K., Russ, C., Bertleff, G., 2013.
and  Caspersz, D. 2010. “A Blueprint for
Caregiving and Race decisions, and to discipline the children,
while women are expected to adhere to these
CAROLE COX decisions and to focus on the home, includ-
Fordham University, USA ing assuming the role of caregiver.
As culture provides a set of guidelines for
Caregiving is a rapidly increasing experience speaking, doing, interpreting, and evaluating
in society. The aging of the population and ourselves and others with whom we interact,
the significant increase in the numbers of it gives meaning to the experience of caregiv-
persons requiring assistance in the commu- ing and to interventions such as the use of
nity has had a dramatic impact on families formal services and supports that can assist
that provide the majority of all assistance. caregivers. In fact, caregiver coping strategies
The older population is becoming increas- are themselves shaped by cultural values and
ingly diverse and ethnicity and race are fac- behaviors. Culture can thus be pivotal in
tors that can greatly impact the caregiving understanding how people justify their
experience. In recent years there has been a beliefs about caregiving, including whether
growing body of research that has explored they are fulfilling a sense of duty or obliga-
and compared caregiving among ethnic tion, or God’s will. It is noteworthy that in
populations. As dementia, and particularly some cultures the term “caregiver” does not
Alzheimer’s disease, has become a major exist; such expected, normative roles and
health issue among the older population, duties are so taken for granted by those in
much of the research on race and caregiving caregiving roles that they do not even need to
focuses on these family caregivers, whose be labeled.
involvement, stress, and demands increase In contrast to race, culture is not constant
with the progression of the disease. or impermeable. Adherence to specific values
and norms changes through assimilation,
particularly across generations. Whereas
first-generation immigrants may be expected
to maintain close ties to traditional values,
Race is an important phenomenon, as it
their children and grandchildren may feel
reflects cultural differences. While race is
less committed. These variations can lead to
based on physical characteristics, culture
dissension within families, as older persons
involves values, norms, and beliefs shared by
may maintain expectations for assistance that
a particular group. It is through culture that
are not shared by their children.
persons learn their roles and expected ways
of  interacting. Cultural expectations are
conveyed through norms which govern CAREGIVING AND DEMENTIA
behaviors and are often most apparent in the
ways in which social roles are enacted. For Dementia poses many challenges for caregiv-
example, men may be expected to be the ers as the progression of the illness entails
main providers in the family, to make the increasing demands for assistance and sup-

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

port. Watching a person gradually deteriorate of a bilingual staff – continue to be major

both mentally and physically, with concomi- barriers to care (Mukadam, Cooper, and
tant needs for more and more assistance, is Livingston 2011). Belief that memory loss is a
extremely stressful and can impact both the normal part of aging, and thus not something
physical and the emotional health of the car- requiring medical intervention, also contin-
egiver. Caregivers are vulnerable to feelings of ues to delay people from seeking care for rela-
stress, burden, and depression, and have been tives. Moreover, when people from minority
found to experience a high level of negative groups go to a physician, they are often at
emotional states and psychiatric morbidity. greater risk of having the symptoms treated as
As culture shapes perceptions and behav- a normal part of old age.
iors, it also shapes responses to cognitive
impairment and dementia. Cultural belief sys-
tems are influential in the ways that symptoms ASIANS AND DEMENTIA
such as wandering, confusion, or forgetfulness
are perceived – for example, whether they are Asian families are less likely than other
seen as being indicative of disease, as a punish- groups to report that a relative has dementia.
ment, or accepted as a normal part of aging. However, data on their responses to caregiv-
Consequently, culture impacts the actions ing are limited and varied. Some findings
that persons take in regard to symptoms and show that they are less likely to be stressed
treatment-seeking. As an example, studies of (National Alliance for Caregiving and AARP
Chinese caregivers found that spiritual pos- 2004), while others (Lee and Sung 1998) find
session or fate was often thought to be the they are more depressed than other groups.
cause of dementia and so persons turned This has been attributed to the fact that it is
toward prayer and faith healing to ward off usually the daughter or daughter-in-law who
the evil spirits believed to be causing the ill- is the caregiver and she may be doing this out
ness (Zhan 2004) In addition, perceiving of obligation rather than preference, and is
dementia as either a stigma or shameful may likely to be more emotionally involved.
make a person reluctant to seek care. Groups It is important to note that the Asian popu-
that are able to combine beliefs that attribute lation is composed of many subgroups with
dementia to stress, worry, loss, or normal both similarities and differences in their per-
aging with Western biomedical knowledge ception of dementia. Chinese, Japanese,
more readily accept treatment. Filipino, and Vietnamese families share com-
Other factors that present barriers to care mon beliefs, including that dementia is a
include language differences, a culturally common part of aging, dementia cannot be
insensitive staff, limited knowledge and cured, children are obligated to care for their
understanding of services, and problems with parents, problems should remain within the
accessibility. Previous negative experiences family, and it is shameful to talk about prob-
with the health care system, such as long lems of senility. Among Chinese, dementia
waiting periods, insensitive staff, and poor may be perceived as an imbalance in the yin
quality care, can further deter people from and yang forms of energy or as retribution for
treatment. A systematic review of literature the sins of one’s ancestors. Symptoms may
on minority caregivers and people seeking also be viewed as resulting from cultural
help for dementia shows that lack of knowl- shock and the stress associated with immi-
edge about the illness, a belief that nothing gration. In comparison, Vietnamese concep-
can help, language barriers – such as the lack tions of dementia integrate many influences

in their definitions, from Western biomedical and King 2005). They prefer informal support
explanations to normal aging to spiritual and are generally less interested in the use of
causes to health beliefs such as that the brain formal assistance than non-Hispanic white
is becoming flat or worn out (Yeo et al. 2001). caregivers. Research has also found that the
Asian caregivers are often confused over use of formal assistance and home care, par-
the causes of dementia and prefer to use ticularly among those with stronger adher-
terms such as “forgetfulness” and dementia ence to norms of filial support, was related to
rather than Alzheimer’s disease, which greater depression among caregivers (Cox
implies shame and mental illness. They are and Monk 1993). Further research indicates
often physically exhausted as well as finan- that this relation between familism and
cially burdened because of the constant depression and burden differs among
caregiving. Language is a major deterrent to Hispanic subgroups, making it difficult to
service use among Asians, with services gen- generalize across cultural contexts (Losada et
erally viewed as not meeting their needs. al. 2006).


Latino caregivers comprise many subgroups, Findings from many studies indicate that
so important variations in experiences and black caregivers report less emotional stress
responses can exist between Cuban, Mexican, than other caregivers (Cox and Monk
Spanish, and Puerto Rican caregivers, among 1996), although they have also report
others. However, certain key values, such as greater role strain (Hilgeman et al. 2009).
beliefs in fatalism and the importance of the Overall, black caregivers are more likely
family, are commonly shared. Studies on than whites to report positive emotional
Latino caregivers show that they experience experiences and perceptions of caregiving
high levels of distress (Adams et al. 2002) and experiences and, over time, report more life
high rates of depression that have been associ- satisfaction and fewer depressive symptoms
ated with their commitment to filial support than other groups.
and a sense of role captivity (Cox and Monk The factors resulting in the greater
1996). They also report less social support adaptability of blacks to the caregiving role
than other ethnic groups (Adams et al. 2002). remain unclear. Greater religiosity and
Their lower socioeconomic status, lack of available social supports have been dis-
health care, higher incidence of certain dis- cussed as forces that help them to adjust to
eases, and even their attempts to juggle many caregiving. But a feeling of insufficient
roles, all contribute to caregiver stress. Often, emotional support among black caregivers
they lack knowledge about Alzheimer’s dis- has been related to depression, a connection
ease and the skills that can help manage it. not found among white caregivers (Cox
Cultural values such as sufrimiento (suffer- and Monk 1995). However, the results of a
ing) and familism (the role of the family) and longitudinal study of caregivers living in
personalisimo (preference for personal touch) the same household as a person with
can further influence caregiver responses to Alzheimer’s disease could not attribute
dementia care and services. the  emotional advantage of black caregiv-
Latino caregivers tend to rely on religion ers to either social supports or religiosity
and spirituality as coping strategies (Morano (Skarupski et al., 2009).

CONCLUSIONS AND FUTURE Much of the research discusses the role of

RESEARCH informal supports in the lives of caregivers.
However, as important as these supports are,
As the aging population continues to increase they should not be perceived as negating a
and to become more diverse, the understand- need for formal services. Even basic cultural
ing of the way in which race and culture are values such as familism can vary among
related to the experiences and responses of subgroups and across different contexts.
caregivers will become even more critical. A Further research on the interaction of tradi-
meta-analysis of the findings of 116 studies of tional cultural values with current demands
ethnicity and the psychological health of car- and institutional responses is needed to fur-
egivers concluded that it was not ethnicity ther explicate their influences on caregivers.
alone that was critical, but rather its relation- Developing services in accordance with spe-
ship and interaction with other variables cific cultural beliefs and values can promote
(Pinquart and Sorensen 2005). Overall, ethnic their utilization.
minority caregivers had a lower socioeconomic The relationship of race and culture to car-
status, were younger, were less likely to be mar- egiving remains a complex issue. It remains
ried, had stronger adherence to norms of filial difficult to generalize from existing studies
obligation, and were more likely to receive given variations in samples, measures, and
informal support than white caregivers. All instruments. Large-scale studies that follow
these factors interact to impact the well-being caregivers over time, and have adequate repre-
of the caregivers, while none protects them sentation of subgroups, are needed to more
against a need for formal assistance. clearly explain the dynamics of caregiving and
Understanding the variations among the relationship of race to caregiver responses.
groups is essential for the development of
interventions appropriate to their needs. SEE ALSO: Aging; Caregiving and Race;
Equally important is the need to refrain Family Caregivers: Dementia; Health and
from making generalizations, since race is Illness, Cultural Perspectives on; Race,
not a homogeneous concept. Heterogeneity Ethnicity, Culture, and Health in the United
exists among subgroups with regard to States
culture, socio-demographic variables, and
familial relationships between caregivers
and for whom they care. Research on race REFERENCES
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Screening it permitted distinctions to be made between
PATRICE PINELL healthy individuals and those who were
Centre National de la Recherche Scientifique, France infected, who could be further divided
into  the potentially infectious and the safe
The emergence of the word “screening” in (Delaporte 1995). As long as treatment effi-
medical language is linked to a series of cacy was poor, the protection of the non-
transformations in the nineteenth century. infected population remained the sanitary
With the rise of bacteriology and of immu- authorities’ main concern. It legitimized a
nology, those transformations were responsi- policy that makes screening of germ carriers
ble for important changes in hygiene policies. a necessary prerequisite for their isolation –
The first practices of screening were devoted the development of that policy being linked
to “hunting” the germs that the microbial to institutions built for the isolation and treat-
theory of the infectious disease considered to ment of patients.
be the causal agent (the French word for From the outset, the social organization
screening, “dépistage,” was drawn from the of  screening policies was a key issue. Given
vocabulary related to hunting). Those prac- that mass screening ought ideally to be all-
tices would use the properties of the immune embracing, there was a central debate about
system to reveal the presence of a germ in the whether it should be made compulsory.
body of asymptomatic patients. Techniques, Organizing compulsory screening for a
like the skin test for tuberculosis or the disease at the level of the whole population
Wassermann test for syphilis, opened up new was an impossible goal. Promoters of social
perspectives in the search for ways of fight- hygiene had to limit their ambitions to legally
ing these two major scourges of the early submitting only specific populations to com-
twentieth century. At the same time, the pulsory screening. Such populations had
invention of radiology, another technique already to be under conditions of legal con-
that allowed some clinically silent lung straint. Examples included schoolchildren in
lesions to become visible, started to be used countries where compulsory education was
in screening for tuberculosis, particularly by established, young men eligible for military
the army medical corps. service, or prostitutes in licensed brothels. All
these groups were submitted to screening for
different diseases. To enforce social hygiene
SOCIAL HYGIENE: THE SCREENING screening policies on a larger number of peo-
OF GERM CARRIERS ple, new legal measures were devised, such as
compulsory medical tests for job applicants
The role of screening in policies for fighting or compulsory pre-marital examinations.
tuberculosis and syphilis served two func- Those policies could rely on the institution-
tions. First, it brought to light the extent to alization of new specialized branches of
which latent infections had spread, contribut- social medicine, such as occupational medi-
ing both to epidemiological knowledge and cine and school medicine in some countries.
to the definition of policy priorities. Second, They could also rely on the development of

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

health center networks and new professions of individuals seen as rational social actors,
(social workers, visiting nurses) whose mis- conscious of their self-interest in the results
sions were to educate and control at-risk rather than the protection of others.
populations. In this new social configuration, the func-
tion of distinguishing between healthy and
asymptomatic patients had three main goals:
NEW PRACTICES 1 The discovery of abnormalities suggesting
the possibility of a hidden disease. The
Social hygiene policies and organizations objective is to facilitate early treatment
changed dramatically with the transforma- enhancing the therapeutic effectiveness.
tions of the medical field after World War II. 2 The discovery of abnormalities (hyper-
The decline of infectious diseases and the rise tension, high cholesterol, genetic pre-
of chronic and degenerative diseases, on the disposition) recognized as a risk factor for
one hand, and the rise of new, highly special- diseases. Screening takes place as part of a
ized, branches of medicine and medical prac- prevention strategy and initiates a medi-
tice, on the other, have been determining calization process for asymptomatic
factors in the evolution of screening practices. patients, with more or less serious conse-
The treatment of new pathologies became an quences for their everyday life (diet,
object of screening, but the nature of the secondary effect of preventive drugs,
tracks of the silent diseases had changed. The preventive excision or transplant of an
focus would now be to locate the presence of organ).
abnormal cells, infra-clinical tumors, defec- 3 Screening in antenatal medicine can be
tive genes, or physiological, metabolic, or used for the detection of genetic or chro-
chromosomal abnormalities. The range of mosomal diseases (antenatal diagnosis,
screening methods increased significantly ultrasound scan), opening the door to
thanks to scientific and technical innovations, therapeutic abortion. Here, screening is an
including smear tests, dosage of metabolites instrument of individual eugenic practices.
and of enzymatic activities, antenatal diagno- But mass screening leading to the possible
sis, medical imagery. The evolution of public eradication of the disease is now conceiv-
health problems that screening practices had able. With such a change in scale, the pro-
to address has also been shaped by social blem becomes a shift from individual
changes in the affected populations. Social eugenic practices to the implementation of
hygiene used to target lower-class children, a eugenic policy, even if the possibility
young people, and mothers; now, the new given to every pregnant woman to have the
health policies would be mainly concerned test is not recognized as a eugenic policy by
with middle-aged adults and older people the public authorities.
belonging to all social classes. The conception
of screening policies was dramatically chang- The changes in the social organization of
ing. The question was no longer that of using screening are linked to the evolution of prac-
legal tools to force an imagined passive, igno- tices. Because of their diversity, policies are
rant, and potentially infectious lower-class sector-based, often restricted to one specific
population into compulsory screening, but of problem and more frequently organized on a
offering screening opportunities to a “public” regional than a national scale. The role played

by institutions of social medicine before policy. The test was developed in a political
World War II is now considerably decreasing, framework characterized by an alliance
to the benefit of general or specialized practi- between hospital doctors in charge of
tioners. It is within the framework of indi- patients, non-governmental organizations
vidual doctor–patient relationships that concerned with AIDS, and sectors of the
a “rational social actor patient” will be offered state bureaucracy. This alliance was based
a range of screening facilities according to on the refusal of compulsory screening, an
his  or her known or presumed risk factors. idea considered as inefficient, stigmatizing
However, this new reality has led to several for the patients, and undermining civil lib-
problems. First, many doctors had to change erties (Rosenbrock et al. 2000). The chosen
their views on medical practices and acquire strategy asserted that screening practices
a public health “culture.” Second, doctors had should respect the voluntary choice and the
to face “real” patient reactions that did not anonymity of people and appealed to indi-
reflect the “rational actor” logic. A medical vidual responsibility. In a medical context
proposal in favor of screening might collide where there is no efficient treatment, it was
with the patient’s fear of confronting the important to develop preventive behaviors
result or with his or her reluctance to accept for people exposed to some risks of contam-
a test requiring an examination hurting his ination, rather than screening the infected.
or her sense of modesty (Fisher 1984). The new public health policy was therefore
Third, medical screening practices may dif- not based on the social control of “germs
fer significantly from one practitioner to carriers,” but on every individual’s self-
another. In order to harmonize practices, control. It was only when some successes
the medical authorities had to create occurred in treating the opportunist dis-
guidelines of good practice defining the eases and, of course, when AIDS itself
conditions of regular screening (for exam- started to be under control with chemo-
ple, from what age and with what frequency therapy treatments that the development of
a mammography control should be proposed screening strategies became a more central
to a patient). Then they had to convince goal, and prevention started losing its prior-
private, or independent, practitioners to ity status.
comply with recommendations that might
clash with their economic interests or their SEE ALSO: Epidemics; Eugenics; Health
personal convictions. Policy; HIV/AIDS and Sexually Transmitted
Diseases, Testing for; Prenatal Diagnosis and
Screening; Sexually Transmitted Infectious
THE AIDS EPIDEMIC AND Diseases and Epidemics, Prevention of
Delaporte, F. 1995. Les Épidémies. Paris: Pocket.
With the AIDS epidemic, the problem of
Fisher, S. 1984. “Doctor–Patient Communication:
fighting a communicable and mortal A Social and Micro-Political Performance.”
disease  was reformulated in new terms. Sociology of Health & Illness 6: 1–29.
Although a serologic test was rapidly made Rosenbrock, R., et al. 2000. “The Normalization of
available to initiate a screening strategy, this AIDS in Western Countries.” Social Science &
did not revive the old compulsory screening Medicine 50: 1607–1629.

FURTHER READING Vigarello, G. 1999. Histoire des pratiques de santé.

Paris: Seuil.
Armstrong, N., and Eborall, H. 2012. “The Soci-
Wilson, J., and Jungner, G. 1968. Principles
ology of Medical Screening: Past, Present
and Practice of Screening for Disease. World
and Future.” Sociology of Health & Illness 34:
Health Organization. http://whqlibdoc.who.
int/php/WHO_PHP_34.pdf. Accessed July
Pinell, P. 1996. “Modern Medicine and the Civilizing
21, 2013.
Process.” Sociology of Health & Illness 18(1): 1–16.
Sex XY, male), hormones (estrogen, female;
testosterone, male), genitalia (clitoris, vagina,
LISA JEAN MOORE and uterus, female; penis and scrotum, male),
Purchase College, State University of New York, USA procreative organs (ovaries and uterus,
female; testes, male), and gametes (ova,
Sex is a term with multiple meanings depend- female; sperm, male). When a fetus is con-
ing on the contexts of its use. There are two ceived, the female contributes an X chromo-
primary definitions of sex, one referring to some, and the male contributes either an X or
social identity grounded in biology and the a Y. A child with the chromosome makeup
other to what people do with themselves or XY is sexed-male, while an XX is sexed-
each other. These definitions are considered female. Most human beings have identifiable
to be related, but it is important to note that primary sex characteristics (genitalia).
sex as both social marker and erotic behavior Secondary sex characteristics are typically
is a highly contested term. Depending on developed during puberty; in most males,
who is defining sex and for what purposes, testosterone increases muscle size and mass,
explanations can be value-laden to indicate deepens the voice, and accelerates growth of
that a behavior or body is “normal” or “abnor- facial and body hair. In most females, estro-
mal.” Therefore, it is necessary to understand gen produces breasts and menstruation,
how sex is always and everywhere a socially widens the pelvis, and increases the amount
constructed category. of body fat in hips, thighs, and buttocks.
First, sex can refer to the biological differ- Testosterone and estrogen are found in both
ence between males and females. Gender is a women and men, and both are important for
broader term that incorporates cultural and human development, but testosterone is the
social definitions. These are separate terms theorized source of aggression and machismo
but are deeply interrelated. Birth sex, the in men, and estrogen supposedly produces
pronouncement of a newborn’s (or fetus’s) empathy and nurturance in women. There
biological sex by birth attendants or sono- are certainly behavioral and emotional effects
grams is the foundation for subsequent gen- of hormones, but the pathway is not linear.
der socialization of individuals. That is, Ethnomethodologists Candace West and
humans who are assigned the sex male at Don Zimmerman (1987), influenced by the
birth are called boys and are supposed to feel, works of Harold Garfinkel and Erving Gof-
behave, and look masculine. The same pro- fman, refined the term “sex category” to refer
cess is supposed to turn female babies into to the processes of self-identification and self-
feminine girls. Throughout our lives, many of display as a female or male; the assumption is
us comply, and some resist, the gendered that identity and self-presentation are congru-
expectations of our original sex categoriza- ent with the sex assigned at birth, but they may
tion at birth by varying our gendered not be. Generally, people assume that the sexed
expressions. physical traits of bodies produce an individu-
Regardless of our social performance, the al’s social characteristics. But physical traits –
biological criteria for sex classification as female genes, hormones, and anatomy – are also
or male include chromosomes (XX, female; affected by behavior and environment.

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

In contemporary Western societies, sex attempts to conceive. Some intersexuals are

designation follows a strict dichotomous cat- not identified until an autopsy is done after
egorization schema where one is either male death. The medicalization of intersexuality
or female. Thus, Western societies do not as a disorder or disease has lead to the medi-
have third genders or sexes, as some other cal management and surgical treatment of
cultures do (Herdt 1994). We expect people some intersex bodies. This medical interven-
to be “women” or “men,” “female” or “male,” tion has been controversial (Preves 2003).
not “other.” We organize society on a two- Historically, some human bodies have been
gender system that most people believe is modified to fit into the binary socially pre-
based on a clear-cut two-sex biology with a scribed sex categories without consent.
clear path to the “appropriate” or socially The term “transgender” is used to identify
acceptable gender display. The way we inter- someone who is challenging, questioning, or
act with others of the same or different gen- changing gender from that assigned at birth
der reflects the “natural attitude,” which to their gender\identity – male-to-female
assumes that there are two and only two (MTF), female-to-male (FTM), transitioning
sexes, that everyone is naturally one sex or (between genders), gender queer (transgres-
the other no matter how they dress or act and sive, challenging gender norms).
will be that sex from birth to death, and that The second definition of sex refers to the
you can’t really change your “natural” sex intimate actions, interactive or solitary, based
(Kessler and Mckenna 1978, 113–14). Those on erotic desires that bring about sexual
who believe that sex differences are biologi- arousal. Several social science research studies
cal believe that most gendered behavior have connected human sexual exchange to
emerges from this biology. The gendered increased quality of life across the life span (e.g.,
social order and the many processes that go Laumann et al. 2006). In many contemporary
into the production of gender differences are cultures, sex is linked with human reproduc-
not seen as powerful structural forces that tion even though this linkage is often a discipli-
shape bodies, identities, and behavior. In this nary mechanism to control human populations
framing, not only is biological sex not the (Foucault 1981). Because of religious, social,
ultimate determinant of gendered bodies and and cultural norms, unprotected penis–vagina,
behavior, but some people construct gen- insertive, heterosexual intercourse aimed at
dered bodies that do not fit the sex declared human reproduction is commonly thought
at their birth. of  as the (only) appropriate form of sex,
A person who is intersexed has procrea- sometimes eclipsing other types of sexual rela-
tive or sexual anatomy that does not seem to tions. There are many other forms of sexual
fit the typical definitions of female or male – exchange, including masturbation, oral sex,
appearing genitally female but having mostly anal sex, fingering, rimming, and fisting.
male-typical anatomy internally, or a girl Just as the designation of biological sex
(XX) born with a noticeably large clitoris or influences one’s social identity, so the type of
lacking a vaginal opening, or a boy (XY) sex, including the partner(s) with whom one
born with a notably small penis or with a has sex, influences self-identification as well
divided scrotum resembling female labia. as social labeling. Engaging a certain set of
There are also people born with mosaic behaviors and actions with someone of the
genetics, so that some cells have XX chromo- “opposite” sex leads to the social assumption
somes and some have XY. Intersex character- that one is heterosexual. Likewise, behaviors
istics may not show up until puberty, or upon and actions with someone of the “same” sex

can lead to social labeling as homosexual or Kessler, Suzanne J., and McKenna, Wendy. 1978.
lesbian. However, individuals may indeed Gender: An Ethnomethodological Approach.
engage in any range of sexual behaviors and Chicago, IL: University of Chicago.
choose to self-identify as homosexual, hetero- Laumann, E. O., Paik, A., Glasser, D. B., et al. 2006.
“A Cross-National Study of Subjective Sexual
sexual, or bisexual. Although attitudes toward
Well-Being among Older Women and Men:
sex can vary greatly by culture and generation,
Findings from the Global Study of Sexual Atti-
the one view of sex that appears to be true tudes and Behaviors.” Archives of Sexual Behav-
across cultures is the taboo placed on incest. ior, 35, 145–161.
As defined by the Centers for Disease Preves, Sharon. 2003. Intersex and Identity: The
Control and Prevention (2011), sexual health Contested Self. New Brunswick, NJ: Rutgers
is “a state of physical, emotional, mental and University Press.
social well-being in relation to sexuality; it is West, Candace, and Zimmerman, Don. 1987.
not merely the absence of disease, dysfunc- “Doing Gender.” Gender and Society 1 (June):
tion or infirmity.” A range of sex-related top- 125–151.
ics must be considered for sexual health,
including sexual violence, birth control, sexu- FURTHER READING
ally transmitted diseases, reproductive health,
Fausto-Sterling, Anne. 2000. Sexing the Body: Gen-
sexual vaccines, fertility, and sexual function.
der Politics and the Construction of Sexuality.
New York: Basic Books.
SEE ALSO: Contraception; Embodiment; Henslin, James M. 1971. Studies in the Sociology of
Lesbian, Gay, Bisexual, and Transgender Stress; Sex. New York: Appleton-Century-Crofts.
Sex, Sexuality, and Health Geography Lorber, Judith, and Moore, Lisa Jean. 2010. Gen-
dered Bodies: Feminist Perspectives. Oxford:
Oxford University Press.
Roberts, Celia. 2007. Messengers of Sex: Hormones,
Centers for Disease Control and Prevention. 2011. Biomedicine and Feminism. New York: Cam-
Sexual Health. bridge University Press.
health/. Accessed March 27, 2013. Seidman, Steve, Fischerm Nancy, and Meeks,
Foucault, Michel. 1981. The History of Sexuality: Chet, eds. 2007. Introducing the New Sexuality
An Introduction. Harmondsworth: Penguin. Studies: Original Essays and Interviews. New
Herdt, Gilbert, ed. 1994. Third Sex, Third Gender: York: Routledge.
Beyond Sexual Dimorphism in Culture and His- Stryker, Susan, and Whittle, Stephen, eds. 2006. The
tory. New York: Zone Books. Transgender Studies Reader. New York: Routledge.
Gender and the Professions sociologists were quite late in connecting
gender with professions.
ELIANNE RISKA A challenge to the normative – or, more
University of Helsinki, Finland precisely, functionalist – perspective of
mainstream (Parsonian) medical sociology
When the sociology of professions emerged as emerged in the early 1970s. A conflict and
a field of study, any particularistic criteria, interactionist perspective introduced the
such as gender or race, were considered concept of professional dominance, which
incommensurable with the concept of the suggested that a certain profession had man-
profession, because such criteria were consid- aged to achieve a market shelter (Freidson
ered, by definition, not to influence the 1970). This perspective has been known as
practice of a professional. This notion derived the professional dominance or monopoliza-
from Talcott Parsons’s view of the characteris- tion thesis. Yet the concepts “professional
tics that defined professional authority and dominance” and “knowledge monopoly” were
professional behavior. The authority and given a gender-neutral meaning, although
behavior of the professions were considered some contemporary feminist scholars did
by Parsons to be based on gender-neutral val- document the male domination and gen-
ues: achievement, universalism, functional dered practice of professions (Ehrenreich
specificity, affective neutrality, and a collective and English 1973). The introduction of
orientation (Parsons 1951, 454). For Parsons, gender in the sociology of professions came
the medical profession was a prototype of from representatives of the neo-Weberian
expert knowledge and of the kind of expert– perspective on professions (Larson 1977),
client relationship that had emerged in the who introduced the concept of “professional
process of modernization. Early sociological project.” This concept made visible both the
studies on the medical profession set out to subordinated status and successful upward
explore the way in which such professional mobility professionalization projects of
behavior and attitudes were socially acquired female occupational groups. New feminist
and the professional role institutionalized. interpretations showed that structural
The first generation of studies on mechanisms (Lorber 1984) and discursive
professions in the 1950s and 1960s was strategies and social closures (Witz 1992)
characterized by a gender-neutral “traits had prevented women from entering into or
approach,” the aim of which was to find the advancing in the medical profession and
special characteristics in the work of the how other subordinate health professions –
occupational groups that could be called nursing, midwifery – had become women’s
professions. The early empirical studies on work (Kuhlmann 2006). The latter studies
the medical profession examined the sociali- identified an explicit linkage between gender
zation process, whereby the norms of the and professional closure.
profession were acquired. These studies did The neo-Weberian approach was further
not consider gender, because of the all-male developed in the systems approach introduced
sample of the studies (Merton, Reader, and by Andrew Abbott (1988), an approach
Kendall 1957; Becker et al. 1961). In short, that  also integrated the earlier interactionist

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

framework. Abbott’s focus is on jurisdictional Turkey, Switzerland, and the US (OECD

claims of various professional groups and the 2012). While pediatrics and general practice
continuing interprofessional conflicts in chal- seem to be heavily female-dominated areas,
lenging and protecting those jurisdictions. surgery continues in Western countries to be a
Although Abbott did not raise gender as an male-dominated medical specialty (about
organizing principle in the definition of a 10–20 percent of surgeons are female).
jurisdictional domain, later research has used Research continues to map these consistent
his model for explaining the inclusion or trends in an effort to find the structural and
exclusion of female-dominated occupational cultural mechanisms that could explain the
groups from those that have the status of connection between gender and the choices
a profession. and constraints related to gendered profes-
Over the past three or four decades, sociol- sional careers in medicine.
ogy of professions has experienced the same The early reports on women’s status in the
development as sociology of work. Although medical profession (Walsh 1977; Lorber
work and professions were central concerns in 1984) have been continually updated with
the classics of sociology (Durkheim) and also new reports that tend to confirm that women
in the grand (Parsons) and middle-range physicians still practice in different and often
theory (Hughes’ [1958] micro-level approach) less prestigious specialties and at lower levels
of early modern sociology, the key inquiries of in the organization of medicine than their
those epoques have moved to research in labor male colleagues (e.g., Riska 2001; Boulis and
market studies and organizational studies. Jacobs 2008; Elston 2009).
Since the 1990s, the latter two disciplines have Two explanations have been presented in
documented the horizontal and vertical segre- research on the connection between gender
gation of women in the professions and mana- and professions: the socialization perspective
gerial positions. Gender segregation in the and the perspective that points to structural
work of professions became a new theme in the constraints. According to the gender sociali-
1990s and has remained an active area of zation perspective, the career choices of men
research in both European and North American and women derive from different interests
research on gender and professions. and values which are part of early gender
In much of the sociological research on socialization and they are reproduced over the
gender and the professions in the health field, life course. Early research was based on sex-
the focus has been on women’s position in the role theory, which suggested that the acquisi-
medical profession. This research has explored tion of the male and female sex role was part
the persistence of gender segregation of medi- of the socialization system in society and of
cal specialties, despite the fact that women’s the gender division of labor in the family and
proportion of practicing physicians has labor market. More recently the so-called
increased in most Western countries. For preference theory follows the same argument,
example, in 2009 women constituted between but rather than depicting the individual as a
50 and 60 percent of practicing physicians passive object of social norms, it emphasizes
in  Poland, the Czech Republic, Hungary, the voluntary aspects of social action. The
Portugal, the Slovak Republic, Slovenia, and preference theory (and human-capital theory)
Finland; between 40 and 47 percent in Austria, highlights the individual choices that women
France, Germany, Israel, New Zealand, make over their lifetime regarding their
Norway, Spain, and the UK; and about a third investment in a career (Hakim 2000). This
of the physicians in Belgium, Canada, Italy, perspective has been used to explain the

specialty choices that women make; for the knowledge and power of the profession.
example, women are assumed to choose More recently, the term “inequality regimes”
specialties that fit female values (pediatrics, (Acker 2006) has been introduced as a way
geriatrics) and their need for regular working to  understand the production of gender,
hours (health centers) in order to strike a bal- race,  and class in organizations and to shed
ance between family and working life demands. light on why so many gender equality policies
Recent research suggests a convergence of and  projects have failed or have only had
men’s and women’s career choices because minor impact.
male physicians have begun to take into The male-gendered values inherent in medi-
consideration lifestyle factors, while female cine were early documented by feminist scholars
physicians are increasingly becoming more who showed that medical knowledge patholo-
career-oriented (Riska 2011). gized the female body, and constructed disease
The second explanation focuses on struc- categories (e.g., mental illness) that medicalized
tural factors that serve as constraints to wom- femininity, female behavior, and life phases.
en’s career choices. This genre of research has Much of the research on the medicalization
been part of the efforts to increase gender argument and on Foucault’s notion of govern-
equality within the professions and in the ance and social control have focused on the
organization of health care, or to support a female body as a way to show how the medical
public gender equity policy in society in gen- profession and medical knowledge have been
eral. Early findings continue to be confirmed used to control women (Clarke et al. 2010). This
in recent research: sexual harassment and a theme is also covered by science and technology
lack of positive role models and mentors in studies, which have documented the subtle ways
medical school are important factors which in which medicine contains gendered values.
often deter women medical students and As women become a majority of medical
residents from opting for careers in male- practitioners, the frequently asked question
dominated and demanding specialties. It has has been: Will women practitioners change the
been argued that the sum of those actions way that medicine is practiced? International
creates an invisible “glass ceiling” in women’s reviews on the topic show that women physi-
careers in professions. The optimists have used cians tend to be more patient-centered and to
these findings to emphasize the importance of have a more empathic practicing style than
mentors for women and for various types of their male colleagues, but otherwise there are
structural solutions to support women in no or only minor gender differences in clinical
medical school and during residencies. The decision-making (Kilminster et al. 2007).
critics have argued and shown that professions The medical profession continues to be a
are inherently male-gendered because they prototype of a profession, and the theme of
valorize the masculine and features associated “social transformation” of doctoring that
with masculinity – for example, scientific began in about the 1970s in the US socio-
objectivity, efficiency, hierarchical structures, logical debate has continued until today.
autonomy of the professions (Davies 1996). The  professional dominance thesis and the
Feminist scholars have suggested that even restratification thesis (Freidson) and the
though women today are entering medical proletarianization-corporatization thesis (e.g.,
schools and the medical profession in increas- Timmermans and Oh 2010) have been ana-
ing numbers, the values embedded in medical lytical tools to describe the loss of autonomy
education and the organization of medicine of the US medical profession. In this debate,
remains male-gendered, because men control the gendered aspects of the process have not

tended to be raised. Instead, the theme of of  the status of professions in so-called
women physicians and the status of the pro- Continental European societies, character-
fession has been brought up in the European ized previously by a large public sector, and
debate, a trend that has to be seen against the Anglo-American, more market-oriented,
the fact that women as a proportion of phy- societies (Evetts 2006). These changes have
sicians overall are already, or soon, reaching a also resulted in new concerns about the sup-
majority in most European countries. Some ply and demand of various types of caring
have used the term “feminization” to indicate professions. At the same time, globalization
both the numerical increase of women in the of labor markets and an aging demographic
profession and the qualitative change in the profile of the population in Western societies
status of professional work when women have changed the demand and supply situa-
become a majority in a previously male- tion for national health care systems. The
dominated profession (Boulis and Jacobs term “global care chain” has been used in
2008). Nevertheless, research has not been describing the movement of health care
able to document a direct relationship professionals (foreign medical graduates –
between gender and a profession’s status. FMGs – as part of the physicians, nurses,
Instead, the results have pointed to the com- migrant care workers who care for the elderly)
plex relationship between global labor mar- from  poorer to richer countries. New terms
ket changes, the structural change of various from classics in social policy, such as T. A.
occupations and professions, and women’s Marshall’s concept of social citizenship and
and men’s choices and opportunities under inclusion/exclusion in the labor market and
such changing conditions of working life as citizen, and the framework of intersection-
(e.g., Boulis and Jacobs 2008). ality and its emphasis on the interrelationship
In the early traits research in the 1960s, between class, race, and gender are used in
various health occupations, such as nursing this genre of research. Gender and profes-
and midwifery, were called “semi-professions” sions form an underlying theme in these
(Etzioni 1969). These women-dominated studies, some of which flag gender in an effort
occupational groups have more recently to make visible the contingent of males
been  examined as “health professionals” among the nurses and health assistants in this
subordinated to the medical profession. new pool of health care workers.
Midwifery as an occupational group has been
the focus of sociological research, while nurs- SEE ALSO: Health Professions and
ing is still mainly examined by scholars of Organization; Health Professions, Sociology of;
nursing science who tend to use a psychologi- Health Professions and the State; Professional
cal framework in their studies. One focus of Careers; Professions and Professionalism
the sociological research on midwifery has
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in the 21st Century: Preference Theory. Oxford: Walsh, Mary Roth. 1977. Doctors Wanted: No
Oxford University Press. Women Need Apply: Sexual Barriers in the Medi-
Hughes, Everett C. 1958. Men and Their Work. cal Profession, 1835–1975. New Haven, CT: Yale
Glencoe, IL: Free Press. University Press.
Kilminster, Sue, Downes, Julia, Gough, Brendan, Witz, Anne. 1992. Professions and Patriarchy.
Murdoch-Eaton, Deborah, and Roberts, London: Routledge.
Interprofessional Conflict early twentieth century at least. Early com-
petitors were marginalized or eradicated –
TRACEY L. ADAMS such as midwifery and some alternate medical
University of Western Ontario, Canada practitioners – or limited to a specific prac-
tice area to minimize conflict – such as phar-
Interprofessional conflict occurs when two or macy, which was limited in many regions to
more professions with related scopes of prac- compounding the drugs prescribed by others
tice contest for privileges, responsibilities, (Willis 1983). Throughout the twentieth cen-
authority, autonomy, and/or rewards. tury, while conflict did occur between the
Interprofessional conflict can occur on a pub- medical profession and other health practi-
lic level, when two or more professions appeal tioners, many emerging health care occupa-
to the state (and consumers) for privileges in tions came to work with, and often under the
the same market, or the right to perform the general supervision of, medical doctors (e.g.,
same (or similar) work roles. An example is nurses, physiotherapists, laboratory techni-
when dental hygienists appeal to the state for cians). By the late twentieth century, inter-
the right to have an expanded scope of prac- professional conflict became more intense as
tice, which overlaps with dentists, and to these groups and others sought wider scopes
practice independently from dentists, while of practice, more autonomy, and higher sta-
the latter oppose them (Adams 2004). tus. Emerging professions have challenged
Interprofessional conflict can also occur on a medicine’s position of dominance, as well as
workplace level when practitioners from two each other’s efforts to expand their market
or more professions disagree about who share and their scopes of practice.
should do what, what is done, and when. Interprofessional conflict on a public level
Timmermans’s (2002) study of medical typically involves lobbying and public rela-
examiners and their conflicts with organ tions campaigns. Professional leaders advance
procurers over when and whether organs can a claim to an area of practice by appealing to
be removed from dead bodies provides an several key audiences: the state, the public,
example of the latter type of conflict. Often, and the workplace (Abbott 1988). Groups
conflict occurs at both levels, but it may be seeking to expand or maintain their scope of
more apparent at one level than another. practice and professional privileges try to
Sociologist Andrew Abbott (1988) has convince state actors that their expertise and
argued that conflict is endemic among pro- training justify special treatment, such as reg-
fessions where jurisdictions or scopes of ulatory legislation granting them the right to
practice overlap, and groups strive to stake a perform specific work tasks (offer a diagno-
claim to an area of expertise. This appears to sis, perform certain treatments, write pre-
be particularly true in the occupationally scriptions, and so on) without supervision. In
crowded and highly specialized health care a context of interprofessional conflict, profes-
field, where interprofessional conflict has sional groups also typically try to convince
been on the rise. Historically, especially in the state that their members are more qualified,
many Western nations, medicine has been or at least as qualified, as other experts
the dominant health profession since the advancing similar claims. To secure a market

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

for their services and protect their market hygiene profession could affect dentists’ own
position from their competitors, professional scope of practice and the market for their
leaders also endeavor to convince members services. Thus, dentists counter that dental
of the public that practitioners have the hygienists do not have enough training or
expertise to provide needed services. These expertise to practice independently on vul-
public campaigns may entail efforts to convince nerable groups, and that there is no cost
consumers that a profession’s services are advantage to more independence for dental
superior to those provided by other experts. hygienists (Adams 2004).
Professions’ public relations campaigns not The outcomes of interprofessional conflict
only emphasize expertise, but also typically are variable. Sometimes a group will win a
contend that there are several gains to be jurisdiction for itself and minimize or subor-
made from recognizing a group’s claims: that dinate another profession. At other times,
is, their services fill a social need, provide members of conflicting groups may compro-
good service at a lower cost, enhance con- mise and share a jurisdiction, or divide it
sumer choice, and/or improve public access (Abbott 1988). Successful groups make more
to services. Since interprofessional conflict effective arguments and win over state actors,
occurs on a workplace level as well, profes- consumers, and others. Further, they are
sionals endeavor to convince employers and more likely to be larger in size, well organ-
co-workers that they possess expertise that ized, and unified. Professional groups with
should be recognized and rewarded. more power and resources – those with more
In today’s crowded health care field, virtu- financial resources, more clients, a stronger
ally all claims to an expanded scope of prac- market position, and practice privileges
tice or privileges affect the claims advanced, ensconced in legislation – tend to gain more
and potentially the work done, by other (or at least lose less) from interprofessional
workers. The latter seek to expand/protect conflict (Adams 2007).
their scopes of practice by advancing Although more groups are seeking to
counterclaims of their own. The result is expand their professional status, and advance
interprofessional conflict. For example, when a claim to a jurisdiction, interprofessional
optometrists seek a larger role in the delivery conflict is not inevitable. Professionals with
of eye-care treatment services, they inher- overlapping scopes of practice find a way to
ently challenge the traditional roles and work together day after day. Cooperation is
authority assumed by general practitioners more likely when two or more groups have a
and medical specialists (ophthalmologists) similar social and organizational status, they
(Stevens et al. 2007). Medical practitioners share an outlook or knowledge base, or where
counter by asserting that they possess exper- an existing hierarchy is viewed as just and is
tise that optometrists lack, and they strive to unchallenged. Further, cooperation is com-
subordinate these alternate providers and mon where two or more groups are working
bring them under medical control. A similar together toward a common goal. When mar-
conflict is occurring in the dental field. kets for services are large, and competition is
Dental hygienists have sought a wider scope not intense, cooperation is also facilitated.
of practice and more autonomy, arguing to Current trends in the regulation of health
state and public audiences that this will professions and the organization of health
extend access to dental health services (and workplaces both foster and discourage
have occasionally argued that this could come inter professional conflict. With the number
at a lower cost). However, an expanded dental of regulated health care professional groups

expanding, and with recent legislation aimed REFERENCES

at undermining traditional health care hier-
Abbott, Andrew. 1988. The System of Professions.
archies and altering divisions of labour, future
Chicago, IL: University of Chicago Press.
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Adams, Tracey L. 2004. “Inter-Professional Con-
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goals of improving patient care and cutting tions and the Emergence of a New Profession:
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stake – market share, income, expertise, and Timmermans, Stefan. 2002. “The Cause of Death
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the coming years. tigation.” Sociology of Health & Illness 24:
SEE ALSO: Countervailing Powers; Inter- Willis, Evan. 1983. Medical Dominance: The Divi-
professional Boundaries; Professional Work, sion of Labour in Australian Health Care. Sydney:
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Neuroscience, Health, investigations of neuroscience have been
by  sociologists of science, and scholars
and Medical Sociology influenced by the philosopher Michel Foucault.
MARTYN PICKERSGILL Susan Leigh Star (1989), for instance, used his-
University of Edinburgh, UK torical and contemporary examples from neuro-
science to examine the sociology of (scientific)
Neuroscience is the study of the brain and the work. More recently, Nikolas Rose (2007) has
nervous system. A highly interdisciplinary broken new ground through an exploration of
endeavor, it includes methods and theories how neuroscientific knowledge is remaking
from traditions such as psychology, psychiatry, ideas about what it means to be human.
medical physics, genetics, and biology. One Scholarship on the neurosciences might
set of techniques often associated with neuro- be regarded as linked to a wider concern
science is neuroimaging, or “brain scanning.” within sociology about the production
A variety of tools has been developed to and  circulation of psychiatric knowledge.
produce images of the brain, such as fMRI Psychiatry in the Western world has
(functional magnetic resonance imaging) increasingly come to promote the role of
and PET (positron emission tomography) neuroscience as a means through which
scans. These are technologies designed to fresh light can  be cast upon the mecha-
pick up the presence of oxygen (fMRI) or an nisms underlying treatments for mental
ingested compound which emits gamma rays disorders (Ehrenberg 2010). In the process,
(PET). It is important to note that these popular and professional understandings of
technologies do not produce unmediated psychiatric categories such as autism and
“pictures” of the brain, even though neuro- depression have come to be reshaped
images may be described as “photos” in popular (Nadesan 2005). Nevertheless, there may
accounts of the technologies. Rather, they are well be important “gaps” between the labo-
colored representations of complex data ratory and the clinic: as with many outside
(Beaulieu 2002) the mental health professions, psychiatrists
A prominent and well-funded feature of and psychologists may sometimes be unsym-
biomedicine since at least the 1980s, neuro- pathetic to neuroscientific explanations of
science has thus far attracted surprisingly lit- mental disorder (Pickersgill 2011).
tle attention from (medical) sociologists. This Psychopharmaceuticals (drugs to alter
might be partly a consequence of the develop- brain chemistry and hence change cogni-
ments in molecular genetics (and later, stem tion or mood) are one particularly impor-
cell research) during the last two decades, tant product of neuroscience research.
which have had a variety of clinical, social, Sociological attention has long been fixed
ethical, and legal issues associated with upon these drugs (Cooperstock and
them – and which in turn have been used as Lennard 1979), and their role in processes
case studies by sociologists, resulting in of medicalization has been extensively
diverse methodological and conceptual inno- mapped (Conrad 2006). Other work has
vations. Some of the earliest sociological examined the complex relationships that

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

long-term users of, for instance, antidepres- and theology (Littlefield and Johnson 2012).
sants have with these medicines (Karp Practitioners of economics, education, and
2006). Increasingly, commentators are law have sought to employ neuroscience to
speculating on the capacity of psychophar- both legitimize some existing policies and
maceuticals to “enhance” healthy individuals, practices, while simultaneously challenging
the legitimacy of which is being debated others. Even sociologists have begun to look
within stories in the media as well as within at how neuroscientific methods and findings
clinical and bioethics conferences and jour- might be integrated with social scientific
nals (Coveney, Nerlich, and Martin 2009). analysis – and how neuroscience, in turn,
More broadly, sociological analyses of the might evolve through engaging with socio-
pharmaceuticalization of social life have logical insights (Franks 2010). A whole new
pointed to the significant place, role, and discipline – “neuroethics” – has likewise
impact of mood-altering drugs in and on emerged as a different, vocal, and seemingly
society (Williams, Martin, and Gabe 2011). influential endeavor. Scholars in this develop-
Aside from the pervasive use of drugs in ing field are concerned with the ethical impli-
mental health settings, the current salience of cations of existing and potential neuroscientific
neuroscience within medicine is unclear. As dilemmas and technologies. However, soci-
stated above, some psychiatrists and psycholo- ologists have called into question the lack of
gists remain skeptical about the therapeutic critical distance that many neuroethicists
promise of neuroscience, and for complex have with neuroscience itself (Brosnan 2011).
ontological and epistemological reasons (aside This expansion in professional discourse on
from cost and practicality) the utility of neuro- neuroscience is taking place at the same time as
imaging techniques to help diagnose psychiat- images of brains and the claims of neuroscien-
ric disorders does not seem great – though tists circulate widely within the popular media.
certainly there are many powerful advocates Neuroscience seems increasingly to be an
for this. Nevertheless, a range of new technolo- attractive form of popular science for a range of
gies and drugs are currently in development; audiences. Following Rose, some sociologists
some of these have been argued to represent have argued that this is promoting a conception
important innovations for diagnosing and of selfhood as being intimately linked with the
treating especially neurological disease. brain (Pitts-Taylor 2010). Nevertheless, other
Sociological analysis of the use of imaging work has shown that people have a more com-
technologies has advanced our understand- plicated understanding of the relationship
ings of how diagnosis is socially organized, between brains and subjectivity, wherein the
expertise ascribed, and professional identities former is only sometimes enrolled as a means
formed (Burri 2008; Gross 2009). In so doing, of accounting for the latter (Pickersgill,
they have produced new insights into the sig- Cunningham-Burley, and Martin 2011).
nificance of visual knowledge within contem- As with other domains of science, technol-
porary societies (Joyce 2008). ogy, and medicine, sociologists have there-
In some senses, the effects of the neuro- fore begun to approach neuroscience in
sciences can be most profoundly felt and two distinct ways: first, as an entry point into
directly observable outside biomedical con- an analysis of wider social issues (such as
texts. Neuroscientific knowledge has been the  organization of everyday working life);
picked up by a range of traditions and profes- and second (and perhaps more commonly),
sions, and the prefix “neuro’” can be seen as an  important topic in its own right.
within areas as diverse as aesthetics, marketing, The  sociology of neuroscience is a growing

area, and – like the science itself – is associated Gross, Sky. 2009. “Experts and ‘Knowledge that
with much interdisciplinary work across Counts’: A Study into the World of Brain Cancer
science and technology studies, Foucauldian Diagnosis.” Social Science and Medicine 69: 1819–
sociology, and the sociology of health and 1826. doi:10.1016/j.socscimed.2009.09.017.
Joyce, Kelly A. 2008. Magnetic Appeal: MRI and the
illness. As the actual and imagined scope of
Myth of Transparency. Ithaca, NY: Cornell Uni-
neuroscience increases, so too do the challenges
versity Press.
and opportunities for sociologists (Pickersgill Karp, David A. 2006. Is It Me or My Meds? Living
and van Keulen 2011; Williams 2010). with Antidepressants. Cambridge, MA: Harvard
University Press.
SEE ALSO: Genetics; Mental Illness, Littlefield, Melissa M., and Jenell Johnson, eds.
Anti-Psychiatry Perspective of; Psychiatry 2012. Theorizing the Neuroscientific Turn: Trans-
disciplinarity in the Age of the Brain. Madison:
and Race; Transcultural Psychiatry
University of Wisconsin Press.
Nadesan, Majia H. 2005. Constructing Autism:
Unravelling the “Truth” and Understanding the
Social. Abingdon, UK: Routledge.
Beaulieu, Anne. 2002. “Images Are Not the Pickersgill, Martyn. 2011. “‘Promising’ Thera-
(Only) Truth: Brain Mapping, Visual Knowl- pies: Neuroscience, Clinical Practice, and
edge, and Iconoclasm.” Science, Tech- the Treatment of Psychopathy.” Sociol-
nology & Human Values 27: 53–86. doi: ogy of Health & Illness 33: 448–464. doi:
10.1177/016224390202700103. 10.1111/j.1467-9566.2010.01286.x.
Brosnan, Caragh. 2011. “The Sociology of Neuro- Pickersgill, Martyn, and van Keulen, Ira. 2011.
ethics: Expectations Discourses and the Rise of a Sociological Reflections on the Neurosciences.
New Discipline.” Sociology Compass 5: 287–297. Bingley, UK: Emerald.
doi: 10.1111/j.1751-9020.2011.00365.x. Pickersgill, Martyn, Cunningham-Burley, Sarah,
Burri, Regula V. 2008. “Doing Distinctions: and Martin, Paul. 2011. “Constituting Neuro-
Boundary Work and Symbolic Capital in Radi- logic Subjects: Neuroscience, Subjectivity and
ology.” Social Studies of Science 38: 35–62. doi: the Mundane Significance of the Brain.” Subjec-
10.1177/0306312707082021. tivity 4: 346–365. doi: 10.1057/sub.2011.10.
Conrad, Peter. 2006. Identifying Hyperactive Chil- Pitts-Taylor, Victoria. 2010. “The Plastic Brain:
dren: The Medicalization of Deviant Behaviour. Neoliberalism and the Neuronal Self.” Health
Aldershot, UK: Ashgate. 14: 635–652. doi: 10.1177/1363459309360796.
Cooperstock, Ruth, and Lennard, Henry L. 1979. Rose, Nikolas. 2007. The Politics of Life Itself: Biomedi-
“Some Social Meanings of Tranquilizer Use.” cine, Power, and Subjectivity in the Twenty-First
Sociology of Health & Illness 1: 331–347. doi: Century. Princeton, NJ: Princeton University Press.
10.1111/1467-9566.ep11007101. Star, Susan L. 1989. Regions of the Mind: Brain
Coveney, Catherine M., Nerlich, Brigitte, and Research and the Quest for Scientific Certainty.
Martin, Paul. 2009. “Modafinil in the Media: Stanford, CA: Stanford University Press.
Metaphors, Medicalisation and the Body.” Social Williams, Simon J. 2010. “New Developments in
Science and Medicine 68: 487–495. doi:10.1016/j. Neuroscience and Medical Sociology.” In The
socscimed.2008.11.016. New Blackwell Companion to Medical Sociol-
Ehrenberg, Alain. 2010. The Weariness of the Self: ogy, edited by William C. Cockerham, 530–551.
Diagnosing the History of Depression in the Con- Malden, MA: Wiley-Blackwell.
temporary Age. Quebec: McGill-Queen’s Uni- Williams, Simon J., Martin, Paul, and Gabe,
versity Press. Jonathan. 2011. “The Pharmaceuticalisation
Franks, David D. 2010. Neurosociology: The Nexus of Society? A Framework for Analysis.” Soci-
between Neuroscience and Social Psychology. ology of Health & Illness 33: 710–725. doi:
New York: Springer. 10.1111/j.1467-9566.2011.01320.x.
Mental Health and Family than was previously thought (for recent
detailed reviews of empirical studies on mari-
Status tal status and mental health, see Umberson,
Thomeer, and Williams 2013; Williams,
University of Texas at Austin, USA Frech, and Carlson 2009).
Longitudinal research indicates that the
Mental health, in this entry, refers to popu- transition to marriage results in modest and
lation-level psychological distress or well- temporary mental health benefits that tend to
being. Sociological research on mental health diminish after about five years of marriage.
most commonly employs the Center for This suggests that the mental health benefits
Epidemiologic Studies Depression Scale of marriage erode with time, as marital qual-
(CES-D), although some studies measure ity declines with marital duration and the
mental health vis-à-vis psychological well- benefits of marriage are dependent on marital
being, which includes measures of happiness quality. However, it may be that the benefits
and life satisfaction. of marriage to mental health accumulate over
Family status refers to intimate partner and the life course, suggesting the need to exam-
parent/child relationships. Research on the ine long-term trajectories of mental health
effects of family status on mental health typi- associated with marriage.
cally focuses on the benefits and costs to While earlier research emphasized a mari-
mental health associated with legal marriage tal resource model, recent longitudinal
and parenthood, as well as how parents affect research provides evidence for a marital crisis
the mental health of minor and adult chil- model. The marital resource model suggests
dren. Family ties, however, are much broader that unmarried individuals will have poorer
than this. For example, contemporary trends mental health than the married as a result of
in cohabitation and the formation of lesbian the protective effect of marriage, whereas the
and gay partnerships suggest that a focus only marital crisis model suggests that marital
on legal marital status is too limited. dissolution through divorce and widowhood
undermines mental health to a greater extent
than marriage protects it. Therefore, the crisis
MARRIAGE model suggests that the better mental health
of  the married as compared to those who
Many studies have demonstrated that marriage are  divorced or widowed reflects the strains
is beneficial for mental health. The benefits associated with marital dissolution, rather
might include an increase in economic than the benefits of marriage. Recent evi-
resources, greater social integration (includ- dence supports this position. Longitudinal
ing emotional support and attachment), and studies show that the mental health costs of
a stronger sense of meaning and purpose. divorce and widowhood are much larger than
However, recent longitudinal research has the small  benefits associated with entering
demonstrated that the positive benefits of marriage.  Moreover, earlier research, which
marriage for mental health are more modest compared the married and unmarried, failed

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

to distinguish the never married from the research consistently finds that widowhood is
divorced and widowed. Research that does more distressing for men than for women.
disentangle these different marital statuses Finally, that marriage is beneficial to men-
reveals that the never married have mental tal health may be historically specific. As
health outcomes that are similar to the mar- remaining single or unmarried becomes
ried, whereas the divorced and widowed have more normative, the benefits of marriage
worse mental health than the married. A may wane. In summary, recent longitudinal
third explanation for mental health differ- research demonstrates that the benefits of
ences between the married and the unmar- marriage to mental health are modest, while
ried is selection bias. From this perspective, the costs of marital dissolution are high and
mentally healthy people are more likely to these benefits and costs to mental health are
enter marriage and to remain married. dependent on a number of factors, including
Research suggests that selection effects marital quality, race, and age.
account for some, but not all, of the mental
health differences between the married and
the unmarried. PARENTHOOD
Another recent advance is the identifica-
tion of heterogeneity in the benefits of mar- Research on the effects of parenthood on
riage and costs of marital dissolution to mental health typically focuses on the ways
mental health. Poor marital quality, for in which parents with young children or
instance, undermines mental health even parents with adult children differ from their
more than being unmarried (Williams 2003). childless peers on measures of psychological
Further, declines in mental health associated well-being. The general conclusion is that
with divorce are smaller for those exiting a parenthood does not predict mental health
marriage with low marital quality (Hawkins in any systematic way, but rather the effects
and Booth 2005). The limited research on of parenthood and the transition to parent-
racial and ethnic differences in the effects of hood on mental health depend on the social
marital status on mental health suggests that context in which parents operate (for detailed
whites benefit more from marriage than recent reviews of empirical studies on parent-
other racial/ethnic groups. In terms of age hood and mental health, see Umberson,
variation, widowhood is more depressing for Pudrovska, and Reczek 2010, Umberson,
younger adults perhaps because it is less nor- Thomeer, and Williams 2013).
mative, whereas divorce is more depressing A life course perspective emphasizes that
for older adults and adults with young chil- major life transitions have important implica-
dren in the home. While earlier research sug- tions for psychological well-being. The transi-
gested that marriage was more beneficial to tion to parenthood is generally understood to
men’s than to women’s mental health, recent be a time of increased distress; however, this is
longitudinal research indicates that the tran- highly dependent on the timing of this transi-
sition to marriage benefits men and women tion as well as social contexts. For example,
equally. While some research suggests that the transition causes more distress when
divorce more adversely affects women’s men- made before the age of 23 (Mirowsky and
tal health, because of the greater financial Ross 2002). Moreover, early transitions to
burdens they are likely to experience, other parenthood influence trajectories of mental
studies find no gender differences in the health, since social disadvantages associated
effect of divorce on mental health, although with early parenthood, such as a truncated

education, accumulate over the life course. than parents with young children, recent
Marital status and marital quality also shape research emphasizes that the quality of parent–
the effects of parenthood on mental health. adult child relationships are fundamental.
Longitudinal analyses suggest that the transi- While supportive relationships with adult
tion to parenthood is associated with increased children contribute to parents’ psychological
levels of distress for unmarried parents, while well-being, strained relationships can under-
married women who transition to parent- mine this (Koropeckyj-Cox 2002). Moreover,
hood have higher levels of well-being than the quality of relationships with adult children
their childless peers and married fathers are appears to be more salient for the mental
no more or less distressed than their childless health of some parents. Research indicates that
peers (Nomaguchi and Milkie 2003). Marital relationship quality with adult children is
quality also moderates the relationship more important for the mental health of moth-
between the transition to parenthood and lev- ers, African Americans, and unmarried and
els of distress, such that mothers who perceive widowed parents. Finally, parents’ mental
their partners to be supportive are less likely health is negatively affected when their adult
to be distressed than those who do not. children face significant problems, such as
Parents of minor children exhibit higher psychological, financial, and developmental
levels of psychological distress than do problems, alcohol/drug dependency, or unem-
childless adults or parents of adult children ployment (Greenfield and Marks 2006).
(Evenson and Simon 2005). Stressors The number of childless women nearly dou-
associated with parenting young children – bled between 1975 and 2000 and researchers
for example, time constraints, increased have become more interested in assessing the
financial responsibilities, work–family con- mental health effects of remaining childless.
flicts, and strain between parents – contribute Coinciding with the dramatic increase in the
to the poorer mental health of parents with number of childless adults, cultural meanings
minor children. Individuals in certain social of childlessness have shifted. In the 1950s and
contexts, however, experience more parent- 1960s, childlessness was viewed as an indicator
ing stress. Unmarried parents, mothers, of immaturity and psychological deficiency;
young parents (especially teens), and parents today, the social pressures to have children have
of lower socioeconomic status typically face lessened significantly. Recent studies show that
more stress around parenting and, as a result, childless adults generally have better mental
experience higher rates of psychological dis- health than their peers with minor children
tress than other parents. For example, while (Nomaguchi and Milkie 2003). There are, how-
men’s participation in childcare has increased ever, a few exceptions, which, again, indicate
in recent decades, women still provide most that social contexts shape the consequences of
childcare, and thus face more stressors related family status for mental health. For example,
to time constraints and work–family conflicts. while childless young adults have better mental
As a result, parenting minor children under- health than young adults with children on aver-
mines women’s mental health more than it does age, this is not true for young adults who want
men’s (Nomaguchi and Milkie 2003). children but are unable to have them or who
Relationships with children are important have negative attitudes toward childlessness
for parents’ mental health throughout life and (McQuillan et al. 2003). Thus, the meaning
likely influence parents’ mental health in a of  parenthood or childlessness, as well as
cumulative fashion. While parents of adult personal choice in whether to have children or
children generally have better mental health not, matter for mental health. Finally, given

recent shifts in the cultural meanings associ- Parent/child relationships are important for
ated with childlessness, it is possible that the the mental health of children throughout the
positive effects of childlessness on mental life course. Adults with parents who make them
health are historically and cohort-specific; the feel loved and cared for have higher levels of
same mental health benefits of childlessness psychological well-being than adults whose
may not accrue to older cohorts, given past parents do not. Strained relationships with par-
stigmatization of childlessness. ents, however, can undermine adults’ mental
health. Moreover, the quality of these relation-
ships may be more important to the mental
CHILDREN’S MENTAL HEALTH health of some groups. For example, supportive
relationships with fathers are more beneficial to
Research that examines how parental ties adult African American children than to chil-
affect minor children’s mental health typically dren of other racial groups (Umberson 1992).
focuses on the effects of family structure, fam- Finally, life expectancy in the Western
ily transitions (such as divorce, remarriage, world nearly doubled during the twentieth
death), and family processes and characteristics century and, as a result, adult children are
(such as level of paternal involvement; for a highly likely to provide care for an aging
detailed recent review of empirical studies on parent. The stress of caregiving contributes to
this topic, see Carr and Springer 2010). Most psychological distress. Daughters are more
research on family structure finds that minor likely than sons to provide care for aging par-
children who live with both biological parents ents and caregiving daughters are also more
have better mental health than children who likely to experience depressive symptoms
live in other family forms, likely due to greater than caregiving sons are. There are, however,
parental attention and financial resources in some mental health benefits of providing care
two-parent biological families, as well as a lack to aging parents; research suggests that help-
of stigmatization associated with this family ing a loved one results in higher levels of psy-
structure. Additionally, research demonstrates chological well-being (Pinquart and Sörensen
that divorce adversely affects young children 2003). The death of a parent is a significant
and adolescents’ psychological well-being, but turning point for adults; longitudinal research
that the degree and duration of these effects shows that the death of a parent contributes to
depend on parenting quality as well as the a significant increase in adults’ psychological
number and timing of family transitions. distress for up to three years following the
Furthermore, stressors that precede, accom- death (Umberson 2003).
pany, or follow parental marital transitions In summary, sociological research that
such as divorce (e.g., conflict between parents, examines the effects of family status on
moving, financial hardship) partially explain mental health suggests that the existence of
why transitions are psychologically distressing family ties, as well as the quality of those ties
for minor children. Finally, family dynamics, and the social context in which those ties
such as childrearing practices and father exist, influence mental health. Moreover,
involvement, affect minor children’s mental family ties have a cumulative effect on mental
health. Parental rejection and criticism health over the life course.
adversely affect children’s mental health, but
high-quality involvement with biological and SEE ALSO: Family and Stress; Mental Health;
social fathers predicts better mental health Mental Health and Marital Status; Parenthood
outcomes for minor children. and Health

Pinquart, Martin, and Sörensen, Silvia. 2003.
Carr, Deborah, and Springer, Kristen W. 2010. “Associations of Stressors and Uplifts of Care-
“Advances in Families and Health Research in giving with Caregiver Burden and Depres-
the 21st Century.” Journal of Marriage and Fam- sive Mood: A Meta-Analysis.” Journals of
ily 72: 743–761. Gerontology: Series B Psychological Sciences 58B:
Evenson, Ranae J., and Simon, Robin W. 2005. P112–128.
“Clarifying the Relationship between Parent- Umberson, Debra. 1992. “Relationships between
hood and Depression.” Journal of Health and Adult Children and Their Parents: Psychologi-
Social Behavior 46: 341–358. cal Consequences for Both Generations.” Jour-
Greenfield, Emily A., and Marks, Nadine F. 2006. nal of Marriage and the Family 54: 664–674.
“Linked Lives: Adult Children’s Problems and Umberson, Debra. 2003. Death of a Parent:
Their Parents’ Psychological and Relational Transition to a New Adult Identity. New York:
Well-Being.” Journal of Marriage and Family 68: Cambridge University Press.
442–454. Umberson, Debra, Pudrovska, Tetyana, and Rec-
Hawkins, Daniel N., and Booth, Alan. 2005. zek, Corinne. 2010. “Parenthood, Childlessness,
“Unhappily Ever After: Effects of Long-Term, and Well-Being.” Journal of Marriage and Fam-
Low-Quality Marriages on Well-Being.” Social ily 72: 612–629.
Forces 84: 451–471. Umberson, Debra, Thomeer, Mieke Beth,
Koropeckyj-Cox, Tanya. 2002. “Beyond Parental and  Williams, Kristi. 2013. “Family Status
Status: Psychological Well-Being in Middle and and Mental Health: Recent Advances and
Old Age.” Journal of Marriage and Family 64: Future Directions.” In Handbook of the Soci-
957–971. ology of Mental Health, 2nd ed., edited by
McQuillan, Julia, Greil, Arthur L., White, Lynn K., Carol S. Aneshensel, Jo C. Phelan, and Alex
and Jacob, Mary Casey. 2003. “Frustrated Fertil- Bierman, 405–432. New York: Springer.
ity: Infertility and Psychological Distress among Williams, Kristi. 2003. “Has the Future of Marriage
Women.” Journal of Marriage and Family 65: Arrived? A Contemporary Examination of Gen-
1007–1018. der, Marriage, and Psychological Well-Being.”
Mirowsky, John, and Ross, Catherine E. 2002. Journal of Health and Social Behavior 44: 470–487.
“Depression, Parenthood, and Age at First Williams, Kristi, Frech, Adrianne, and Carlson, Dan-
Birth.” Social Science & Medicine, 54: 1281–1298. iel L. 2009. “Marital Status and Mental Health.” In
Nomaguchi, Kei M., and Milkie, Melissa A. 2003. A Handbook for the Study of Mental Health: Social
“Costs and Rewards of Children: The Effects of Contexts, Theories, and Systems, 2nd ed., edited
Becoming a Parent on Adults’ Lives.” Journal of by Teresa L. Scheid and Tony N. Brown, 306–320.
Marriage and Family 65: 356–374. Cambridge: Cambridge University Press.
Diagnostic and Statistical the International Classification of Disease
(ICD), to be used for administrative pur-
Manual of Mental poses. The 20 disorder chapters in DSM-5 are
Disorders (DSM) positioned within the manual so that disor-
der groupings believed to share common
OWEN WHOOLEY underlying vulnerabilities and neurological
University of New Mexico, USA substrates are located in close proximity to
each other.
Published by the American Psychiatric Originally developed in 1952 to facilitate
Association (APA), the Diagnostic and the accumulation of statistical data in mental
Statistical Manual of Mental Disorders (DSM) hospitals, the DSM’s influence has grown tre-
is the standard classification of mental disor- mendously since the 1980s. Widely credited
ders in the United States. Often called the with conferring professional prestige upon
“bible of mental illness,” the DSM provides the APA, its influence is evident in an array of
criteria for making psychiatric diagnoses and, settings and by a diverse range of actors.
in turn, a common language with which to These assorted uses include: clinicians in for-
discuss mental disorders. Periodically revised, mulating diagnoses; scientific researchers in
the most recent edition is DSM-5, which was the design of research protocols and study
released in May 2013. The DSM-5 Task Force populations; pharmaceutical companies in
has announced that this will be the last of the the research and design of psychopharma-
major revisions, as DSM will now become a ceutical drugs and in direct-to-consumer
“living document” subjected to continuous advertising; epidemiologists and public health
revision. This change is reflected in the deci- officials in conducting community surveys
sion to alter DSM’s naming convention from and statistical analyses; health insurance
Roman to Arabic numerals with incremental companies in the calculation and allocation
updates identified with decimals (i.e., DSM- of benefits; and patient advocacy organiza-
5.1, DSM-5.2, etc.). tions in mobilizing constituents and advocat-
The DSM offers a descriptive nosology that ing for policy change. Therefore, through the
uses a syndromal model to categorize mental DSM, the APA is able to influence multiple
disorders. Such a classificatory system under- aspects of mental health practice by literally
stands mental disorders as discrete and defining the universe of mental illness. The
categorical, qualitatively distinct from nor- DSM also provides an important revenue
mal functioning. A disorder is defined by a stream for the APA, as both DSM-III and
cluster of relevant symptoms. A diagnosis is DSM-IV have sold more than a million cop-
made when a patient demonstrates a certain ies (Spiegel 2005). Given its influence and
number of symptoms within the criteria of reach, the DSM – and its periodic revisions –
the syndrome. For example, to meet the has attracted controversy, both from within
threshold for a diagnosis of major depressive and without psychiatry, as multiple actors
disorder (MDD), a patient must have at least attempt to influence its content.
five of the nine listed symptoms. Each disor- Prior to DSM-I, psychiatric classification
der is assigned a numerical code, taken from was plagued by a lack of standardization

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

and the proliferation of numerous different to reorient the field along the lines of medical
nosological systems. This made it difficult science. Robert Spitzer, a research psychia-
to collect accurate statistical data on mental trist instrumental in the resolution of the
disorders. Classification of mental disor- homosexuality debate, assumed the chair of the
ders remained in this primitive state until DSM-III Task Force. Spitzer chose members
World War II, when the administrative for his Task Force from the neo-Krapelenian
demands of screening soldiers led to a call school of psychiatry, which sought to align
for greater specificity in psychiatric classifi- psychiatry with biomedical science by view-
cation. DSM-I hewed closely to the system ing mental disorders as equivalent to physical
developed by the US Navy. Like its succes- diseases. In revising DSM-III along these
sor DSM-II, the DSM-I classification system lines, the DSM-III Task Force overthrew the
reflected the dominance of the psychody- broad and continuous categories of dynamic
namic and psychoanalytic models of mental psychiatry, importing a medicalized frame-
illness within psychiatry at that time (Grob work organized around specific disease enti-
1991). The two earliest editions remained ties. Ostensibly agnostic toward different
largely incidental to clinical practice and schools of psychiatry, the new classification
were used primarily by mental hospitals in system was underlain by the biomedical
conducting institutional censuses on their model of mental illness, and thus the revi-
populations. sions led to an outcry among psychoanalyti-
In the 1970s, psychiatry experienced a pro- cally inclined psychiatrists, especially over
fessional crisis that ultimately led to a “para- the exclusion of neurosis from the manual
digm shift,” evident in the DSM-III’s embrace (Bayer and Spitzer 1985). Despite this initial
of a biomedical model of mental illness controversy, DSM-III was a tremendous suc-
(Horwitz 2002). Psychiatry’s postwar embrace cess and was rapidly adopted in a variety of
of psychoanalysis widened the gap between settings.
psychiatrists and other medical professionals. DSM-IV, published in 1994, maintained
Psychiatry faced a number of challenges in the basic structure and philosophy of
the late 1960s, including: the emergence of DSM-III and DSM-III-R. Over time, the
other mental health professionals offering revisions to the DSM have led to a dra-
alternative therapies to psychoanalysis; criti- matic growth in  both its size and number
cal, social scientific research that exposed the of diagnostic categories it recognizes.
inconsistency psychiatric diagnoses (e.g., DSM-I listed 109 disorders and was 130
Kendell et al. 1971; Rosenhan 1973); and an pages long; DSM-IV-TR identifies 365
anti-psychiatry movement that popularized disorders in its 943 pages.
depictions of the inhumane conditions of the The most recent edition, DSM-5, was
asylum. The prestige of psychiatry was fur- released in May 2013. When the DSM-5 revi-
ther compromised by the very public contro- sion process began, the Task Force sought to
versy over the diagnosis of homosexuality, radically change the manual and, in the pro-
which was eventually eliminated from the cess, usher in a “paradigm shift.” To do so, it
DSM by a vote from the APA membership proposed moving the DSM to a dimensional
(Bayer 1987). model of mental illness in an attempt to
Reformers within the APA interpreted this acknowledge that mental disorders exist on a
professional crisis as emanating from the lack spectrum. The hope was that a dimensional
of reliability in psychiatric diagnoses and model would provide more flexibility and
used the revision of the DSM-III as a means sensitivity to psychiatric research by avoiding

rigid categorical conceptualizations, so as to normal behavior, and a neglect of social

detect biological markers for mental disor- factors affecting mental well-being (e.g.,
ders (Kupfer et al. 2009). To achieve dimen- Horwitz and Wakefield, 2007). Others, espe-
sionalization, the Task Force proposed cially more psychodynamically inclined
introducing numerical severity scales for each physicians, have criticized the DSM for its
disorder, as well as a cross-cutting scale of “cookbook” approach to the diagnosis and
general mental health functionality. These treatment of mental problems, directing cli-
proposals caused controversy within the APA, nicians’ focus to superficial symptoms rather
as former DSM Task Force chairs, Spitzer and than the whole patient. This last concern has
Allen Frances, publicly criticized the pro- led the American Psychoanalytic Association
posed revisions. In 2012, the APA Assembly, to produce its own classification manual, the
citing undue burden on clinicians, rejected Psychoanalytic Diagnostic Manual. Despite
the proposed scales and voted to relegate these myriad criticisms, the DSM remains the
them to the appendix. As a result, the DSM-5 dominant classificatory system of mental dis-
Task Force settled for more modest revisions. orders, as it is institutionalized in nearly all
The prestige of DSM-5 received a blow facets of mental health practice.
when, on the eve of its publication, the
National Institute of Mental Health (NIMH) SEE ALSO: Medical Knowledge; Mental
announced that it was moving away from the Health and Psychiatric Medicine; Mental
DSM in funding mental health research. The Illness, Diagnosis of
NIMH has commissioned the development
of a new classification system of psychopa-
thology based on the basic functions of the
brain (i.e., neurocircuitry) called the Research Bayer, R. 1987. Homosexuality and American Psy-
Domain Criteria (RDoC), to be used for chiatry: The Politics of Diagnosis. Princeton, NJ:
research purposes only. Although RDoC is Princeton University Press.
Bayer, R., and Spitzer, R. 1985. “Neurosis, Psy-
not framed as an alternative to DSM, the
chodynamics, and DSM-III: A History of the
NIMH’s decision reflects an underlying con-
Controversy.” Archives of General Psychiatry 42:
cern that the DSM has not been effective in 187–196.
realizing more valid diagnostic categories. Grob, G. N. 1991. “Origins of DSM-I: A Study in
Since the major revisions in 1980, the DSM Appearance and Reality.” American Journal of
has experienced numerous controversies. A Psychiatry 148: 421–431.
number of specific diagnoses – attention defi- Horwitz, A. 2002. Creating Mental Illness. Chicago,
cit hyperactivity disorder, autism spectrum IL: University of Chicago Press.
disorder, psychosis risk syndrome, and pre- Horwitz, A., and Wakefield, J. 2007. The Loss of
menstrual dysphonic disorder – have been Sadness: How Psychiatry Transformed Normal
challenged by social scientists and mental Sorrow into Depressive Disorder. New York:
Oxford University Press.
health advocates as being invalid or too
Kendell, R. E., Cooper, J. E., Gourlay, A. J., Cope-
all-encompassing. The DSM is also seen as
land, J. R. M., Sharpe, L., and Gurland, B. J.
contributing to the dramatic increase in the 1971. “Diagnostic Criteria of American and
use of psychopharmaceutical drugs by ambi- British Psychiatrists.” Archives of General Psy-
tiously medicalizing a diverse range of human chiatry 25: 123.
behavior. Such medicalization, critics argue, Kupfer, D. J., First, M. B., and Regier, D. A. 2002. A
has led to a narrow conceptualization of Research Agenda for DSM-V. Washington, DC:
human behavior, the pathologization of American Psychiatric Publishing.

Rosenhan, D. L. 1973. “On Being Sane in Insane
Places.” Science 179: 250. Kirk, S. A., and Kutchins, H. 1992. The Selling of
Spiegel, A. 2005. “The Dictionary of Disorder.” DSM: The Rhetoric of Science in Psychiatry. Pis-
New Yorker 80: 56–63. cataway, NJ: Aldine.
Health and Culture sociology phenomena, such as attitudes
toward death and the link between “changing
STELLA R. QUAH forms of social solidarity and changing per-
Duke-NUS Graduate Medical School, Singapore ceptions of health, disease, and medicine.”
One of Durkheim’s contemporaries was
Practically all social science research on health Max Weber. Weber’s (1905; 1978) conceptu-
and illness in the twenty-first century acknowl- alization of ethnic group and traditional action
edges the influence of culture on health-related offers the most relevant insights to the study
behavior and attitudes. We have advanced of culture. His concept of traditional action
from the early assumption that culture was one (one of four in his typology of social action)
of several predictors of health behavior. Today elucidates the pervasiveness of customs,
we know that culture is not just one of many beliefs, and practices of different ethnic or
factors associated with health, but is the con- cultural communities upon their health-
text within which health-related behavior related behavior. Weber’s analyses have
unfolds. This entry discusses in three sections inspired subsequent research and contributed
why culture is significant in health-related to the understanding of the pervasiveness of
behavior: the definition of culture, the link culturally inspired and culturally sustained
between culture and health behavior, and the health practices (Gerhardt 1989) and lifestyles
link between culture and healing systems. (Cockerham 2010). The interest in culture
was passed along to subsequent generations of
social scientists such as Kluckhohn (1951)
and Malinowski (1944). Malinowski pro-
posed “hygiene” as the “cultural response” to
The meaning of the term “culture” varies
health. Hygiene involves all “sanitary arrange-
widely across disciplines and conceptual per-
ments” in a community, “native beliefs as to
spectives. To keep within the scope of this
health and magical dangers,” “rules about
Encyclopedia, the focus is on the contribu-
exposure, extreme fatigue, the avoidance of
tions of sociology and anthropology. We
dangers or accidents,” and the “never absent
begin with an historical glance at the efforts
range of household remedies” (1944, 91, 108).
made to define and understand “culture.”
Another valuable contribution to the
understanding of culture was provided
The classics
by Talcott Parsons. He conceptualized social
In his Rules of Sociological Method, first action as taking place within a three-
published in 1895, Durkheim proposed dimensional context comprising personality,
guidelines for the study of social phenomena culture, and the social system and defined
as social facts and saw social solidarity and, culture as “ordered systems of symbols” that
particularly, collective consciousness as guide social action  and  are “internalized
reflective of culture and concurrently present components of the personalities of individual
within and external to the individual. For actors and institutionalized patterns of social
Taylor and Ashworth (1987, 43) Durkheim’s systems” (1951, 327). For Parsons, the shared
ideas are applicable to the study of medical symbolic systems are fundamental for the

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

functioning of the social system and they rep- individuals from different ethnic groups into
resent “a cultural tradition.” He argued that a another process, pragmatic acculturation – that
cultural tradition has three principal compo- is, the process of culture borrowing motivated
nents or systems: value orientations, beliefs, by the desire to satisfy specific needs (Quah
and expressive symbols (1951, 11, 326–7). 1989, 181). Inspiration from the  classics has
Parsons’s concepts of culture and cultural tra- guided the identification of these  processes.
ditions and his identification of culture as Assimilation and pragmatic acculturation have
transmitted, learned, and  shared, together been found to influence health behavior sig-
with the contributions from Durkheim, nificantly. These processes will be discussed
Weber, Kluckhohn, and Malinowski, form later. But first, let us review some of the con-
the significant inheritance from the social temporary leading ideas on culture and health.
science pioneers on the study of culture. An
additional heritage of the study of culture is
Main contemporary research trends
the cross-fertilization of insights and research
from sociology and anthropology. Most cur- Some “neoclassical approaches” have sprung
rent studies on culture and on the link out of the work of Weber, Durkheim, and
between culture and health have built on this Marx; for example, interpretations of reli-
rich patrimony. gion, studies of social control, and feminist
By identifying the fundamental components perspectives of the body and gender. Among
of culture, the collective wisdom inherited from this type of study are those of Goffman and of
the classics permits us to consider culture and Foucault. Goffman (1968a; 1968b) focuses on
ethnicity as the same phenomenon. Although the person’s subjective definition of the situa-
Mead (1956) and Paul (1963) proposed that cul- tion and the concept of stigma. Unfortunately,
tural differences cut across racial and religious he and many of his followers have neglected
lines, these two factors are very much part of the to apply his conceptual approach fully to their
cultural landscape within which individuals own studies: they overlook cross-cultural
and groups operate. This idea is captured well comparisons (Scambler 1984). Foucault
by Stanley King’s definition of an ethnic group: (1973; 1977) awakened awareness to the sym-
a combination of “common backgrounds in bolic and perceived meaning of the body.
language, customs, beliefs, habits and traditions, Research findings since the 1990s show that
frequently in racial stock or country of origin” the symbolic meaning of the body in relation
and, more importantly, “a consciousness of to health and illness, manipulation, com-
kind” (1962, 79). These ethnic similarities pleteness, and mutilation varies substantially
may be factual or perceived and may include a across cultures. One of the most dramatic
formal religion. The sharing of the same geo- illustrations of this finding is the cultural
graphical settlement is not as important as was interpretation of female genital cutting (FGC)
once thought, mainly because large migrations by Western groups advocating the eradica-
(voluntary or not) of people from different tion of FGC, as opposed to the symbolic
ethnic groups have resulted in the formation of meaning of FGC held by some African
diaspora beyond their ancestral lands and the communities that are struggling to preserve it
subsequent increase of multiethnic settlements. (Greer 1999).
The process of assimilation (becoming a mem- The preceding discussion might suggest
ber of the host culture) is commonly observed consensus on what culture is and how to study
when individuals settle in a new country. it. But there is no consensus. Jeffrey Alexander
Living in close proximity to each other leads sees one point of agreement: the “emphasis on

the autonomy of culture from social structure.” CULTURE AND HEALTH BEHAVIOR
But he finds in the contemporary literature
“extraordinary disagreement over what is A complete review of the vast body of sociologi-
actually inside the cultural system itself.” Is it cal and anthropological literature dealing with
symbols, or values, or feelings, or metaphy- the influence of culture upon the individual’s
sical  ideas? Alexander proposes that culture health behavior is beyond the scope of this
embraces all these and requires a multidisci- entry. Instead, I will highlight relevant findings
plinary approach (1990, 25–6). Renée Fox within the framework of three types of health-
(1976; 1989) also promotes multidisciplinary related behavior: preventive health behavior, ill-
analysis. She has contributed to the search for ness behavior (Kasl and Cobb 1966), and
evidence on the impact of values and beliefs sick-role behavior (Parsons 1951, 436–8).
on health behavior at the microlevel through
her analysis of individuals and at the mac-
Culture and preventive health behavior
rolevel by focusing on institutional aspects of
medical care such as the medical school and Preventive health behavior refers to the activ-
the hospital. ity of a person who believes he or she is
The multidisciplinary approach is indeed healthy for the purpose of preventing illness
one of two main trends in the research on cul- (Kasl and Cobb 1966, 246). Kasl and Cobb
ture. Sociology and anthropology research labeled this “health behavior,” but the qualify-
findings confirm that culture influences ing term preventive differentiates it clearly
health behavior and attitudes significantly. from the other two types of health-related
However, a second main trend in research behavior. Relevant research on preventive
work over the past half century or so is the health behavior includes healthy individuals
absence of one dominant theory to explain as well as studies on substance addiction or
the influence of culture systematically and abuse (drugs, alcohol, cigarettes) that seek to
comprehensibly. understand the path toward addiction and
The inclusion of ethnicity has become to identify the factors involved. The subjective
fashionable in biomedical research since the evaluation of one’s own health status may
1980s, but it appears that medical studies propel or retard preventive action against
make no, or only a very tenuous, link with disease. As health status is in many respects a
social science research findings on ethnicity. value, cultural variations are commonly
Reviewing the uses of the concept “ethnicity” found in people’s evaluation of their own
in articles published in the American Journal health status and the way in which they
of Public Health from 1980 to 1989, Ahdieh evaluate it. Two of many examples of studies
and Hahn (1996, 97–8) found that “there was on culture and preventive health behavior are
little consensus in the scientific [biomedical] those on ethnicity and alcohol drinking
community regarding the meaning or use of (Guttman 1999; Gureje et al. 1997) showing
terms such as race, ethnicity or national ori- that the difficulties encountered in the pre-
gin.” Efforts have been made to assist health vention of alcoholism are greater in some
care practitioners to appreciate the complex- cultures than in others.
ity of culture (LaVeist 1994; Williams 1994). Guttman’s (1999) investigation into the
The social sciences and, in particular, sociol- relative influence of culture upon alcohol
ogy and anthropology remain the disciplines abuse among Mexican immigrants in the
most dedicated to the study of health and ill- United States found culture to be equivocal in
ness in the context of culture. situations where acculturation takes place.

Guttman defined acculturation as “the pro- manner in which they react to symptoms, and
cess whereby one culture group adopts the the meaning they attach to symptoms have all
beliefs and practices of another culture group been found to vary across cultures. Illness
over time” (1999, 175). behavior encompasses the timespan between a
A second and more critical difficulty in person’s first awareness of symptoms and his
the study of preventive and other types of or her decision to seek expert assistance or
health behavior among immigrants is their “technically competent” help (to borrow
concurrent exposure to multiple cultural Parsons’s term: 1951, 437). Early studies on ill-
influences. Guttman (1999, 175) proposed ness behavior and ethnicity (e.g., Suchman
that immigrants “engaged in the creation, 1964; 1965; Geertsen et al. 1975; Kosa and Zola
elaboration, and even intensification of new 1975) found significant cultural variations in
cultural identities.” However, the presence of the perception of symptoms. In fact, the rela-
multiple cultural influences does not neces- tive saturation of the literature regarding the
sarily lead to the creation of new identities. ethnicity–illness behavior link was already
Other outcomes are possible. A significant manifested in Mechanic’s observation in the
outcome is what I label pragmatic accultura- late 1970s: “Cultures are so recognizably differ-
tion: the borrowing of cultural elements ent that variations in illness behavior in differ-
(concepts, ways of doing things, ways of ent societies hardly need demonstration”
organizing and planning) and adapting them (1978, 261). Nevertheless, research on the
to meet practical needs (Quah 1985; 1989; association between culture and illness behav-
1993). Individuals “borrow” healing options ior continues (e.g., McKelvy, Sang, and Hoang,
from cultures other than their own, but they 1997; Cockerham, 2010).
may or may not incorporate those options or
more aspects of the other cultures into their
Culture and sick-role behavior
lives permanently (for a detailed discussion
of pragmatic acculturation, see the entry To recapitulate: sick-role behavior is the activity
“Medical Systems, Mixed Utilization of ” in undertaken by a person who considers himself
this Encyclopedia). or herself ill for the purpose of getting well
Yet another angle of analysis in the study of (based on Parsons 1951, 436–8). Sick-role
culture and health is the identification ofcul- behavior is typically preceded by illness behavior
tural differences in health behavior among and encompasses the sick person’s response to
subgroups of a community or country assumed symptoms, in particular, the seeking of what he
to be culturally homogeneous. Such is the or she perceives as “technically competent” help
case of differences commonly found between (Parsons 1951), as well as doctor–patient or
“rural” and “urban” ways of life and ways of healer–patient interaction. A major direct
thinking in the same country (see, for exam- implication of the concept of role is the sym-
ple, the study of Thai  villagers and AIDS bolic, perceived, or actual presence of others.
prevention: Lyttleton 1993). Sick-role behavior implies the presence of the
healing expert (irrespective of what healing sys-
Culture and illness behavior
tem is at work). A large body of research into the
As mentioned earlier, illness behavior refers to doctor–patient relationship and other aspects of
the activity undertaken by a person who feels the sick role has produced interesting informa-
ill for the purpose of defining the illness and tion confirming the relevance of culture.
seeking a solution (Kasl and Cobb 1966). What Saunders (1954) and Zborowski (1952; 1969)
people do when they begin to feel unwell, the were among the first sociologists to observe

cultural differences in doctor–patient interac- Regarding the biomedical researchers’

tion and responses to pain, respectively. Along awareness of social science findings on culture,
the same line of investigation, Zola (1966; 1973; some publications have addressed the need of
1983) pursued the analysis of how culture physicians and other health care personnel to
shapes the subjective perception of symptoms. be informed on the importance of cultural dif-
Twaddle (1978) replicated Zborowski’s study ferences that may affect the doctor–patient
and found that Parsons’s configuration of the interaction (MacLachlan 1997).
“sick role” varied among ethnic groups; the
same trend was reported by Nitcher (1994) and
Koffman et al. (2008), among others. CULTURE AND HEALING SYSTEMS
Considering this trend, an expected finding
is that cultural similarities, such as physical The options available to people seeking health
appearance and language, among other char- care vary greatly across countries and cultures.
acteristics, between doctor (or healer) and For the sake of clarity and expediency, it is use-
patient facilitate the relationship and increase ful to consider all healing options as falling
the possibility of positive patient outcomes into two main general categories: the modern
(Kleinman 1980, 203–58; Cockerham 2010). or Western biomedicine system, and tradi-
A note of caution: similarities in culture do tional medicine systems. A medical or healing
not secure success in the doctor–patient rela- system is understood as “a patterned, interre-
tionship. Many other aspects come into play, lated body of values and deliberate practices
including ecological factors, as Ralph Catalano governed by a single paradigm of the meaning,
(1989) found. identification, prevention and treatment of …
The structural features of the healer–patient illness and/or disease” (Press 1980, 47).
relationship, such as how the interaction is Traditional medical systems flourished well
conducted and who is involved, also vary before Western biomedicine and their history
across cultures. Haug and colleagues (1995) goes back more than one millennium. Three
found interesting differences in the manner in ancient healing traditions are considered to be
which the doctor–patient interaction develops the most important: the Arabic, the Hindu,
in Japan and the United States. Kleinman and the Chinese healing traditions (Leslie
(1980, 250–310) shows that the relationship is 1976, 15–17). However, there is a revival of
not always a dyad, as in some communities the interest in cultural traditions today around the
patient’s family is often directly involved. In two best-known traditional medicine systems:
some communities, the quality of the interper- traditional Chinese medicine (Unschuld 1985)
sonal relationship built between patient and and Hindu or Ayurvedic medicine (Basham
healer is paramount and may become as sig- 1976). Practices divergent from distinctive
nificant to the patient as “the technical quality” paradigms of healing may be collectively called
of the medical care received (Haddad et al. popular medicine (Press 1980).
1998). Just as cultural variations are observed Healing systems are constantly evolving and
among sick people searching for help from two features of their internal dynamics are rel-
healing experts (whether traditional or mod- evant here: divergence and pragmatic accul-
ern), so the seeking of emotional and social turation. Divergence in a healing system is the
support and the presence and quality of infor- emergence of subgroups within the system
mal social support from family and friends supporting different interpretations of the sys-
also vary across cultures (see, e.g., Kagawa- tem’s core values (Fox 1976). A manifestation
Singer, Wellisch, and Durvasula 1997). of pragmatic acculturation in a healing system

is the inclination of its practitioners to borrow internally consistent; different interpretations

ideas or procedures from other systems to of the core values or principles of the system
solve specific problems without necessarily may be held by subgroups within the system.
accepting the core values or premises of the Third, pragmatic acculturation is very preva-
system or systems from which they do the bor- lent in matters of health and illness and is
rowing (Quah 1989; Norheim and Fonnebo found in all types of health-related behavior.
1998; Harmsen et al. 2008). Finally, a comprehensive review of the rel-
The presence and relative success of groups evant literature is not possible in this entry
and institutions (e.g., the medical profession, given the enormous body of medical sociol-
hospitals, and other health care organizations) ogy research on health and culture. Instead,
involved in the provision of health care unfold illustrations and the list of references are
in the context of culture. Arthur Kleinman offered for each main argument in this
(1980) highlights the relevance of the “social discussion in the hope that the reader be
space” occupied by health systems. This aspect enticed to pursue his or her own journey into
is well illustrated by a study on mental health this engaging research topic.
in Vietnam by McKelvy, Sang, and Hoang
(1997) documenting the population’s skepti- SEE ALSO: Durkheim, Émile; Healing and
cism on the need for child psychiatric clinics. Gender Roles; Health, Cultural Competence
in; Health and Illness, Cultural Perspectives
on; Medical Systems, Mixed Utilization of;
Weber, Max

In sum, culture has influenced, does influence, ACKNOWLEDGMENT

and will continue to influence health-related
behavior. There is a wealth of social science This is an abbreviated version of S. R. Quah,
and, in particular, medical sociology research “Health and Culture.” In The New Blackwell
demonstrating the pervasiveness of cultural Companion to Medical Sociology, edited by W.
values and norms upon preventive health C. Cockerham. Oxford, UK: Wiley-Blackwell,
behavior, illness behavior, and sick-role behav- 2010, pp. 27–46.
ior among individuals and groups, as well as at
the macrolevel of healing systems.
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Complementary and Some note that what we call “alternative” med-
icine in the United States is “traditional”
Alternative Medicine Usage medicine for much of the world. Traditional
among Men and Women Chinese medicine (TCM) and Ayurvedic
medicine are comprehensive medical systems
MELINDA GOLDNER dating back thousands of years in countries
Union College, USA like China and India. This review focuses on
the United States, where most of the studies are
Complementary and alternative medicine conducted. Alternative medicine re-emerged
(CAM) refers to a broad range of practices in the United States during the late 1960s and
and beliefs that consumers, especially women, early 1970s, for a variety of reasons. To name
increasingly turn to in the United States. just a few, some individuals were first intro-
People in the United States are more likely to duced through James Reston’s account in the
be familiar with herbal products and dietary July 26, 1971 edition of the New York Times,
supplements, chiropractic, and mind–body which described his experience with acupunc-
techniques such as meditation; in addition, ture in order to relieve postoperative symp-
CAM includes modalities based upon move- toms and discomfort associated with an
ment (e.g., Pilates), energy fields (e.g., Reiki), emergency appendectomy in China. Others
and traditional or indigenous practices. Since were introduced through their involvement
a significant and growing number of consum- with a variety of social movements interested
ers are trying these techniques, it is important in challenging institutional authority or
to understand demographic variations in pat- exploring holism and spirituality, including
terns of usage. One consistent finding in the feminism. The sociological literature has taken
sociological research is that, given their differ- an extensive look at these movements.
ing health needs and behaviors, women are Usage increased substantially in the 1990s,
more likely than men to try CAM. and this has led to growing acceptance and
Larger numbers of individuals began to institutionalization. Two studies led by David
embrace various alternative techniques begin- Eisenberg, a physician and professor of medi-
ning in the 1960s, and most notably in the cine at Harvard Medical School, documented
1990s, but the history of alternative medicine much higher usage than expected, and physi-
goes back much further both in the United cians became familiar with these findings
States and in other countries. In the United after they were published in The New England
States, for example, homeopathy was very pop- Journal of Medicine in 1993 and The Journal of
ular in the 1840s. Much of the nineteenth cen- the American Medical Association (JAMA) in
tury, in fact, was characterized by medical 1998. The National Institutes of Health began
pluralism, until medical knowledge (e.g., germ to fund research on the safety and efficacy of
theory) and techniques (e.g., antiseptic tech- alternative therapies, and to educate the pub-
niques) improved and physicians achieved lic and health care practitioners through the
professional dominance. At that point fewer National Center for Complementary and
people turned to alternative practices. Also, we Alternative Medicine. This center was formerly
see a much longer history of usage globally. the Office of Alternative Medicine, which was

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

established by congressional legislation in Usage typically varies by gender, even

1991, but renamed in 1998. The combination though substantial numbers of both men and
of consumer demand and scientific research women try CAM. To illustrate, a large-scale
led some hospitals to incorporate these nationally representative survey found that
modalities, some physicians to refer patients, one-third of men but 43 percent of women had
and a few insurance companies to cover some tried at least one type of CAM in 2007, and
forms of CAM. Language reflects the social women were more likely than men to use
context, and consequently these historical each category of CAM (i.e., biologically based
changes. Some consumers use techniques therapies, mind–body therapies, alternative
such as acupuncture, homeopathy, and herbs medical systems, energy healing therapies,
in lieu of Western, conventional, or main- and  manipulative or body-based therapies)
stream medicine (e.g., prescription drugs, sur- (Barnes, Bloom, and Nahin 2008). There are
gery), and one of the early definitions of numerous motivations for trying these tech-
alternative medicine focused on their absence niques, but the following factors can be corre-
in most medical school curricula and hospi- lated with gendered patterns. Sociologists have
tals (Eisenberg et al. 1993). Beginning in the provided a detailed understanding of gender,
1990s, the term “complementary and alterna- and how this affects our behaviors, expecta-
tive medicine,” or CAM, was adopted to reflect tions, and perceptions. Thus, they are uniquely
the fact that most consumers use these tech- situated to understand usage patterns.
niques in conjunction with conventional Some consumers are drawn to comple-
medicine. Growing acceptance among hospi- mentary and alternative techniques for the
tals and physicians has led some to use the ideology. Advocates of CAM focus on pro-
term “integrated or integrative medicine,” moting health, not just curing disease, by
where both types of medicine are combined. treating the body, mind, and spirit holisti-
Today, anywhere from about 20 to 75 per- cally, individualizing treatments, and empha-
cent of respondents have tried CAM, depend- sizing self-care and taking individual
ing on what modalities are included and what responsibility. Women are more likely to use
sample is studied. Studies often focus on spe- self-help techniques than men, so they may
cific groups, such as people with cancer, and find the expectation that patients take a more
this can potentially overstate usage in the gen- active role in their health appealing. Holism
eral population because people are often provides another explanation for the greater
drawn to CAM through a chronic or terminal numbers of women using CAM. The cultural
illness. Thus, it is important to note that larger expectation that women are more attuned to
nationally representative studies place this fig- their emotions can increase the likelihood
ure around 40 percent. It has been estimated that they would perceive a connection
that consumers spend more than $30 billion between their emotional and physical health,
on CAM (Nahin et al. 2009). The most com- and appreciate that CAM practitioners ask
monly used techniques are typically herbs about emotional health. Women’s desire for a
(especially fish oil, glucosamine, Echinacea, holistic approach can lead to dissatisfaction
flaxseed, and ginseng), relaxation techniques with Western or conventional medicine.
such as deep breathing and meditation, Other patients turn to complementary and
chiropractic or osteopathic manipulation, alternative medicine out of frustration with the
massage, and yoga. A sociological perspective type of care offered by their physicians.
enables us to understand key demographic Sociologists have documented that some
differences in CAM usage. patients believe their physicians are too rushed,

impersonal, objectifying, and authoritative. There are two important caveats to keep in
Some financial models focus on cost savings mind when discussing gendered patterns in
and profit, which may restrict the amount of CAM usage. First, a sociological approach
time that physicians can spend with patients. allows us to examine key demographic differ-
Also, at medical school physicians are trained ences in usage among women. Insurance
in emotional detachment. Some patients are reimbursement is still limited, forcing most
left feeling like a body part or illness, rather consumers to pay out-of-pocket for tech-
than a whole person. This can be exacerbated niques that can be costly; as a result, the more
by our medical system’s reliance on specialists affluent women are more likely to be able to
and high-tech medicine. Sociologists have afford CAM. Typically, research has found
documented examples of sexism in medicine, that non-Hispanic white women are more
and this may leave some women feeling objec- likely to try CAM, but this can vary by modal-
tified and alienated. Women may be more ity. Second, while most studies find that
likely to have these negative perceptions of women are more likely than men to try com-
their physicians or the health care system more plementary and alternative medicine, we should
generally insofar as they may prefer a holistic not ignore the growing number of men who
approach and individualized treatments, as turn to these techniques. Some studies find no
well as what is perceived to be a more caring significant gender differences, including one
and nurturing relationship with CAM practi- nationally representative survey in the late
tioners (Sointu 2011). 1990s (Astin 1998), and a very small number
Finally, some individuals try CAM because of studies find that men are more likely than
they are looking for better results. Now that life women to use CAM. Men’s usage will also be
expectancy has increased, our predominant gendered. For example, a holistic approach
disease pattern is chronic disease. Treatments can challenge traditional notions of masculin-
are focused on disease management, because ity given its emphasis on assessing emotions
chronic diseases are rarely cured. Patients are and developing nurturing relationships with
often left with symptoms that affect their qual- CAM practitioners (Sointu 2011).
ity of life. Many proponents of CAM argue that Sociologists who study CAM are attentive
while Western medicine provides the best care to how usage varies between men and women,
for acute conditions such as broken bones and but we need further information on the role
bacterial infections, it has less to offer for that gender plays. In other words, what are
chronic diseases. Some patients become frus- the main reasons as to why we see these gen-
trated with the lack of results or the side effects dered patterns? Do men and women perceive
of mainstream treatments, and turn to CAM, CAM differently? Do men and women have
especially when it has been recommended by different motivations for using CAM? Do
family or friends. Women are more likely to be they respond differently to specific tech-
diagnosed with certain chronic diseases such niques? How do women’s roles as mothers
as arthritis, and experience greater rates of affect children’s growing use of CAM? How
morbidity than men given their longer life does women and men’s use of CAM reaffirm
expectancy. Women seek all types of health or contest traditional notions of gender?
care, including CAM, more frequently than Sociologists need to continue to explore the
men, because the social construction of femi- intersections between gender and socio-
ninity allows for them to seek assistance, and demographics, such as socioeconomic status,
places the expectation that they will nurture race, ethnicity, and age, because these affect
and care for their family’s health needs. usage. There is a lack of consistency in defini-

tions (e.g., which  modalities are included) Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel,
and samples (e.g., many focus on one type of S., Wilkey, S., Van Rompay, M., and Kessler, R.
patient, especially those diagnosed with a C. 1998. “Trends in Alternative Medicine Use in
particular disease), which makes it hard to the United States, 1990–1997: Results of a Follow-
Up National Survey.” Journal of the American
compare studies; however, sociologists are
Medical Association 280: 1569–1575.
poised to understand this important transfor-
Eisenberg, D. M., Kessler, R. C., Foster, C., Nor-
mation in health care. lock, F. E., Calkins, D. R., and Delbanco, T. L.
1993. “Unconventional Medicine in the United
SEE ALSO: Chiropractors; Complementary States: Prevalence, Costs, and Patterns of Use.”
and Alternative Medicine Usage and Race; New England Journal of Medicine 328: 246–252.
Holistic Therapies; Medical Systems, Mixed Nahin, Richard L., Barnes, Patricia M., Stussman,
Utilization of; Osteopaths; Traditional Health Barbara J., and Bloom, Barbara. 2009. “Costs
Services Utilization among Cancer Patients of Complementary and Alternative Medicine
in Developing Countries; Traditional Health (CAM) and Frequency of Visits to CAM Prac-
Services Utilization among Cancer Patients in titioners: United States, 2007.” National Health
Western Countries; Traditional Health Services Statistics Reports 18. Hyattsville, MD: National
Utilization among Indigenous Peoples Center for Health Statistics.
Sointu, Eeva. 2011. “Detraditionalisation, Gen-
der and Alternative and Complementary
REFERENCES Medicines.” Sociology of Health & Illness 33:
Astin, John A. 1998. “Why Patients Use Alterna-
tive Medicine: Results of a National Study.”
JAMA 279: 1548–1553.
Barnes, Patricia M., Bloom, Barbara, and Nahin,
Richard L. 2008. “Complementary and Alterna- Kronenfeld, Jennie Jacobs, and Ayers, Stephanie
tive Medicine Use among Adults and Children: L. 2009. “Social Sources of Disparities in Use
United States, 2007.” National Health Statistics of Complementary and Alternative Medicine.”
Reports 12. Hyattsville, MD: National Center for Research in the Sociology of Health Care 27:
Health Statistics. 83–107.
Medical Systems, Mixed borrowing (Quah 2009). Let us look in more
detail at the patterns, conceptual definition,
Utilization of and  empirical manifestations of mixed
utilization of medical systems.
Duke-NUS Graduate Medical School, Singapore
Mixed utilization of medical systems refers OF MEDICAL SYSTEMS
to a person’s use of healing solutions from
more than one healing system; that is, the The notion of health system is central to the
combination of biomedicine – Western analysis of mixed use of medical systems. But
medicine – and any of a wide array of tradi- considering that most of the definitions of
tional healing systems. Research findings in health system in the literature focus on logis-
medical sociology and anthropology over tics, financial arrangements, and procedures
the past five to six decades show that the in biomedical health care (Stevens and Zee
main questions for anyone feeling ill are 2008; Wang 2008), it is important to begin by
about the cause of the illness and finding a clarifying what “health system” means in this
cure. These concerns are present irrespec- discussion of mixed use of medical systems. A
tive of geographical location, lifestyle, and health system is “a patterned, interrelated
ethnic, religious, linguistic, or other back- body of values and deliberate practices gov-
ground of the individual feeling ill. While erned by a single paradigm of meaning, iden-
the questions on etiology and cures tend to tification, prevention and treatment of illness
be the same, the answers vary widely, as and disease” (Press 1980, 47–8). Thus under-
they are fashioned precisely by people’s stood, the concept helps us to identify two
location, way of life, sociocultural, religious, general categories of healing systems in terms
linguistic, and other differences. More of their “paradigms of meaning.” One category
importantly, amid the rainbow of healing is biomedicine – also known as Western,
options and solutions, one trend predomi- modern, or allopathic medicine – rooted in
nates: people do cross cultural boundaries the single paradigm of science. The other
in search of a cure or in their quest for the category is traditional healing systems com-
proverbial fountain of youth. Conceptually, prising all other healing systems which are
this phenomenon is pragmatic acculturation – based on a large and intricate range of non-
that is, the borrowing of ideas, ways of scientific paradigms driven by cultural
thinking, or ways of doing things from a and  religious values, beliefs, and practices.
culture that is not your own, for the purpose Traditional healing systems across the world
of solving a particular problem. As the vary widely in their levels of complexity and
borrower, you choose procedures or reme- sophistication. There is a third type of prac-
dies that you consider helpful in solving tices loosely labeled “popular medicine” that
your problem without necessarily adopting refers to “those beliefs and practices which,
the conceptual paradigm or cosmology of though compatible with the underlying para-
the healing system from which you are digm of a medical system, are materially or

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

behaviorally divergent from official medical The first three premises or arguments
practice” (Press 1980, 48). Popular medicine is (that crossing cultural borders in search of
also labeled “alternative” medicine or therapies. healing is part of our daily life; that to identify
I will return to this point later. We speak of meaningful trends sociologists should
“mixed utilization” or pragmatic accultura- address not only local but also international
tion when an individual uses healing services or global trends; and that the practice of
from both categories: biomedicine and one or pragmatic acculturation is facilitated by the
more traditional healing systems. wide variety of healing options available in
Five interrelated premises are particularly most societies today) do not require much
relevant to the sociological analysis of people’s elaboration, as they are amply documented
pursuit of healing solutions across healing by social science research carried out since
systems. First, pragmatic acculturation as the 1970s. A wealth of relevant studies
defined above is common, normal behavior is  found in books (e.g., Leslie 1976;
in everyday life, everywhere, as illustrated by Ademuwagun et al. 1979; Kleinman 1980;
international reviews (WHO 2001, 2007). Akerele, Stott, and Lu 1985; Quah 1989;
Second, given the prevalence of pragmatic Fadiman 1997), manuals (e.g., WHO 2001;
acculturation, the most adequate research 2007) and journals such as Social Science &
designs for the study of trends in the use and Medicine, Journal of Health and Social
provision of healing options involve multi- Behavior, Culture, Medicine, and Psychiatry,
cultural samples and cross-national compari- and Health Sociology Review, among others.
sons. Third, countries with homogeneous or But more attention must be given to the
single-system health care arrangements are fourth and fifth arguments: the need for suit-
becoming the exception rather than the rule. able analytical tools and the importance of
Trade globalization and large waves of immi- identifying differences, similarities, and
gration promoting the growth of ethnic dias- trends at four distinct levels of analysis: at the
poras around the world have transformed the macrolevel, biomedical and non-biomedical
market of healing services in most countries: healing systems; and at the microlevel, the
today, you find a wide range of options along users and providers of healing services.
a continuum of scientific sophistication, from
biomedicine to quasi-scientific or mock “bio-
medical” options, to traditional healing prac- THE CONCEPTUAL CHALLENGE
tices and remedies from ancient healing
systems such Chinese, Indian, and Arabic Regarding the fourth argument on analytical
traditions, to less systematic and multihued tools to study social phenomena, the first
folk and tribal beliefs and healing rituals. requirement is clarity of concepts. It is unfor-
Fourth, given this wide and complex array of tunate that the discussion of healing options
alternatives, sociological research on healing in the social science literature has incorpo-
options and people’s choices requires clarity rated terms from the popular media and
of concepts and analytical tools that can iden- introduced new labels without rigorous scru-
tify trends while reflecting the rich variations tiny of their meaning and consistency. Terms
in agency and structure. And fifth, pragmatic that may lead to confusion are, for example,
acculturation is observed at the macrolevel integrative medicine, complementary medi-
involving healing systems and structures, as cine, and alternative medicine (Sharma 1990),
well as at the microlevel involving agency the latter two sometimes used separately, but
among health care users and providers. recently presented together in the acronym

“CAM,” and terms such as folk, popular, and standard terminologies” in WHO 2007), we
traditional medicine. Fries (2008, 353) rightly must use consistent analytical tools to identify
states that “integrative medicine is a term as the underlying trends and possible changes in
politically charged as it is culturally loaded.” the unique paradigms of biomedicine and
Baer and Coulter (2008, 331–2) acknowledge non-biomedical healing systems. The concept
the confusion in terminology. They argue of pragmatic acculturation is one of those ana-
that CAM is different from integrative medi- lytical tools in the study of healing and health-
cine but that “alternative medicine is often related agency and structure: it can be applied
defined as functioning outside biomedicine to both the users and the providers and it
and complementary medicine beside it; helps in discerning the various modes of
integrative medicine purports to combine the knowledge “borrowing” and practice “borrow-
best of both biomedicine and CAM.” The ing” that take place across the boundaries
authors note that the US Office of Alternative dividing biomedical and non-biomedical
Medicine is aware of the nebulous nature healing systems.
of  CAM. Similarly, Willison (2008), Fries
(2008), and other researchers point to the
serious problem of definition, but use the PRAGMATIC ACCULTURATION,
terms in their studies. They are not alone: AGENCY AND STRUCTURE
Singer and Fisher (2007, 20) report that CAM
“is now the most common nomenclature The fifth relevant argument is the presence
used in the literature to refer to a wide range of pragmatic acculturation at two levels: the
of non-biomedical products and practices.” macrolevel involving healing systems and
While “CAM,” “integrative medicine,” and structures, and the microlevel involving
similar labels are common in the popular agency among health care users and provid-
media, they are not conceptually illuminating ers. Pragmatic acculturation takes place
as the presumably different categories of among users as well as among providers, but
healing practices they aim to represent are in different fashions and driven by different
not comprehensive or mutually exclusive. The motivations. To facilitate the observation of
conceptual ambiguity has led some research- pragmatic acculturation from the perspec-
ers to believe that biomedicine is already tive of agency, the activities of health care
engaged in incorporating non-biomedical users may be classified into three categories
systems in the US and Europe, resulting in based roughly on the stages of their illness
“integrative” medicine; some researchers have trajectory: preventive health behavior (the
announced that integration has become “a behavior of people who consider themselves
social movement” (Baer and Coulter 2008, healthy and wish to avoid illness); illness
332). Notwithstanding the enthusiasm of sup- behavior (the activities of a person who feels
porters of “integration,” this conclusion is pre- ill for the purpose of defining the illness and
mature given the absence of clarity on the finding a solution); and sick-role behavior
nature of the phenomenon under study. The which refers to the activities of a person
conceptual and methodological frameworks diagnosed with a disease for the purpose of
for the analysis must be strengthened first. recovering (Quah 2010). Research findings
In addition to applying a systematic, compre- suggest that pragmatic acculturation is com-
hensive, and mutually exclusive classification mon at the preventive health behavior stage as
of healing practices and traditions (see as an people combine biomedicine products such
example the effort to arrive at “international as vitamins with traditional herbal tonics

and/or non-biomedical health-strengthening scarce, such as in rural Africa (Nelms and

products and practices. Pragmatic accultura- Gorski 2006) or rural Indochina (Au 2011).
tion is also observed among people at the This “borrowing” and testing are still the work
illness behavior stage in the form of self- of a minority of biomedical practitioners in
medication and self-treatment, usually with some countries and their agency has not yet
a combination of over-the-counter biomedi- led to the structural transformation of
cal drugs and traditional remedies. Among biomedical health services in a comprehen-
people at the sick-role stage, those diagnosed sive manner. In fact, there are significant con-
with a chronic disease and who are satisfied ceptual and logistical obstacles along the path
with the biomedical treatment they are toward “integrated medicine” as reported by
receiving are less likely to practice pragmatic Coulter et al. (2008).
acculturation compared to patients who are In contrast, the analysis of pragmatic
dissatisfied with biomedicine or have a ter- acculturation in non-biomedical healing sys-
minal illness. The latter are inclined to go tems at the structural level indicates that the
beyond biomedicine in their search for a cosmologies of non-biomedical healing tradi-
cure or for relief of the collateral damage tions are more flexible but, even then, there
inflicted by harsh biomedical treatments are exceptions. The ethos of pragmatic healing
such as radiation and chemotherapy (in in traditional Chinese medicine (TCM), for
addition to the abundant examples of this example, represents a serious stumbling block
trend in the literature, see also Coulter et al. to collaboration with biomedicine as TCM
2008; Fries 2008; Tovey and Broom 2008; practitioners steer clear of conceptual analy-
Shahid et al. 2010) or use traditional healing sis and the measurement of errors and biases,
as a substitute when biomedical treatment is focusing instead on whatever works (Quah
beyond their means (see, e.g., Jombo et al. 2003, 2008–9). Both the ethos of pragmatic
2010; Au 2011). healing and state intervention have facilitated
Regarding practitioners, the sociological a trend toward structural integration in China
analysis of health care providers is enriched by and to a lesser extent in some other Asian
the application of a comparative approach that countries. In China, structural integration is
contrasts biomedical and non-biomedical evidenced by at least three main features:
healers and by the use of conceptual frame- government initiatives in the design of a
works from both medical sociology and the mixed curriculum in medical schools includ-
sociology of professions. The ethos of science ing biomedicine and TCM; the availability of
in biomedicine precludes a complete integra- both biomedical and TCM services in hospi-
tion with other systems of healing or even the tals and other health care institutions; and the
automatic incorporation of non-biomedical introduction of modern technology in the
practices or remedies. Considering the processing and packing of TCM remedies,
requirements of the ethos of science, it is which is a key reason for the success of the
expected that biomedical practitioners feel TCM pharmaceutical industry. In terms of
obliged to apply scientific scrutiny to selected agency, as indicated earlier, practitioners of
non-biomedical ideas, procedures, or reme- non-biomedical healing are not bound by the
dies and, depending on the outcome, incor- imperative of scientific testing and, thus,
porate them into biomedicine (Quah 2003; while keeping their paradigms and cosmol-
Sim et al. 2003; Tang 2003) or explore very ogy intact, they are inclined to “borrow” bio-
cautiously the possibility of collaboration in medicine symbols and procedures if and
situations where biomedical services are when they are deemed useful. TCM offers a

good illustration of this trend: some TCM evidence-based research and scientific scrutiny.
practitioners wear white coats, use stetho- The increasing interest in this area of research
scopes to measure blood pressure, sterilize augurs well for the considerable task ahead: to
needles in autoclaves, and now are using laser fine-tune concepts, formulate testable concep-
techniques in acupuncture (Quah 1989; 2003; tual frameworks, and use suitable research
Sim et al. 2003), and some countries have designs.
regulations on the practice of acupuncture as
anesthesia in surgery and  dentistry by, or SEE ALSO: Ethnopharmacology; Health and
under the supervision of, a biomedical practi- Culture; Health and Illness, Cultural
tioner (WHO 2001, 49). Perspectives on; Pharmaceuticalization

Ademuwagun, Z. A., Ayoade, J. A. A., Harrisson, I.
E., and Warren, D. M., eds. 1979. African Thera-
In sum, sociologists’ historical interest in the
peutic Systems. Walthan, MA: African Studies
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tive, complementary, and alternative medicine. Care in China. Manila, Philippines: World
However, I agree with Baer and Coulter (2008, Health Organization.
338) that it is important “to separate out the Au, S. 2011. Mixed Medicines. Health and Cul-
rhetoric from reality.” We need to take a sober ture in French Colonial Cambodia. Chicago, IL:
look at the road traveled to assess how much we University of Chicago Press.
know so far about mixed utilization of medical Baer, H. A. and Coulter, I. 2008. “Introduction –
systems, how valid and reliable are the data we Taking Stock of Integrative Medicine:
collect, and what are the most pressing knowl- Broadening Biomedicine or Co-option of Com-
plementary and Alternative Medicine?” Health
edge gaps. I have suggested in this brief discus-
Sociology Review 17(4): 331–341.
sion that we need conceptual clarity and testable
Coulter, I., Hilton, L., Ryan, G., Ellison, M., and
conceptual frameworks to analyze the nature, Rhodes, H. 2008. “Trials and Tribulations on
growth, and transformation of the “borrowing” the Road to Implementing Integrative Medicine
taking place across healing systems by practi- in a Hospital Setting.” Health Sociology Review
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Disability Disabled people are spread across all social
NICK WATSON locations and social identities. Its prevalence
University of Glasgow, UK does, however, reflect macro socioeconomic
inequalities: roughly 80 percent of the world’s
Disability is part of the human condition and disabled people live in the global south.
disabled people make up the world’s largest Disability and poverty are, as would be
minority group. According to the World expected, closely linked, and the World Bank
Health Survey, around 15 percent of the estimates that around 20 percent of the
world’s population (just over one billion peo- world’s poorest people are disabled. Disabled
ple) have some form of impairment and of people are disproportionately poor, and poor
these between 110 million and 190 million people are disproportionately vulnerable to
have significant difficulties in functioning becoming disabled. The reasons for this are
(WHO 2011a). It is something that will affect fairly straightforward: poor people are more
almost everyone; everybody will at some point likely to become disabled as a direct result of
in their life have an impairment, which may their material conditions of existence and
be either temporary or permanent; almost disabled people are more likely to face barri-
every family will have a disabled member; and ers to education, employment, and public
many non-disabled people will take responsi- services. In addition, many cultures have per-
bility for supporting and caring for a disabled secuted, expelled, or neglected people with
relative or friend. As people age, this tendency disabilities, and this adds to their economic
will increase; people become increasingly location. Disabled people have less access to
impaired in their final years and the preva- health care services and many of their health
lence of disability rises with age. In the United care needs are unmet. Disabled people tend
Kingdom, for example, around 6 percent of to be seen within their own communities as
children are disabled, compared to 15 percent being among the most disadvantaged.
of working age adults and 45 percent of adults Disabled people do not, however, constitute
aged 65 and over. While the majority of disa- a homogeneous group. Disability is a multi-
bled people are older, there are significant dimensional and cross-cutting issue and the
numbers of disabled people spread across the disadvantage that disabled people experience
age range; the World Health Organization can intersect with and reinforce other equality
(WHO 2008) has estimated that 95 million issues. Disabled women, for example, might
children (5.1 percent) under the age of 14 have experience discrimination that arises both as a
some form of impairment, of whom 13 mil- result of inequitable gender arrangements and
lion (0.7 percent) are defined as having a as a result of oppressive disablist practices,
“severe disability.” The numbers of disabled which can combine and serve to reinforce each
people are increasing, largely, although not other (WHO 2011b). There are other intersec-
solely, due to demographic changes, with tions, such as age, ethnicity, sexuality, religion,
increases in the prevalence of chronic condi- and location. The disadvantage that disabled
tions associated with aging, coupled with people experience can arise because govern-
advances in medical science and new medical ments and policymakers have not understood
interventions which can prolong life. or recognized a need for action. The

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

requirements of disabled people rarely reach communities and, under the guise of rehabili-
the top of the policy agenda, and this is espe- tation, denied access to a full curriculum.
cially so in less resourced settings where Social policy for disability now has a much
investment may be lacking for the establish- greater emphasis toward equality as well as
ment and/or maintenance of effective pro- community and educational inclusion, and
grams and/or services. Disability is, as the policies which may in the past have prior-
WHO World Report on Disability (2011b) itized medically focused solutions have been
reminds us, highly complex and variable, and replaced by more interactive approaches
it is not possible to claim that disabled people which recognize that many of the problems
represent a cohesive collective with a common disabled people face arise as the result of
identity and interests. There are numerous social, cultural, and environmental factors
subgroups – for example, women with disa- which serve to exclude people with impair-
bilities, disabled children, people with mental ments (WHO 2011b).
health conditions and intellectual There have been a number of national and
disabilities. international initiatives and treaties – such as
Definitions of, and policy responses to, dis- the United Nations (UN) Standard Rules on
ability have changed dramatically since the Equalization of Opportunities of Persons
the  1970s and the aim of this entry is to with Disabilities – which have promoted the
broadly examine how disability has been rep- human rights of disabled people. Perhaps
resented within sociology. It will show how most importantly has been the adoption in
disabled people and their organizations have 2006 of the UN Convention on the Rights of
demanded, and to some extent achieved, a Persons with Disabilities. This convention,
rethinking of what it means to be a disabled with 155 signatories and 127 ratifications and
person. It will discuss the way that sociology accessions, outlines the civil, cultural, politi-
defines disability and disabled people, and its cal, social, and economic rights of disabled
responses to the disability problem. people. Its aim is to “promote, protect, and
ensure the full and equal enjoyment of all
human rights and fundamental freedoms
THE MEANING OF DISABILITY by  people with disabilities.” The increasing
acceptance of this new human rights para-
The meaning of disability and the personal digm marks an approach which recognizes
consequences for being a disabled person disabled people as equal members of society,
have changed considerably since the 1970s. entitled to respect and dignity, deserving of
This is as true for many countries in the inclusion, and capable of making a contribu-
global south as it is in the global north. Prior tion, placing disablism on a par with racism,
to the 1970s, the majority of disabled people sexism, or homophobia.
would have been located in segregated estab- In response to inequality and social exclu-
lishments. Employment opportunities were sion, people with disabilities have organized
often restricted to segregated training centers together in every region of the world to
or sheltered accommodation, which typically challenge the neglect of their needs (Charlton
offered little opportunity for advancement and 2000). Disabled people have united and,
where wage levels were low. Disabled children regardless of their impairments, formed a
were segregated from their nondisabled peers, broad coalition, one that has acted both as a
and many were placed in residential institu- means to provide mutual support and as a plat-
tions and special schools outside their home form for political action. Slogans such as

“nothing about us without us,” “rights not contemporary social organisation which takes
charity,” and “piss on pity” highlight the little or no account of people who have physical
demand for effective participation and for rec- impairments and thus excludes them from the
mainstream of social activities. Physical disability
ognition of human rights. These demands have
is therefore a particular form of social oppression.
had significant effects and anti-discrimination (UPIAS 1976, 3–4)
legislation such as the 1990 Americans with
Disabilities Act and the UK’s Disability Under this model, being disabled is about
Discrimination Act (1995) are a direct result. discrimination and prejudice, and disability
Central to this global movement has been the is a collective experience. It is a problem that
rejection of the individualized, medicalized is located within society and not the individ-
understandings of disability that dominated ual, and the way to tackle disability is to alter
medical sociology from in its first inception. the social, physical, or cultural environment.
Work such as that by Bury (1982), where the It closely follows Marxist paradigms and early
focus was on the impact that acquiring an second-wave feminism. Where feminists dis-
impairment had on an individual and the way tinguish between sex and gender, so disability
they responded to that impairment, were studies separate impairment and disability,
rejected and replaced by an approach that the former biological, the latter social and
emphasized the material and structural factors cultural (Shakespeare 2006).
that affected disabled people (Oliver 1990). A key aim of both disability studies and the
Variously called “the social model of disability” disabled people’s movement has been to place
in the United Kingdom, or the minority group disability on the political agenda and remove
model of disability in the United States, atten- disability from the domain of medical and
tion in this approach has shifted from the welfare professionals. Disability research, it is
impairment or illness to the context, culture, or argued, should not be about investigating
environment in which people live (Oliver how people come to terms with acquiring an
1990). Disability is defined as a form of social impairment or the experience of living with a
oppression and, in  slogan form, the claim is chronic condition; the focus instead should
that people are disabled by society, not by their be on the physical, social, and cultural barri-
bodies. ers that serve to exclude disabled people
The social model was built on the ideas of (Barnes and Mercer 2010). Disability is a
the Union of the Physically Impaired Against matter of political power and oppression.
Segregation which, in 1976, set out the main There is no doubting the power and the
elements of this approach: influence of this approach to disability, and it
has been adopted by disabled people’s organi-
In our view it is society which disables physically
impaired people. Disability is something imposed zations all over the world. Not only has it
on top of our impairments by the way we are helped these organizations identify a political
unnecessarily isolated and excluded from full par- strategy and been personally liberating for
ticipation in society. Disabled people are therefore disabled people, but it has also set the frame-
an oppressed group in society. To understand this work for national and international policies
it is necessary to grasp the distinction between the and has aided UK government policy (Prime
physical impairment and the social situation,
Minister’s Strategy Unit 2005) and European
called “disability” of people with such impair-
ment. Thus we define impairment as lacking
Union policy (European Commission of the
part of or all of a limb, or having a defective limb, European Communities 2003, 4). The social
organ or part of the body; and disability as the model is, however, not without its critics, and
disadvantage or restriction of activity caused by a there are a number of people both from

within disability studies and from outside she terms a relational understanding of disa-
who have argued that the model is not as bility. In this approach, disability is defined as
all-embracing as it might be. It is, many argue, “a form of social oppression involving the
too simplistic, and its radical rhetoric is social imposition of restrictions of activity on
perhaps better suited to the political arena people with impairments and the socially
rather than as the basis for an academic engendered undermining of their psycho-
model (Shakespeare 2006). This entry now emotional well-being” (1999, 3). In contrast to
moves on to discuss these critiques and some the strictly materialist social model of disabil-
of the recent developments that have emerged ity, Thomas does not exclude the possibility
within disability studies. that disabled people will face some restrictions
and limitations of activity that are not the
CRITIQUING THE SOCIAL MODEL result of social organization. She argued that
the original UPIAS statement did not argue
There is no doubting that disabled people are that all restrictions of activity were socially
subject to discrimination and disadvantage imposed but, importantly, it is only those that
and that these arise as the result of barriers. It are that constitute “disability.” She employs the
is, however, too simplistic to suggest that term “impairment effects” (1999, 43) to encap-
the  experiences of disabled people can be sulate restrictions which are “directly associ-
reduced solely to an analysis of these barriers ated with or ‘caused by’, having a physical,
(Shakespeare 2006). Disability is far too com- sensory or intellectual impairment” (1999, 42).
plex and multidimensional and it cuts across Also, contra the social model, she argues that
the range of political, social, and cultural impairment is important and that impairment
agendas. The social model provides but a effects combine with, and may be reinforced
small, one-dimensional analysis (Watson by, disability and that they are all interlinked.
2012). Key to these critiques has been the Any research on disability, she argues, must
neglect of impairment and how living with a engage fully both with an analysis of the social,
long-term condition impacts on people’s economic, and cultural barriers faced by disa-
lives. Disabled feminists were among the first bled people and with the effects of their
to point this out. Liz Crow, for example, impairment (1999, 137). Thomas argues that
wrote: “As individuals, most of us simply her approach enables a fuller and more com-
cannot pretend with any conviction that our plete analysis of disablement and the experi-
impairments are irrelevant because they ences of people who have an impairment.
influence every aspect of our lives. We must In developing her ideas, she has also
find a way to integrate them into our whole introduced the concept of psycho-emotional
experience and identity for the sake of our disablism, a process which she argues can
physical and emotional well-being, and, sub- arise through the actions of others with whom
sequently, for our capacity to work against disabled people have direct contact. This form
Disability” (1996, 59). Different impairments of disablism exists in addition to the material
also produce different responses from the disablism experienced within society at large
broader cultural and social milieu and the (Thomas 1999). Her model argues for a two-
experiences of people with different impair- pronged approach to the problems of disab-
ments may be different (Watson 2012). lism and for the incorporation of both the
In response to these criticisms, Carol sociostructural barriers and restrictions that
Thomas (1999) has developed a new, albeit exclude disabled people and the social pro-
still materialist, approach to disability, which cesses and practices which, by placing limits

on disabled people’s inclusion, damage the avoid the dangers inherent in the more tradi-
psycho-emotional well-being of people with tional medical sociological approaches to
impairments (Watson 2012). Thomas’s studies on the experience of living with a
approach aims to develop a model that allows disability.
an examination of what she terms “barriers to
doing and barriers to being.” Her intention is SEE ALSO: Disability and Chronic Illness;
to develop a sociology of disablism and a soci- Disability Theory; Geographies of Health
ology of impairment and impairment effects. Inequality; Informal Care; Medicalization;
Connors and Stalker (2007) have applied Patient/User Associations; Public Health
Thomas’s ideas to the study of disabled child-
hood. They concluded that her approach REFERENCES
provides a useful framework through which
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(2007, 31). In exploring how different disabled ity. Cambridge, UK: Polity.
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children experienced their different impair-
cal Disruption.” Sociology of Health & Illness 4:
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effects, they were able to show how life experi- Charlton, J. (2000) Nothing About Us Without Us:
ences for children with learning disabilities Disability Oppression and Empowerment. Berke-
compared to those with physical or sensory ley: University of California Press.
impairment. They also suggest that children Connors, C., and Stalker, K. 2007. “Children’s
face greater barriers to being than doing, and Experiences of Disability: Pointers to a Social
that these barriers may be of particular impor- Model of Childhood Disability.” Disability &
tance to young people. Society 22: 19–33.
Crow, L. 1996. “Including All Our Lives: Renew-
CONCLUSION ing the Social Model of Disability.” In Explor-
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Mercer, 55–72. Leeds: Disability Press. http://
The social model of disability has emerged
from disabled people themselves and has
played a central role in the development of a Accessed July 28, 2013.
strong and active disability rights movement. European Commission of the European Com-
It is, however, a model that is perhaps best munities. 2003. Equal Opportunities for Peo-
suited to the political as a basis for radical ple with Disabilities: A European Action Plan
rhetoric, and while its use as a tool for cam- (2004–2010).
paigning has been invaluable, the problems of summaries/employment_and_social_policy/
disability cannot be fully explained by the disability_and_old_age/c11414_en.htm.
social model alone. It is, as many have argued, Accessed July 28, 2013.
too simplistic and too reductionist in its Oliver, M. 1990. The Politics of Disablement. Bas-
ingstoke, UK: Macmillan.
approach. The social relational model of
Prime Minister’s Strategy Unit. 2005. Improving
disability proposed by Thomas has the poten-
the Life Chances of Disabled People. London:
tial to help rectify many of the social model’s Prime Minister’s Strategy Unit.
weaknesses. By incorporating an experi- Shakespeare, T. 2006. Disability Rights and Wrongs.
ential element and combining this with a London: Routledge.
focus on barriers, it offers a way to explore Thomas, C. 1999. Female Forms: Experiencing and
disability without privileging one approach Understanding Disability. Buckingham, UK:
over the other. In this way, it also helps to Open University Press.

UPIAS. 1976. Fundamental Principles of Disability. int/disabilities/world_report/2011/en/index.

Union of the Physically Impaired Against Seg- html. Accessed July 28, 2013.
pdf. Accessed July 28, 2013. FURTHER READING
Watson, N. 2012. “Theorising the Lives of Disabled
Children: How Can Disability Theory Help?” Goodley, D. 2011. Disability Studies: An Interdisci-
Children & Society 26(3): 192–202. plinary Introduction. London, Sage.
WHO. 2008. The Global Burden of Disease: 2004 Morris, J. 1991. Pride Against Prejudice. London:
Update. Geneva: World Health Organization. Women’s Press.
http:// Oliver, M., and Barnes, C. 2012. The New Poli-
den_disease/2004_report_update/en/index. tics of Disablement. Basingstoke, UK: Palgrave
html. Accessed July 28, 2013. Macmillan.
WHO. 2011a. Disability and Health. Fact Sheet Thomas, C. 2007. Sociologies of Disability and Illness.
No. 352. Geneva: World Health Organization. Contested Ideas in Disability Studies and Medical Sociology. Basingstoke, UK: Palgrave Macmillan.
fs352/en/. Accessed July 28, 2013. Watson, N., Roulstone, A., and Thomas, C.
WHO. 2011b. World Report on Disability. Geneva: 2012. Handbook of Disability Studies. London:
World Health Organization. http://www.who. Routledge.
Health Care Delivery Health care systems vary across countries
in response to a wide array of forces, includ-
System: Singapore ing political ideology and level of socio-
economic development, but there are some
Duke-NUS Graduate Medical School, Singapore interesting similarities and differences. Zee,
Boerma, and Kroneman (2004) and Stevens
This entry presents and discusses the and Zee (2008) classified health care arrange-
distinguishing features of Singapore’s health ments in contemporary society worldwide
care system: the island republic’s distinctive into four main health system models: the free
pragmatic approach balancing the principles of market model, the social insurance model,
universal access, public sector scrutiny, and the national health system model, and the
private sector development. The analysis is based socialist model. Each model is based on a
on relevant figures on inputs and outcomes from different definition of health care. Health care
Singapore discussed in a comparative fashion was defined as a “state provided public ser-
vis-à-vis five countries that illustrate three main vice” in the socialist model; as “a guaranteed
health care system models: the United Kingdom state-supported consumer service” in the
and New Zealand representing the national national health service model; as “a guaran-
health service; Germany and Japan representing teed insurance good” in the social security
the social security model; and the United States model; and as “a commodity” in the free mar-
illustrating the free market model. ket model. Accordingly, as Stevens and Zee
point out, the role of the government varies in
each model: in the socialist model, the state
INTERNATIONAL VARIATION IN plays a “very strong” role since it owns the
HEALTH CARE MODELS infrastructure and pays “providers directly.”
In the national health service model, the role
Two important, practical, and related sets of of the government is “strong,” as it “controls
issues in the analysis of health care delivery and finances facilities”; in the social security
systems in any country are the organization model, the state plays an “intermediate” role
and capability of the country’s health care by regulating the system; and in the free mar-
delivery system and the financial arrange- ket model, the role of the government is com-
ments available to health care users, including paratively “weak,” as it oversees only some
the main financial obstacles they experience. specific population groups while allowing
These questions and the overall analysis of providers to be “private entrepreneurs”
health care systems have been addressed by a (Stevens and Zee 2008, 253). A few countries
wealth of social science studies, particularly illustrate best each of the four models. The
sociology and economics, with some of the former Soviet Union, China under Maoist
main aspects of health systems identified in rule, and Cuba under Castro are all countries
the 1970s (see, e.g., Babson 1972; Anderson that exemplify the old socialist model which
1973; Kosa and Zola 1975; Quah 1977) and Stevens and Zee consider now defunct. The
examined with sustained interest ever since. national health service model is established

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

in the United Kingdom, Australia, New countries, as is Singapore’s score (5.48) and
Zealand, Canada, and Norway, among others; rank (3) in the Global Competitiveness Index
the social security model is followed in (see Table 1). Demographically, Singapore has
Germany, Japan, the Netherlands, France, the lowest proportion (15 percent) of people
and Belgium; and the free market model is over 60 years of age and, as a global city, 100
dominant in the United States, South Africa, percent of its population are city dwellers.
and Switzerland (Stevens and Zee 2008). Compared to the lead countries represent-
Framing the analysis of the Singapore ing the current three health system models
health care delivery system in the wider con- (see Table 1), Singapore rates very favorably
text of the four models outlined above helps in terms of inputs and outputs of its health
us to identify its distinctiveness. Table 1 pre- care system. Proportionally, the size of
sents the most common performance indica- Singapore’s health services is smaller than
tors for countries representing each of the that of the other five countries: it has fewer
three main models and Singapore. The physicians, dentists, nurses, and pharmacists
uniqueness of Singapore comes across in per 10,000 population than all the other
many ways. Singapore is a small island of only countries except Japan. Singapore’s per capita
712.4 square kilometers, geographically government expenditure on health is the low-
located between Malaysia and Indonesia. In est: $625 in contrast to $3,426 in the United
2010, the population reached 5 million of States, $2,927 in Germany, $2,662 in the
whom 3.2 million are Singapore citizens. The United Kingdom, $2,268 in Japan, and $2,130
population density is 7,126 persons per in New Zealand. Yet, in terms of disease
square kilometer. The resident population burden, Singapore presents very positive out-
comprises three main ethnic groups: Chinese comes, with the exception of some tropical
(74.2 percent), Malays (13.4 percent), and infectious diseases common in the countries
Indians (9.1 percent) (DOS 2011b) and there within the equatorial region. Singapore’s
are four official languages: Mandarin, Malay, infant mortality rate is as low as Japan’s; its
Tamil, and English. Singapore is a global city adult mortality rate per 1,000 population is the
and has been governed as an independent lowest; and life expectancy at birth is second
republic based on the British model of parlia- only to Japan’s. How has Singapore accom-
mentary democracy since it gained inde- plished this? The answer may be found in two
pendence from the United Kingdom on aspects of governance: the organizational struc-
August 9, 1965. Besides retaining the parlia- ture and the financing of the health care system.
mentary political system after independence, In Singapore, both aspects are guided by the
Singapore also chose to maintain the British operational tenet of continuous upgrading and
judicial and civil service systems established the dual principle of individual responsibility
when it was part of the British colonial and government support (MOH 2011a). Let
empire. Over the years, these institutions us look into each of these aspects in more detail.
(political, judicial, and administrative) have
been fine-tuned and improved upon, and
new institutions have been created in tandem ORGANIZATIONAL STRUCTURE OF
with the rapid pace of the country’s socio- HEALTH SERVICE PROVISION
economic development.
Figures for 2009 show that Singapore’s The health services system in Singapore
gross domestic product per capita ($49,780 encompasses 29 acute and extended care
in  PPP dollars) is the highest of the six hospitals, 15 of which are in the private sector
Table 1 Singapore in the context of health care system models

Indicators Free market Social insurance National health service model Singapore
model model

United States Germany Japan United Kingdom New Zealand

Socioeconomic and demographic features, 2009

Gross national income per capita1 $45,640 $36,780 $33,470 $37,230 $27,870 $49,780
Aged over 60 (%)2 18 26 30 22 18 15
Living in urban areas (%)3 79 74 67 90 87 100
Global Competitiveness Score (6 highest)4 5.43 5.39 5.37 5.25 4.92 5.48
Global Competitiveness Rank (1 highest)5 4 5 6 12 23 3
Health expenditure
Total expenditure on health as % of GDP6 2000 13.4 10.3 7.7 7.0 7.7 2.8
2008 15.2 10.5 8.3 8.7 9.7 3.3
General government expenditure on health as % 2000 43.2 79.8 81.3 79.3 78.0 44.9
of total health expenditure7 2008 47.8 74.6 80.5 82.6 80.2 34.1
Per capita government health expenditure8 2000 $2,032 $2,128 $1,600 $1,453 $1,257 $421
2008 $3,426 $2,927 $2,268 $2,662 $2,130 $625
Population health, 2008, 2009
Infant mortality rate per 1000 population9 7 3 2 5 4 2
Maternal mortality rate per 100,000 live births10 24 7 6 12 14 9
Adult mortality rate per 1000 population11 106 76 64 77 72 59
Life expectancy at birth (in years)12 79 80 83 80 81 82
Age-standardized mortality rates by cause, per 100,000
Communicable 34 21 40 36 15 66
Non-communicable 418 394 273 401 369 313
Injuries 53 25 36 25 37 21
Distribution of years of life lost (%)13
Communicable 9 5 9 8 5 11
Non-communicable 72 87 77 83 77 78
Injuries 19 8 15 9 18 11

Table 1 (Cont’d)

Indicators Free market Social insurance National health service model Singapore
model model

United States Germany Japan United Kingdom New Zealand

Health Services, 2000–2010

Physicians per 10,000 population14 26.7 35.3 20.6 27.4 23.8 18.3
Nurses and midwives per 10,000 population 15 98.2 108.2 41.1 103.0 108.7 59.0
Dentists per 10,000 population16 16.3 7.7 7.4 5.2 4.6 3.2
Pharmacists per 10,000 population17 8.8 6.0 13.6 6.6 7.1 3.7
Hospital beds per 10,000 population18 31.0 82.0 138.0 34.0 62.0 31.0

WHO (2011). Gross national income per capita in PPP international dollars, 2009.
WHO (2011). % of population aged 60 and older, 2009.
WHO (2011). % of population living in cities, 2009.
World Economic Forum (2011). Competitiveness is defined as “the set of institutions, policies, and factors that determine the level of productivity of a
country” (2011, 4). The scores of the competitiveness index range from 1 (lowest) to 6 (highest).
World Economic Forum (2011). Global competitiveness ranks vary from 1 (highest) to 139 (lowest).
WHO (2011). Total expenditure on health as % of gross domestic product. Total expenditure has two components: government expenditure and private
WHO (2011). General government expenditure on health as % of total expenditure on health.
WHO (2011) Per capita government expenditure on health (PPP international $).
WHO (2011). Infant mortality rate as probability of dying by age 1, per 1000 live births, 2009.
WHO (2011). Maternal mortality ratio per 100,000 live births, 2008.
WHO (2011). Adult mortality rate as probability of dying between 15 and 60 years, per 1000 population; both sexes, 2009.
WHO (2011). Life expectancy at birth in years, for both sexes, 2009.
WHO (2011).
WHO (2011). Biomedical physicians per 10,000 population for the period 2000–10.
WHO (2011). Nursing and midwifery personnel per 10,000 population for the period 2000–10.
WHO (2011). Dentistry personnel per 10,000 population for the period 2000–10.
WHO (2011). Pharmaceutical personnel per 10,000 population for the period 2000–10.
WHO (2011). Hospital beds per 10,000 population for the period 2000–9.

(DOS 2011a); private sector specialist and in 2009 – work in public sector health care
general practitioner – lately labeled family services (DOS 2011a; MOH 2011c).
medicine – outpatient clinics; 18 public sector The private sector of health care includes
polyclinics and 10 specialty centers dedicated the services of traditional Chinese medicine
to research and health care provision on can- (TCM) practitioners. Culturally and histori-
cer, heart disease, neuroscience, skin diseases, cally, TCM has deep roots in Singapore (Quah
eye health, and dental care (MOH 2011a). In 2003), but the incorporation of TCM practi-
2009, 81.4 percent of all hospital beds were tioners into the formal health care system in
provided by public sector hospitals and 18.6 Singapore started only in November 2000,
percent by private sector hospitals. In addi- when the Traditional Chinese Medicine
tion to acute and extended care hospitals, Practitioners Act was passed by the Singapore
patients whose condition is stabilized but Parliament, mandating the registration of
still require continuous medical care are TCM practitioners, the formulation of an offi-
attended to by a network of intermediate cial code of ethics to regulate their professional
and long-term care, or ILTC, comprising conduct, and the accreditation of TCM
“community hospitals, nursing homes, schools. By the end of 2010, there were 2323
chronic sick units, hospices, day rehabilita- registered TCM practitioners – approximately
tion centres, home medical and home 6 per 10,000 resident population. Although no
nursing services.” Most ILTC services are comprehensive figures are available, one
offered by voluntary welfare organizations observer estimated that about 12 percent of all
receiving government subsidies, although patient consultations in 2007 were to TCM
a  few are run by for-profit operators (MOH practitioners (Callick 2008).
2010, 5). A less tangible but important dimension of
The public sector health services are divided health care provision is patient outcomes,
into five clusters: National Health Group comprising patients’ understanding and recall-
(NHG), SingHealth, National University ing of information, their compliance, and their
Hospital (NUH), Alexandra Hospital Pte Ltd, satisfaction. Patients’ satisfaction refers to their
and Jurong Health. The two largest clusters are perception of the quality of services, including,
NHG and SingHealth, each comprising three among other aspects, communication with
major hospitals and nine polyclinics, in addi- doctors and nurses, effectiveness of treatment,
tion to several medical institutes and specialist information received, and courtesy (Heritage
centers. One characteristic feature that sets and Maynard, 2006; Bridges, Loukanova,
Singapore apart from other countries is that and Carrera 2008; Cockerham 2010). In an
while these clusters comprise non-profit pub- evaluation of a new observation unit at the
lic sector hospitals and primary health care emergency department of one of the largest
facilities, they are nevertheless “run as private hospitals, six out of every ten discharged
companies” (Callick 2008), expected to com- patients answering a self-administered ques-
pete with each other in quality of care, effi- tionnaire were satisfied with health services,
ciency, and productivity. but researchers found evidence of the negative
The overall health care services provision consequences of the increased recruitment of
is shared by the public and private sectors. foreign doctors and nurses: four out of every
The public sector provides 76 percent of acute ten patients were dissatisfied with the way
hospital beds and 100 percent of the specialty explanations were given to them by foreign
hospital beds. About one of every two medical health personnel because of the language
doctors – 47.6 percent in 1999 and 55.4 percent barrier (Ng et al. 2011, 3). An increasing

number of foreign doctors coming from endowment fund that works as a “financial
Western and Asian countries are now learning safety net” to help “subsidised patients who
Mandarin and Malay to improve communica- need financial assistance to pay their medi-
tion with older patients who prefer to speak in cal bills” (MOH, 2010, 23). In 2009, a new
their mother tongue; foreign doctors com- scheme, the Primary Care Partnership
prise around 20 percent of biomedical physi- Scheme or PCPS, was introduced to further
cians practicing in Singapore (Khalik 2011). extend the health care safety net for needy
elderly and disabled Singaporeans. The
PCPS offers subsidized basic primary care at
FINANCIAL FRAMEWORK private sector general practitioners’ clinics
and private dental clinics. General practi-
Health care cost is the uppermost concern of tioners and dentists in the private sector who
users, providers, and policymakers in most wish to participate get their clinics registered
countries. Singapore’s health care financial in the PCPS to work in partnership with the
framework is officially defined as a system Ministry of Health to provide common out-
offering “universal healthcare coverage to our patient care in addition to treatment for eight
citizens, with a financing system anchored on chronic diseases: diabetes mellitus, hyper-
the twin philosophies of individual responsi- tension, lipid disorders, stroke, asthma,
bility and affordable healthcare for all” COPD, schizophrenia, and major depres-
(MOH 2011b) carried out through four health sion. Singaporeans aged 65 and older and
financing schemes: Medisave, MediShield, Singaporeans of any age who are disabled
ElderShield, and Medifund. Medisave is the can use the PCPS if their per capita monthly
health care component of the social security household income is below S$800 (about
savings plan called the Central Provident Fund US$630). The PCPS is also open to all desti-
(CPF), whereby the employee contributes tute persons receiving Public Assistance, a
20 percent among other aspects and the means-tested scheme. Patients meeting the
employer 15.5 percent among other aspects, PCPS requirements apply for a PCPS card
monthly (CPF 2011). The Medisave account that entitles them to subsidized fees when
can be used for hospitalization expenses and attending a PCPS private clinic in their
approved medical insurance plans such as neighborhood; after the subsidy is deducted,
MediShield and ElderShield. MediShield is for the remaining amount is paid by the patient.
prolonged or serious illnesses; ElderShield is a
low-cost severe disability insurance scheme for
long-term care that automatically covers all CONCLUSION
CPF members when they reach the age of 40,
unless they opt out. WHO’s analysis of the efforts made since the
The principle of individual responsibility is 1980s to provide affordable health care and
implemented in two main ways: by actively the lessons “on the failings of direct payments
promoting illness prevention and a healthy life- such as user fees in financing health systems”
style and by the requirement of co-payments led its experts to conclude that “the answer is
for Medisave, MediShield, and ElderShield to move towards a system of prepayment and
(MOH 2011b). Indigent or low-income pooling, sharing the financial risks of ill
Singaporeans who cannot afford the co-payment health  across the largest population group
required for Medisave and MediShield may possible.” They recommend that “countries
use Medifund, a government-instituted can accelerate progress towards universal

coverage by reducing reliance on direct private sector development. The Singapore

payments.” This requires introducing or approach is to balance state control and flex-
“strengthening forms of prepayment and ibility to ensure universal coverage, to
pooling” within a framework of universal encourage the participation of private sector
coverage, instead of reliance on direct providers, and to continuously expand and
payments (WHO 2010, 40, 52–3). In the improve consumer choices. This approach
search for the best healthcare finance system, began as a seed of an idea after the creation of
countries are advised to follow a prudent the republic and has been evolving and
principle: “policy-makers must remember adjusting to national socioeconomic condi-
that health financing systems that are tions and growth ever since. Thus, the
perceived to be fair [by the population] have Singapore health care system does not fit
the best chance at long-term sustainability” comfortably into any of the three main mod-
(WHO 2010, 50); and irrespective of the els: the free market model, the social insur-
universal system put in place, policymakers ance model, or the national  health service
must remember that “there will always be model. Although it defies standard classifica-
needy people for whom health care really tion, the Singapore health care system has
must be free” (WHO 2010, 53). The long-term received positive international attention
goals for affordable health care set by WHO along the way, typically as a model to be emu-
(2010, 53) are: “To lower the level of direct lated by other countries (Purcal 1989; Lyon,
payments to below 15–20% of total health 1992; Barraclough and Morrow 1995; Liu
expenditure and to increase the proportion of et al. 2009).
combined government and compulsory insur-
ance expenditure in GDP to about 5–6%.” SEE ALSO: British National Health Service;
Naturally, cost is only one of the barriers to Health Care Delivery System: Germany;
healthcare access. The WHO (2010, 51–2) Health Care Delivery System: Japan; Health
recognizes other significant impediments Care Delivery System: United States
such as transportation, as well as quantitative
and qualitative availability of services.
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Alienation concerns as adequate nutrition, shelter, and
warmth, and social needs that relate to par-
CHRIS YUILL ticipating in the relative norms and cultures
Robert Gordon University, UK of a given society.
Marx also identifies something distinctive
Alienation in its most general sense speaks to and special about human labor. When
the subjective state of mental and physical humans work on the environment around
suffering that emerges from certain forms of them in order to meet their natural and social
society and relationships between people. needs they not only change the environment
Mainly associated with Karl Marx (1818–83), but they also change themselves. This self-
the concept of alienation does, however, pos- transformation occurs because, as humans
sess a long and diverse history before Marx use their creative powers to develop new
began to develop his theory of alienation in solutions to meet their needs, they create new
the 1840s. Alienation has also appeared, for possibilities and potentials of what humans as
example, in various forms in fields such as a species can achieve and do. They are not
religion, philosophy, the arts, and literature, bound – as non-human animals broadly
as well as in sociology. But Marx developed speaking are – to repeat the same patterns of
the concept into a more detailed and specific behaviors, but can instead continually change
theory that not only captured the alienated how they are in the world by creating new
and damaged emotional and physical states of social forms and different types of society,
suffering experienced by individual people, which they have done throughout history.
but additionally drew attention to the under- Another important element of Marx’s
lying social causes of those states. Doing so understanding of what is to be human states
adds sociological depth to the concept of that people are essentially social. It is by coop-
alienation, as other versions of the concept erating together, sharing ideas, memories,
tend to focus on the subjective and psycho- and resources that humans have been able to
logical experiences of alienation and say very create the solutions to meet their needs and to
little about the objective causes of that subjec- create all the innovations that make them
tive state of alienation. distinctive from other species. Being a social
Marx’s understanding of what it is to be animal also allows humans to develop complex
human provides the basis and starting point interactions with other humans, through
for his theory of alienation. He begins with which a sense of both individual self-identity
the position that all humans, and not just a and group identity can be formed.
select few, are essentially creative beings. As Certain types of society, however, have
such, humans possess the abilities and capaci- developed over time that do not always allow
ties to actively and purposefully transform for the free exercise of that ability to creatively
through their labor the world and environ- labor as humans engage in their work.
ment around them. This labor is necessary in Contemporary capitalist society is an instance
order to meet a range of needs. These partic- of such a society. The various power relation-
ular needs are natural needs that include such ships and social structures which it comprises

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

distort or invert that essential human ability corrode and people perceive others as
to engage in creative labor, and it is this sti- rivals or as problems. Instead of cooperating
fling of a fundamental human ability that with other humans, competition and
results in alienation. It is in the workplace hostility become the ways by which peo-
that alienation is primarily encountered, ple relate to each other.
with work becoming dull, repetitive, and 4 Human nature alienation: where humans
stressful instead of liberating and reward- are separated from their innate abilities to
ing. It is useful to highlight that Marx did find solutions to the problems affecting
not hold to a fixed idea of what constitutes the lives of other humans.
labor and work. The actual form that labor
takes as an activity changes constantly over Despite the theory’s potential in offering
time and does not necessarily refer only to explanations of how and why health can be
workers in traditional heavy industries or influenced by social structures acting against
factory work. Modern forms of “immate- basic human abilities, it has been underused
rial” labor – such as working in the services in the sociology of health (Yuill 2005). This
industries, call centers, or with computers – situation is especially noteworthy given
are jobs where certain emotional displays recent trends in medical sociology, which
(for example, being friendly and caring, have seen a growing interest in the body,
smiling and attentive) all count as work. emotions, and suffering, as well as the increas-
Hochschild’s (1983) classic study of airline ing focus in the effects of social inequalities
stewardesses is a useful example of the latter and health. These areas offer fertile terrain for
form of work. In her research, the steward- a theory that brings together an understand-
esses reported that their emotions and ing of objective social structures with subjec-
smiles were what they produced in the tive emotional and physical states. The very
course of their everyday work. Marx also few exceptions include, for example, research
notes that alienation can spill out beyond by Coburn (1979), who identified that work-
the workplace into wider society, affecting place alienation, where workers lacked con-
people in quite profound ways, as can be trol over both what they produced and the
seen in the four examples below: circumstances in which they produced, was a
factor behind the poor well-being of a sample
1 Product alienation: loss or lack of control of Canadian workers. It is easy to speculate
in the workplace over what is produced. how alienation theory could inform an
Very few people in contemporary capital- understanding of stress and poor health in
ist societies control the actual product of the workplace that goes beyond the surface
their labor and this can include not just level of the psychology of individuals and
physical objects but also emotional dis- opens insights into the deeper social and his-
plays that are required as part of a day’s or torical causal mechanisms. The vast output of
night’s work. research from the Whitehall I and Whitehall
2 Process alienation: loss or lack of control II studies in England found that working
in the workplace over how the act of labor experiences defined by low control and high
is organized. This lack of control can refer work-rates are bad for the health and could
to rate of work, intensity of work, or how be seen as forms of product and process
the actual workplace itself is organized. alienation (Siegrist and Marmot 2006).
3 Fellow human being alienation: where Alienation theory may also be able to articu-
social bonds between people begin to late the negative health effects of living in

societies marked by high inequality, where REFERENCES

people are distanced from each other by the Coburn, D. 1979. “Job Alienation and Well-Being.”
increasing disorganization of society created International Journal of Health Services 9(1): 41–59.
by the similarly increasing amounts of power Hochschild, A. 1983. The Managed Heart: The
concentrated into the small executive capital- Commercialization of Human Feeling. Berkeley:
ist elite. Wilkinson and Pickett’s (2010) University of California Press.
research, for example, could be interpreted as Siegrist, J., and Marmot, M., eds. 2006. Social
giving an example of an alienated society Inequalities in Health: New Evidence and Policy
where people appear more likely to turn Implications. Oxford: Oxford University Press.
against each other as income inequalities Wilkinson, R., and Pickett, K. 2010. The Spirit
Level: Why Equality Is Better for Everyone.
London: Penguin.
Alienation, though a greatly underused
Yuill, C. 2005. “Marx: Capitalism, Alienation and
theory in the sociology of health, offers Health.” Social Theory and Health 3: 126–143.
great potential for articulating the causes
and experiences of a wide range of complex
emotional and health problems that are the FURTHER READING
cause of suffering and distress in contem- Marx, K. 2000. Early Writings. London: Penguin.
porary society. Ollman, B. 1977. Alienation: Marx’s Conception of
Man in Capitalist Society. Cambridge: Cambridge
SEE ALSO: Emotions, Sociology of; Health University Press.
and Marxism; Mental Health; Socioeconomic Yuill, C. 2011. “Forgetting and Remembering
Status and Health; Stress and Work; Whitehall Alienation Theory.” The History of Human Sci-
Studies ences 24(2): 103–119.
Healing and Gender Roles (Mathers et al. 2000, 17). The multiple pre-
dictors of differential morbidity of men and
Duke-NUS Graduate Medical School, Singapore women, including socioeconomic and cul-
tural factors, are well documented by, for
example, Annandale (2010) and Quah (2011).
INTRODUCTION Differential gender morbidity provides a suit-
able background for this discussion of gender
The discussion of gender roles is often and healing. The substantive aspects of gen-
focused on the roles of women irrespective of der differences in healing are best understood
the area of social behavior, whether it is poli- in terms of the social setting where they
tics, war, the economy, religion, health, fam- evolve: informal and formal settings.
ily, or any other. Differing from that trend,
this discussion on healing scrutinizes the
roles of both men and women and their dif- HEALING AND GENDER
ferences. In the realm of health, the centrality IN INFORMAL SETTINGS
of the concern about women sprang histori-
cally from social science studies on the impact Much needs to be explored on the link
of illness on people’s lives: early data on com- between gender and healing, but, so far, the
munity health – and current data from eco- most researched aspect has been the role of
nomically disadvantaged communities and women as healers at home (Nathason
countries – suggest that, in contrast to men, 1975). The domestic aspect of gender and
gender status is a social disadvantage for health may be summarized thus: women
women. Referring to the abundant literature are more likely than men to perform the
and data documenting a wide range of dis- role of informal healers at home. Using
parities between men and women – from per- their social patterns hypothesis, David
sonal income to life expectancy – Lois M. Mechanic and Edward Suchman proposed
Verbrugge (1985) found that significant mor- that women may have “more interest in and
bidity differences between men and women knowledge of health” compared to men
in the United States increased among adults (Mechanic 1978, 188). This assumption is
aged between 17 and 44 and diminished with based on role theory. Since the 1980s, the
age; and that while morbidity was higher for research literature on this assumption has
women, it typically involved non-serious been limited compared to that of studies on
conditions, whereas men were more likely to gender and health, and has produced
be affected by life-threatening diseases. As inconclusive results. Nevertheless, research
she put it: “one sex is ‘sicker’ in the short run on gender differences in healing roles
and the other in the long run” (1985, 162–3). continues to provide interesting findings.
Inadequate access to health care is normally Gender differences in healing roles are bet-
mentioned as one of the reasons that make ter understood from the perspective of health-
gender – being a woman – a “social disadvan- related behavior. Just as in the case of gender
tage” for women in low-income countries and disease burden mentioned above (Quah

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

2011), a very likely predictor of women’s of the “nurturing role” learned by girls
enactment of the healing role at home is the through child socialization (Quah 1990),
nature, stage, and seriousness of the disease in but the content of child socialization changes
question. We know that gender differences in across generations (Read and Gorman 2010;
health-related behavior tend to diminish or McLean, Sweeting, and Hunt 2010). Thus,
disappear for serious and life-threatening dis- the difference between men and women in
eases (see, e.g., Mechanic 1978; Read and health-related behavior and attitudes due to
Gorman, 2010). This means that at the differential role sets and role socialization is
domestic level, involving personal attitudes expected to change over time, although the
and actions, the weakening of gender differ- pace of sociocultural change differs across
ences occurs primarily in the realm of the sick countries. In Asian homes, for example, tra-
role – that is, the actions taken by a person diag- ditional values on gender roles are changing
nosed with a disease for the purpose of recover- slowly, but the traditional gender division of
ing (see a detailed explanation in Quah 2010). labor at home can still be observed. Compared
Men and women affected by a life-threatening to men, wives, mothers, or other female
disease tend to display similar sick-role behavior members of the family are more inclined to
(which comprises help-seeking, treatment com- take charge of informal healing and care –
pliance, and use of health services, among other and often formal care if a family member suf-
aspects). But gender differences appear to influ- fers from an incapacitating illness (Quah
ence the two previous stages of the illness trajec- 1990; Anson and Sun 2002; Asai and Kameoka
tory: preventive health behavior as indicated 2005; Chun et al. 2008; Chiu et al. 2010; Kim
earlier, and illness behavior. and Ruger 2010). This trend is observed in
This distinction of three types of health- non-Asian societies as well (Harmon and
related behavior along the illness trajectory Perry 2011; Thornton and Hopp 2011).
(preventive health behavior, illness behavior,
and sick-role behavior) provides a useful
framework for the analysis of gender differ- HEALING AND GENDER
ences in healing roles. Women as spouses IN FORMAL SETTINGS
and/or mothers tend to play an important
role – positive or negative but seldom neu- Abundant evidence, from archaeological evi-
tral – in their families’ disease prevention dence to contemporary studies, on the role of
(preventive health behavior) through deci- women as childbirth attendants or midwives
sions on nutrition, meal preparation and suggests that the personal involvement of
purchase, and leisure activities. Women’s women in gestation and childbirth has been
intervention on illness behavior takes place extended to the attribution of the healing role
as wives and mothers pay attention to symp- to women across cultures and time. Two of
toms of illness in their children and others at the popular illustrations of this stereotype
home, seek relevant health information to come from the US press’s highlighting of
understand the observed symptoms, use Marie Curie in the 1920s, not as a scientist
herbal and other traditional remedies to but as a mother and healer (see Owens 2011)
manage minor symptoms at home, and and the iconic image of Florence Nightingale
make decisions on the use of medical ser- as the quintessential healer (Hegge 2011). In
vices (Quah 1990). This inclination of the twenty-first century, this trend is observed
women to look after their family’s health is informally within the family and formally
commonly interpreted as the manifestation in  the predominance of female traditional

healers as herbalists and midwives in rural observers appear to agree with the view well
areas and immigrant communities in devel- expressed by Amering, Schrank, and Sibitz,
oped and developing countries (Epp 2007; that “women are still underrepresented in
Popper-Giveon and Al-Krenawi 2010; leadership positions [in the profession] and in
Goswami, Dash, and Dash 2011). academic medicine,” and suggest, as possible
Studies of traditional healers suggest a reasons worth exploring, women’s “desire for a
wide variety of styles and types of work better work/life balance and developments
among female healers, but no definitive concerning part-time careers” (2011, 946,
trends, mainly because of the differences in 951). A similar trend was found in a study of a
methodological approaches and the impossi- representative sample of medical residents in
bility of drawing representative and comparative Japan, in which family was selected as “the
samples of traditional healers. Nevertheless, most important thing in life” by 70 percent of
two features can be cautiously discerned from the female physicians interviewed compared
published research. The first tentative feature to 54 percent of their male counterparts
is the area of “specialization”: while male tra- (Nomura, Yano, and Fukui 2010).
ditional healers work as bone setters, herbal- Both possible predictors – work/life balance
ists, spirit mediums, and several other modes and part-time careers – are a sex-role manifes-
of healing, female traditional healers tend to tation: the prevailing social expectation of
be herbalists, and evolve their knowledge of heal- women’s family roles as wife and mother tak-
ing herbs and foods from their own direct ing precedence over other roles women may
experience with food ingredients and prepa- wish to take on, including a medical career or,
ration methods, in addition to their work as if in medicine, a specialty that requires long
childbirth attendants. This role combination years of training. Women doctors are likely to
is well documented by Pieroni and Gray (2008) postpone childbearing until they complete
and Voeck (2007). The second tentative their specialization training; similarly, their
feature distinguishing female healers from choice of specialization area tends to be influ-
their male counterparts is that the practice of enced by the length of training as well as by the
healing as an occupation is a more effective nature of the field (Elta 2011). For example,
vehicle of social mobility for female traditional figures on specialty fields of active physicians
healers, particularly in communities where from the American Medical Association show
women occupy a subordinate position vis- pediatrics as being the area with the largest
à-vis men (Popper-Giveon and Al-Krenawi proportion of female specialists – over 55
2010). percent – in contrast to thoracic surgery, ortho-
It appears that the gender situation among pedic surgery, and urology with fewer than 5
practitioners in the biomedical healing sys- per cent (Elta 2011, 442).
tem differs from that in traditional healing Two notable exceptions to this trend of
systems. In contrast to the feminine image of underrepresentation of women in the medi-
traditional healers and birth attendants, cal profession are the former Soviet Union
historically the biomedical profession has a and Israel. The Soviet Union’s manpower
male image worldwide. planning in the 1950s led to a situation
There is an upward trend in the number of whereby about 77 percent of all physicians
female biomedical physicians in developed were women (Bernstein and Shuval 1999).
countries (Amering, Schrank, and Sibitz, This had a spill-over effect in Israel, which
2011; Elta, 2011) including Japan (Koike et al. was the destination country for a large num-
2009; Nomura, Yano, and Fukui 2010). Yet, ber of immigrant physicians, mostly women,

from the former Soviet Union in the early evidence-based studies, but deserve closer
1990s. Bernstein and Shuval (1999, 2) report scrutiny in future research.
that during the period 1989–95, more than
600,000 immigrants arrived in Israel from the SEE ALSO: Caregiving and Gender Roles;
former Soviet Union, including more than Childbirth Practices; Health and Culture;
13,000 physicians. Health, Education, and Gender


Studies on gender as a predictor of enacting Amering, M., Schrank, B., and Sibitz, I. 2011. “The
the healer role are scarce compared to research Gender Gap in High-Impact Psychiatry Jour-
interest in other areas of health and illness. nals.” Academic Medicine 86(8): 946–952.
This review of the current literature presents Annandale, E. 2010. “Health Status and Gender.”
In The New Blackwell Companion to Medical
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Sociology, edited by William C. Cockerham,
the informal context of family and home, and
97–112. Oxford, UK: Wiley-Blackwell.
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income-earning activity and requires training. in Rural China – Hubei.” Social Science & Medi-
The formal context, in turn, takes two forms cine 55(6): 1039–1054.
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medicine and traditional healing systems. ence of Sekentei on Family Caregiving and
In the informal setting comprising the Underutilization of Social Services among Japa-
realm of home and kin, research findings sug- nese Caregivers.” Social Work 50(2): 111–118.
gest that women in most cultures tend to Bernstein, J. H., and Shuval, J. T. 1999. “The Occupa-
adopt the role of healers in their own families tional Integration of Former Soviet Physicians in
Israel.” Social Science & Medicine 47(6): 809–819.
as an integral part of being mothers and wives,
Chiu, Y. W., Huang, C. T., Yin, S. M., Huang, Y. C.,
but also as “proxy” caregiver daughters or
Chien, C. H., and Chuang, H. Y. 2010. “Deter-
grandmothers. The allocation of this family minants of Complicated Grief in Caregivers
role to female members of the family is based Who Cared for Terminal Cancer Patients.” Sup-
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monly attributed to women in contrast to the Chun, H., Khan, Y. H., Kim, I. H., and Cho, S.
assumed absence of such instincts among I. 2008. “Exploring Gender Differences in Ill
men. In the formal setting, the relatively scarce Health in South Korea.” Social Science & Medi-
research evidence on the importance of a cine 67(6): 988–1001.
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Epp, M. 2007. “Midwife-Healers in Canadian
physicians are underrepresented in the bio-
Mennonite Immigrant Community: Women
medical profession and, according to some
Who Make Things Right.” Histoire Sociale/
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24(2): 152–162. therapy Research 22: 889–901.
Kim, H. J., and Ruger, J. P. 2010. “Socioeconomic Popper-Giveon, A., and Al-Krenawi, A. 2010.
Disparities in Behavioural Risk Factors and “Women as Healers, Women as Clients: The
Health Outcomes by Gender in the Republic of Encounter between Traditional Arab Women
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Rationalization education. In sociology, all three positions have
found supporters, as exemplified by the divide
STELLA R. QUAH on social research methodologies and the criti-
Duke-NUS Graduate Medical School, Singapore cal conceptual debate on what motivates social
action. Parsons and other sociologists have
Rationalization, also referred to as rationality, postulated that social action is typically
has multiple meanings, ranging from the motivated by “non-rational commitments.”
colloquial sense of justifying one’s actions However, rational choice theory proposes that
based on reason rather than emotion, to the the main motive of action is profit, so that peo-
application of the principles of scientific ple choose actions that they calculate will pro-
management, to evidence-based explanation duce the best outcome, although the action
in science. This discussion will focus on the once implemented may give unexpected or
latter two. Rationality in science is contested, unintended outcomes (Voss and Abraham
and three general positions may be identified 2000). Indeed, the ethics perspective proposes
in the long-standing and ongoing debate. At that “a person’s plan for life is rational if … [1] it
one extreme of the range of opinions is the is … consistent with the principles of rational
“relativist” position, which argues that there choice … and [2] it is … chosen by him with
is no valid scientific method or rules at all. full deliberative rationality, that is, with full
The opposite position is held by the “logical awareness of the relevant facts and after a care-
empiricists,” who assert the validity of “at ful consideration of the consequences” (Rawls
least some universal and fixed criteria for 1999, 358–9).
theory choice” and propose that “these crite- The concept of profit in rational choice
ria guarantee the rationality of science.” The theory and Rawls’s ethical perspective of
intermediate position is held by the “natural- rationality face a seemingly unsolvable
ists” who argue that “theory evaluation can be impediment: acting based on profit or delib-
rational even though there are no absolute erative rationality is seldom possible because
rules for science applicable in every situation” the social actor typically has to “calculate” or
(Shrader-Frechette 1991, 7–8). estimate profit and consequences based on
The three positions are found among incomplete, uncertain, or non-empirical
researchers from different disciplines studying information. Basically, to calculate the best
health and illness, as well as among decision- outcome and take rational action, the person
makers involved in the formulation, imple- needs to have information on the relevant
mentation, and evaluation of health policy and facts and possible consequences. However,
risk assessment. The logical empiricist posi- those prerequisites are difficult to meet.
tion  is prevalent in modern biomedicine Enter the concept of trust in health care: in
through its  emphasis on science, evidence- the absence of direct information, the person
based medical research, evidence-based clini- needs to rely on the expertise of others. This
cal practice, and   vidence-based medical is the case of a sick person seeking medical

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

help or, collectively, a community facing a the concern with effectiveness. The pursuit of
disease threat: they would depend on medi- effectiveness has propelled the design, man-
cal expertise and the assumed expertise of agement, and reorganization of health care
the health authorities. Trust is best observed services in many countries. Rationality aspects
in aspects  such as the doctor–patient rela- such as increase in productivity, minimization
tionship (Cook et al. 2004) and citizens’ of financial costs, optimization of resources,
acceptance of health policies and regulations and “outcome targets” dominate health ser-
(Dirks and Skarlicki 2004; Quah 2007). Still, vices provision in developed countries.
an interesting aspect of rationality is that Performance outcomes are measured using
people tend to follow the expert authorities’ internationally recognized standard measure-
directives only to the extent that the latter are ments or procedures such as ISO 9000, accred-
perceived as trustworthy (Cook et al. 2004; itation schemes for medical schools, hospitals,
Quah 2007). medical laboratories, and even medical ethical
Another problematic aspect of rationaliza- review boards for medical research with
tion is that it assumes that the individual would human subjects. Currently, health organiza-
always seek to protect his/her self-interest. The tions in the public and private sectors tend to
pursuit of individual self-interest, however, focus on rationalization as efficiency – that is,
may be damaging to the welfare of the collec- the attainment of the same outcome at a lower
tive, as in the case of corrupt individuals who cost and with fewer resources. In some coun-
abuse the power of their official position or tries this approach is labeled managed care.
profession to exploit the system or health care However, the depiction of rationality as effi-
users. Corruption is found in all areas of the ciency in the sense of cost effectiveness is more
health care system – for example, in the con- likely found in private sector organizations
struction of health care facilities, purchase of where profit is the target, but, given the rapid
equipment, facilities, and medicines, financial increase in the cost of health care and public
management of health care, and services deliv- resistance to an increase in taxation in many
ery, among other aspects (Vian 2008). countries, efficiency is also becoming a goal in
Having reviewed the concept of rationali- the public sector. Still, Axelsson and Kullén
zation, let us turn now to the different forms Engström (2001) argue that elected policymak-
that rationalization takes in three dimensions ers are more concerned about reaching politi-
of health care: health systems, health care cal objectives than pursuing rational plans, and
providers, and users of health care. this position may not be shared by non-elected
officials. In their study of a Swedish regional
public health care organization, these authors
RATIONALIZATION IN HEALTH found discrepant views on rationalization
SYSTEMS defined in terms of effectiveness and outputs,
between two sectors: on the one hand, non-
A manifestation of rationalization in health medical operational managers and “politicians”
systems is the application of economics and who were focused on the efficiency of the busi-
systems analysis as main staples of health pol- ness understood as “keeping to the budget”
icy formulation and evaluation, although pol- and, on the other, the medical managers who
icy decisions continue to be driven by political focused on the individual patients.
ideology and the availability of resources, Examining the concept of rationalization in
among other factors. Nevertheless, a common the context of health systems, medical sociolo-
manifestation of rationality in health policy is gists articulate the problem as affecting also

the professional autonomy of physicians. It has Latin America, and the critical examination
been observed that when the emphasis is of improvement options such as the “National
mostly on cost containment, health care is Preventative Health Strategy” in Australia
treated as a commodity and the provision of (AMOHA 2009) and “transformative change”
health care becomes “a system of care charac- for national health services in Canada
terized by a distrust of professional authority, (Heshka et al. 2011).
external accountability and monitoring, and The same trend toward the improvement
the rise of corporate health care systems” of flexible health systems integrating acute
(Scheid 2003, 143). Scheid argues that ration- and primary health care using teams of
alization that focuses on the quality of care and “health providers with the necessary early
patient outcomes is not only positive but nec- diagnostic and intervention competencies” is
essary. But what is important in rationalization also considered optimal for mental health
and rational health policy is the balanced services (Kutcher, Davidson, and Manion
assessment of both, the quality and cost of 2009), although the emphasis on rationaliza-
health care rather than cost containment alone tion of mental health services tends to be pri-
(Scheid 2003) marily on cost containment (Scheid 2003).
The rational integration of services is also
crucial for communities of people for whom
RATIONALIZATION IN HEALTH CARE health services are not directly accessible
PROVISION given their remote locations in terms of either
residence or place of work. This is the case for
Rationalization in health care is well illus- rural populations (Heshka et al. 2011) and for
trated by the organization and provision of personnel in the shipping and oil exploration
health services which require continuous and industries. The origins of long-distance
systematic analysis, delivery, and evaluation medical assistance may be traced back to the
of human, software, and hardware resources. twentieth century’s emergency help to ships
The challenge to rationalization is its moving on high seas that could only be provided by
target: the physical, political, and social set- radio. Currently, numerous national and
tings of the demand and delivery of health international regulations and agencies deliver
services – whether in primary health care, medical advice, medical assistance, and evac-
acute care, or public health – evolve rapidly in uation to ships and people in remote loca-
tandem with, among other factors, advancing tions. The expansion of services and the
technology and fluctuations in political ideol- increase in workload made  it necessary to
ogy and economic development. Typical rationalize the services, adding training pro-
examples of these phenomena are: control grams for medical staff and formal audits of
programs for endemic diseases such as yellow their service (Aujla et al. 2003).
fever, smallpox, poliomyelitis, sleeping sick- With the rapid expansion of urban popula-
ness, and malaria (Balen 2004), and heart dis- tions in the twenty-first century, the provision of
ease, diabetes, asthma, and other chronic medical services in large cities is also urgent and
diseases. Balen (2004, A25) proposes that the perhaps more complex than the provision of
appropriate rationalization response to this medical services in rural and remote areas. One
challenge is the emergence of “flexible health of many examples of the application of rationali-
systems” in primary healthcare – for example, zation to the planning and implementation of
SYLOS (système local de santé) in Belgium urban health care services is the use of mathe-
and SILOS (Sistemas Locales de Salud) in matical models for the optimum deployment of

ambulance services and rapid response in acci- health habits: the Japanese government
dent and emergency units (Kim et al. 2011; introduced its “National Mandatory Chronic
Nakstad, Strand, and Sandberg 2011), as well as Disease Prevention Program” in 2008
in the  preparation for disaster management whereby insurance companies must provide
(Bayram, Zuabi, and Subbarao 2011). a prevention program for people aged
Another health care aspect requiring careful between 40 and 70 whose metabolic rates
monitoring and rational assessment by health and other biomarkers suggest high risk of
authorities is the prescription, distribution, lifestyle-related diseases (Kobayashi 2008).
and use of medications and other pharmaceu- The other two types of individual
tical products. Two examples of the govern- health-related behavior are less likely to be
mental introduction of rationalization in guided by personal decisions alone, whether
medications are the European Union’s effort to or not they are rational actions. This is because
improve its “pharmacovigilance” legislation at the stage of illness behavior, the severity of
(Borg et al. 2011), and South Korea’s “pharma- symptoms leads a person to seek expert help,
coeconomic guidelines” to control the rising and once diagnosed, the patient – now enact-
costs of medicines (Bae and Lee 2009). ing the sick role – is more directly influenced
by medical advice and pressure from his/her
personal network of family and friends to take
RATIONAL ACTION AND HEALTH the “prescribed” course of action. One signifi-
CARE USERS cant illustration of this complex path to health
care is the case of mental health services
From the perspective of users of health ser- (Pescosolido, Gardner, and Lubell 1998).
vices, rational action would take place, if at In sum, while the concept of rationalization
all, within the realm of their health-related is the cornerstone of science and is found in
behavior: in decisions people make to keep all aspects of health care and health-related
illness at bay (preventive health behavior), to behavior, rationalization has been and
select the best course of action when con- continues to be the subject of intense study
fronting symptoms (illness behavior), and to and debate from the perspective of social sci-
deal with an illness after diagnosis (sick-role ences and philosophy. The examination of
behavior). rationality highlights its main limitation: the
In terms of preventive health behavior, prerequisites of rational action are difficult to
studies of populations and communities meet. Its application to today’s health care sys-
indicate two main predictors of preventive tem, including service provision and utiliza-
action in individuals. One predictor is cul- tion, is inevitable, but it needs to be conducted
tural and/or religious beliefs and practices with full awareness of its limitations. Providing
that unintentionally lead to healthy out- comprehensive information on relevant facts
comes – for example, alcohol abstention, diet and expected consequences to policymakers
restrictions, and regular meditation. The and health care users to help them make
other main predictor is government inter- informed choices should be an essential
vention in the form of health campaigns and component of rationalization in health care.
prevention programs such as anti-smoking
and “If you drink, don’t drive” campaigns, SEE ALSO: Health Administration; Health
now common in many countries. Some pre- and Culture; Health Maintenance Organization
vention programs go beyond promoting (HMO); Health Policy

Dilemmas and Approaches, edited by R. M.
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The Roadmap for Action.” Schommer, K., Weir, L., and Wollbaum, M. 2011. Leading Collaboration among the Providers
nsf/Content/nphs-roadmap-toc. Accessed April of Primary Health Care. Saskachewan, Canada:
2, 2013. Saskatchewan Institute of Health Leadership.
Aujla, K., Nag, R., Ferguson, J., Howell, M., and
Cahill, C. 2003. “Rationalizing Radio Medical sihl/2010-11LeadingCollaborationamongth-
Advice for Maritime Emergencies.” Journal of eProvidersofPrimaryHealthCare-march2011.
Telemedicine and Telecare 9 (Suppl. 1): S12–14. pdf. Accessed April 2, 2013.
Axelsson, L., and Kullén Engström, A. 2001. “The Kim, Y. K., Kim, K. Y., Lee, K. H., Kim, S. C., Kim,
Concept of Effectiveness – A Blind Alley? A H., Hwang, S. O., and Cha, K. C. 2011. “Clini-
Study of Different Interpretations in a Swed- cal Outcomes on Real-Time Telemetry System
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nomic Guidelines and Their Implementation in datory Chronic Disease Prevention Program in
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in Health 12(2): S36–S41. 16(4): 217–225.
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Bayram, J. D., Zuabi, S., and Subbarao, I. 2011. Based Teams.” Paediatric Child Health 14(5):
“Disaster Metrics: Quantitative Benchmarking 315–318.
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Multiple Casualty Events.” Disaster Medicine “Landing Sites and Intubation May Influence
and Public Health Preparedness 5(2): 117–124. Helicopter Emergency Medical Services On-
Borg, J. J., Aislaitmer, G., Pirozynski, M., and Scene Time.” Journal of Emergency Medicine
Mifsud, S. 2011. “Strengthening and Rational- 40(6): 651–657.
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Europe Heading to? A review of the New EU K. M. 1998. “How People Get into Health Ser-
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sell Sage Foundation. bridge, MA: Harvard University Press.
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Schrader-Frechette, K. S. 1991. Risk and Rationality. Instrument for Rational Health Policy.” Health
Philosophical Foundations for Populist Reforms. Care Analysis 10: 261–275.
Berkeley: University of California Press. Coleman, J. S., and Fararo, T. J., eds. 1992. Rational
Vian, T. 2008. “Corruption and the Consequences Choice Theory – Advocacy and Critique. London:
for Public Health.” In International Encyclopedia of Sage.
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NCOSS (Council of Social Service of New South
Wales-Australia). 2011. National Health Reform:
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R. T. 2002. “Evidence-Based Medicine as an Paper. Canberra: NCOSS.
Aging and Stress health of an aging person can be seriously
affected by the individual stresses associated
RONALD W. BERKOWSKY with normal movement through the life
University of Alabama at Birmingham, USA course as well as the stresses associated with
the social changes experienced. An example
There exists an interplay between the process of this relationship can be found when exam-
of aging and the experience of stress such that ining the status of the US Social Security
an individual’s physical and mental health Program. Because the long-term financial sta-
can be greatly affected by the stressful events bility of the program has come into question
that are experienced over time. While some over recent years, many aging Americans have
of these events can be considered normal become concerned over their ability to live
and  expected occurrences of an individual comfortably in the coming decades should the
moving through the life course, others can be program be unable to support the elderly who
described as a product of the historical con- have little or no income. This stress, however,
text in which the individual resides. The is not shared with previous age cohorts, as
combination of these stressful events, whether there are many older adults who already began
in the form of major role transitions, the to receive Social Security payments before the
development of chronic conditions, or the program’s current financial concerns and are
perpetuation of daily hassles, can have sig- less worried about receiving their benefits.
nificant consequences on the health of aging The totality of an aging individual’s experi-
individuals, and these consequences can be enced stressful events is thus not limited to
mediated by a host of other factors. typical life course occurrences, but is also
The interplay between the process of aging affected by the social changes of the time
and the experience of stress can be framed period, and it is this combination of life course
using age stratification theory. Outlined by and historical stresses that helps dictate the
Riley (1987), age stratification theory dictates physical and mental health outcomes experi-
that an individual’s experience with aging is a enced in old age.
product of the interaction between the nor- This is not to say, however, that typical life
mal life course trajectory shared by all aging course occurrences experienced by aging
individuals and the social processes of the individuals are inferior in magnitude and
time period. While all individuals follow the importance to the stresses associated with a
same path through the life course, the histori- time period’s social changes, since a consider-
cal context in which people experience this able amount of research on aging has been
path can greatly affect the experience of aging, devoted to examining the effects that major
and thus there is an interdependence between life transitions, chronic conditions, and daily
the individual and the social changes that hassles shared by older persons have on
occur over time. The experience of stress can health outcomes. With regards to major life
therefore vary greatly between aging individ- transitions, events such as widowhood, retire-
uals, as it depends not only on a person’s loca- ment from work, and residential relocation
tion through the life course, but also on social and institutionalization have been cited as
factors. As such, the physical and mental potentially stressful occurrences with possible

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

negative consequences with regards to relationship (Cui and Vaillant 2001). Control
physical and mental health in older adults over potentially stressful events and whether
(Cui and Vaillant 2001; Dave, Rashad, and or not the event occurs expectedly or unex-
Spasojevic 2008; Lutgendorf et al. 2001; pectedly are examples of such mediators. The
Markides and Cooper 1989; Wilcox et al. stresses associated with retirement are con-
2003). Noticeably, each of these life transi- siderably less for individuals who choose to
tions is associated with changes in social retire compared to those who are forced to
life: respectively, the loss of a life partner retire (Sharpley and Layton 1998). Likewise,
and strong social tie, the loss of working those who lose a spouse as a result of a
relationships, and the loss of community chronic disease may be better able to psycho-
interaction and involvement. Life transitions logically handle the stress associated with
such as those mentioned are accompanied widowhood compared to those who lose a
by significant changes in social environment, spouse unexpectedly as a result of an acci-
contributing to the amount of stress experi- dent or acute illness; the former would not
enced by the aging individual. experience such an increase in depression or
The development of chronic conditions anxiety upon the loss of a spouse (Carnelley,
through the life course can also be a source Wortman, and Kessler 1999). Having control
of  great stress to individuals entering and over the events that occur through the life
progressing through old age. In particular, course, and being physically and mentally
the diagnosis of a chronic and potentially able to prepare for events not possible to
life-threatening disease can have major psy- control, mediate how the stresses associated
chological consequences on those suffering with aging ultimately impact health (Cui and
from the illness (Markides and Cooper 1989). Vaillant 2001).
In addition, the daily hassles associated with Other mediators associated with stress and
the aging process can lead to new sources of health in aged individuals include coping
stress that negatively affect health. An exam- strategies and social support networks. With
ple of this can be found in aged individuals regards to coping styles, Cui and Vaillant
who need assistance with walking and stand- (2001) argue that when aged individuals
ing as a result of physical deterioration result- experience a stressful event, a number of vol-
ing from multiple sclerosis; the likelihood of a untary and involuntary protective reactions
fall and consequent injury increases dramati- may be employed to assist in adjusting or
cally if the individual does not have the equip- handling the source of the stress. An example
ment or personnel to help them move around, of a successful coping strategy may be found
and the stress associated with a loss of mobil- in an older adult who, after being forced into
ity as well as a new reliance on others may retirement earlier than expected, takes up a
have a detrimental effect on mental well- hobby to fill the void left by the loss of
being (Finlayson and Van Denend 2003). employment. Not all coping strategies are
This stress can be elevated in older adults beneficial to health, however, as can be seen
with poorer socioeconomic standing, as these in those who take to drinking excessively as a
individuals may lack the monetary resources way to cope with stress. With regards to social
to purchase the required assistance. support, having quality social relationships
Yet while there are a number of potentially and friends to confide in or call upon in times
stressful events that can affect an aging of need has been shown to act as a buffer
individual’s health, there are also mediating when experiencing stressful events (Markides
factors that can affect the magnitude of this and Cooper 1989). For example, individuals

with strong support networks may be better to research how aging-related stress differs
able to cope with the diagnosis of a life- across nations and cultures. Continued
threatening ailment, as these networks can research in this field may provide insight to
provide physical assistance needed for treat- policy and applications that can be enacted to
ment and activities of daily living as well as alleviate or cope with stress and promote
emotional support. health in old age.
The previous discussion on aging and
stress is framed on the US experience of SEE ALSO: Aging and Health; Stress across
aging; however, it is also important for social the Life Course; Stressful Life Events
scientists to consider how the experience of
stress may differ across different countries
and different cultures. Different ethnic and
cultural expectations and norms can drasti- Anugwom, N. Kenechukwu. 2011. “The Socio-
cally affect the levels of stress experienced by Psychological Impact of Widowhood on Elderly
aging individuals, which can, in turn, have a Women in Nigeria.” OIDA International Journal
of Sustainable Development 2(6): 89–96.
noticeable effect on health. As an example,
Carnelley, Katherine B., Wortman, Camille B., and
much like in the United States, elderly women
Kessler, Ronald C. 1999. “The Impact of Wid-
entering widowhood in Nigeria typically owhood on Depression: Findings from a Pro-
experience elevated feelings of anxiety and spective Study.” Psychological Medicine 29(5):
depression as a result of the physical and 1111–1123.
emotional stresses that come from losing a Cui, Xing-jia, and Vaillant, George E. 2001.
spouse. However, in Nigeria as well as in “Stressful Life Events and Late Adulthood
other African nations, it is customary and Adaptation.” In Aging in Good Health: Multidis-
culturally expected for women entering into ciplinary Perspectives, edited by Sue E. Levkoff,
widowhood to be the “chief mourner” of the Yeon Kyung Chee, and Shohei Noguchi, 9–27.
deceased and to outwardly grieve (by physi- New York: Springer.
Dave, Dhaval, Rashad, Inas, and Spasojevic, Jas-
cally “wailing and weeping”) for days before
mina. 2008. “The Effects of Retirement on
the burial. This “prolonged anguish” can add
Physical and Mental Health Outcomes.” South-
to the stress experienced by the aged widow ern Economic Journal 75(2): 497–523.
and can have serious consequences regarding Finlayson, Marcia, and Van Denend, Toni. 2003.
her mental state (Anugwom 2011). Thus, “Experiencing the Loss of Mobility: Perspec-
while the stresses experienced in old age may tives of Older Adults with MS.” Disability and
be similar across nations and cultures, the Rehabilitation 25(20): 1168–1180.
overall effect on physical and mental well- Lutgendorf, Susan K., Reimer, Toni T., Harvey,
being can be heavily influenced by certain John H., Marks, Glenn, Hong, Sue-Young,
norms and expectations. Hillis, Stephen L., and Lubaroff, David M. 2001.
The role of the social sciences with regards “Effects of Housing Relocation on Immuno-
to aging and stress is to continue exploring competence and Psychosocial Functioning in
Older Adults.” Journals of Gerontology Series A
how an aged individual’s experience of stress
56(2): M97–M105.
is both a product of individual life course
Markides, Kyriakos S., and Cooper, Cary L., eds.
events as well as a product of historical social 1989. Aging, Stress, and Health. Chichester, UK:
change; social scientists must also continue to Wiley.
investigate how factors such as social support Riley, Matilda White. 1987. “On the Significance of
may mediate the relationship between stress Age in Sociology.” American Sociological Review
and health in the elderly, as well as continue 52(1): 1–14.

Sharply, Christopher F., and Layton, Renaty. FURTHER READING

1998. “Effects of Age of Retirement, Reason
George, Linda K. 1993. “Sociological Perspectives
for Retirement, and Pre-Retirement Training
on Life Transitions.” Annual Review of Sociology
on Psychological and Physical Health During
19: 353–373.
Retirement.” Australian Psychologist 33(2):
Pearlin, Leonard I. 1989. “The Sociological Study
of Stress.” Journal of Health and Social Behavior
Wilcox, Sara, Evenson, Kelly R., Aragaki, Aaron,
30: 241–256.
Wassertheil-Smoller, Sylvia, Mouton, Charles
Pearlin, Leonard I., Schieman, Scott, Fazio, Elena
P., and Loevinger, Barbara L. 2003. “The Effects
M., and Meersman, Stephen C. 2005. “Stress,
of Widowhood on Physical and Mental Health,
Health, and the Life Course: Some Concep-
Health Behaviors, and Health Outcomes: The
tual Perspectives.” Journal of Health and Social
Women’s Health Initiative.” Health Psychology
Behavior 46: 205–219.
22(5): 513–522.
Asian Americans, Health of population by 2050 (US Census Bureau 2010).
Asian Americans are defined as persons whose
CHAU TRINH-SHEVRIN AND REBECCA PARK ethnic backgrounds originate in the Far East,
New York University School of Medicine, USA Southeast Asia, the Indian subcontinent, and/
or the Pacific Islands including Native
Asian Americans are reported to have better Hawaiians. There has been a dramatic rise in
health compared to other racial/ethnic the proportion of Asian immigrants to the
groups. According to the Office of Minority United States; they accounted for 9 percent of
Health (Leigh and Lindquist 2006), Asian all US immigrants in 1960, but have grown to
American women have the highest life expec- approximately 40 percent of the immigrant
tancy (85.8 years) of any group in the United population at the time of writing (Trinh-
States, and a California Health Interview Shevrin, Islam, and Rey 2009).
Study (UCLA 2008) shows that Asian Asian Americans are widely dispersed
Americans have better outcomes in self-care across the United States, but are highly con-
and health risk behaviors overall. However, centrated in urban and suburban regions of
these statistics demonstrate the “model the west (49 percent) and the northeast
minority” myth first coined by sociologist (21 percent). According to US Census Bureau
William Petersen (1966), referring to a per- (2010) results, the five states with the largest
ception that Asian Americans achieve higher percentage of Asian Americans are: California
degrees of economic and educational success (13 percent), New York (7.3 percent), New
and have fewer health problems than the Jersey (8.3 percent), Hawaii (38.6 percent),
overall population. Indeed, they are one of and Washington (7.0 percent). The largest
the most poorly understood racial/ethnic subgroups are Chinese (24.3 percent), Filipino
minority groups in the nation. Although (19.9 percent), Asian Indian (18.2 percent),
Asian Americans may share common experi- Vietnamese (10.9 percent), Korean (10.4 per-
ences, the “model minority” stereotype also cent), and Japanese (8.3 percent), while a
tends to reify Asian culture as a singularity, smaller proportion are Pakistani (1.4 percent),
when in fact it represents nearly 50 countries Cambodian (1.6 percent), Laotian (1.5 per-
and ethnic groups with distinct cultures, his- cent), Hmong (1.4 percent), Thai (1.4 per-
tories, dialects, and languages. The diversity cent), Indonesian (0.6 percent), Bangladeshi
of this rapidly growing population makes it (0.5 percent), and other Asians (0.5 percent)
vital for researchers and health care profes- (Trinh-Shevrin, Islam, and Rey 2009).
sionals, in collaboration with communities Asian Americans, as a whole, suffer dispro-
and governments, to examine more carefully portionately from certain diseases, especially
and address the variety of pressing health cancer, stress-related diseases, and stroke.
challenges facing Asian Americans. Although cancer mortality rates are low for
Asian Americans are the fastest growing Asian Americans compared with other
racial/ethnic group in the United States, repre- groups, they have the highest incidence rates
senting 5 percent of the overall US population of liver and stomach cancer among both
in 2010 and an estimated 10 percent of the US males and females. Data in California shows

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

that age-adjusted mortality rates for liver can- social, cultural, and economic contexts of
cer were 23.8 per 100,000 males for all Asians, the  Asian American community must be
compared with non-Hispanic whites at 6.8 accounted for in order to develop effective
(Barnes, Adams, and Powell-Griner 2008). health programs and research.
Chronic hepatitis B infection is the leading A large segment of Asian Americans face
cause of liver cancer. The Center for Disease linguistic, cultural, and socioeconomic barri-
Control and Prevention (2011) reports that ers to health care. Factors contributing to
while Asian Americans make up approxi- health disparities for this group include tradi-
mately 5 percent of the total population, they tional access barriers such as insurance status
account for more than 50 percent of Americans and low socioeconomic status. However, they
living with chronic hepatitis B. Hepatitis B, a also face barriers unique to largely immigrant
viral infection that attacks the liver, is 50 to groups, such as language, acculturation, and
100 times more infectious than HIV. Despite length of time in the United States. which
the existence of a safe and effective vaccine affects health practices and behaviors. For
that can prevent this disease, limited resources example, although roughly 36 percent of
have been devoted to its prevention in the Asian Americans have limited English profi-
United States. A review of the existing public ciency (LEP), this is higher in some sub-
health literature demonstrates an overall lack groups such as Vietnamese (61 percent) and
of knowledge of hepatitis B among Asian Taiwanese (51 percent), and lower in others,
Americans, as well as among health providers. such as Japanese (21 percent) and Sri Lanken
The lack of funding, resources, and knowl- (18  percent) (Trinh-Shevrin, Islam, and Rey
edge continues to contribute to this significant 2009). LEP ultimately promotes vulnerability
health disparity. when seeking health coverage and care and
Health disparities are particularly evident can limit resources to health education and
when looking at differences across Asian access to health care in a timely manner,
American subgroups. For instance, the preva- and can cause miscommunication and misdi-
lence of diabetes among Asian Americans is a agnosis among patients, family members, and
growing health concern and is the fifth leading providers (Trinh-Shevrin, Islam, and Rey
cause of death in the population. However, the 2009). Other barriers to accessing care  may
prevalence of diabetes greatly differs according be attributable to Asian American cultural
to ethnicity. The prevalence of diabetes is 14 per- norms and behaviors such as social  stigma
cent among Asian Indian  adults, 6 percent around certain conditions and diseases – for
among Chinese, and 5 percent among Japanese example, mental health and depression.
adults. Hypertension also reflects disparities While Asian American women have the
along  ethnic lines, where Filipino adults highest life expectancy of any other group,
(27percent) are more likely to be diagnosed with they have the lowest rates of cancer screening,
hypertension compared to Chinese (17 percent) including mammograms and pap tests (Trinh-
and Korean (17 percent) adults (Barnes, Adams, Shevrin, Islam, and Rey 2009). More than 36
and Powell-Griner 2008). percent of Asian American women under the
Health is shaped by social, cultural, and age of 65 have no health insurance, with
environmental determinants, including insti- Korean Americans being the least likely to be
tutions, neighborhoods, organizations, and insured of any racial or ethnic group (Barnes,
policies that are linked to different health Adams, and Powell-Griner 2008). Reasons for
behaviors, diseases, and well-being (Trinh- this may include the fact that many Asian
Shevrin, Islam, and Rey 2009). Thus, the immigrants work in low-wage jobs, which

means they rely more heavily on Medicaid and for medical, public health, and social services
other public programs, while others work in will be critical to realizing better health out-
privately owned businesses that are less likely comes among this group and for increasing
to have employer-sponsored health coverage. evidence-based efforts.
Approximately 60 percent of non-elderly adult
Korean workers are employed at a firm with SEE ALSO: Race, Ethnicity, Culture, and
fewer than 100 employees, compared to 40 Health in the United States; Socioeconomic
percent among other Asian Americans (Kaiser Status and Health
Family Foundation 2008).
Although public and private entities have
made efforts to reinforce studies of Asian
American health disparities, there is still an Barnes, Patricia, Adams, Patricia, and Powell-Griner,
ongoing need for innovative research designs Eve. 2008. “Health Characteristics of the Asian
to achieve systematic change and improve- Adult Population: United States, 2004–2006.”
Advance Data from Vital and Health Statistics 394.
ment in policy, health care access, and health
Hyattsville, MD: National Center for Health
care quality, and to optimize the health status
of underserved populations (Ghosh 2010). pdf. Accessed April 9, 2013.
Since the early 2000s, a successful strategy for Centers for Disease Control and Prevention.
addressing health disparities in underserved 2011. “Chronic Hepatitis B and Asian and
populations has been through community- Pacific Islanders.”
based participatory research (CBPR). CBPR ChronicHepatitisB/. Accessed April 9, 2013.
highlights community stakeholders as active Ghosh, Chandak. 2010. “A National Health
and equal collaborators throughout the Agenda for Asian Americans and Pacific Island-
research process to build community engage- ers.” Journal of the American Medical Association
ment and research capacity to address health 304: 1381–1382.
Kaiser Family Foundation. 2008. “Fact Sheet: Health
needs and initiate community-led social
Coverage and Access to Care among Asian
change or action (Trinh-Shevrin, Islam, and
Americans, Native Hawaiians and Pacific Island-
Rey 2009). CBPR aims to foster bridges ers.” Accessed April 9, 2013.
between communities and their emerging Leigh, Wilhelmina, and Lindquist, Malinda. 2006.
health needs through diverse and equitable Women of Color Health Data Book: Adoles-
partnerships by sharing resources and knowl- cents to Seniors. Office of Research on Women’s
edge to develop and evaluate tailored pro- Health, Office of the Director, National Institutes
grams and interventions. This is important of Health.
for the health of a variety of immigrant Petersen, William. 1966. “Success Story: Japanese
groups, including Asian Americans, because American Style.” New York Times Magazine,
CBPR allows the incorporation of unique January 9.
social, cultural, and economic factors that Trinh-Shevrin, Chau, Islam, Nadia S., and
Rey,  Mariano J., eds. 2009. Asian Americans
constrain or enable health among particular
Communities and Health: Context, Research, Pol-
ethnic groups and community enclaves.
icy, and Action. San Francisco, CA: Jossey-Bass.
Asian American health issues will continue UCLA Center for Health Policy Research. 2008.
to emerge as the population continues to “California Health Interview Survey.” http://
grow in the United States. Analyses of public Accessed April 9, 2013.
and private funding for Asian American US Census Bureau. 2010. “Interactive Popula-
health have shown disparities in the distribu- tion Map.”
tion of resources. Continued financial support Accessed April 9, 2013.
Childbearing in the trained by other midwives, were profoundly
honored and respected in their communities.
United States Believing birth to be a perfectly natural, organic
process, midwives traditionally played a sup-
ROTHMAN portive role in birth. Physicians intervened
City University of New York, USA only in the event that labor did not progress
naturally. Otherwise, midwives orchestrated
Maternity care in the United States, like all all the events of labor and delivery (Leavitt
other aspects of health care, has become a 1986; Litoff 1982; Ulrich 1990; Wertz and
highly politicized, highly contested subject. Wertz 1989).
Many argue that the United States is experi- Medical schools proliferated during the
encing a crisis in the availability, quality, and nineteenth century, thereby increasing the
cost of maternity care. Though the total number of available male birth attendants
amount spent on health care in the United and new medical interventions. The inven-
States is greater than in any other country in tion of analgesic drugs offered women a rem-
the world, US women are at greater risk of edy to childbirth pains, and anesthetic drugs
dying of pregnancy-related complications created the possibility for more surgical inter-
than women in 40 other countries (Amnesty vention into the childbirth process in an
International 2010). While the US infant attempt to lessen the possibility of maternal
mortality rate generally declined in the twen- morbidity. Middle- to upper-income women,
tieth century, it is still higher than those in specifically those located near major cities,
most other developed countries, and the gap began to avail themselves of the perceived
between the US infant mortality rate and the benefits of medical advancements and the
rates for the countries with the lowest infant expertise of science by giving birth in hospi-
mortality appears to be widening. US infant tals under the direction of a physician. Such
mortality rates, an important indicator of the a  transition from home to hospital, for
health of a nation, are especially alarming. In these women, symbolized modernization and
2006, for example, black babies were nearly upward social mobility.
three times more likely to die than white Increasing standards for, and entrance into,
babies (MacDorman and Matthews 2008). medical schools and, specifically, greater
Today, 99 percent of all US births occur in professional mobilization for the obstetrics and
the hospital, but childbearing has a long, gynecology (OB/GYN) specialty introduced
complicated history outside the hospital set- tension between physicians and midwives.
ting. From the arrival of colonial settlers up to Frances Kobrin (1966) notes the deliberate
the nineteenth century, US women delivered efforts of OB/GYNs to publish articles in
their babies at home. Birth was a communal medical, public health, and nursing journals
event in which women, their families, and a on “the midwife problem.” Racist, nationalist,
midwife prepared to welcome the child into and eugenic language was used to describe
the world at home. Midwives, often spiritu- black and immigrant midwives as ignorant,
ally “called” into the work and historically dirty, dangerous, and, perhaps most

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

significant, unclean. Midwives, working in Mexican-American communities, and the

the home and generally non-white and of midwives who cared for separate religious
lower socioeconomic status, were portrayed sects like the Amish in Pennsylvania and the
as being unaware of the necessity to ensure a Mormons in Utah (Buss 1980; Lee 1996).
safe and sanitary environment for birth in the Throughout the United States, midwives
way that the physicians in hospitals could; delivered half of all babies as late as 1910
and even if they had been aware of this need, (Litoff 1982). The United States Children’s
they were incapable of providing such an Bureau in 1912 and the Sheppard-Towner
environment because of lack of resources. Maternity and Infancy Protection Act of 1921
Midwives’ reliance on indigenous herbal and provided federal funding to states to imple-
folk practices were inconsistent with current ment maternity and childcare programs in
scientific knowledge. By contrast, those in the response to nationally high infant and mater-
medical profession positioned themselves as nal mortality rates. This era introduced state
being scientifically trained, able to provide a and municipal bureaus of child hygiene, pre-
seemingly safer and cleaner birth process natal and child health conferences, educa-
than the apparently ignorant midwife. Mid- tional programs for birth attendants and
wives came to be seen as competitors, both mothers, and, believing midwives to be
because they monopolized the pool of low- responsible for the poor health outcomes, the
income women who were needed for medical issuance (or denial) of licenses to midwives.
teaching and because they depressed the status By the early 1940s, midwives were formally
and economic gain of physicians. As medical supervised, trained, and evaluated by public
professionals worked to define childbirth as nurses (Brickman 1983). Midwives were
a risky, dangerous, and pathological event, required to attend monthly training sessions
the hospital was promoted as the best place with the nurses, with funding from the
to give birth, and physicians were deemed Sheppard-Towner Act, where they were
the only appropriate specialist to attend a instructed in safe, sterile, and sanitary
delivery, despite the ironic fact that infant birthing procedures, equipment, and uni-
and maternal mortality rates rose with this form. The historical pattern of having
professionalization of birth (DeVries 1985). several  midwives in a community, trained
Even so, midwifery flourished during the via  the apprenticeship model, was broken.
late nineteenth and early twentieth centuries, Instead, nurses sought to replace older mid-
largely as a result of segregation in the south- wives with younger women who were more
ern United States and southern and eastern likely to have greater literacy skills, follow
European immigration. Midwives served medical doctrine, and advocate for greater
mothers who had a stronger preference for, professionalization (Ladd-Taylor 1988).
and connection to, midwives as they were a A coalition of medical organizations, chief
part of their own community and the hospi- among them the American Medical
tals were often too expensive, too far away, Association (AMA), fought at the local and
and, in some cases, presented a cultural and national levels against the renewal of the
language barrier. It is important to note that Sheppard-Towner Act in 1927. Most physi-
because physicians had succeeded in replac- cians believed that midwives were uneduca-
ing midwives among most upper- and middle- ble and should be eliminated by law. Others
class urban white women, the resurgence of supported midwife training by physicians and
midwifery occurred primarily in the rural saw them as a “necessary evil” – necessary,
areas, with the granny midwife of the black because there were not adequate numbers of
community, immigrant midwives, partera in trained physicians to care for large numbers

of poor women; evil, because they were herbal teas and oils. This greater attention to
allegedly responsible for birth complications. the efficacy and safety of lay midwifery
Despite such strong opposition, supporters increased their clientele and thereby fostered
did succeed in securing federal funding for a need to appeal to a broader range of women,
two more years, but the act was ultimately not just those who were part of their imme-
repealed in 1929. The withdrawal of funds diate community which had hitherto been
restricted the operation of midwife regula- the  case. Increased occupational visibility
tion, allowing them to continue practicing in resulted in greater pushes for legal profes-
remote areas. Fearful that midwifery would sionalization. Legalization of lay midwifery
become institutionalized, physicians lobbied presented a double-edged sword. On the one
for the use of nurse-midwives – registered hand, legalization legitimates their work and
nurses with additional training in midwifery – allows them full state and legal support to
to become licensed birth attendants. This attend birthing women. But, on the other,
marked the beginning of the distinction legalization requires application to, and
between “lay” midwifery, those trained under acceptance of, an approved school and the
the apprenticeship tradition rather than for- passing of all required examinations, in
mal training, and nurse-midwifery, which accordance with state regulations, which not
has the legal and social benefit of formal only requires financial and other resources,
training. There emerged an association of but is in stark contrast to midwifery’s tradi-
largely white, professional nurse-midwives, tional roots of being spiritually called into the
well indoctrinated into medical practice and profession and serving as an apprentice to a
ultimately trained and supervised by physi- senior midwife. To this end, in 1982, the
cians, attending to middle- and upper-class Midwives Alliance of North America (MANA)
women, on the one hand, and, by contrast, was established as a professional organiza-
poorer women who would continue to rely tion for all midwives. In 1987, MANA created
on the services of black and immigrant lay the North American Registry of Midwives
midwives. This left lay midwives at a consid- (NARM), an international certification
erable disadvantage because they did not agency that establishes standards and admin-
have the resources to establish schools and isters certification for the Certified
organizations to secure their legitimacy as Professional Midwife (CPM) credential. The
professionals. CPM credential recognizes the diverse ways
Yet, the late 1950s and the two decades that in which people enter into midwifery –
followed were a period of great social and cul- namely, apprenticeship, self-study, private
tural transformation. Greatly influenced by midwifery schools, college- and university-
the civil rights and feminist movements, the based midwifery programs, and nurse-
home birth movement began in northern midwifery. It is important to note that CPMs
California in the mid-1960s, sparking are now considered under the umbrella
another resurgence of lay midwifery. Ironically, term “direct-entry midwife,” which clearly
increasing scientific evidence demonstrated recognizes the diverse entry points. Also
that the traditional practices of immigrant direct-entry midwives comprise both the
and granny midwives, who were by this time certified midwife (CM), who is not a nurse
dying out after having been subjected to mar- but has met all qualifications set by
ginalization and eventual elimination by the the  American College of Nurse Midwives
medical profession, were being confirmed as (ACNM), and the licensed midwife (LM),
advantageous and safe – for example, keeping who is licensed to practice only in a particular
women ambulant during labor and the use of jurisdiction (usually a state or province). (It is

important to note here that the lay midwives supported by a resolution passed at the 2008
described herein – e.g., grannies, la partera, AMA annual meeting. Nevertheless, research
etc. – refer to those who were uncertified or studies have demonstrated that midwives pro-
unlicensed and educated through informal duce equally good or better birth outcomes for
routes such as self-study or apprenticeship low-risk women (Amnesty International 2010).
rather than through a formal program. In most other industrialized countries, mid-
The CPM credential allowed the opportunity wives attend the majority of births, and
for lay midwives to be certified.) women experience fewer interventions and
Today’s legal regulation of midwives in the better outcomes than in the United States. The
United States is complex. CPMs are legal in all World Health Organization (WHO), the
50 states. While the ACNM has established ACNM, and the American Public Health
guidelines for the functions, standards, and Association (APHA) all support home and
qualification of CPMs, their practice is actu- out-of-hospital birth options for low-risk
ally regulated at the state level like that of all women (MacDorman et al. 2010).
other health professionals. In most states, In recent years, from Ricki Lake’s popular
nurse-midwifery practice is managed by the documentary The Business of Being Born
state board of nursing. Regulations concern- (2008), mainstream books like Tina Cassidy’s
ing the level of education, actual scope of Birth (2006) and Jennifer Block’s Pushed
practice, prescriptive authority, relationships (2007), as well as increasing local and national
with physicians, and even the site of practice television and newspaper coverage, much
vary considerably from state to state. The media attention has been cast on these issues.
majority of nurse-midwives are employed by Still, only 1 percent of American women
physicians or medical centers. While nurse- have out-of-hospital births and this per-
midwives may attend births in the home or centage has remained relatively steady for
freestanding birth centers, approximately 95 several decades. These births, in residences,
percent of all births attended by nurse-mid- freestanding birthing centers, clinic/doctor’s
wives occur in hospitals. By contrast, regula- offices, or other locations, are most prevalent
tion of direct-entry midwives is even more for non-Hispanic white, married women
complex. State regulations range from clear aged 25 years and over (MacDorman et al.
prohibition, to no legal definition, to recogni- 2010). A growing number of women are
tion of midwives who have completed appren- choosing unassisted childbirth – i.e., inten-
ticeships or licensure for graduates tionally giving birth without the assistance
of midwifery schools. To date, 26 states now of a medical or professional birth attendant
recognize direct-entry midwives. There are (Shanley n.d.).
eight freestanding midwifery schools and Such a complicated history of childbearing
two midwifery programs within other institu- in the United States reveals that it is defined
tions. Direct-entry midwives attend births in by, and situated within, the ideological dis-
homes or freestanding birth centers, but, courses of its time. For example, prior to the
despite positive research findings, the safety of medicalization of birth, it was generally
these births is the subject of ongoing political thought to be a natural, organic process that
controversy. In 2007, the American College of required medical intervention in extreme
Obstetricians and Gynecologists (ACOG), cases, whereas the medicalization era has
citing concerns about the safety of home generally redefined birth as a risky event
births for mothers and infants, issued a policy that requires medical and/or surgical inter-
statement opposing home births, a statement vention (Lupton 2000; Peterson 1996). This

is evident, for example, from the fact that in a  machine, manipulated for maximum pro-
2008 the cesarean delivery rate was 32.3 per- duction, it can be bought and sold for a
cent – a 56 percent increase since 1996 – and desired end, as evidenced by great increases
the number is steadily rising (Martin et al. in surrogacy and medical tourism in recent
2010). Rothman has observed that childbearing, decades. The challenge in a capitalist society,
and motherhood in general, is situated however, is that not all workers and products
within three main ideologies of patriarchy, are equally valued, as value is heavily inter-
technology, and capitalism. First, the patri- twined with race, ethnicity, class, gender,
archal ideology views the male body as the nation, and other social identifiers. Unequal
working norm such that solely female pro- value, in a capitalist society, translates into une-
cesses of menstruation, pregnancy, birth, qual price, such that women and their bodies
and menopause are constructed as patho- are commodities, a phenomenon that Debora
logical. Once defined as pathological, a Spar (2006) aptly terms “the baby business.”
series of interventions, diagnoses, and treat-
ments, debatably helpful or harmful, follow.
Second, within the ideology of technology, SEE ALSO: Childbearing, International
the body is viewed as a machine and tech- Practices; Childbirth Practices; Medicalization
nological interventions are introduced to and Medicines
maximize speed, efficiency, productivity,
and control. This ideology supports the
Cartesian mind–body dualism whereby
the pregnant body is thought to operate like Amnesty International. 2010. Deadly Delivery:
a machine, requiring repair, monitoring, The Maternal Health Care Crisis in the USA.
and surveillance, with the physician as the London: Amnesty International Secretariat.
mechanic, and such physical operations Block, J. 2007. Pushed: The Painful Truth about
are  thought to be separate from the mind. Childbirth and Modern Maternity Care. Cam-
bridge, MA: Da Capo Lifelong.
The fetus is thought to be disconnected from
Brickman, J. P. 1983. Public Health, Midwives,
the mother, such that her mental and
and  Nurses, 1880–1930. Nursing History: New
emotional needs are secondarily present, if Perspectives, New Possibilities. E. C. Lagemann,
at  all, thereby alienating her from the NY: Teachers College Press.
full  experience of laboring. With prenatal Buss, F. L. 1980. La Partera: Story of a Midwife.
diagnoses, electronic fetal monitoring, anal- Ann Arbor: The University of Michigan Press.
gesic, anesthetic drugs, increased rates of Cassidy, T. 2006. Birth: The Surprising History of
episiotomies, forceps, and cesarean section, How We Are Born. New York: Grove Press.
among other interventions, the focus is on DeVries, R. 1985. Regulating Birth: Midwives,
the mechanics of production (Goer 1995; Medicine and the Law. Philadelphia, PA: Temple
Rothman 1991). University Press.
Goer, H. 1995. Obstetric Myths versus Research
Finally, within a capitalist ideology and in
Realities: A Guide to the Medical Literature.
close connection to ideologies of patriarchy
Westport, CT: Bergin and Garvey.
and capitalism, if mind and body are viewed Kobrin, F. 1966. “The American Midwife Contro-
as separate, Rothman argues, it becomes rela- versy: A Crisis of Professionalization.” Bulletin
tively easy to see the ways in which women’s of the History of Medicine 40: 350–378.
reproductive bodies can be understood and Ladd-Taylor, M. 1988. “‘Grannies’ and ‘Spinsters’:
consequently used like any other commodity Midwife Education under the Sheppard-Towner
in a capitalist society. That is, if the body is Act.” Journal of Social History 22(2): 255–275.

Lake, R., Executive Producer, and Epstein, A., Dir. M. J. K. 2010. Births: Final Data for 2008.
2008. The Business of Being Born (DVD). United Hyattsville, MD: National Center for Health
States: New Line Home Video. Statistics.
Leavitt, J. W. 1986. Brought to Bed: Childbearing Matthews, T. J., and MacDorman, M. 2010.
in America 1750 to 1950. New York: Oxford Infant Mortality Statistics from the 2006
University Press. Period Linked Birth/Infant Death Data Set.
Lee, V. 1996. Granny Midwives and Black Women Hyattsville, MD: National Center for Health
Writers: Double-Dutched Readings. New York: Statistics.
Routledge. Peterson, A. 1996. “Risk and the Regulated Self:
Litoff, J. B. 1982. “The Midwife Throughout His- The Discourse of Health Promotion as Politics
tory.” Journal of Nurse-Midwifery 27(6): 3–11. of Uncertainty.” Australia & New Zealand Jour-
Lupton, D. 2000. “Risk and the Ontology of Preg- nal of Statistics 32(1): 44–57.
nant Embodiment.” In Risk and Sociocultural Rothman, B. K. 1991. In Labor: Women and Power
Theory: New Directions and Perspectives, edited in the Birthplace. New York: W.W. Norton &
by D. Lupton, 59–85. Cambridge: Cambridge Company.
University Press. Shanley, L. n.d. “Bornfree!.” http://www.unassist-
MacDorman, M., and Matthews, T. J. 2008. Recent Accessed July 28, 2013.
Trends in Infant Mortality in the United States. Spar, D. L. 2006. The Baby Business: How Money,
Hyattsville, MD: National Center for Health Science, and Politics Drive the Commerce of Con-
Statistics. ception. Boston, MA: Harvard Business School
MacDorman, M., Menacker, F., and Declercq, Press.
E. 2010. Trends and Characteristics of Home Ulrich, L. T. 1990. A Midwife’s Tale: The Life of
and Other Out-of-Hospital Births in the United Martha Ballard, Based on her Diary, 1785–1812.
States, 1990–2006. Hyattsville, MD: National New York: Vintage Books.
Center for Health Statistics. Wertz, R. W., and Wertz, D. C.. 1989. Lying-In: A
Martin, J. A., Hamilton, B. E., Sutton, P. D., History of Childbirth in America. New Haven,
Ventura, S. J., Matthews, T. J., and Osterman, CT: Yale University Press.
Differential Vulnerability effects of stressors as more harmful – these
circumstances could provide a faulty under-
ROBYN LEWIS BROWN standing of the differential vulnerability of
DePaul University, USA one status group compared to another.
The differential vulnerability hypothesis
The term differential vulnerability refers to a was introduced as a response to the differen-
theoretical explanation for social status dif- tial exposure hypothesis. This perspective
ferences in the effects of exposure to social suggests that social status variation in the
stressors that was introduced by Ronald C. association between social stressors and men-
Kessler in 1979. According to this explana- tal health outcomes stems from status varia-
tion, people of disadvantaged social statuses tion in exposure to stress. According to this
experience more deleterious health conse- theory, for example, women would be thought
quences than their higher status counterparts to experience greater psychological distress
when faced with similar levels of exposure to than men because they are exposed to more
social stressors, because such stressors exert a stressful life events than men. However,
greater impact on them (Kessler 1979). This research at the time the differential vulnera-
may be due to biological influences, which bility hypothesis was conceived consistently
refer to the sources of greater physiological demonstrated that social status variation in
frailty among members of one contrast group the association between social stressors and
compared to another. Status variation may mental health was not well explained by dif-
also derive from environmental influences, or ferential exposure to stress. In fact, numerous
the ways in which individuals are socialized studies had failed to find any evidence of
to respond to social stressors, their sense of social status differences in exposure to social
personal competency in the face of adversity, stressors (e.g., Markush and Favero 1974).
as well as the social resources at their dis- Several scholars, thus, suggested that varia-
posal. As an illustration, it was posited that tion in mental health among particular sta-
women experience greater psychological dis- tuses (e.g., sex and socioeconomic status)
tress than men because they may be constitu- might derive from the differential degree of
tionally more vulnerable and have fewer strain a stressor exerts on status counterparts
personal and social resources with which to (Dohrenwend and Dohrenwend 1976; Gove
cope with the effects of life stressors com- 1972). The differential vulnerability hypoth-
pared with men. Kessler (1979) additionally esis introduced by Kessler (1979) is an elabo-
envisioned that methodological issues could ration of this work in that it is oriented to a
provide false evidence that one contrast more general understanding of variation in
group is more vulnerable to social stressors the effects of social stressors among multiple
than another. For example, if researchers fail status categories. It also provides empirical
to include a full inventory of the types of guidelines for testing the differential impact
social stressors most relevant to those con- of a stressor for status counterparts.
trast groups under investigation, or if one It should be noted, however, that the dif-
contrast group is more prone to report social ferential vulnerability hypothesis is most
stressors than another – or to report the commonly associated with understanding

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

gender differences in the relationship between or economic downturn have also been con-
social stressors and psychological outcomes. sidered in greater detail. Research employ-
Support for this hypothesis as an explanation ing more comprehensive measures of
for gender differences in mental health is social stressors tends to support that it is
found in work suggesting that women have differential exposure to stress rather than
fewer resources with which to cope with differential vulnerability that underlies
social stressors compared to men (Belle 1982) status differences in mental health (see
and that women are socialized in such a way Turner and Avison 2003). However, the
that depressive affect is an acceptable development of more comprehensive stress
response to stressful circumstances (for a inventories has also provided grounds for
review, see Rosenfield 1999). Most work, expanding upon the original differential
however, has failed to support this hypothesis vulnerability hypothesis. One elaboration
with respect to gender differences in psycho- of the differential vulnerability hypothesis
logical distress. For example, a direct test of specific to understanding gender differences
the differential vulnerability hypothesis in psychological distress, for example, sug-
conducted by Kessler and McLeod (1984) gests that the stronger social ties women
did not support that women are more vul- tend to experience compared to men may
nerable to the effects of stress in the predic- make them more vulnerable to the effects
tion of psychological distress compared to of their loved ones’ life stressors. Some
men. In fact, it supported the differential evidence suggests that this “cost of caring”
exposure hypothesis. The findings of this helps explain gender differences in psy-
study indicate that women report greater chological distress (Kessler, McLeod, and
exposure to social stressors than men and Wethington 1985), though it is uncertain
that this difference in stress exposure sub- whether it is of relevance in understanding
stantially accounted for gender differences other social status contrasts.
in psychological distress. Another critical issue concerning the util-
The differential vulnerability versus dif- ity of the differential vulnerability hypothesis
ferential exposure issue remains of interest is the question of whether status group differ-
to mental health researchers. Over the past ences associated with the effects of a stressor
several decades, there has been continued necessarily reflect de facto differences in vul-
interest in more broadly defining and nerability. Research utilizing the differential
measuring stressor exposure. This devel- vulnerability model has been useful in identi-
opment is critical to an understanding of fying the particular stressors that are most
the  differential vulnerability hypothesis relevant for certain social status contrasts in
because of the methodological issues that mental health outcomes. However, critics of
Kessler (1979) long ago noted. Stress the theory have noted that it cannot be
inventories have been expanded upon to assumed that these group differences stem
include a wider range of life strains, includ- from the biological and environmental
ing chronic stressors and the experience of sources of vulnerability that Kessler (1979)
prejudice and discrimination, in addition identified. Greater theoretical development
to major and potentially traumatic life of how these sources of vulnerability might
events. The characteristics of one’s social be broadly patterned by statuses such as race,
environment (e.g., school, neighborhood, class, or gender has been called for. A chal-
or workplace) and macrolevel stressors lenge to such theory making, however, is
such as the experience of a natural disaster emerging research indicating that it is not

status alone but other contextual factors Kessler, Ronald C., McLeod, Jane D., and Weth-
(e.g., role transitions) that determine the ington, Elaine. 1985. “The Cost of Caring: A
mental health impact of a particular stressor Perspective on the Relationship between Sex
(Wheaton 1990). and Psychological Distress.” In Social Support:
Theory, Research, and Applications, edited
by Irwin G. Sarason and Barbara R. Sarason,
SEE ALSO: Differential Exposure; Gender, 491–506. Dordrecht: Martinus Nijhoff.
Stress, and Health; Stress and Health Markush, R. E.. and Favero, R. V. 1974. “Epide-
miologic Assessment of Stressful Life Events,
Depressed Mood, and Psychophysiological
Symptoms – A Preliminary Report.” In Stressful
Belle, Deborah. 1982. Lives in Stress: Women Life Events: Their Nature and Effects, edited by
and Depression. Thousand Oaks, CA: Sage Barbara S. Dohrenwend and Bruce P. Dohren-
Publications. wend, 171–190. New York: Wiley.
Dohrenwend, Bruce P., and Dohrenwend, Barbara Rosenfield, Sarah. 1999. “Gender and Mental
R. 1976. “Sex Differences and Psychiatric Dis- Health: Do Women Have More Psychopathol-
orders.” American Journal of Sociology 81(6): ogy, Men More, or Both the Same (and Why)?”
1447–1454. In A Handbook for the Study of Mental Health:
Gove, Walter R. 1972. “The Relationship between Social Contexts, Theories, and Systems, edited
Sex Roles, Marital Status, and Mental Illness.” by Allan Horwitz and Teresa Scheid. New York:
Social Forces 51(1): 34–44. Cambridge University Press.
Kessler, Ronald C. 1979. “A Strategy for Studying Turner, R. Jay, and Avison, William R. 2003.
Differential Vulnerability to the Psychological “Status Variations in Stress Exposure: Implica-
Consequences of Stress.” Journal of Health and tions for the Interpretation of Research on Race,
Social Behavior 20(2): 100–108. Socioeconomic Status, and Gender.” Journal of
Kessler, Ronald C., and McLeod, Jane D. 1984. Health and Social Behavior 44(4): 488–505.
“Sex Differences in Vulnerability to Undesirable Wheaton, Blair. 1990. “Life Transitions, Role His-
Life Events.” American Sociological Review 49: tories, and Mental Health.” American Sociologi-
620–631. cal Review 55(2): 209–223.
Illness Behavior The concern with people’s responses to
symptoms and their delay in seeking medical
STELLA R. QUAH help has led to a large body of research since
Duke-NUS Graduate Medical School, Singapore the middle of the last century. One of the
earliest studies was conducted by Kutner,
Makover, and Oppenheim (1958). But it was
Mechanic and Volkart (1961) who identified
illness behavior as a precedent to seeking
What is “illness behavior”? The brief answer
medical help. They offered one of the earliest
is what people do when they first become
systematic definitions of illness behavior:
aware that “something is wrong” with their
“The way in which symptoms are perceived,
health or what people do in response to
evaluated, and acted upon by a person who
symptoms. I will discuss the conceptual and
recognizes some pain, discomfort, or other
empirical importance of illness behavior in
signs of organic malfunction” (1961, 52).
clinical and sociocultural research on health
Mechanic and Volkart distinguished illness
and illness, identifying some important
behavior from “sick-role behavior” which in
trends that impinge upon the effectiveness
their study was ascertained by the tendency
of  health services utilization and medical
to seek medical care, one of the dimensions
of Parsons’s (1951) definition of the sick role.
In a later study, Mechanic elaborated: “Illness
ILLNESS BEHAVIOR: CONCEPTUAL behavior refers to the varying ways individu-
DIMENSION OF RESPONSE TO als respond to bodily indications, how they
SYMPTOMS monitor internal states, define and interpret
symptoms, make attributions, take remedial
One obstacle to the rapid advance in our actions and utilize various sources of infor-
understanding of illness behavior is the incon- mal and formal care” (1995, 1208). Mechanic
sistency in its conceptual definition. Two rightly considers illness behavior as the key
main types of definition are found in the lit- phenomenon explaining “why the need for
erature. One type is systematic and based on care imperfectly predicts use of services”
the person’s history of an illness episode or (Mechanic and McAlpine 2010, S150).
time sequence of events, better described as A more comprehensive definition of
illness trajectory; the most precise definition illness behavior is obtained with the intro-
within this type presents illness behavior as duction of the notion of time sequence or
the intermediate stage of a three-stage illness history of the person’s illness experience
trajectory. In contrast, the second type of def- (Kasl and Cobb 1966), best conveyed by the
inition found mostly, but not exclusively, in concept of illness trajectory (Suchman
medical literature is general and ambiguous: 1965a; 1965b; Zola 1973; Mechanic 1995,
“illness behavior” is used to denote every- 1213; Carpentier et al. 2010). The analysis
thing that people do when they are sick and of  health-related behavior is more accurate
under medical care, and typically refers to when it takes into account its temporal
individuals as “patients.” dimension or trajectory in the context of the

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

individual’s personal history. The illness EVIDENCE-BASED RESEARCH ON

trajectory comprises three stages: (1) ILLNESS BEHAVIOR
preventive health behavior that involves the
actions and attitudes of people who believe Compared to studies on preventive behavior
themselves healthy toward disease preven- and sick-role behavior, evidence-based
tion; (2) illness behavior, the behavior of the research on responses to symptoms – or
person who feels ill trying to define the more  specifically illness behavior as defined
problem and to find a remedy (Kasl and above – is sparse, conceptually equivocal, and
Cobb, 1966); and (3) sick-role behavior, or comprises a wide range of methodological
what people do as patients after they have approaches. The two most common and
been diagnosed with a particular disease or related drawbacks of evidence-based studies
disability (Parsons 1951; Kassebaum and in the literature are the conceptual definition
Baumann 1965; Kasl and Cobb 1966). of the problem under investigation – response
Following the notion of a trajectory, the illness to symptoms and its conceptual version illness
behavior stage begins with the awareness of behavior – and its empirical measurement.
one or more symptoms. The individual enters The definition and hypotheses formulated
the illness behavior stage when he/she first by early researchers on illness behavior,
becomes aware that something is “wrong” mainly Mechanic and Volkart (1961),
with his/her health. Upon the perception of Mechanic (1978; 1995), Suchman (1965a;
symptoms, the individual typically assumes a 1965b), Zola (1973), and Kasl and Cobb
wait-and-see stance, hoping the symptoms (1966), have been consistently supported
will go away. If the symptoms persist or by  sparse but systematic empirical studies
increase, the individual’s procrastination, or over the past decades (Mechanic and
“temporalizing of symptomatology” – using McAlpine 2010). Other studies have explored
Zola’s (1973, 683) term – may be followed responses to symptoms using less systematic
by  attempts to solve the  problem with self- definitions of illness behavior (for example,
medication or self-treatment, searching for Andersen et al. 2010; Carpentier et al. 2010;
information, and talking about the problem Henriksson et al. 2011). The overall picture
with family, close friends, or other members that emerges from these and other evidence-
of the person’s primary or informal social based studies may be summarized as follows.
network. Eventually, the symptomatic indi- Illness behavior encompasses the timespan
vidual may seek medical care. between the individual’s first awareness of
The two poles of the illness trajectory, symptoms and his/her decision to seek expert
preventive behavior and sick-role behavior, help. If and when the individual receives
tend to receive more research attention, while and  accepts a diagnosis by a biomedical or
illness behavior, the important intermediate traditional healer whose expertise he/she
stage in the illness trajectory, was, in comparison, trusts, the individual enters the third stage
neglected until the 2000s. There is now an of  the illness trajectory, the sick role, and
increased interest in the sociological study of then  becomes a “patient.” The typical  pro-
illness behavior (Cockerham 2010, 134–56), as crastination in seeking medical help
well as in the medical literature driven by that characterizes the illness behavior stage is
improved diagnostic and treatment technolo- brought about by the individual’s effort to
gies and heightened concern with the serious sort out the fear and anxiety about the
consequences of delaying medical attention. threat of a disease and the perceived meaning

of symptoms. The intensity and seriousness with health care services, all of which are
of symptoms, together with information elements of sick-role behavior.
sought from various sources and social Additional conceptual confusion is
pressure from family and support network, brought about by the use of different terms
may eventually lead the individual to seek for the same phenomenon: for example, “care
expert advice and possible entry into the trajectory” (Carpentier et al. 2010) and
sick  role if and when a disease is actually “patient delay” (Andersen et al. 2010; Unger-
diagnosed. Saldaña and Infante-Castañeda 2011) refer to
It is important to note that, as a temporal the same time sequence addressed by illness
phase in the individual’s biography, illness behavior: “the period from the first onset of
behavior takes place irrespective of the nature symptoms to the first medical contact”
of symptoms, but the length of time spent in (Andersen et al. 2010, 378); “the period that
the illness behavior stage varies from person goes from first recognition of the symptoms
to person and – it must be reiterated – is … to the point at which the illness is diag-
influenced by many factors, including symp- nosed” (Carpentier et al. 2010, 1506). The
tom severity, level of social pressure and sup- timespan in both definitions is consistent
port from one’s informal social networks, with that used in the definition of illness
cost, and the individual’s history of health behavior given in the first section of this
services utilization. In other words, the indi- entry, but the use of the term “illness behav-
vidual is most likely to shorten the illness ior” in this type of study is inadequate for at
behavior stage and seek medical help sooner least three reasons. First, researchers who use
if one, or a combination, of these factors is the rubric “patient delay” define it operation-
present: if the individual considers the symp- ally only as the period of time between the
toms as severe, if family members or others recognition of symptoms and medical con-
in the social support network put pressure on sultation. This narrow definition does not
him/her to seek medical attention and help capture the sociocultural and economic
him/her to obtain it, if financial cost is setting where illness behavior unfolds. Second,
affordable, and if the individual has used the study subjects are typically patients – that
health services before or has a regular physi- is, at the time of the study, they had left the
cian or healer. illness behavior stage as they sought medical
Some other studies of responses to symp- care and were diagnosed. And third, the term
toms use the term “illness behavior” inaccu- “patient delay” conveys the key biomedical
rately by applying it to actions that take place concern with the unchecked advance of the
after the person seeks medical attention. The disease caused by the delay in diagnosis, but
main focus in this type of study is the behavior it  also appears to blame the patient, while
of “‘patients” – that is, people who have ignoring the circumstances and hurdles that
entered the third stage of the illness trajectory: individuals have to overcome and that are
sick-role behavior (see, e.g., Prior and Bond encapsulated in the concept illness behavior.
2007; Jae, Jang, and Lee 2008; Hilbert et al. The concept illness behavior captures more
2010; Koekkoek et al. 2011; Levy 2011; Stoller than the time delay in response to symptoms.
et al. 2011). Consequently, the data from this As the intermediate stage in the illness trajec-
type of study do not constitute illness behavior, tory experienced by every individual, illness
but rather, the patients’ responses to diagnosis, behavior sheds light on the individual’s con-
to medical treatment, and to the encounter frontation with the threat of disease, his/her

efforts at dealing with that threat, and the with no known cause. Experts indicate that the
impact of multiple sociocultural, economic, difference between a stroke and a TIA is that a
demographic, and other predictors on his/her TIA is transient and may last one to five minutes
response to symptoms and help-seeking only, leaving no permanent injury (AHA 2011).
patterns. One of these important components The briefness of the TIA leads people to ignore
of illness behavior is the influence of family the signs and carry on their usual routine with-
and other support networks. Analyzing out seeking medical attention. Experts recom-
the  trajectory to hospitalization followed by mend that a person undergoing one or more
a  group of mentally ill patients, Zola (1973, of those five stroke warning symptoms
679) concluded: “The hospitalization occurred should seek medical attention immediately.
not when the patient became sicker, but when Unfortunately, people either do not know how
the accommodation of the family, of the sur- to recognize TIAs or tend to ignore them.
rounding social context, broke down.” The Indeed, evidence from hospital data on coro-
role of the family and the family’s “accommo- nary artery disease, thrombolysis, myocardial
dation” to or level of tolerance of the sick infarction, and other diseases indicates that
member’s symptoms as an important deter- people with chest pains or other evident symp-
minant of health care utilization has been toms tend to see the problem as not serious
found in other studies (Morgan and Thomas enough to call an ambulance. But the damage
2009; Carpentier et al. 2010; Boss 2002). inflicted could have been avoided or minimized
Considering that illness behavior is the pre- if the individual or a family member, friend, or
cursor of medical attention (i.e., the stage pre- co-worker had taken early symptoms seriously
ceding sick-role behavior) and that people tend and sought medical attention earlier (e.g.,
to procrastinate, ignoring or dismissing symp- Henriksson et al. 2011; Kim et al. 2011).
toms, the neglect of this area of investigation Other illustrations of illness behavior come
belies the high significance of prompt and early from colorectal cancer (symptoms involve
medical attention for major killer diseases such blood in stools), stomach cancer (symptoms
as cancer and cardiovascular diseases, where include persistent digestive problems), and
the person may see early symptoms as mild or mental illness. Regarding the latter, the onset
harmless, especially if they last only for a short of Alzheimer’s disease illustrates vividly the
while even though they may be recurrent. challenges and importance of identifying early
One of the clearest illustrations of symptom symptoms during the illness behavior stage.
neglect and its consequences is the case of stroke Carpentier and colleagues’ (2010) study of the
warnings called “transient ischemic attacks” initial stages of Alzheimer’s disease suggests
or  TIAs. The American Heart Association that a family member may be the first per-
explained in its 2011 website page on stroke that son  to observe symptoms. The researchers’
TIAs are “warning strokes that produce stroke- description of their findings closely reflects the
like symptoms but not lasting damage,” but are process of illness behavior discussed in this
“strong predictors of stroke.” The most com- entry as undergone by the family member, not
mon five stroke symptoms are: sudden numb- the affected individual: the family member or
ness or weakness of the face, arm, or leg, family caregiver who first becomes aware of
especially on one side of the body; sudden con- the symptoms may postpone seeking medical
fusion, trouble speaking or understanding; sud- help, but searches for information, discusses
den trouble seeing in one or both eyes; sudden the matter with other family members and
trouble walking, dizziness, loss of balance or friends, and may have to sort out family disa-
coordination; and sudden, severe headache greements on the best course of action before

contacting a doctor; this process and the pro- an Analytical Framework for Understanding
crastination by the family member may take Patient Delay: A Qualitative Study of Cancer
months or years (Carpentier et al. 2010, 1503). Patients’ Symptom Interpretation Processes.”
Social Science & Medicine 71: 378–385.
Boss, P. 2002. Family Stress Management: A
CONCLUSION Contextual Approach, 2nd ed. Newbury Park,
CA: Sage.
Compared to the long-standing research Carpentier, N., Bernard, P., Grenier, A., and
interest in illness prevention and the behavior Guberman, N. 2010. “Using the Life Course
of patients (sick-role behavior), illness behavior Perspective to Study the Entry into the Illness
is a neglected area of investigation that Trajectory: The Perspective of Caregivers of
People with Alzheimer’s Disease.” Social Science
requires urgent and systematic research. One
& Medicine 70: 1501–1508.
necessary improvement is the standardiza-
Cockerham, W. C. 2010. Medical Sociology, 11th
tion of the conceptual definition of illness ed. Upper Saddle River, NJ: Prentice Hall.
behavior. The conceptual foundations were Henriksson, C., Larsson, M., Arnetz, J., Berglin-
laid down in the 1960s and 1970s by David Jarlöv, M., et al. 2011. “Knowledge and Attitudes
Mechanic, Stanislav Kasl, Sidney Cobb, Irvin Toward Seeking Medical Care for AMI-Symp-
Zola, and Edward Suchman, and these pio- toms.” International Journal of Cardiology 147:
neers also tested their constructs and assump- 224–227.
tions empirically. Their conceptual and Hilbert, A., Martin, A., Zech, T., Rauh, E., and
methodological rigor should be emulated in Rief, W. 2010. “Patients with Medically Unex-
current research. While the conceptual defi- plained Symptoms and Their Significant
Others: Illness Attributions and Behaviors as
nition of illness behavior examined in this
Predictors of Patient Functioning over Time.”
entry is robust, its operational definition or
Journal of Psychosomatic Research 68: 253–262.
empirical measurement needs to be expanded Jae, Y. M., Jang, S. H., and Lee, D. S. 2008. “The
beyond the single indicator “length of delay.” Differences in Abnormal Illness Behaviour
Equally important is the analysis of illness Questionnaire between Non-Somatization and
behavior for different diseases across cultures Somatization Groups.” European Neuropsy-
and countries at different levels of socioeco- chophamarcology 18(4): S306–S307.
nomic development. Kasl, S. V., and Cobb, S. 1966. “Health Behavior, Ill-
ness Behavior, and Sick Role Behavior.” Archives
SEE ALSO: Complementary and Alternative of Environmental Health 12: 246–55.
Kassebaum, G. G., and Baumann, B. O. 1965.
Medicine; Ethnopharmacology; Health
“Dimensions of the Sick Role in Chronic Ill-
Behavior; Health and Culture; Illness
ness.” Journal of Health and Human Behavior
Experience; Indigenous Health; Medical
6(1): 16–22.
Pluralism; Patient Trajectories
Kim, Y. S., Park, S. S., Bae, H. J., et al. 2011.
“Stroke Awareness Decreases Prehospital
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Eating Disorders families in Western or Westernized contempo-
rary societies such as South Africa and
SIMONA GIORDANO Santiago (Chile) (Katzman and Waller 1998)
University of Manchester, UK or countries that are becoming economically
emancipated, such as China (Joyce 2007).
Eating disorders (EDs) refer to a wide Studies have thus attempted to understand the
spectrum of self-harming behaviors involving social factors that may be associated with or
eating. There is a proliferation of names that even responsible for the spread of EDs. Those
seem to capture “variants” of EDs (anorexia identified in literature, in brief, are: (1) central-
athletica, healthism, orthorexia, and others). ity of the children in the family; (2) longer
However, in clinical psychology and psychia- dependency of children upon parents; (3)
try, anorexia nervosa (AN) and bulimia ner- change of the social/familial role of the woman;
vosa (BN) are thought to be the major EDs (4) abundance of food; (5) the social impera-
(APA 2000, 307.1). tive of thinness; (6) the modification of eating
AN refers to a syndrome whose central habits (culinary multiculturalism, presence of
features are dread of fatness and deliberate fast foods, missing lunch, eating alone); (7)
weight loss. Low body weight is upheld by sedentary life and increasing obesity rates
cathartic practices, aimed at reducing the (Nasser and Katzman 2003, 145). Because the
assimilation of calories. These include vomit- vast majority of sufferers are women, studies
ing (generally self-induced), abuse of laxa- have imputed EDs to the changes in the role of
tives, enemas, excessive exercise, and use of the woman in Western societies during the
appetite suppressants and/or diuretics. BN twentieth century (Bruch 1985, 9).
refers to bingeing followed by self-induced It has been argued that EDs are caused by
vomiting and other cathartic practices. EDs the conflicting and lacerating expectations
are a serious condition, with high mortality that modern societies have of women
rates, and whose causes are still under inves- (MacSween 1995). They are expected to be
tigation (Giordano 2010, Ch. 1). independent achievers and, at the same time,
AN affects about 1 percent of young women, dependent and willing to embrace their tradi-
and BN about 17 percent of college-aged tional nurturing role. According to this inter-
women (of these, 30–80 percent have had a pretation, in order to avoid the contradictions
history of AN) (APA 2000, 370.51). EDs of full womanhood, the sufferer refuses food,
increasingly affect older people and males. unconsciously refusing, in this way, to
Males are now thought to represent around become a woman (Crisp 1977).
8  percent of AN sufferers and 15 percent of These and similar studies have the merit of
BN sufferers. Males on average develop EDs highlighting the social factors that may explain
slightly later in life than women (Fichter and the spread of EDs in societies that have wit-
Krenn 2003). nessed important social changes in gender
EDs have been named “a social epidemic” roles. However, the studies fall short of explain-
(Gordon 1990) and a “culturally bound ing why men and older women are increas-
syndrome” (Nasser 1997, 14), because they ingly afflicted by the condition. They also do
appear nearly exclusively in middle-class not explain the emergence of BN, where a

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

normal weight person may have disordered portrayed, or by the sense of identity and
eating habits (Giordano 2005, Chs. 8, 10). community offered in the pro-ana Internet
Another social phenomenon that has been sites (Vandereycken 2011). The questions to
studied in connection with EDs is the spread be asked, thus, are why is thinness valuable in
of the images of emaciated models in the certain societies? Why does thinness appear
media and in the fashion industry. It has been to provide a worthwhile goal to some of those
suggested that the media may be responsible with a low sense of self-worth? (Giordano
for the spread of EDs (BMA 2000). In 2006 2005).
the Madrid regional government banned Studies of the families and societies where
overly thin models at top-level fashion shows EDs appear suggest that there may be com-
in Madrid. Reactions were mixed. New York’s mon moral values that characterize sufferers.
Elite modeling agency claimed that the ban Typically, people with eating disorders are
was discriminatory against many models, particularly sensitive to the ethics of perfec-
and would curtail the freedom and creativity tionism, discipline, austerity, hard work, spir-
of designers. The head of Marks & Spencer ituality, guilt, and the belief that the
declared it was up to the designers to decide submission of the “physical” to the “spiritual”
the size of their models. Dove, the producer is a manifestation of moral integrity. Those
of deodorants and soap, on the other hand, who develop EDs are invariably “rule-bound”
introduced “normal size models,” encourag- people. Values such as hard work, self-
ing the use of models of body mass index control, responsibility, intellectual achievement,
(BMI) between 18 and 25, in accordance with postponing gratification to work, and not
the United Nations guidelines for health accepting any form of pleasure unless it is
(Giordano 2010, Ch. 5). earned are typically those around which the
Similar concerns have been raised around life of the person with EDs is organized. Food
another recent phenomenon: the dissemina- and fat are the expression of the most repug-
tion of pro-anorexia (or, colloquially, pro- nant vices: indolence, weakness, and moral
ana) sites on the web. These websites typically collapse. This is why, paradoxically, the frailer
portray AN as “a friend” or an achievement. the emaciated sufferers become, the more
They contain advice on how to become ano- powerful and invulnerable they feel, and also
rexic, on how to trick others, and on how to why BN, with its lack of control over food, is
maintain low body weight. The worry is that a reason for shame and guilt.
by idealizing anorexic behavior, these sites may The values that seem to underpin EDs are
induce people to fall into the trap of EDs and deeply rooted in Western societies – but per-
contribute to the spread of the disorder haps EDs are not just a phenomenon of mod-
(Vandereycken 2011). ern times: the history of self-starvation and
Whether or not it is true that the media or body castigation (for example, religious fast-
the Internet contribute to  the onset of the ing, political fasting, use of corsets for women
spread of EDs remains undecided. It is, for of the 1800s) is indeed much older than the
example, unclear why only a minority of first nosological classifications of AN and BN
those exposed to very thin top models (Vandereycken and Van Deth 1994). Maybe
develop eating disorders. It is also suggested this is why EDs are so difficult to understand
that the vulnerability to media and Internet and resolve: they perhaps spring from a ter-
images depends on low self-esteem, low rain, and from a moral background, that is
sense  of self-worth, and other underlying common to EDs sufferers and the socio-
vulnerabilities, triggered by the images cultural groups in which they arise.

SEE ALSO: Culture-Bound Syndrome; Mental Giordano, S. 2010. Exercise and Eating Disor-
Health; Mental Illness in Adolescence and ders: An Ethical and Legal Analysis. London:
Young Adulthood; Mental Illness and the Routledge.
Media; Mental Illness and Psychiatry Gordon, R. 1990. Anorexia and Bulimia, Anatomy
of a Social Epidemic. Oxford: Blackwell.
Joyce, L. C. 2007. “‘Meanings of Eating Disor-
ders Discerned from Family Treatment and Its
Implications for Family Education: The Case of
APA (American Psychiatric Association). 2000. Shenzhen.” Child and Family Social Work 12(4):
Diagnostic and Statistical Manual of Mental 409–416.
Disorders, DSM-IV-TR (Text Revision), 4th Katzman, M. A., and Waller, G. 1998. “Gender of
ed. Washington, DC: American Psychiatric the Therapist: Daring to Ask the Questions.”
Association. In Treating Eating Disorders: Ethical, Legal
BMA (British Medical Association). 2000. Eating and Personal Issues, edited by W. Vander-
Disorders, Body Image and the Media. London: eycken and P. J. V. Beumont, 56–79. New York:
British Medical Association. Athlone.
Bruch, Hilde. 1985. “Four Decades of Eating Dis- MacSween, M. 1995. Anorexic Bodies: A Feminist
orders.” In Handbook for the Psychotherapy of and Social Perspective. London: Routledge.
Anorexia Nervosa and Bulimia, edited by D. M. Nasser, M. 1997. Culture and Weight Conscious-
Gardner and P. E. Garfinkel, 7–19. New York: ness. London: Routledge.
Guilford Press. Nasser, M., and Katzman, M. 2003. “Sociocultural
Crisp, A. H. 1977. “Diagnosis and Outcome of Theories of Eating Disorders: An Evaluation in
Anorexia Nervosa; The St George’s View.” Pro- Thought.” In Handbook of Eating Disorders, 2nd
ceedings of the Royal Society of Medicine 70: ed., edited by J. Treasure, U. Schmidt, and E. Van
464–470. Furth, 139–150. Chichester, UK: Wiley.
Fichter, M., and Krenn, H. 2003. “Eating Disorders Vandereycken, W. 2011. “Can Eating Disorders
in Males.” In Handbook of Eating Disorders, 2nd Become ‘Contagious’ in Group Therapy and
ed., edited by J. Treasure, U. Schmidt, and E. Van Specialized Inpatient Care?” European Eating
Furth, 369–383. Chichester, UK: Wiley. Disorders Review 19(4), 289–295. doi: 10.1002/
Giordano, S. 2005. Understanding Eating Disor- erv.1087.
ders. Conceptual and Ethical Issues in the Treat- Vandereycken, W., and Van Deth, R. 1994. From
ment of Anorexia and Bulimia Nervosa. Oxford: Fasting Saints to Anorexic Girls: The History of
Oxford University Press. Self-Starvation. London: Athlone.
Biobanks and DNA their potential to be resources to improve
human health, governments envisaged that
Databases such biobanks could also provide the means
RICHARD TUTTON for boosting national biotechnology and
Lancaster University, UK pharmaceutical industries. The most famous
example is that of deCODE Genetics Inc.,
In Spring 2009, Time magazine produced a which aimed to combine genetic, genealogi-
list of ten ideas which it considered were cal, and health care data on the Icelandic pop-
changing the world. At number eight was ulation in the bid to develop new medicines.
biobanks. Since the late 1990s, significant Following in the footsteps of this Icelandic
investment has been made in the creation of initiative, projects in other countries such as
biobanks all over the world both for law- Great Britain (1998), Estonia (1999), Norway
enforcement purposes to aid identification of (1999), Singapore (2000), Tonga (2000),
criminal suspects and to advance biomedical Latvia (2001), and Japan (2003) emerged to
research. This entry focuses only on this sec- establish population-based biobanks. For
ond kind of biobank. It has been estimated governments in these countries, biobanks
that more than US$1 billion has been invested were represented as ways of using DNA as an
in biomedical biobanking by research agen- economic resource to generate inward invest-
cies, governments, academic institutions, ment in capital and jobs to these economies.
pharmaceutical and biotechnology compa- Many of these initiatives involved state
nies, medical charities, and disease advocacy medical research agencies working in part-
organizations. To some extent, these initia- nership with commercial companies, leading
tives build on a longer history of medical and academic institutions, or medical charities.
genetic registers and epidemiological cohort With varying success since the early 2000s,
studies. The term biobank itself describes a the leaders of such biobanks have sought
diverse range of activities, from research in funding to establish their databases and
epidemiology of common complex diseases, storage facilities and commenced enrolment
pharmacogenetics, rare genetic diseases, of volunteers. While some have been success-
oncology, and stem cells, to therapeutic appli- ful, others have fallen by the wayside and
cations such as blood transfusion or organ closed down.
transplantation. Given this, biobanks are also Population-based biobanks, as promoted
characterized by multiple expectations about in these countries, depended on the enrol-
their potential to be used to develop new sci- ment of large numbers of public volunteers,
entific knowledge and new diagnostics and and were designed as prospective resources to
therapeutics. facilitate open-ended research. As such, they
During the “genomics” speculative bubble highlighted the need to revisit existing ethical
of the late 1990s, a number of national gov- and governance arrangements and to con-
ernments supported the creation of biobanks sider which new ones needed to be established.
designed for research into the genetic causes The issue of consent emerged as a dominant
of common, complex diseases. As well as concern of much academic scholarship on

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

prospective biobanks (Hoeyer 2008). Since biobanks and the prospect of their commercial
they are designed to be used by multiple exploitation by firms have been a thorny
researchers over a potentially long period of issue. This has prompted social scientists to
time, it is not possible to tell individuals who explore questions of benefit-sharing and ways
provide them with both biological samples of negotiating public and private interests in
and personal data how these will be used in biobanks. The thrust of these contributions is
the future with any degree of specificity. This that those in charge of biobanks need to rec-
has led most biobanks to adopt a broad con- ognize that some form of reciprocation is
sent approach, which provides only a general necessary for the free, voluntary contribu-
sense to volunteers of the kinds of research tions of individuals and families to these
that will be undertaken. Given the open- resources (Haddow et al. 2007).
ended nature of biobanks, questions of trust, While significant academic interest has
data security, confidentiality, and commercial been shown in prospective biobanks, efforts by
exploitation have also come to the fore. Social pharmaceutical companies to establish DNA
scientists, legal scholars, and ethicists have all databases from individuals who participate in
called for meaningful public engagement on clinical trials has attracted less attention.
these issues and a number of biobanks have Corporate-held DNA databases are not as
undertaken various forms of community and closely well-documented or scrutinized, partly
public consultations (Godard et al. 2004). because information about the size, scope, and
These efforts could be read in part as a nature of these databases is commercially sen-
response to the problems that deCODE sitive. However, some social scientists have
Genetics Inc. encountered in Iceland, where investigated the way that pharmaceutical com-
the firm faced legal challenges and organized panies such as GlaxoSmithKline, Novartis,
resistance to some of its plans. AstraZeneca, Roche, and Pfizer have routinely
However, academic commentators and and systematically collected biological samples
policymakers have sometimes found efforts from clinical trials to build up large collections
at public consultation to be wanting because of both tissue and personal patient informa-
of the way they are narrowly defined and con- tion since the 1990s (Lewis 2004). The primary
trolled to the exclusion of addressing more reason for doing this has been to support
substantial issues (Petersen 2007). In Great research in pharmacogenomics and biomarker
Britain, the UK Biobank put significant effort discovery.
into formulating an “ethics and governance Attention has also been given to disease
framework” for the resource, and one of its advocacy organizations and how they have
funders – the Wellcome Trust – helped estab- also become players in establishing disease-
lish a quasi-independent body to provide specific biobanks with the aim of producing
oversight of its implementation. Some social therapies for people with these conditions.
scientists have played a role in this process. One notable example is that of PXE (pseudo-
On the other hand, biobanks in other coun- xanthona elasticum) International, a disease
tries, such as Japan, appear to have been advocacy organization based in the United
developed with little consultation with either States that has helped to promote research on
the public or the academic community this rare genetic condition. Concerned that
(Triendl and Gottweis 2008). Therefore, different groups of researchers were engaged
social science has called attention to the in taking and storing multiple tissue samples
national differences involved. Moreover, but not collaborating with each other in the
the  anticipated economic benefits of such interests of the people affected by the condi-

tion, PXE International set up a genetic register. Haddow, G., Laurie, G., Cunningham-Burley, S.,
By holding the tissue to which scientists then and Hunter, K. G. 2007. “Tackling Commu-
had to negotiate access, the organization was nity Concerns about Commercialisation and
in a position to exercise some control over Genetic Research: A Modest Interdisciplinary
Proposal.” Social Science & Medicine 64(2):
research into this condition and to promote a
coordinated effort to identify the gene
Hoeyer, K. 2008. “The Ethics of Research Biobank-
involved. This proved to be a successful strat- ing: A Critical Review of the Literature.”
egy. In Britain, Breakthrough Breast Cancer Biotechnology and Genetic Engineering Ethics
has also collaborated with research scientists 25: 429–452.
to establish its own prospective biobank, Lewis, G. 2004. “Tissue Collection and the Phar-
called Breakthrough Generations, that aims maceutical Industry: Corporate Biobanks.” In
to study the genetic, environmental, and life- Genetic Databases: Socio-Ethical Issues in the
style factors involved in the development of Collection and Use of DNA, edited by R. Tutton
breast cancer. and O. Corrigan, 181–202. London: Routledge.
Biobanks, whether designed for epidemio- Petersen, A. 2007. “Biobanks’ ‘Engagements’:
logical, pharmacogenetic, cancer, or stem cell Engendering Trust or Engineering Consent?”
Genomics, Society and Policy 3(1): 31–43
research, continue to be important elements in
Triendl, R. and Gottweis, H. 2008. “Governance
the contemporary landscape of biotechnology
by Stealth: Large-Scale Pharmacogenomics and
and biomedicine. Over the next decade, Biobanking in Japan.” In Biobanks: Govern-
biobanks may well come to play increasingly ance in Comparative Perspective, edited by H.
important roles in stem cell research and in the Gottweis and A. Petersen, 123–140. London:
identification of the causes of common, com- Routledge.
plex diseases, amongst other things. As poten-
tial discoveries are made and interventions FURTHER READING
developed, some of the issues discussed above
are likely to come to the fore again. Arnason, G., Nordal, S., and Arnason, V., eds.
(2004) Blood and Data: Ethical, Legal and Social
SEE ALSO: Biomedical Techniques and Aspects of Human Genetic Databases. Reykjavík:
Innovations; Genetics and Genomics in Public Haskolautgafan.
Health; Health; Technology; Tissue Economies Faulkner-Sleebom, M. 2008. Human Genetic
Biobanks in Asia: Politics of Trust and Scientific
Advancement. London: Routledge.
Gottweis, H. and Petersen, A., eds. 2008. Biobanks:
Godard, B., Marshall, J., Laberge, C., Knoppers, Governance in Comparative Perspective. Lon-
B. M. 2004. “Strategies for Consulting with the don: Routledge.
Community: The Cases of Four Large Scale Tutton, R. and Corrigan, O., eds. 2004. Genetic
Genetic Databases.” Science and Engineering Databases: Socio-ethical Issues in the Collection
Ethics 10(3): 457–478. and Use of DNA. London: Routledge.
Bourdieu, Pierre can be defined as a social arena or space,
bounded in experiential context, in which
SASHA SCAMBLER actors attend to the self and/or a given situa-
King’s College London, UK tion. Each field encompasses a series of struc-
tural configurations incorporating both
INTRODUCTION power and social relations. These structural
configurations affect the actions of all those
Pierre Bourdieu (1930–2002) is widely within the field and prompt certain types of
regarded as a social theorist who provides a behavior influenced by the distribution and
framework through which to explore the transaction of various forms of capital, which
interplay between structure and agency, power may be field-specific or cut across multiple
and capital, giving an insight into the complex- fields. The field, then, can be seen as a struc-
ities of daily life in whichever sphere we choose tured space in which people act and which is
to study (Jenkins 2002; Scambler and Newton shaped by the actions of those within it and
2011). Bourdieu’s concepts of field and habitus which also imposes constraints on those
seek to address the ways in which agency and actions, and capital is the resource used to
reflexivity (habitus) are shaped by or embed- negotiate through and act within the field. It
ded within structure (field) (Bourdieu 1990; may be possible to transfer capital between
1999; Bourdieu and Wacquant 1992). Bourdieu fields, but the value of the capital may vary
believes that the phenomena which make up according to the structural constraints of
the social world in which we live are not natu- each specific field (Behague et al. 2008).
rally occurring, to be studied in isolation, but Bourdieu identifies four different types of
socially constructed, culturally and historically capital which operate within and across fields.
bounded, and temporal in nature. He rejects, These are economic, social, cultural, and
however, the label of theorist, describing his symbolic capital. Economic capital relates to
work as a means of interpreting the empirical commodities such as money, wealth, and
world in which we live. Furthermore, he rejects property and is institutionalized through laws
the notion of creating theory divorced from such as those concerning property rights or
empiricism and, undoubtedly, the concepts of through the welfare system. Economic capital
field, habitus, and capital give us practical tools may refer to income through a salary, but also
with which to examine the empirical world incorporates benefits, welfare, and other
and to think about the role of the researcher in funds available to people. This is particularly
conducting such an examination. important when using Bourdieu’s framework
to explore the experiences of people living
with chronic illnesses or disabilities, where
FIELD AND CAPITAL this kind of alternative state or charity fund-
ing may play an increasingly important role
The space within which the relations and in economic capital transactions. Social capi-
transactions of the empirical world are tal relates to the relationships and support
located, for Bourdieu, is the “field.” The field networks available to people and to social

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

obligations that they may have. These include within fields is to successfully maintain or
formal (professional) and informal (family improve their positions within the field, and the
and friendship) networks, and may be con- ability to do this depends on their ability to
vertible to economic capital and institutional- negotiate the power structures within the field.
ized through social networks. The third type These take the form of socioeconomic, gender,
of capital, cultural capital, is based on socially age, and ethnic divisions, but can also be seen in
“legitimated” knowledge and practices, which cultural commonalities. Social hierarchies, and
in certain circumstances are convertible to even patterns of bodily form and deportment,
economic capital and institutionalized are reproduced through practice and evaluated
through educational qualifications and mem- and accorded differential status and social, cul-
bership of professional bodies. In a health tural, and economic values in a pre-existing
context, the accumulation and ability to field according to the structures at work within
mobilize this form of capital is relevant to that field. This leads Bourdieu to his concept of
debates around the legitimated power of the habitus, the agentic part of his theory.
medical profession or the expert patient/
empowerment debate. Finally, symbolic capi-
tal is identified by Bourdieu as the status, HABITUS AND BODILY HEXIS
honor, or prestige ascribed to particular insti-
tutions, groups, or social relations. Symbolic The field is the structured social space within
capital is institutionalized through systems which people act, and capital is the resource
which ascribe status such as that associated available to people within and across fields.
with parental authority or the peerage. Habitus concerns the role of agency, choice,
Symbolic capital is of particular interest and individual action and is the second part
within the health field when the symbolic of Bourdieu’s theoretical framework. As
capital of individual adults or parents is chal- such, habitus is the agentic part of Bourdieu’s
lenged by, or clashes with, health policy or the theory and reflects the unthinking or uncon-
legitimated cultural capital of the medical scious ways in which people act on a day-to-
profession. This can create barriers to the day basis. These actions are shaped by the
mobilization of capital for people within the knowledge that we acquire through the pro-
field and is of particular interest in light of cess of socialization (Layder 1994) and by the
debates about patient-centered care, empow- social context or field in which habitus is
erment, and the expert patient. These four exercised. Habitus can be seen then as the
types of capital are the currency via which ways in which we think and act, as influ-
actors negotiate their way through fields. enced by the social environment within
They may be used across fields, but their which act. When seen in the context of
equivalent value in each field will be depend- health, the ways in which our bodies act
ent on the specific nature of that field and its “become shaped through daily unconscious
structural configurations. practices that are nonetheless related to
The structure within a field determines the social relations of class, gender and ethnicity
and balance of power both within and between operating in society” (McDonnell et al. 2009,
species of capital and fields. Although the 43). The choices that we make in relation to
accrual of capital yields power, capital requires a promoting health or damaging behaviors are
field in which to operate, and the value of thus shaped or constrained by the structured
accrued capital is not always directly transfera- environment (materially and culturally) in
ble between fields. The primary aim of people which such decisions are made. Habitus is

shaped by the social/structural context of the habitus are congruent, social, economic, and
field in which it is exercised, and throughout psychological capital are accumulated which
the interaction between field, capital, and provide them with the resources for life. If
habitus, the structure is both produced and this congruity is challenged or absent, then
reproduced. the ability to accumulate such capital is also
Bourdieu suggests that actors move compromised (Forbes and Wainwright 2001).
through a series of fields throughout their Bourdieu terms the awareness of moving
lives, but that most fields are familiar to them, through a non-doxic field and the need to
or doxic. By this, he means that we under- adapt and moderate habitus within the field
stand how we are supposed to act within the as reflexivity. Capacity for reflexivity is indi-
field and the types of capital which will enable vidual and may develop as an altered state of
us to negotiate our way through the field suc- habitus or as a required constituent of a par-
cessfully. Most actors within the field of ticular field. As such, reflexivity is exercised
higher education, for example, will be aware within the structured environment of the
of the power structures within the university field in which it is utilized or enacted. Thus,
and academy and the types of cultural and parents who seek to develop medical knowl-
symbolic capital, predominantly in the form edge and skills to enable them to best care for
of academic qualifications and professional a child with a rare condition must fight to get
esteem, that are required to successfully their knowledge and skills legitimated within
negotiate the field. This understanding of the dominant biomedical structure in which
how to act in a familiar field does not mean they find themselves (Scambler and Newton
that there is no space for deliberate and inten- 2011). Similarly, parents seeking to transmit
tional actions, but rather that these deliberate dominant cultural values through involve-
and intentional actions are located within the ment in their children’s education may face a
logic of experiences of reality within a known greater challenge if the field of academia is
social context. This is what Bourdieu terms as non-doxic (Reay 1998). Thus, those with
doxic habitus. In his own words: “Each agent, direct experience of academic expectations
wittingly or unwittingly, willy nilly, is producer and/or achievement (middle-class parents)
and reproducer of objective meaning … it is are involved in a process of replicating habi-
because the subjects do not, strictly speaking, tus within their children, while those without
know what they are doing that what they do this background/social position/capital base
has more meaning than they know” (cited in (working-class parents) are involved in the
Williams 1995, 582). far harder task of transforming habitus. In
Some fields that people find themselves in, this way “choices” given to people, whether
however, are categorized as non-doxic. These concerning the type of school that their chil-
are fields in which actors do not know the dren attend, or the hospital which best meets
structural configurations or what is expected their particular needs, may be rendered
of them. Non-doxic fields are exemplified by meaningless to those who lack the resources
chronic illness fields, such as that of Batten to make a meaningful choice.
disease (see Scambler 2012; Scambler and The importance of habitus as individual
Newton 2011), where actors find themselves, action shaped, but not determined, by struc-
often reluctantly, within an alien field know- ture can be illustrated through Bourdieu’s
ing neither the power structure nor the types work on lifestyle. He suggests that individual
of capital needed to negotiate the field. lifestyle choices are inherently structured
Bourdieu suggests that when a field and through the internalization of class conditions

transforming them into personal disposi- and talk. The embodied nature of habitus is
tions toward action. While no two people referred to by Bourdieu as bodily hexis.
can have exactly the same experiences, Bodily hexis is the manner and style in
Bourdieu suggests that people from the which actors carry themselves and is where
same social class background are more likely the personal combines with the social. It is
to share similar experiences and be required also where illness, disability, or bodily
to act as a result of finding themselves in abnormality affects the actors and may
similar situations than those from other become visible or obvious. This is of partic-
class backgrounds. This leads to a shared ular interest as a way of exploring the impact
disposition toward the adoption of certain of disability or long-term illness on everyday
lifestyles amongst members of the same life. Bourdieu sees the body as the physical
social class. Taking this further, and based embodiment of the foundations of habitus
on his work Distinction (1984), which that we learn, knowingly or unknowingly,
explores the lives of French professional and through the process of socialization from
working-class respondents, Bourdieu devel- childhood. This raises interesting questions
oped the idea of “distance from necessity” to about the impact of illness or impairment on
explain class-based differences in lifestyle bodily hexis. Does an impaired body result
choices. The situations in which people find in impaired bodily hexis? And what is the
themselves can be understood in relation to impact of this on capital accumulation and
the degree of economic necessity involved. transactions and the ability to successfully
Thus, those with the least material resources negotiate a field? Bourdieu’s theory can be
focus on obtaining items of necessity (cheap seen as providing a new way of exploring
filling food, shelter, clothing), while those structured and agentic experiences of disa-
with more capital resources can make bility, pulling together ideas of oppression
choices which are less driven by necessity and discrimination with personal experi-
and reflect different priorities – such as ences and agency.
health. The further an individual is from
“necessity,” the more it is that lifestyle
choices become concerned with social and THE RELEVANCE OF BOURDIEU TO
cultural capital accumulation and with HEALTH AND ILLNESS
attaining higher status through the adoption
of increasingly specialized lifestyle choices. The main criticisms of Bourdieu’s work
This is particularly useful in relation to the stem from the charge that he is unnecessar-
theory of health lifestyles (Cockerham ily structurally deterministic (see Adams
2013), as it reinforces the structural dimen- 2006) and, while talking about agency, has
sion of lifestyle practices. developed a concept of agency that is struc-
Habitus concerns the ways in which people turally bounded. If Bourdieu’s work is used
think and understand and act. It is not, in the way that he suggests, however, as a
however, merely an abstract concept that tool to help researchers to think about their
manifests itself in different types of behav- empirical data, or a practical framework
ior. For Bourdieu, habitus is “embodied through which individual experiences can
behavior.” Learned dispositions, thought be contextualized, this allows us to look both
processes, and attitudes can be seen in the at the everyday experiences of individuals
ways that people move, carry themselves, living in varying states of health and illness,

and at the impact of structure (power, gen- Bourdieu, Pierre. 1984. Distinction. Cambridge
der, ethnicity, social class) on  these daily MA: Harvard University Press.
lives. Bourdieu’s work incorporates individ- Bourdieu, Pierre. 1990. The Logic of Practice. Cam-
ual action and structure in a way which bridge, UK: Polity.
Bourdieu, Pierre. 1999 The Weight of the World:
allows us to explore both individual actions
Social Suffering in Contemporary Society. Cam-
and choices and the structural factors which
bridge, UK: Polity.
shape or influence these actions. Bourdieu’s Bourdieu, Pierre, and Wacquant, Loïc. 1992 An
framework, as I have previously argued Invitation to Reflexive Sociology. Cambridge:
(Scambler 2012), can offer us a sophisti- Polity.
cated way of exploring the impact of health Cockerham, William. 2013. “Bourdieu and an
on daily life, whether through charting Update on Health Lifestyle Theory.” In Health
the  daily lives of people living with long- Sociology on the Move: New Theoretical Direc-
term conditions (Scambler and Newton tions, edited by W. Cockerham. Dordrecht:
2010; 2011), exploring the negotiation of Springer.
health  and medication (Lumme-Sandt and Emirbayer, Mustafa, and Williams, Eva M. 2005.
Virtanen 2002), or examining health care “Bourdieu and Social Work.” Social Service
Review 79: 689–724.
encounters (Behague et al. 2008). Emirbayer
Forbes, Angus, and Wainwright, Stephen. 2001.
and Williams (2005) use the field and the
“On the Methodological, Theoretical and
power structures within it to explore the Philosophical Context of Health Inequalities
provision of homeless services in New York Research: A Critique.” Social Science and Medi-
City. In addition, there is plenty of evidence cine 53: 801–816.
that the types of capital outlined by Bourdieu Jenkins, Richard. 2002. Pierre Bourdieu. London:
are both affected by health, illness, old age, Routledge.
social class, disability and also affect the Layder, Derek. 1994. Understanding Social Theory.
ability of people living with illness or disa- London: Sage.
bility to manage their lives on a day-to-day Lumme-Sandt, Kirsi, and Virtanen, Pekka. 2002.
basis. The concepts of field, capital, and “Older People in the Field of Medication.” Soci-
ology of Health and Illness 24: 285–304.
habitus allow us to explore these complex
McDonnell, Orla, Lohan, Maria, Hyde, Abbey, and
interrelations in a fresh way.
Porter, Sam. 2009. Social Theory, Health and
Healthcare. Basingstoke, UK: Palgrave Macmillan.
SEE ALSO: Contemporary Theory; Disability Reay, Diane. 1998. “Cultural Reproduction: Moth-
and Chronic Illness; Habitus, Class, and ers’ Involvement in Their Children’s Primary
Health; Social Capital Schooling.” In Bourdieu and Education: Acts
of Practical Theory, edited by M. Grenfell and
REFERENCES D. James, 55–70. London: Routledge.
Scambler, Sasha. 2012. “Long-term Disabling
Adams, Matthew. 2006. “Hybridizing Habitus and Conditions and Disability Theory, a Socio-
Reflexivity: Towards an Understanding of Con- logical Perspective.” In Routledge Handbook
temporary Identity?” Sociology 40: 511–528. of Disability Studies, edited by N. Watson, C.
Behague, D. P., Kanhonou, L. G., Filippi, V., Legonou, Thomas, and A. Roulstone, 136–150. London:
S., and Ronsmans, C. 2008. “Pierre Bourdieu and Routledge.
Transformative Agency: A Study of How Patients Scambler, Sasha, and Newton, Paul. 2010. “Where
in Benin Negotiate Blame and Accountability in the Biological Predominates: Habitus, Reflexiv-
the Context of Severe Obstetric Events.” Sociology ity and Capital Accrual within the Field of Batten
of Health and Illness 30: 489–510. Disease.” In New Directions in the Sociology of

Chronic and Disabling Conditions: Assaults on the Personal Capital in a Lifeworld Under Attack.”
Lifeworld, edited by G. Scambler and S. Scambler, Social Theory and Health 9: 130–146.
77–105. London: Routledge. Williams, Simon. 1995 “Theorising, Class, Health
Scambler, Sasha, and Paul Newton. 2011. “Capital and Lifestyles: Can Bourdieu Help Us?” Sociol-
Transactions, Disruptions and the Emergence of ogy of Health and Illness 52: 577–604.
Health Administration and executive leadership. The derivation of
“administration” from the Latin administrare,
DAVID HUGHES meaning to serve, carries a passive connotation
Swansea University, UK that is unattractive to contemporary “manag-
ers.” In many countries, including the United
Health administration can be understood as a States and the United Kingdom, one may dis-
process of organizing personnel and resources cern a kind of natural history whereby early
to achieve defined institutional goals. It can control of health care organizations by physi-
encompass such activities as management and cian administrators gave way to an era when
supervision, governance, planning or organiz- professionals were supported by bureaucratic
ing service delivery, budgeting, human resource administrators, and then to the appearance of
management, logistics, and the provision of more powerful general managers working in
bureaucratic services, including general corporatized or “new public  management”
administrative support and information and (NPM) environments that threaten to erode
communication technologies. Health admin- professional power (Shortell et al. 1996;
istration takes place in a wide range of supervi- Harrison and Lim 2003). The discourses of
sory, purchaser, and provider organizations. In administration, general management, and,
the commercial environment of an American more recently, leadership provide revealing
Health Maintenance Organization (HMO) the insights into the changing division of labor
work may cover such areas as provider creden- and distribution of power within health care
tialing, underwriting, claims validation, and organizations (Learmonth 2005).
marketing, while activity in an English National The shared knowledge base of scientific
Health Service Clinical Commissioning Group medicine may be seen as a convergent force
(CCG) may be more concerned with commis- which pushes health care systems in a similar
sioning, procurement, and quality assurance. direction, but approaches to administration
Traditionally, administration has been seen as are more diverse and subject to shorter-term
involving the interpretation and implementa- cycles of change. The content and style of the
tion of policy rather than policy formation work in, for example, a provincial health office
itself, but this distinction is breaking down as in a developing country, a Western European
senior managers become more involved in social insurance fund, an English CCG, and a
policy networks. Health administration is US HMO are strikingly different. There is lit-
increasingly undertaken by specialized and tle consensus about the core expertise of
appropriately qualified personnel, although administration, so that at different times and
sometimes health care professionals may take places the “product” that administrators offer
on administrative responsibilities in tandem varies markedly. It may range across a spec-
with, or instead of, their clinical duties. trum from basic accountancy, office, and
Health administrators operate on a terrain financial management skills, to the techniques
that can be highly politicized and conflictual. associated with “administrative science,” and
Administration itself is a controversial term on to notions such as general management,
that in many health care systems is being transformational leadership, and the new
displaced by notions of general management public management. Administrators have

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

often been the conduit via which innovations been growing interest in the role of networks
from the business sector, such as total quality and integrated working in the reorganization
management (TQM), Six Sigma, and pay-for- of health care services. These changes have
performance (PFP), enter the health domain. led some to argue that NPM is a transitional
Sometimes these developments are little more step on the path toward new forms of decen-
than fads and fashions having little cumula- tralized governance, arm’s length regulation,
tive impact, but in many countries changing and steering. Significant changes in regulatory
administrative practices are related to the rise structures and the use of networks operating
of neoliberal policies that presage a longer- across organizational boundaries can be
term trend toward markets and competition. observed in many nations, but it is easy to
Administration in many countries has been underestimate the continuing role of line-of-
affected by the rise of rationalized manage- command management in systems that often
ment instruments and approaches affecting contain contradictory centralizing and
both private and public systems. US-style decentralizing tendencies.
managed care has had a near-global influence, The above developments have the potential
even where health care markets are relatively to transform the landscape of administration,
underdeveloped, through innovations such particularly in terms of relationships between
as tariff-based reimbursement, utilization professionals and managers. More profes-
review, shorter hospital stays, redesigned pro- sionals have been drawn into management
vider incentives and selective contracting. roles, so that many occupy hybrid positions
Public systems have adopted NPM-style combining organizational and clinical
reforms (Hood 1991; Osborne and Gaebler responsibilities, with uncertain implications
1992) such as the introduction of decentral- for professional autonomy (Fitzgerald and
ized cost centers, clinical budgets, contracting Ferlie 2000). For some commentators this
out of specialist services, and internal markets. heralds the deprofessionalization of medicine
At the management level, this has translated (McKinlay and Arches 1985), while others
into greater emphasis on accountability and contend that professional power has been
performance, measured via such tools as key consolidated through the emergence of new
performance indicators, outcomes targets, professional strata that remain under medical
and benchmarking. In many nations, the new control (Freidson 1984). The restratification
management tools have gone hand in hand thesis is less developed in relation to lay
with shorter employment contracts, individu- administrators, but it seems clear that chang-
alized targets, annual performance review, ing economic and political contexts have
and performance-related pay. resulted in the parallel emergence of new
The traditional view of administration is strata within health care administration. For
closely wedded to the exercise of rational-legal example, where corporate health care is
authority in the Weberian bureaucracy, char- strong, one may discern the presence of a cor-
acterized by hierarchical organization, top- porate elite, resembling business elites in
down control, rational allocation of tasks to other sectors, which sits above the various
offices, and a well-developed system of rules. levels of operational management and the
However, in the health domain many admin- administrators working within functional
istrators find themselves working in market or management divisions. There is little social
market-like environments, or within hybrid science research on these new layers of
institutional settings in the space between management, or, perhaps more surprisingly, on
market and bureaucratic hierarchy. There has the “middle managers” and the army of “lower

participants” (Mechanic 1962) – secretaries, within which administrators work, remain

clerks, receptionists, IT staff – who are an relatively neglected.
established part of most health care systems.
The gender and social class order of manage- SEE ALSO: Care, Managed; Countervailing
ment hierarchies appears to change markedly Powers; Health Maintenance Organization
as one moves from top to bottom, but much (HMO); Health Professions and Organization;
work remains to be done to investigate inter- Neoliberalism and Health; Rationalization
system variations.
Although the balance of power between
administrators and professionals is changing,
there are no clear winners in many systems Fitzgerald, Louise, and Ferlie, Ewan. 2000. “Profes-
around the world. In such situations the sionals: Back to the Future?” Human Relations
contemporary dynamic of administrator/pro- 53: 713–739. doi: 10.1177/0018726700535005.
Freidson, Eliot. 1984. “The Changing Nature of
fessional relations is well captured by the the-
Professional Control.” Annual Review of Sociol-
ory of countervailing powers (Light 2004). The
ogy 10: 1–20.
concept refers to the existence of competing Harrison, Stephen, and Lim, Jennifer. 2003. “The
forces – including the state and employers as Frontier of Control: Doctors and Managers in
payers, purchasing and provider organizations, the NHS 1966 to 1997.” Clinical Governance 8:
the pharmaceutical and medical services 13–18. doi: 10.1108/14777270310459922.
industries, and patients/consumers – which Hood, Christopher. 1991. “A Public Management
pursue divergent interests, sometimes by form- for All Seasons?” Public Administration 69:
ing alliances with other parties. Administrators 3–19. doi: 10.1111/j.1467-9299.1991.tb00779.x.
become implicated in these struggles for domi- Learmonth, Mark. 2005. “Doing Things with
nance as agents of their employing organiza- Words: The Case of ‘Management’ and ‘Admin-
istration.’” Public Administration 83: 617–637.
tions and,  depending on their positions, as
doi: 10.1111/j.0033-3298.2005.00465.x.
enforcers of government or corporate policies.
Light, Donald W. 2004. “Introduction: Ironies
But in pluralistic societies, the balance of of Success: A New History of the American
advantage may ebb and flow over time, so that, Health Care ‘System.’” Journal of Health and
for  example, in the United States, a period of Social Behavior 45: 1–24 (Extra Issue: Health
professional dominance gave way to a buyers’ and Health Care in the United States: Origins and
revolt and the rise of managed care, and then a Dynamics).
consumer backlash that left the way open for McKinlay, John. B., and Arches, Joan. 1985.
the reconsolidation of professional power. “Towards the Proletarization of Physicians.” Inter-
Sociological studies of health administra- national Journal of Health Services 15: 161–195.
tion remain thin on the ground and have Mechanic, David. 1962. “Sources of Power of
focused mainly on professional/management Lower Participants in Complex Organizations.”
Administrative Science Quarterly 7(3): 349–364.
relations, the changing discourses of manage-
Osborne, David, and Gaebler, Ted. 1992. Reinvent-
ment, and the normative or symbolic influ-
ing Government. Reading, MA: Addison-Wesley.
ences affecting management work. Topics Shortell, Stephen M., Gillies, Robin R., Anderson,
such as the internal differentiation of admin- David A., Erickson, Karen M., and Mitchell,
istration, the role of managers as mediators or John B. 1996. Remaking Health Care in Amer-
shapers of government and corporate policy, ica: Building Organized Delivery Systems. San
and the changing institutional structures Francisco, CA: Jossey-Bass.
Health Care Delivery makeup of the area, they did not explore
immediately. In 1808, the Portuguese royal
System: Brazil court arrived in Brazil. Among the important
initiatives founded by Prince João in his years
Campinas State University, Brazil in Brazil (1808–21) were commerce and indus-
try incentives, the permission to print news-
The Brazilian health care system is marked by papers and books, the construction of military
the following phases, which coincide with his- academies, and the creation of the first Bank of
torical periods: (1) colonial Brazil, from the Brazil. A project for regulatory actions, includ-
Portuguese settlement in 1500 until Brazil’s ing those regulating surgical activities, was
independence; (2) Brazil’s independence as an created. The country’s first medical schools
imperial state, from the declaration of inde- were opened in Bahia and in Rio de Janeiro in
pendence in 1822 to the  installation of the 1808, and in 1829 the Brazilian Medical and
republic in 1899; and (3) the Brazilian Republic, Surgical Society, which fought to develop and
from 1899 to the present day. It is also impor- lead a public health care system, was founded
tant to have some facts and figures about the (Machado et al. 1978). Some authors believe
country: Brazil is a federative republic, located that the Society’s vision of medical awareness
in the central-eastern portion of South America. in urban space was much more a proposal
The country is made up of 26 states, plus a fed- than a realization (Lima and Carvalho 1992).
eral district; it is the fifth largest country in the They recognize that the research they carried
world in area, with 8,547,404 square kilometers. out offers important contributions to the
The population was reported as 190,755,799 understanding of the project that was idealized
people in 2010. The first census, which was car- by the medical intellectuals of the second half
ried out in 1872, reported 9,993,478 inhabit- of the nineteenth century, though they fail to
ants. From 2000 to 2010 there was an annual clarify which conditions permitted the prac-
increase of approximately 1.1 percent as a result tice of medicine. In general, the colonial period
of natural growth. The estimated birthrate in saw little access to medicine; there was no
2011 was 17.79 per 1000 people, and the esti- overarching control or monitoring of the
mated fertility rate was 1.8 per 1000. In 2010, health care available, and health care for slaves
the total population comprised 97,342,162 was non-existent.
women and 93,390,532 men. In terms of race,
Brazil’s 2008 population distribution was 48.8 INDEPENDENCE AS AN IMPERIAL
percent white, 6.8 percent black, 43.8 percent STATE TO THE INSTALLATION OF
mixed race, and 0.6 percent Amerindian. THE REPUBLIC IN 1899

COLONIAL BRAZIL THROUGH Historians are unanimous in describing the

INDEPENDENCE 20-year period before the Proclamation of the
Republic (1889) as one of transition and crisis.
Portuguese settlers arrived in Brazil in 1500, Slavery was replaced by other forms of
but because of the natural and geographical production in pre-capitalist northern and

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

northeastern regions and in the capitalist states The last decades of the nineteenth century
of São Paulo and Rio de Janeiro. The expansion were a time of considerable medical advance-
of coffee plantations created a fundamental ment in Brazil, as well as a period of discoveries
challenge: farm owners needed to substitute in the field of tropical pathology. Individual
slave labor, and they found a new labor force in medical assistance was provided by the Holy
recent European immigrants to the country. Houses of Mercy (Santas Casas de Misericórdia),
This started a political process of centralizing and industrial workers benefited from this also.
the imperial state, which entered into a period Some companies offered medical services,
of crisis after 1870. The crisis during this period though part of the costs were transferred to the
was caused by the growing strength of the workers themselves (about 2 percent of their
army, the friction between Church and state, salaries).
the deterioration of the liberal party, the growth
of republican ideology, external and internal
pressures against slavery, and the inflationary THE BRAZILIAN REPUBLIC, 1899 TO
policies of the 1880s. These factors aided in the THE PRESENT
transition from slavery to capitalism and from
a monarchy to a republic. From 1870 to 1890 From 1930 to 1945, the Brazilian economy
the industrial sector was not well organized – was involved in the industrial revolution as a
only short-term movements occurred. It was result of its imports. That meant that the
not until 1919 that the state began to intervene country’s economy changed and it experi-
in labor relations (First Labor Accident Law). enced a growing internal market. The increase
In 1923, the first law on social security was in production was associated with an increase
made. Though the country had a rural econ- in consumption. These changes occurred
omy, no social policies for rural workers were during the agro-export crisis, which was a
created – this issue was not addressed until the consequence of the 1929 Depression. Cohn
beginning of the 1950s. (1973) points out that the industrial sector
The long period from 1870 to 1930 brought showed notable growth (60 percent) between
important changes to Brazil. It must be men- 1939 and 1946, while the agricultural sector
tioned that, in the period before 1930, and grew only 7 percent. Important developments
especially from the end of the nineteenth cen- in the period were the expansion of the steel
tury until 1920, there were high rates of dis- industry, the emergence of new factories, and
ease. For example, yellow fever, smallpox, the development of the National Petroleum
tuberculosis, and malaria led to high mortal- Council (Conselho Nacional de Petróleo).
ity rates, and, from 1870 to 1890, life expec- However, it was not only the economic field
tancy at birth was 33.9 years. One must also that saw profound changes during the 1930s.
remember that there was no national health There were also political changes. Following
care policy, only sporadic and localized inter- the Revolution of 1930, Getúlio Vargas
ventions. It was not until the early 1900s that assumed power, and Congress, the state legis-
the country began to take the first measures latures, and the municipal chambers were
against these diseases, such as the creation of dissolved. Vargas defeated a movement to
the first tuberculosis dispensary in Rio de oust him in 1932; he was elected president by
Janeiro in 1902, the scientific battle against a constitutional assembly in 1934, and he
yellow fever in 1903, led by Oswaldo Cruz, stayed in power until 1945. In 1937, alleging
and the obligatory vaccination against small- the existence of a communist plan (the Cohen
pox, which started in 1904. Plan), Vargas shut down Congress and

proclaimed a new constitution. At this point, security (with medical expenses) varied from
an authoritarian regime was established, 8.9 percent (1930) to 14.9 percent (1966). The
called the New State (Estado Novo). It would most frequent use of the money was to hire
last until 1945, when Vargas was ousted by a third-party services (generally hospitals) that, in
military coup (Nunes and Rocha 1993). turn, needed to accept the rules and norms of
With this centralization of power, the the program. Because the programs were differ-
field of health care also became more cen- ent for different industries, the benefits received
tralized. Before 1930, any actions taken to by different employees depended on the extent
improve health care were attributed to local to which they organized themselves within that
entities (departments, services, sanitary industry. For example, bank workers, sailors,
directories), but the Vargas administration and commerce employees were always guaran-
set up the Ministry of Education and Health teed medical services, while factory workers
in 1931. Among the numerous modifica- (50 percent of all employees) received almost no
tions that followed, a notable change was the medical services. During this period, retirement
transfer of control of workplace hygiene and policies demanded a minimum of 30  years of
job safety to the Ministry of Labor, Industry, employment, and the legal retirement age was 50
and Commerce. In 1942, the Special Public for women and 55 for men. These ages were
Health Service (Serviço Especial de Saúde soon increased to 65 years for men and 55 for
Pública) was created. It was an important urban working women.
international pact with some organizations Oliveira and Teixeira (1986) point out that
from the US government in order to fight from 1930 to 1945 the principal characteris-
malaria and yellow fever in the Amazon tics of social security were: a decrease in the
region, where rubber was produced during benefits and services offered, the adoption of a
World War II. model that would result in financial reserves,
Health conditions in the country during this increased government participation in admin-
period were quite precarious in general, espe- istering and assuming expenses (though only
cially those related to industrial activities. There in theory), and the extension of social security
was a high incidence of work-related accidents. to workers in previously excluded industries.
A very important event was the creation of the The authors show that social security
Institutes of Retirement and Pension (Institutos resources were used to finance national indus-
de Aposentadoria e Pensão), which was a tries, including steel, cellulose, electric energy,
national social security program. The founding and farming. Unions were controlled by the
of these institutes demonstrated the new rela- government, which changed workforce legis-
tionship that was forming between health care lation (setting working hours, holidays, female
and public policies in the country. It was a capi- and minor workers’ rights) and these laws
talist model that served to accumulate wealth for led  to better living conditions. Although
the country (Oliveira and Teixeira 1986). With these programs offered retirement benefits,
this creation, a new image of the state developed: pensions, funeral services, doctors, and
the government was seen as a “donor” and a pro- employment insurance after 10 years of work,
ponent of workers’ rights. However, there were Nunes and Rocha (1993, 105) point out that
two sides to this social security program: on the “only the urban worker had access to medical
one hand, it met the desires of the workers; on attention.” In the period after World War II,
the other, it was a mechanism of control (Cohn there was an accelerated process of industri-
1980). Data from 1930 to 1960 show that the alization. The country also experienced a pro-
percentage of government expenditure on social cess of democratization with the fall of the

New State (Estado Novo) in 1945 and the Janio Quadros replaced Kubitscheck as presi-
election of General Eurico Gaspar Dutra, who dent, but he resigned in 1961. His resignation
faced a serious economic crisis and the created a significant political crisis in the eyes of
acceleration of inflation. In 1950, Getúlio the dictatorship, because the military sectors
Vargas was re-elected by a large majority of opposed having the vice-president, João
votes; but when the country began to demand Goulart, take office, even though he had the
his impeachment, he committed suicide, on confidence of the people, the Congress, the
August 24, 1954. Until 1955, industrialization press, and some sections of the armed forces. To
favored national industries, but under Juscelino avoid the crisis, a parliamentary regime was
Kubitscheck’s government (1956–60), the installed, which lasted until 1963. Goulart
country was opened to foreign capital. received full presidential power, but he faced
Two public health care policies mark the serious problems and was finally deposed by a
1950s: the transformation of the Ministry of military coup on March 31, 1964. At this time,
Health into an autonomous ministry in 1953, the military took office and stayed in power
and the creation of the National Department until 1984, during which period the country
of Rural Endemic Diseases (Departamento was the victim of an authoritarian and dictato-
Nacional de Endemias Rurais) in 1956. These rial government.
changes centralized health care campaigns. This long period can be divided into two
Nunes and Rocha (1993, 119) summarize parts: 1964–74 and 1974–84. The first phase,
three main aspects of public health care known as the “economic miracle,” was a time
during this period: the centralization of tech- of economic growth. The government put
nological and bureaucratic areas of the caps on salaries and controls on union move-
government; the country’s determination to ments, which it justified with the theory that
increase the efficiency of campaigns against the benefits could not be redistributed until
endemic rural diseases (because high rates of after the economy had experienced more
disease coincided with less industrialized growth. Noronha and Levcovitz (1994, 76)
areas); and an emphasis on preventive point out: “The centralist logic of the dicta-
health care education as a way to improve the torship and the complete suppression using
national health care statistics. violence, as well as the political alternative
Despite increasing economic development debates in midst of society, and even in aca-
in the 1960s, data on health in the country demic surroundings, made it easier for the
was unsettling. Brazilians lived an average of government to introduce its institutional
51.3 years; and, out of every 1000 live births, reforms quickly, and they profoundly affected
105.23 children died before reaching their the models of public health and social medi-
first birthday. Most were victims of malnutri- cine that had originated previously.” In gen-
tion and/or a lack of sanitation. During this eral, these changes were based on the model
period, the most common causes of death of individual medical care as a standard of
shifted: in 1950, infectious and parasitic dis- health, and they resulted in an increase in
eases resulted in the deaths of 35.9 percent of medical actions, the construction of hospitals
the population, and 14.2 percent died from (with financing from public funds), and the
circulatory problems. In 1960, the same data development of laboratories and private ser-
show that there were fewer deaths caused by vices. After 1974, a period of world economic
infectious and parasitic diseases (25.9 percent) crisis would affect the Brazilian economy.
and more deaths caused by circulatory prob- There was an increase in petroleum prices
lems (21.5 percent). and it became difficult to export Brazilian

products such as coffee and cotton. At the beginnings of democracy began to show.
same time, there was also an increase in work- There was the period of amnesty in 1979,
ers in industries that worked with both natu- which brought back many politicians who
ral resources and manufactured resources, had been in exile. However, direct elections
from 2,600,000 in 1970 to 4,900,000 in 1976 were not approved by Congress until May
(Rocha and Nunes 1993). 1985. The first democratic election was in
The 1970s saw an increase in the popula- 1989, and Fernando Collor was elected presi-
tion’s average lifespan, from 52.8 years in 1970 dent. However, he was accused of serious
to 57.9 years in 1977, though there were crimes, including embezzlement, and he was
regional differences (the state of São Paulo’s censured by Congress. He resigned in 1992,
average was 64.5 years, while the average in and he lost his right to participate in politics for
the northeast of the country was only 49.1 eight years. His vice-president, Itamar Franco,
years). However, the country also experienced took over. Fernando Henrique Cardoso was
high infant mortality rates in this period: the next president to be elected. He served for
108.68 per 1000 live births in 1970. These two terms, from 1995 to 2002, and produced
numbers demonstrate a decrease in access to a highly successful economic and currency
health care at that time, because in 1964 the plan called Plano Real (Real Plan, with the
infant mortality rate had been 102.41 per 1000 word real also referring to the name of the
live births. There was also alarming data on country’s new currency). This plan gave sta-
work-related accidents during this period: bility to the Brazilian economy. The peaceful
with a workforce of 7.3 million employees, transition of power to Luis Inácio Lula da
there were 1,401,922 accidents, which affected Silva in 2002 and again after his re-election in
close to 20 percent of the workforce (Rocha 2006 proved that the country had finally suc-
and Nunes 1993, 125). It must be highlighted ceeded in achieving its long sought-after
that, with infectious and parasitic disease political stability. Lula was succeeded in 2011
mortality running at 15.7 percent and circula- by Dilma Rousseff. From 1980 to 1988 there
tory diseases accounting for 24.85 percent of was a process of economic stagnation, with
total deaths, it would be more exact to speak expanded inflation (from 110 percent to 1037
of a double morbidity and mortality profile. percent per annum), an internal public debt
It has been observed that this period was that increased from 6.4 percent to 35 percent
marked by individual medical assistance and of GDP, and with no GDP growth. These prob-
its extension to various categories of workers, lems contributed to the increase in poverty
including rural workers, domestic employees, that occurred in the country during this time.
and the self-employed. An important fact was Facing the turbulent political, economic,
the unification of the Institutes of Retirement and health care situation, all of which was
and Pension in 1966, which equalized bene- the result of the country’s upheaval since the
fits and services. Successive changes took place 1970s, progressive intellectual sectors, medi-
in the area of social security. In 1975, the cal school professors, and health research-
National Health Care System was founded. The ers, along with union leaders and activities
National System of Social Security and Social within some political parties, adopted “a
Assistance (Sistema Nacional de Previdência e radically critical view of the centralizing
Assistência Social) was developed in 1977. authoritarian military regime,” and they
After years with a government that uti- proposed “decentralization and universal
lized the highest degree of military authori- and unifying measures, which are essential
tarianism, there followed a period when the components of democratic reforms for the

health care field” (Noronha and Levcovitz municipal levels, the Brazilian health care
1994, 80). These ideas were echoed at the system also includes a private sector and a pri-
8th Brazilian National Health Conference vate health insurance subsector, with different
(1986) and in health care and sanitation forms of health care plans, varying insurance
reform movements, as well as in the creation premiums, and tax subsidies. Health care in
of unified and decentralized health care sys- Brazil still faces numerous problems. The
tems. The decentralizing innovations all advances achieved include the definition of
came together in Brazil’s 1988 Constitution the universal right to health, with importance
in the following terms: “The Public Health given to public services. The country has been
Care options and services form a regional successful in establishing national health care
and hierarchical network that represents a uni- and a system in which the participation of the
fied system that is organized in accordance private sector is complementary.
with the following directives: decentralization,
with a dedicated administration in each branch SEE ALSO: Health Care Systems of the World,
of government, full-scale attention, with prior- Changing; Health and Illness, Cultural
ity given to preventive activities, and participa- Perspectives on; Public Health
tion from the community” (Oliveira 1989). In
1990, the Unified Health System was founded,
known nationally as SUS. Today, it successfully REFERENCES
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According to the Ministry of Health, SUS has Político no Brasil [Social Security and Political
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health care locations, and 28,000 family health Cohn, Gabriel. 1973. “Problemas da Industri-
care teams, which provide at-home care for alização no Século XX” [“Problems of Indus-
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Traditional Health the belief that prolonged used of biomedicine
Services Utilization has  negative side-effects (Suwankhong,
Liamputtong, and Rumbold 2012).
among Indigenous Peoples Besides seeking help with physical illness,
DUSANEE SUWANKHONG traditional healers are also consulted for ill-
Thaksin University, Thailand nesses that people believe are caused by social
PRANEE LIAMPUTTONG and spiritual circumstances (Helman 2007).
La Trobe University, Australia These illnesses do not have clear physical
symptoms, but are manifested through emo-
Traditional health services (THS) play a tional signs which traditional healers believed
significant role in the health care systems of they can recognize because they have more
indigenous peoples in developed and develop- experience in dealing with invisible or unex-
ing nations (World Health Organization plained causes of illness (Helman 2007;
2002). In most rural areas, in particular, Suwankhong, Liamputtong, and Rumbold
THS  provide the main source of care for 2011). More importantly, traditional healers
many  people (Sermsri, 1989; Suwankhong, are concerned with returning their customers
Liamputtong, and Rumbold 2012). The prin- to normal physical health and helping them to
ciples of THS are related to natural, folk, and achieve balanced living conditions after recov-
spiritual remedies and these involve the use ery (Golomb 1985; Helman 2007). Traditional
of  plants and herbs, physical manipulation, healers believe biomedicine may not be able to
spiritual healing rituals, and religious prac- achieve this, as it requires knowledge relating
tices, rather than basing on scientific premises to the individual’s social and cultural contexts,
(Sermsri 1989; Kayne 2010). These principles while, in their view, THS tend to be more
are continually practiced by indigenous heal- effective because they operate around an indi-
ers through their healing traditions, which vidual’s living conditions and thus provide
link with historical circumstances, social better support in achieving holistic health
contexts, and the cultural beliefs of indigenous among indigenous peoples (Chuengsatiansup
peoples to achieve a desired outcome (World 2007; Tantipidoke 2005).
Health Organization 2002). It should be noted that not all THS are ben-
Public interest in THS has increased mark- eficial. There is considerable doubt about the
edly in recent decades. Studies of THS users healing capacity of many types of THS treat-
suggest a wide variety of reasons for prefer- ments (Bodeker, Kronenberg, and Burford
ring THS over biomedical care. These include 2007; Kayne 2010). Traditional healers have
dissatisfaction with biomedicine due to diffi- limited or no scientific knowledge and some
cult doctor–patient communication; the need of their practices may lead to harm to their
to travel long distances to reach biomedical customers (Ernst, Cohen, and Stone 2004;
care; the holistic approach of THS to care in Kayne 2010). Individuals with an acute illness
contrast to biomedicine’s focus on high are particularly vulnerable to harm caused by
technology (Helman 2007; Kleinman 1980); THS if they delay seeking biomedical care or
the belief that modern treatments are not safe use traditional medicines without consulting
or can aggravate the person’s condition; and biomedical professionals (Armishaw and

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Grant 1999). Despite this, many people, par- treat illnesses, but also provide a more holis-
ticularly in indigenous communities, con- tic approach to health care than most bio-
tinue to seek care from THS. medical professionals. Most perform multiple
A good illustration of traditional health tasks invocating supernatural spirits, con-
services utilization among indigenous peoples ducting healing ceremonies, and using natu-
is offered by cases in Thailand. Historically, ral plant products to treat various health
THS had been practiced in Thailand before the problems. Some healers also refer patients to
introduction of biomedicine, when no formal biomedicine or other healers if they cannot
health care systems were available. The knowl- adequately manage the illness themselves.
edge and practices of THS have been handed Traditional healers provide a holistic ser-
down from one generation to the next (Golomb vice by attending informally to family mem-
1985). Traditional healing practices have been a bers, friends, and relatives, who participate
valuable health care resource for Thai people throughout the healing process, by providing
and remain so today, despite the fact that bio- personal care, and by spending as much time
medical services are now accessible even at the with patients as the patients need. These
village level, as a result of the health care reform strategies can reduce communication prob-
initiated by the Thai government during the lems between traditional healers and custom-
economic crisis in 1997. An important aspect ers (Spector 2009), and help the customers to
of that reform was the adoption of the primary cope better with their health problems.
health care approach which emphasizes the According to Kleinman (1980), traditional
promotion of multisector contributions and healers adapt their services to suit customers’
the need for individuals to take responsibility contexts, culture, and lifestyles. They do not
for their own health, as stated in the 2009 isolate patients from their family, friends, and
“Health Policy Strategy” of the Bureau of Policy relatives when  treating them. This holistic
and Strategy in the Thai Ministry of Public approach is welcomed by patients, as it pre-
Health. The Bureau hoped that this approach serves the link between them and their com-
would decrease health care cost and increase munity. Customers hope for a faster recovery
health care resources for the Thai people. because they have familiar people around
THS in Thailand have played a particularly them who share their suffering, participate in
significant role in the health care of indige- the healing processes, and can decide upon
nous people. A study conducted with treatments in an environment familiar to
THS  practitioners in southern Thailand them.
(Suwankhong, Liamputtong, and Rumbold Thai health policy has promoted the inte-
2011) shows that the provision of traditional gration of THS into the formal health care
healing services is flexible and based on a system. The integration plan was introduced
holistic approach that suits people’s lifestyles in the Seventh National Economic and Social
and needs, improves access to health care in Plan (1992–6). Currently, indigenous tradi-
rural areas, and offers an alternative to bio- tional healers can be found in all regions of
medical care, which often has a limited role. Thailand. In 2005, the Department for
Traditional healers meet the needs of their Development of Thai Traditional and
customers that biomedical professions do Alternative Medicine (DTAM) surveyed 39
not. For example, spiritual and ceremonial provinces in Thailand and found 3075
practices are traditional methods that provide traditional healers practicing indigenous
a healing dimension not offered by biomedi- medicine.  These numbers included spiritual
cal practices. Traditional healers not only healers, herbal healers, massage healers, and

traditional midwives. A 2006 survey across the same time, non-licensed healers are being
75 provinces found a total of 27,760 tradi- excluded from the mainstream health system
tional healers. The northeast region had the by being discouraged from having an involve-
highest number, with 14,146 practitioners, ment in any curative role to reduce malprac-
and there were 3520 in the south of Thailand. tices which may occur (Medical Registration
These healers do home visits and attend cus- Division 2008).
tomers at places of business or work, while As has been observed in other countries
some also work in local health centers (Ovuga, Boardman, and Oluka 1999), there are
(Suwankhong, Liamputtong, and Rumbold significant obstacles to the cooperation between
2011). traditional healers and modern health practi-
The current range of traditional treatments tioners. On the one hand, most unlicensed THS
provided by THS include Thai massage, hot practitioners in Thailand have difficulty adapt-
herbal compresses, herbal steam baths, and ing to and following government regulations.
processed traditional medications such as On the other hand,  biomedicine regards tradi-
tablets, powders, or syrups. Traditional heal- tional healers’ knowledge and practices as
ers see their services as the promotion of unscientific and potentially dangerous to the
good health, prevention of illnesses, treat- public’s health. However, despite the fact that
ment of symptoms, and rehabilitation of they are unlicensed, traditional healers remain a
chronic illnesses. They offer their treatments popular health care resource for indigenous
as both a complement to biomedical care and customers, who, apparently, are not too con-
an alternative healing method. The integra- cerned about licensing; rather, they expect
tion of THS in the Thai mainstream health effective recovery with the help of these healers.
system is being expanded to make it more Also, people in many regions in Thailand con-
accessible to people with diverse health con- tinue to use THS because they have strong ties
ditions (Chokevivat, Wibulpolprasert, and to the culture and belief systems of local people
Petrakard 2010; Ratthanawilai 2007). (Kulsomboon and Adthasit 2007).
Practitioners of THS have also been Traditional healing services accounted for
encouraged to play a formal role in Thailand’s the main form of health care for people for
modern  health system. To do so, however, whom there was nothing else available
they are expected to obtain a formal license as (Kleinman 1980; Meissner 2004), a pattern
legitimate proof of their medical expertise. A that is still evident in rural indigenous com-
formal license can be obtained by taking a munities. Traditional healing remains signifi-
training course, or undertaking a license test, cant to many indigenous people because,
both of which have to be approved or organ- although biomedical care has advanced, it
ized by the Ministry of Public Health . It is may not meet their perceived health and cul-
argued that the license is the means by which tural needs. Indigenous practitioners in many
customers are protected from harm caused by parts of the globe have been encouraged to
unlicensed traditional healers. As in other seek a legitimate place in health care systems
parts of the world (World Health Organization so that indigenous peoples are able to choose
2002), a series of regulatory measures have the form of care that meets their health needs.
been put in place to protect the users of THS, In Thailand, despite resistance from biomedi-
among them the licensing requirement for cine and difficulties for traditional healers in
practitioners and the establishment of a gov- integrating into the formal health care sys-
ernment department for the development of tem, customers of THS continue to believe in
THS in the Thai national health service. At the beneficial power of traditional healing.

SEE ALSO: Health Care Delivery System: Kulsomboon, S., and Adthasit, R. 2007. The
Thailand; Indigenous Health; Medical Systems, Status and Trend of Research in Local Wisdom 
Mixed Utilization of for Health. Bangkok: The War Veterans
Medical Registration Division. 2008. Teaching and
Learning Manual for Thai Traditional Medicine.
Nonthaburi: Medical Registration Division.
Armishaw, J., and Grant, C. C. 1999. “Use of Com- Meissner, O. 2004. “The Traditional Healer as
plementary Treatment by Those Hospitalised Part of the Primary Health Care Team?” South
with Acute Illness.” Archives of Disease in Child- African Medical Journal 94(11): 901–902.
hood 81(2): 133–137. Ovuga, E., Boardman, J., and Oluka, E. G. A. O.
Bodeker, G., Kronenberg, F., and Burford, G. 1999. “Traditional Healers and Mental Illness in
2007. “Policy and Public Health Perspectives Uganda.” Psychiatric Bulletin 23: 276–279.
on Traditional, Complementary and Alternative Pal, S. K. 2002. “Complementary and Alternative
Medicine: An Overview.” In Traditional, Com- Medicine: An Overview.” Current Science 82(5):
plementary and Alternative Medicine: Policy and 518–524.
Public Health Perspectives, edited by G. Bodeker Ratthanawilai, S. 2007. “Evaluation of the Service
and G. Burford, 9–40. London: Imperial College of Traditional Medicine in Public Health Care
Press. Settings According to Health Care Insurance
Chokevivat, V., Wibulpolprasert, S., and Petra- Schemes.” Journal of Thai Traditional and Alter-
kard, eds. 2010. Thai Traditional Health Pro- native Medicine 5(2): 131–140.
file 2009–2010. Bangkok: The War Veterans Sermsri, S. 1989. “Utilization of Traditional and
Organization. Modern Health Care Services in Thailand.”
Chuengsatiansup, K. 2007. “Indigenous Health In The Triumph of Practicality: Tradition
System in the Rural Thailand.” In Thai Health and Modernity in Health Care Utilization in
Thai Culture, edited by K. Chuengsatian- Selected Asian Countries, edited by S. R. Quah,
sup and Y. Tantipidoke, 113–144. Bangkok: 160–179. Singapore: Institute of Southeast
Nungsurdeeone. Asian Studies.
Ernst, E., Cohen, M. H., and Stone, J. 2004. “Ethi- Spector, R. E. 2009. Cultural Diversity in Health
cal Problems Arising in Evidence Based Com- and Illness, 7th ed. Upper Saddle River, NJ:
plementary and Alternative Medicine.” Journal Prentice Hall.
of Medical Ethics 30: 156–159. Suwankhong, D., Liamputtong, P., and Rumbold,
Golomb, L. 1985. An Anthropology of Curing in B. 2011. “Existing Roles of Traditional Healers
Multiethnic Thailand. Urbana: University of Illi- (mor baan) in Southern Thailand.” Journal of
nois Press. Community Health 36(3): 438–445
Helman, C. G. 2007. Culture, Health and Illness, Suwankhong, D., Liamputtong, P., and Rumbold,
5th ed. London: Hodder Arnold. B. 2012. “Seeking Help chaow baan Ways in
Kayne, S. B. 2010. “Introduction to Traditional Southern Thailand.” Australian Journal of Pri-
Medicine.” In Traditional Medicine: A Global mary Health 18(2): 105–111.
Perspective, edited by S. B. Kayne, 1–24. Lon- Tantipidoke, Y. 2005. Network of Traditional Heal-
don: Pharmaceutical Press. ers and Their Social Space in Thai Health Care
Kleinman, A. 1980. Patients and Healers in the System. Bangkok: Desire.
Context of Culture: An Exploration of the Bor- World Health Organization. 2002. “WHO Tradi-
derland Between Anthropology, Medicine, and tional Medicine Strategy 2002–2005.” http://
psychiatry. Berkeley: University of California
Press. TRM_2002.1.pdf. Accessed April 10, 2013.
Aging aging must occur progressively during the
latter part of the lifespan. Finally, aging must
PAUL HIGGS and CHRIS GILLEARD be deleterious to the individual’s health and
University College London, UK survival. Development, like aging, is also uni-
versal, intrinsic, and progressive but, unlike
Conventionally, aging is considered the aging, it is beneficial rather than deleterious
consequence of a long life; and a long life for health and survival. It is, therefore, this last
typically (a) exceeds the age of reproductive principle that has made aging so important
fitness and (b) approximates to the “natural” for its consequences for health.
human lifespan. Since there have always been At some point in the life course, there is a
some people living such conventionally gradual transition from increasing to decreas-
“long” lives, there have always been opportu- ing fitness, and from a declining to a growing
nities for people to witness the bodily changes risk of illness and disability. Across the human
of aging and form ideas about what it is and lifespan, decreases and increases in morbidity
what might be its cause. In contrast to old age, and mortality are U-shaped. Throughout
which is a status or social category conferred recorded history, for example, birth and infancy
on individuals at a particular chronological have been periods of greater risk of death and
age and/or as the result of a particular combi- disease than childhood or adolescence, while
nation of physical signs and social markers, old age, however defined, has been a period
aging is a more diffuse process, referring to of greater risk than youth or young adult-
almost everything that takes away or lessens hood. The precise shape of this U curve in the
“youth” and “fitness.” Older mechanistic mod- lifetime risk of morbidity and mortality has
els of aging that sought to explain aging as the varied over time, since for much of human
result of some singular fundamental process history death has been a significant risk at all
of decay have largely been abandoned. ages. As the 23rd Psalm of the Old Testament
Researchers now acknowledge that multiple points out, “we live in the shadow of the val-
complex interacting processes probably ley of death.” As long as life expectancy was
account for the changes that take place as and limited by high infant mortality rates and
when we grow old. It is necessary, therefore, high attrition rates across the whole of the life
to separate the processes of aging from the course, the personal experience of aging and
state or status of old age. the acquisition of the status of “old age” were
It is also important to distinguish between confined to a relatively small minority of the
the processes of aging and those of develop- population, and the age structure of most
ment, which also reflects processes of physical societies resembled a pyramid, with many
and social change. Strehler (1962) defines more younger, “developing” people than
aging in terms of four key principles. It must older, “aging” ones.
be universal across all members of a species There were many reasons for this. Infectious
even if it is subject to some variation over tim- water and food-borne diseases such as chol-
ing and impact. It must be intrinsic in that the era, alongside vector-borne diseases like the
causes must not depend on external factors. It bubonic plague, could strike down whole
must be progressive in that changes due to populations time and again. Cyclical patterns

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

of famine and pervasive small- and medium- progressively compressed into a smaller age
scale violence added to the picture, making range within the human lifespan. Survival in
the progressive risk to life posed by aging a later life, in the presence of morbidity, has
matter of limited concern to pre-modern soci- also increased. These two trends make it dif-
eties. These circumstances began to change ficult to ascertain whether we are aging at a
during the course of the nineteenth century later age in life, or aging much the same as
when a number of initiatives were undertaken ever and simply surviving longer with
to improve living standards and public health. greater morbidity. But, however one frames
These included the construction of sewage it, there is certainly more “aging” about.
systems, the provision of clean water and The contemporary surplus of age has made
legislation to ensure food safety, as well as uni- gerontology, the study of aging, a topic of
versal education, more control of health and increasing public and academic interest. One
safety in the workplace, and, not least, rising particular concern has been whether the
wages. The cumulative effect of these pro- increases in life expectancy of the last half-
cesses of “modernization” was the diminution century are the result, not of any real change
of the effect of infectious diseases across the in aging, but of an expansion of later life mor-
life course. This is known as the “epidemio- bidity (Fogel 1994). By this is meant that each
logical transition” (Omran 2005), when the additional year of life gained has also pro-
decline in infectious diseases during develop- duced an equivalent increase in the amount
ment was balanced by a rise in diseases mainly of time spent in ill-health. In effect, the argu-
affecting older members of the population, ment goes, aging remains much the same as
and morbidity became patterned around the ever – a universal process whose speed and
so-called “degenerative diseases” of later life: direction of travel are fixed by our intrinsic
cancer, cardiovascular and respiratory dis- makeup – and all the apparent gains in life
ease, and metabolic illnesses like diabetes. expectancy mean is that we are living longer
This “epidemiological transition” can be and sicker rather than dying quicker and
represented graphically as the “rectangulariza- fitter.
tion of the survival curve” (Fries 1980). What Despite such claims that nothing funda-
Fries meant by this was that set of circum- mentally has changed about aging, Fries’s
stances whereby modern populations show (2003) prediction of a “compression of morbid-
diminishing evidence of mortality before ity,” where life grows longer and the proportion
adulthood and an acceleration of morbidity of life spent in ill-health grows shorter, has
and mortality after people reach midlife (from challenged many of the old assumptions about
age 40 upward). From this point in the life the connection between aging, illness, and
course, there is a steady acceleration of mor- death. Analyses of subjective measures of
bidity and mortality, resulting in the greatest health have indeed suggested that longer lives
mortality rate being observed in “old age.” are resulting in an increasing burden of dis-
There is considerable variability within ease in later life, but other more objective
populations, and the point at which this indicators of disability offer a different, more
acceleration occurs does not seem to be optimistic view (Schoeni, Freedman, and
fixed at any specific age. Trends toward an Martin 2008). For some time, disability rates
increasing rectangularization of the lifespan in the United States have been falling at  an
are shifting the age at which accelerative accelerating rate, mirroring the deceleration
mortality occurs, as well as the speed with in mortality (Manton, Gu, and Lamb 2006).
which it rises in later life. Death has become These changes appear even more dramatic

when data over a much longer historical to argue that once the basic biological pro-
period are examined. Costa (2000), for exam- cesses of somatic maintenance and error repair
ple, used US data going back to 1900 in order are understood, longevity can be extended
to show that age-associated morbidity – the indefinitely. That life expectancy is increasing
diseases associated with midlife and beyond – at a rate never previously observed adds
declined dramatically over the course of the weight to his argument. Rau et al. (2006), for
twentieth century. She calculated that func- example, have shown that while mortality
tional disability “has fallen at an average rate rates for men aged 80–89 dropped by a mere
of 0.6% per year among men age 50 … to 74 0.81 percent between the 1950s and 1960s,
from the early twentieth century … [with] a they dropped by more than twice that rate
large proportion of the decline in disability at (1.88 percent) from the 1980s to the 1990s.
older ages … [occurring] only recently” For women of the same age group the rates of
(2000, 38). decline were 0.91 percent and 2.45 percent,
What this brief overview of the demogra- respectively. Despite these signs of change in
phy and epidemiology of aging shows is that the nature of human aging, there is still a con-
aging need not be seen as an endogenously cern among other, more pessimistic research-
determined, singular process of bodily ers that the current circumstances of aging
decline, the inevitable consequence of an might yet represent a “failure of success.” By
unchanging and unchangeable human this, they mean that the “epidemiological
nature. As a process or set of interlinked transition” has merely succeeded in shifting
processes, it is perhaps more contingent upon the burden of disease from infectious diseases
time, circumstance, and the organization of that individuals either overcame or were
social relations than Strehler’s definition overcome by and died, to chronic conditions
acknowledged. Such heterodoxy in aging in later life that one may manage to survive
may be related to the as yet unknown capac- but never overcome (Crimmins 2004). Others
ity for repair of the human body and the have also argued against what they see as a
consequent indeterminacy of its maximum premature optimism, claiming that the emer-
lifespan. Some biogerontologists would go gence of an “obesity epidemic” may soon
still further, arguing that aging is essentially reverse the recent decline in mortality and
indeterminate. Age-related mortality, they disability, ushering in new patterns of chronic
claim, only occurs because of accumulated, illness and accelerated aging (Olshansky et al.
unrepaired damage to cells and tissues aris- 2005). Set against these gloomy predictions,
ing from the limited investment evolution however, Schoeni, Freedman, and Martin
has made in developing efficient, long-term, (2008) have noted how changes in smoking
somatic repair mechanisms. This pattern behavior, greater educational attainment, and
of  “selective investment” is a consequence declines in poverty have impacted measura-
of  somatic cells only needing to last in a bly on the decline in disability levels in the
body for one generation – in contrast to United States, arguing that as long as stand-
the  effective husbandry provided for ards of living continue to improve, aging will
those  cells that provide the germ line that follow suit.
survive and retain their identity successfully Aging even in the mind of the pessimists
across innumerable generations (Kirkwood then seems at least partly contingent. It involves
1999). both intrinsic and extrinsic factors, and even
These ideas have led more futuristic the intrinsic factors may be modifiable by
biogerontologists like Aubrey de Grey (2007) other, extrinsic factors (Kirkwood 2005).

Lifestyle and physical constitution play a part, education, paid work, and labor productivity,
although most of the changes that have taken women’s lives remained tied to the “natural”
place in both the extent and the rate of “post- landscapes of age and aging – menarche, fer-
developmental” morbidity and mortality seem tility, menopause, and widowhood. To some
incidental to broader developments in work, extent, therefore, women’s aging was socially
home life, leisure, and health care. Direct invisible, even after the introduction of uni-
manipulation of aging, whether through per- versal old age pensions. It was men’s old age,
sonal or medical anti-aging regimes, has little eventually defined by retirement age and
claim to have contributed to these historical their eligibility for an old age pension, that
changes. Still, intended or not, aging does had declined in status. Despite increasing
seem to be changing and with it has come numbers of men leaving work and collecting
change in the position and status of old age. their pension at age 65, retirement for many
In traditional, pre-modern societies, where of them represented a personal tragedy or a
the experience of aging was less common and “role-less role” (Parsons 1942).
the numbers of people surviving into old age The sharp delineation of retirement meant
were few, the status of old age was often quite that men’s old age was soon seen uncompli-
high – or perhaps more accurately, the status catedly as starting at age 65. The endless
of old men in the elite classes was. According debates about when old age began, conducted
to “modernization theory” the status of old in books, periodicals, reports, and even in the
age declined as societies transformed from British Parliament during the latter decades
agricultural to industrial economies (Cowgill of the nineteenth century, were soon forgot-
and Holmes 1972). The introduction of factory ten. By the time that the postwar welfare state
work put a premium on selling one’s labor was established in the UK in the late 1940s,
and encouraged the migration of young men old age was unquestionably placed at 65 for
and women into the cities where wages were men and 60 for women. The discrepancy in
highest. These new industrial cities favored men’s and women’s retirement ages that had
the young, whereas old age was increasingly been established as the basis for pension enti-
linked to poverty. The rise and decline of tlement seemed permissible at the time, in
earning power over the course of a man’s part because women’s aging counted so much
working life came to reflect the rise and fall in less while her “ageless” role within the family
his power to sustain his family, and hence his meant that it was her husband’s retirement –
status. Concerns about the impoverishment or death – that represented the public onset of
of old age in industrial society rose markedly her old age. The inner signs of women’s
during the course of the nineteenth century. aging – the menopause and its various seque-
These concerns led to the introduction of the lae – were matters that went largely unspoken,
old age pension as a means of financially whether they were experienced personally as
securing old age. With it came the final con- a loss or a relief. Within the sphere of home
solidation of the modern, institutionalized and family, the exterior signs of aging went
life course organized sequentially around equally unremarked.
home, then school, then work, and finally Change in the social organization of old
retirement and death. age and its gendered nature came about after
The social organization of the life course in the cultural revolution of the “long” 1960s.
modernity was clearly gendered. While the During this period the classical features of
course of men’s lives was structured by “modernity,” stable occupational identities,
their  relationship to society, in the form of ascribed class and ethnic identities, marriage

and the nuclear family, became much looser. seemed to exist without any coherent policy
In their place came a culture based upon con- or common set of practices to justify their
sumption and lifestyle, a culture that put a existence. Deinstitutionalization and disin-
premium on youth and unconventionality vestment followed as the numbers of over 60s
rather than age and experience. This also living “independently” steadily increased.
affected the circumstances surrounding old Despite more aging, the stereotypes of old age
age. There was a steady increase in women seemed to be less common.
entering, staying in, and/or returning to the In short, the 1980s saw the demise of the
workforce, with a parallel drop in the number category “old age pensioner” (OAP) as the
of men staying in work into their 60s and archetype of old age. Rising standards of liv-
beyond. Old age as retirement became less ing, gender equalization in workforce partici-
narrow, less impoverishing, and less homoge- pation rates, falling rates of employment, and
neous, at the same time as it become a more increased wealth and earnings had redefined
universal experience. Rising incomes in the situation of most people aged over 60 in
retirement in the UK were primarily the most Western societies. “Real” old age, physi-
result of the pre- and postwar expansion of cally dependent, psychically impoverished,
occupational pensions; in the United States, and socially isolated, was confined to a small
the result of improvements in the conditions and shrinking segment of the population
for social security and the introduction of (Gilleard and Higgs 2010). As aging
Medicare, as well as the expansion of occupa- expanded, it became increasingly confusing,
tional pensions; and in continental Europe, while as old age, real or “deep” old age, shrank,
the main effect was the rise in the value of it became increasingly frightening, as talk
state-administered pensions that were linked turned increasingly to the “rising tide” of
directly to the more general rise in wages. dementia. Alzheimer’s disease, once the little-
From the 1980s, the standard of living of known psychiatric name for a rare “pre-senile”
retired people rose at a faster rate than that of form of mental decay, was now replacing the
working people. A new “third age” was being term “senile dementia” as the “cause” of later-
fashioned that contrasted sharply with the life mental decline. Following the putative
narrow and gendered old age fashioned by identification in the late 1970s of the neuro-
the old age pension. The boundaries of what chemical lesion associated with late life mental
constituted “old age” were challenged by the deterioration, and drawing parallels with the
new opportunities presented to increasing potentially much more treatable Parkinson’s
numbers of retired and near retired men and disease, researchers and the pharmaceutical
women, who found themselves owners of industry were keen to explore new frontiers of
property and recipients of disposable income. neurotherapeutics. The Alzheimerization of
This did not seem to be “real” old age. At the aging was under way.
same time, the last institutions housing “real By the 1990s the cultural revolution of the
old age” – the welfare homes, the ex-work- 1960s had settled down, its radical sell suc-
house infirmaries, and the long-stay hospitals cessfully integrated into postwar consumer
in which the “elderly poor and infirm” had society. Aging meantime was becoming ever
long been confined – were seen as increasingly more diverse, surrounded by a growing mass
expensive and unnecessary resources. Long- of competing and conflicting interests.
stay “beds” accommodating a bewilderingly Critical gerontologists were busy identifying
inconsistent number of “geriatric” and the accumulating economic inequalities of
“psychogeriatric” patients and old age residents later life. Cultural gerontologists were equally

eager to draw attention to the double stand- found a reason to exist, not so much prevent-
ard of aging that made men distinguished ing the universal intrinsic irreversible deleteri-
while leaving women devastated. Having dec- ous processes of aging, but more in helping
imated the group of younger gay men in the people “look younger.” At the same time, this
1980s, the AIDS epidemic ended the twentieth concentration on the appearance of aging
century being controlled by anti-retroviral arguably least represented what Strehler (1962)
drugs. This created a new cohort of older gay had defined as aging. Aging of appearance is at
men both as successful survivors and as least in part extrinsic (Antell and Taczanowski
members of another “new aging population.” 1999); it varies systematically by gender and
Since Alison Norman (1985) introduced the race and is not obviously “deleterious” to
gerontological world to the idea of “triple health and longevity (Schnoer et al. 1998).
jeopardy” to describe the very different and Aging, however, can now no longer be
very disadvantaged position of people who constrained by Strehler’s definitional “iron
were neither white, male, nor young, triple cage.” It is, in a way, reverting to what had been
jeopardy was being discovered in ever more portrayed in older pre-modern discourses,
diverse communities, while Geronimus (1996) something that anyone from age 30 onward
introduced the “weathering hypothesis” might reasonably bemoan – whether because
which argued that African Americans were of the appearance of gray hair, lines and wrin-
aging at a faster rate than their Anglo kles, absent mindedness, or the loss of stature
American compatriots because of the endless and definition. If human physiological devel-
burden of “blackness” in America. Older peo- opment can be said to be more or less
ple were also beginning to be seen by some as complete by people’s mid-20s, it follows that
becoming “more equal” than others, as politi- from that point on we are all open to seeing
cians and policy think-tanks began to fulmi- ourselves and others on a road to ruin. In cir-
nate over a growing “generational inequity.” cumstances of what Zygmunt Bauman (2000)
By this, they seemed to mean that older peo- has termed “liquid modernity,” we are
ple were leaving the ranks of the poor at a compelled to think that we must attain, if not
faster rate than all other age groups. Social perfection, then at least the prime of life.
security, these authors claimed, must imme- Yet such attainment is always the subject
diately be privatized and people allowed to of uncertainty as competing discourses and
establish their own “investment strategies” to narratives threaten to undermine our sense
best manage “aging.” In short, “diversity” in of success. Aging is constantly presented as a
aging competed with “inequality” in aging to challenge to the desiring subjects of contem-
be the dominant gerontological narrative. porary society: can we successfully negotiate
These many differences over aging were ourselves through the threats posed by
also recognized as potential commercial aging? The active “will to health” is now
opportunities. Following the introduction of expected of people of all ages. It takes many
so-called “cosmeceuticals,” consumers of a cer- forms, including diet and exercise, mental
tain age were soon discovering that anti-aging attitude, and an  engagement with a variety
remedies could be found on the shelves of of “technologies of the self.” This has now
pharmacies and supermarkets across the been extended to later  life. The 1980s saw
world. Aging was becoming surrounded by the appearance of what would soon become
anxiety and confusion almost as soon as it an avalanche of do-it-yourself books on
seemed to have freed itself from the mantle of aging. Gerontology has followed where life-
old age. Anti-aging practices and products style pioneers led. It discovered “successful

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century modernity has been replaced by Crimmins, E. M. 2004. “Trends in the Health of
more diverse cultures of aging, complex and the Elderly.” Annual Review of Public Health 25:
contradictory narratives, and practices that 79–98.
are redolent of that “normativity of diversity” de Grey, A. 2007. Ending Aging: The Rejuvenation
which Ulrich Beck (2007) saw as defining a Breakthroughs That Could Reverse Human Aging
second reflexive modernity. Aging, shorn of in Our Lifetime. New York: St. Martin’s Press.
its bearings in the social institutions of Fogel, R. 1994. The Relevance of Malthus for the
modernity, seems to be everywhere, in differ- Study of Mortality Today. Long-Run Influences
ent forms and with different meanings. As on Health, Mortality, Labor Force Participation,
and Population Growth. NBER Working Paper
Jones and Higgs (2010) point out, the notions
no. 54. Washington DC: National Bureau of
of natural aging, normal aging, and ever more
Economic Research.
normative aging have become contested ter- Fries, J. F. 1980. “Aging, Natural Death and the
rains. This increasingly separates out the pro- Compression of Morbidity.” New England Jour-
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both at the social and at the biological level. weight: A Population Based Test of the Weath-
Aging is not what it once was, and it is not ering Hypothesis.” Social Science and Medicine
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SEE ALSO: Aging and Gender; Aging and Jones, I. R., and Higgs, P. 2010. “The Natural, the
Health; Aging and Stress; Beauty Products and Normal and the Normative: Contested Terrains
Health; Body, Sociology of the; Elderly, Health in Ageing and Old Age.” Social Science & Medi-
of the; Third and Fourth Ages cine 71(8): 1513–1519.

Kirkwood, T. 1999. Time of Our Lives: The Science of Parsons, T. 1942. “Age and Sex in the Social
Human Aging. Oxford: Oxford University Press. Structure of the United States.” American Socio-
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Manton, K. G., Gu, X., and Lamb, V. L. 2006. J. W. 2006. 10 Years after Kannisto: Further Evi-
“Change in Chronic Disability from 1982 to dence for Mortality Decline at Advanced Ages in
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Sciences 103(48): 18374–18379. April 10, 2013.
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lation Change.” The Milbank Quarterly 83(4): Strehler B. 1962. Time, Cells and Aging. New York:
731–757. Academic Press.
Geographies of Health TRADITIONAL FOCI
Care Provision
Geographical studies of health service delivery
ROSS BARNETT have had a long history, which, along with the
University of Canterbury, New Zealand mapping and modeling of disease, represents
one of the two traditions of medical geogra-
phy (Rosenberg 1998). Once considered to be
INTRODUCTION minor and neglected part of human geogra-
phy, recent years have seen a partial metamor-
In recent years health systems around the phosis of medical geography into a more
world have come under increasing pressure theoretically enriched geography of health
due to the increased demands which have (Kearns and Moon 2002). While not totally
been placed upon them. These pressures supplanting traditional concerns, this new
have resulted in the continual search for focus has increasingly replaced space with
new organizational structures which it is place and raw empiricism with a greater atten-
hoped will be more effective in dealing tion to social theory, and, in contrast to much
with the problems which have arisen. The of contemporary human geography, has begun
continually changing nature of modern to grapple with important policy questions.
health systems raises a number of impor- Methodological advances, such as multilevel
tant issues for geographers concerned with modeling, have accentuated this trend.
understanding both the nature of change Traditional studies of health service deliv-
and its impacts, but also how different ery were explicitly concerned with the role of
health systems have responded to similar space and how it affected the organization
problems relating to the organization, and distribution of health services and pat-
funding, and delivery of services. terns of use. Generally, four themes were
In the light of such comments, this entry emphasized: geographical bases of service
provides a brief overview of health services organization, locational variations in the pro-
research in geography, focusing on early vision of health services, resource allocation
areas of concern together with new forms in relation to need, and variations in service
of inquiry that have developed since the use. Much of this work reflected the impor-
1980s. It focuses on neglected concerns – tance of logical positivism in human geogra-
key, but relatively unexplored, issues asso- phy as geographers searched for universal
ciated with geographies of health service empirical regularities such as the “inverse
provision and restructuring. Further, it care law,” the presence of “supplier induced
suggests some avenues for future inquiry demand” or “distance-decay” patterns in the
and a need for a certain reorientation of use of health services (Joseph and Phillips
geographical health services research with 1984). While there was some attention to the-
a view to providing more policy relevant ory, it was strongly focused on patterns of
analyses. individual behavior and much less on health

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

institutions, or key public and private health service delivery and less on the wider
stakeholders and the role they played in socioeconomic and political context which
determining access to health services. For affected the funding, regulation, and delivery
example, much of the early welfarist work on of health services. Studies which did so have
the inverse care law focused on individual tended to be focused on highly individualized
doctors and the locational decisions they patterns of care and grounded in the specifics
made and, with few exceptions, said little of particular localities (e.g., Conradson 2005),
about institutional policies of social exclusion and were less interested in broader structural
and how they affected access to care. Similarly, processes affecting health system change.
studies of hospital location also emphasized While this situation has been rectified to
welfarist themes or empirical patterns of some extent in recent years, as is evident, for
hospital use such as “Roemer’s Law,” (a widely example, in recent work on emerging geogra-
cited principle in health policy which states phies of voluntarism (Skinner and Power
that the supply of hospital beds is a key deter- 2011) or primary care (Crooks and Andrews
minant of hospitalization rates) but were 2009), geographic work on health systems
largely silent about the wider organizational and health services remains partial.
context affecting the structure of modern
hospital systems. To a large extent, this largely
reflected the invisibility of Marxist theory in NEGLECTED THEMES
medical geography despite its importance in
some other areas of human geography. Where Observation of the limited number of papers
structural analyses of health policy did take presented on health systems and health ser-
place, this mostly occurred on the part of vices at International Medical Geography
other social scientists (e.g., Doyal 1995). Symposia in recent years reinforces this view.
While health services have a distinctly Perhaps part of the reason for the lack of a
spatial component, attention must also be stronger emphasis on health services lies in
focused on the role of place or contextual fac- greater interest in neighborhood effects on
tors and how these may influence patterns of health and health behaviors and perhaps
service delivery. Stimulated by the “cultural partly reflects an aversion to re-engage with
turn,” health geographers, beginning with political economy or structural interpreta-
writers such as Kearns and Gesler (1998), tions of health and health service change.
increasingly began to explore how aspects of Important themes which have been relatively
place affected health, the delivery of health neglected are emphasized.
services, and health policy. In what has been First, research which has taken a more
termed the “new” geography of health, analy- global perspective on differences between
ses of health care delivery have focused on the health systems and their links to health has
ways in which places of delivery of health been largely absent in health geography.
services could be designed according to the Given our long-standing focus on globaliza-
principles of therapeutic landscapes. These tion, I find this omission surprising. So topics
were seen to encourage healing either by such as the global pharmaceutical industry,
being places of refuge and relaxation, or multinational hospital chains, the diffusion of
because they demedicalized hospital environ- neoliberal ideology and its incorporation into
ments. However, since much of this work was attempts at health reform, whether in transi-
heavily influenced by cultural geography, it tional or developing economies, or the inter-
strongly focused on more micro-aspects of nationalization of the medical workforce all

remain largely unexplored. However, recent the evolution of health services. One of the
interest in medical tourism (e.g., Connell few exceptions is Moon and North’s (2002)
2011; Crooks et al. 2011) provides a refresh- analysis of the evolution of primary care in
ing attempt to place the global back into geo- the United Kingdom, which not only focuses
graphical health services research. upon the political developments which have
Second, despite much evidence over the altered the complexion of the National Health
importance of health systems in affecting Service (NHS), but which has also located
levels of health and health inequalities (e.g., such changes within a wider international
Kunitz, McKee, and Nolte 2010), again there context. Also important is how health care
is a dearth of work in this area. There are reform, particularly in primary care, has
many different types of health care systems influenced patterns of hospitalization and
where state or provincial governments have a health outcomes (e.g., Lostao et al. 2011). The
large impact on the structure and direction of “managed care” debate in the United States
health policy. To a large extent, these varia- and the differing views on the relative com-
tions reflect the importance of differences in munity benefits of for-profit and not-for-profit
levels of economic development between care is a case in point (Simonet 2005).
places, but they also point to the significance Fourth, over the years geographers have
of different political cultures upon patterns of contributed much to a greater understanding
health spending and health outcomes. Given of how place and space have affected the
that some research shows such a link (e.g., delivery of health services. But issues of
Gorey et al. 2000), it suggests that there is patient need and questions of how to service
scope for more insightful studies of the “hard to reach” populations still remain
impact of different welfare regimes on health important and deserve more attention than
inequalities. they have received. This is particularly true
Third, the lack of a global focus by geogra- with respect to emerging research on the
phers is also evident in studies of health quality of health services and whether pat-
reform. To date, most of the published litera- terns of social and racial exclusion in the
ture by geographers has emanated from a delivery of services affect health outcomes.
small number of developed countries which
unfortunately has not included the United
States. Health care reform has been likened to WHERE TO NOW?
“revolving doors,” whereby governments in
particular have repeatedly sought to improve This provision of high-quality health services
the performance of health services. in a cost effective and equitable fashion is one
Identifying, comparing, and understanding of the most important functions of the con-
such changes within a political economy temporary welfare state. Yet it remains one of
framework is a major challenge. Generally, the most difficult, mainly due to the compet-
most analyses of health sector restructuring ing demands for increasingly scarce resources
have been country-specific and, while they as populations age and as medical technolo-
have provided much historical detail on the gies become more complex. Also, its pluralis-
policy processes operating within different tic character means that governments face the
countries, they have largely lacked a compar- difficult task of funding and regulating a
ative focus in which the different aspects diverse array of health care providers as they
of  place are emphasized and how the attempt to improve levels of service efficiency
political  and social environment has shaped and to ensure an equitable provision of care.

Unfortunately, achieving these two goals has and neoliberalism, which have affected the
often proved illusory as costs have continued structure of the welfare state. Third, it is
to rise and because of professional resistance important that geographies of health services
to any loss of professional autonomy. pay greater attention to more macro-processes,
Consequently, there have been repeated since these affect the micro-contexts which
episodes of health sector restructuring in dif- we have been so concerned about in recent
ferent countries, the precise form of which has years. This is not to downplay the significance
depended very much upon the local political of cultural concerns in health service delivery
culture. New public management managerial but simply to re-emphasize the significance
reforms which characterized many countries in of the bigger picture. The recent resurgence
the 1980s were often superseded by market- of interest in landscapes of voluntarism
based initiatives aimed at increasing competi- (Milligan and Conradson 2006) provides a
tion and choice. Yet because such changes model of integrating macro- and micro-
produced few fiscal benefits while at the same concerns. Similarly, the integration of structural
time intensifying health inequalities, we have and cultural viewpoints evident in past work
seen a reversion to a mix of market and mana- on hospital restructuring (e.g., Kearns and
gerial policies, as is evident in the complex Barnett 2003; Moon and Brown 2001)
pluralistic (“third way”) now typical of many resulted in greater insights into processes of
health systems. Important here has been the restructuring than if one perspective had
increased emphasis upon primary care in been relied upon alone. Milligan, Kearns, and
health spending, the development of a popula- Conradson (2011) make the point that in
tion health approach which emphasizes equity order to understand the larger story of soci-
concerns more than before and an increased etal shifts and organizational change, we need
focus in meeting certain performance targets, the micro-stories of people’s trials and trajec-
such as improved access to care. tories and how they fit into this bigger pic-
While the above concerns featured in ture. While this may be the case, the “bigger
health geography research in the 1980s and picture” also needs far more attention than it
1990s (e.g., Scarpaci 1989; Mohan 2002), the has currently received. This is an important
interest in organizational change and the oversight and one that needs to be rectified if
social and health effects of system changes we are to better understand processes of
has not continued. Thus the challenge for health restructuring and the wider implica-
health geography is to gain a better under- tions of such changes for tackling inequalities
standing of such trends, both in terms of their in health and health care.
causes and how they vary from place to place,
and also how local political cultures have SEE ALSO: Geographies of Health Care
affected the nature of power relationships and Access; Geographies of Health Inequality;
the health care policies which result. Such Health Care Delivery Systems: various
work would be beneficial for a number of rea- countries
sons. First, it is important to develop more
comparative research which emphasizes the REFERENCES
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Crooks, V. A., Turner, L., Snyder, J., Johnston, Elicited Biographies of Activism in Mental
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Health into Place: Landscape, Identity and Well-
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Mental Health and Work jobs. Yet, workers don’t create the jobs that
cause them stress and not all workers are
MARK TAUSIG exposed to stressful jobs. Workers don’t initi-
University of Akron, USA ate layoffs or create economic downturns that
generate job insecurity or make remaining
The relationship between the work that jobs more stressful. Workers deal with work–
people do to earn a living and their psycho- family stressors in part because of women’s
logical well-being has been the object of increased participation in the labor force,
study by sociologists since the writings of which reflects a change in gender roles, and in
Engels, Marx, Durkheim, and Weber (i.e., part because a dual income is now essential to
on alienation and anomie). These early soci- economic well-being. The organizations in
ologists viewed work conditions and the which people work – and hence the structures
psychological reactions of workers to their of their jobs – have also changed for complex
work as outcomes of structured social and institutional and economic reasons. Hence, we
economic relations. Thus, to understand the need to view the relationship between work
relationship between work and mental and mental health as the “outcome of struc-
health we require a systematic sociological tured social and economic relations” and not
study of the way that various social and solely as individual reactions to stressful work.
economic structures affect work conditions The research on individual job stress and
that are known to affect the mental health mental health examines how features of jobs –
of workers. such as the level of job demands, decision
Today, much research on the relationship latitude, autonomy, substantive complexity,
between work and mental health is concerned co-worker support, and job insecurity – are
with job stress and, indeed, research shows that related to individual levels of strain. The job
many workers feel “stressed out” by their jobs, demand/control (support) model is most fre-
unhappy about the amount of control they have quently used to account for individual levels
over their work, unsure of continued employ- of work stress as it is related to those job
ment, and at greater risk of gastrointestinal conditions (Karasek and Theörell 1990). In
disorder, cancer, musculoskeletal disorders, this model bad jobs, in terms of higher expe-
cardiovascular disease-related mortality, and rienced stress by workers, are characterized
psychological disorders, including depression as those with high levels of job demands and
and burnout. The total health and productivity low levels of “decision latitude” (control over
cost to business firms of worker stress in terms the way work is done and the use of one’s
of absenteeism, health care costs, workers’ com- skills and abilities). The lack of co-worker
pensation costs, and turnover is enormous. support, low job complexity, poor pay, the
Most of the research on the relationship absence of promotion possibilities, job inse-
between work and mental health has been curity, poor access to the resources needed to
conducted by occupational health psycholo- do a job, and the lack of feedback about work
gists and focuses on the reactions of individ- performed have also been shown to be related
ual workers to the conditions of their specific to higher levels of job-related stress and

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

psychological ill-health. These studies do not Since the late 1990s, the nature of work
connect job conditions to larger economic has  also changed substantially, as has the
and social conditions. As a result, we do not relationship between employers and employees.
obtain an understanding of why jobs are Recent discussions of the restructuring of the
structured in particular ways or why those employment relationship include considera-
jobs are differentially distributed across occu- tion of how downsizing, non-standard work
pations, nor how job conditions change. arrangements, labor market segmentation,
Some studies, however, examine the effects “new forms of work,” and the proliferation of
of macro-economic structures and change on low-wage jobs – types of macroeconomic and
aggregate or individual job-related mental social institutional change – affect job condi-
health. These studies generally assess the rela- tions and well-being. Many of these changes
tionship between aggregate macroeconomic appear to be independent of economic cycles
conditions, such as unemployment rates, and and to represent historic changes in the way in
aggregate rates of disorder (Brenner 1984), which workers are exposed to and cope with
but occasionally link aggregate economic work-related stressors. For the most part, these
conditions such as changes in unemployment changes have increased worker insecurity,
rates (e.g., economic recessions) to individual decreased the complexity of work, reduced the
psychological outcomes (Tausig and Fenwick availability of full-time, permanent jobs, and
1999). We can also regard unemployment as increased non-standard forms of employment
one end of a continuum of work status, and that have all been shown to be related to
there is a significant research literature on the increases in worker stress and distress.
mental health effects of unemployment. Jobs in traditional bureaucratic institutions
Persons who lose their jobs because of large- are organized around principles in which jobs
scale economic conditions such as recessions, are clearly described and distinguished from
plant closings, downsizing, or the export of one another. These jobs are embedded in an
jobs to other regions or countries are exposed organizational structure that emphasizes cen-
to significant personal and financial stressors tralized decision-making and control. Job
that cause psychological distress (Horwitz demands are prescribed and unchangeable
1984). Research also shows that when unem- and decision-making is not in the hands of the
ployment rates increase (such as in a reces- average worker. Workers, then, sometimes
sion), levels of stress increase among workers find themselves simultaneously unable to meet
who manage to retain their jobs because the job demands of their position and unable
firms often redefine work conditions by to change the way in which the job is done
increasing job demands and decreasing job (decision latitude). High job demands and low
control. The globalization of the economy, decision latitude can result in job stress.
deregulation of US businesses, technological New forms of work, however, are said to
changes, and the worldwide surplus of labor radically alter these traditional features of the
have now also created a general and enduring job. New forms of work are defined by loose
“precarity” of employment (Kalleberg 2009). organizational coordination of work per-
The growth of precarious work has decreased formed by “flexibly specialized” workers
employees’ attachment to their employers, whose jobs are characterized by recognition of
increased long-term unemployment, and worker knowledge and judgment. Workers
increased perceived job insecurity. Precarious are expected to be active problem solvers who
work leads to insecure workers and to greater flexibly bring personal and organizational
distress levels. resources to bear to efficiently solve problems.

Work may be done in teams and may involve Another focus of research is reflected in
continual and varied training. Supervision studies that attempt to explain the relation-
and management are minimized. ship between positions in social structures
Based on the demand/control argument, of  inequality, work, and well-being. This
we would, therefore, predict that workers literature is based on the sociological study
would report less job stress in these different of labor markets that is principally used to
conditions. It has been suggested, however, explain economic outcomes but can be
that new forms of work and work organiza- extended to account for psychological out-
tion contain contradictions that can create comes (Tausig and Fenwick 2012). Social
job stress. New forms of work often demand status differences (including gender, race,
substantially more from the worker. Different social economic status, and citizenship sta-
skills such as those related to interpersonal tus) affect participation in the labor market
relationships (team play) and logistics may and consequent worker exposure to stressful
be called for. Workers may find that the level job conditions.
of job demands has increased dramatically. The labor market is the mechanism that
Workers may also discover that the greater links workers to jobs. Segmented labor market
autonomy promised by the reorganization of theory argues that labor markets are divided
work is illusory, or offset by normative pro- in such a way that different types of workers
cesses within work groups. Workers may also have different access to specific types of jobs.
be more exposed to the uncertainty of the In particular, some workers have access to
labor market. “good,” economically and psychologically
Part of the “New Deal at Work” includes rewarding jobs, while others only have access
the notion that having a job no longer implies to largely “bad,” economically and psychologi-
permanent, secure employment, and part of cally stressful jobs. Women, those with a high
that is reflected in the concepts of downsizing school education or less, racial/ethnic minori-
and contingent, temporary jobs. Downsizing ties, and non-citizens are more likely to have
is often a method that organizations use to bad jobs as a result of their presence in the
reduce costs and improve financial perfor- secondary part of the labor market that
mance (objectives of the restructured mod- contains such jobs. Hence, these groups are
ern organization), and not necessarily as a also more likely to be exposed to the stressful
response to a decline in business. While it is elements of work – particularly low wages,
typical for hiring to follow business cycles, absence of benefits, insecurity, and low
adjustments to workforces are now inde- decision latitude. To put this in another way,
pendent of economic cycles. The new deal at social stratification affects exposure to
work is a recognition that the former social stressful job conditions through the way that
employment contract in which workers such stratification affects participation in the
exchanged their labor for secure, lifetime jobs labor market and may be regarded as one
with stable pay has been replaced by a mechanism that links work-related distress to
market-driven temporary relationship in the observed social gradient in health.
which neither organizations nor employees Finally, some research examines the inter-
make long-term commitments to one section of work with the family. This litera-
another. In doing so, the salience of job secu- ture has developed, in part, because of
rity as a work characteristic that is related to increased female participation in the labor
job stress has increased for downsized, tem- force and, in part, because of the more gen-
porary, and even “permanent” workers. eral recognition that the impact of work on

mental health cannot be properly understood market conditions that do not favor positive job
without accounting for other social contexts conditions. This includes the notion that jobs
(Schieman, Milkie, and Glavin 2009). The that might contain characteristics associated
increased participation of women in the paid with lower stress and resources to manage
labor force, and the psychological effects on work–family tensions may be difficult for
women of that participation, can be partly women (especially) to obtain because such
understood as a function of the consequences jobs are not available in the peripheral sector
of social structures of inequality on work- of the labor market that includes part-time,
related stress and distress (see above). But, temporary, and contingent jobs.
particularly because of the increased partici- In addition to family effects on labor market
pation of women in the labor force (although participation and the availability of family-
not exclusively so), the intersection of the friendly job conditions, there is a sizable
family as a social institution with work has research literature on the psychological conse-
also been studied as a source of work and/or quences of work-to-family interference and
family-related stress (family–work interference, family-to-work interference. What may generi-
work–family interference). One way that the cally be called work–family conflict can be
family affects work-related stress is that fam- viewed as leading to work-related or family-
ily conditions affect self-selection into the related stress and is intended to describe the
standard work arrangement – the primary literal intersection of work and family demands
segment of the labor market with “good” and the negative psychological outcomes based
jobs – or into the non-standard work arrange- on that intersection. The specific structures of
ment – the secondary segment of the labor paid work and family work may cause distress
market with “bad” jobs. The participation of that spills over or contaminates the level of
women in the labor force has also directly psychological well-being associated with the
affected some aspects of work organization and other role. Meeting expectations in both the
subsequent job conditions. In order to retain paid labor force and in families requires the
permanent workers who have conflicting or management of job demands and scheduling
demanding family obligations, some firms have demands in both spheres of activities. In short,
introduced “family-friendly” work policies that the simultaneous demands of work and family
include flexible work scheduling, provisions plus the existing degrees of conflict and strain
for childcare, and extended maternity or in each sphere can be used to predict psycho-
paternity leave. It has been suggested that logical well-being. To the extent that structural
family-friendly work policies may be regarded features linked to job conditions affect job
as job conditions related to work stress exactly stress, it may be inferred that those same fea-
in the sense that job demands, decision lati- tures will indirectly affect work-to-family-
tude, and co-worker and supervisor support related distress. This is precisely what Schieman,
have been. Family-friendly work policies Milkie, and Glavin (2009) argue.
should reduce work stress and work–family
distress. These policies are, however, usually
only available to core or higher level workers CONCLUSION
and thus do not help many or most other
workers who may need these resources to To understand stress at work and its psycho-
manage work and family demands. logical consequences, we must go beyond
One consequence of attempts to balance individual-based explanations. We need a social
work and family roles is exposure to labor structural explanation for the relationship

between work and psychological well-being. Socioeconomic Status and Stress; Stress and
The research literature shows that macro- Mental Illness; Stress and Work.
economic structure and change, labor market
structures, social structures of inequality, the
organization of work, and the intersection of
work with family affect the stress levels of Brenner, M. Harvey. 1984. Estimating the Effect of
jobs. These social structures affect exposure Economic Change on National Mental Health
to risk (work-related stressors) and access and Social Well-Being. Washington, DC: Gov-
ernment Printing Office.
to  resources that contribute to feelings of
Horwitz, Allan V. 1984. “The Economy and Social
well-being or distress. The macroeconomy
Pathology.” Annual Review of Sociology 10: 95–119.
defines the overall demand for labor and its Kalleberg, Arne L. 2009. “Precarious Work, Inse-
form. The labor market distributes those jobs. cure Workers: Employment Relations in Tran-
Social structures of inequality influence labor sition.” American Sociological Review 74: 1–22.
market participation, and family situations Karasek, Robert A., and Theörell, Tores, 1990.
affect labor market participation and prefer- Healthy Work: Stress, Productivity, and the
ences. The way firms are structured to Reconstruction of Working Life. New York: Basic.
participate in the global economy affects the Schieman, Scott, Milkie, Melissa A., and Glavin,
types of jobs available and their structure. Paul. 2009. “When Work Interferes with Life:
The outcome of these structural effects Work-Nonwork Interference and the Influence
of Work-Related Demands and Resources.”
defines the immediate work context of
American Sociological Review 74: 966–988.
employees, including their exposure to stress-
Tausig, Mark, and Fenwick, Rudy. 1999. “Reces-
ful job conditions and coping resources and, sion and Well-Being.” Journal of Health and
hence, stress. Social Behavior 40: 1–16.
Tausig, Mark, and Fenwick, Rudy. 2012. Work
SEE ALSO: Health and Economic Stress; and Mental Health in Social Context. New York:
Occupational Health and Safety; Springer.
vocational training school, 20 percent; junior
Health Care Delivery college, 31 percent); 39 percent of doctors
System: China had a bachelor’s degree and another 7 percent
had a postgraduate degree. The diversity in
The Chinese University of Hong Kong
Chinese doctors’ educational background
largely resulted from a number of innovative
programs of medical education introduced in
the 1960s and 1970s, which aimed to train
health care personnel quickly so as to expand
basic medical services. For example, a large
number of rural residents, typically with only
Health care providers
a few years of education, were given very
In China, rural and urban residents seek health basic medical training so that they could
care in different types of organizations. serve the rural communities in which they
Township health centers, village health stations, lived. Vocational medical schools were also
and county hospitals serve the rural popula- established to provide two to three years of
tion. In urban areas, secondary and tertiary medical training to individuals with junior
hospitals provide most of the outpatient and high school education. In the 1980s, China
inpatient care (Yip et al. 2010). Chinese hospi- started to shift the focus of medical education
tals are classified into three grades and within to the tertiary level. At the time of writing,
each grade they are further divided into levels individuals can go through two to three years
A, B, and C, according to their performance, of medical training after high school and
technological sophistication, and quality of become a licensed assistant doctor, or go
personnel. The A-level tertiary hospitals are through five to eight years of training after
considered the best in the country; inpatient high school and become a licensed doctor.
beds and consultation with doctors in these Around 90 percent of nurses received their
hospitals are highly sought after. In addition to training in junior colleges (42 percent) or
hospitals, community health centers and sta- vocational nursing schools (47 percent)
tions provide routine outpatient care to the (Ministry of Health 2010). The distribution
urban population (Bhattacharyya et al. 2011). of health care resources between urban and
Independent outpatient clinics, which are a rural populations is highly unequal. In 2009,
relatively new organizational form, may be the average number of inpatient beds per
located in either urban or rural areas and pro- 1000 people was 4.31 in cities and 1.05 in
vided roughly 7 percent of all outpatient care in rural areas; the average number of doctors
2009 (Ministry of Health 2010). per 1000 people was 4.61 in cities and 1.89 in
In 2009, the Chinese health care delivery rural areas. The distribution of more highly
system employed 4.2 million doctors and educated medical personnel is also very unequal.
1.9 million licensed nurses. More than half of About 62 percent of doctors working in
Chinese doctors did not have a bachelor’s hospitals had a bachelor’s or postgraduate
degree (high school or lower, 2.4 percent; degree, but only 11 percent of those working

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

in township health centers were educated at jointly funded by the central and local govern-
the tertiary level (Ministry of Health 2010). ment and rural residents (Ministry of Health
Most of the health care in China is provided 2010). NCMS is managed by county govern-
by public not-for-profit organizations. Although ments and the risk pooling takes place at
22 percent of all hospitals were private-for- county level. Regional variations exist in the
profit, they tended to be small and specialty- contributions to and benefits of the NCMS
based, and in 2009 accounted for only programs, but most of the programs empha-
4.5 percent of outpatient and 4.3 percent of size relief for catastrophic health care spending
inpatient care provided in hospitals. Almost all rather than providing a comprehensive bene-
township health centers and over 95 percent of fits package (Wagstaff et al. 2009). On average,
community health centers are not-for-profit. NCMS reimbursed about one-third of inpa-
The for-profit sector plays a more important tient and outpatient expenditures in 2008
role in delivering outpatient care. About one- (Ministry of Health 2009). In cities, as of 2009,
third of village health stations and more than around 80–90 percent of urban residents were
90 percent of outpatient clinics are private-for- covered by the urban basic medical insurance
profit. In 2009, the for-profit sector accounted (BMI) programs (Ministry of Health 2010).
for about 12 percent of outpatient and 3 percent For the employed, the employers contribute 6
of inpatient care; about 12 percent of doctors percent and the employees contribute 2 per-
and 8 percent of nurses worked in privately run cent of the salary as the insurance premium.
health care organizations (Ministry of Health The premium for those not in a job is subsi-
2010). Table  1 shows the five major types of dized by the local government (Lin, Liu, and
health care organizations mentioned above, the Chen, 2009). Again, contributions to and ben-
shares of inpatient and outpatient care they efits of the urban insurance programs vary
provided, and the percentage of for-profit from one locale to the other. On average, in
organizations in each type in 2009. 2008, the reimbursement rates for inpatient
expenditure were 66 percent for the employed
and 49  percent for the non-employed, and
The financing of health care
those for outpatient expenditure were 74 per-
Rural and urban residents are covered by dif- cent for the employed and 34 percent for the
ferent types of public health care insurance non-employed (Ministry of Health 2009). In
programs. As of 2009, 94 percent of the rural 2009, total health care spending was about 5.13
population was covered by the new coopera- percent of China’s GDP, 27 percent of which
tive medical scheme (NCMS), which was came from government spending, 35 percent

Table 1 Five major types of healthcare organizations in China: their numbers, the shares of outpatient
and inpatient care they provided, and the percentage of for-profit organizations in each type in 2009

Number % Outpatient care % Inpatient care % For profit

Hospitals 20,291 36 64 22
Village health stations 632,770 26 — 33
Township health centers 38,475 17 29 0.1
Outpatient clinics 138,197 7.2 — 93
Community health centers (stations) 27,308 6.8 1.6 4.0

Source: Ministry of Health 2010


from social risk pooling, and the out-of-pocket in particular, the system’s major problems, it
spending of individual citizens made up the is crucial to examine its evolution since 1949,
remaining 38 percent (Ministry of Health when the People’s Republic of China was
2010). Large gaps also exist between urban and established. In 1949, after the Japanese inva-
rural residents in terms of their utilization of sion and years of civil war, modern medicine
health care resources. For example, in 2008, was virtually non-existent except in a few
the per capita health care spending of urban large cities. The health conditions of the
residents was ¥1862 (US$285), four times as Chinese people were among the worst in the
much as that of rural residents (¥455 (US$70)) world. The estimated life expectancy was
(Ministry of Health 2010). around 35, and 20 percent of infants died
during the first year of their lives (Blumenthal
and Hsiao 2005). During the 1950s and 1960s,
Traditional Chinese medicine
separate health care delivery systems were
Traditional Chinese medicine (TCM) is an developed for rural and urban residents.
established component in China’s health care The main components of the rural system
delivery system. The practice of TCM is super- were barefoot doctors, the cooperative medi-
vised by its own administrative infrastructure in cal scheme, and the three-tier referral
the Ministry of Health, and Chinese medicine system. A large number of farmers went
practitioners have their own professional asso- through three to six months of basic medical
ciations and journals. Independent Chinese training and became barefoot doctors; by
medicine colleges and vocational schools train 1978, there were 1.6 million barefoot doctors
future practitioners (Scheid 2002). As of 2009, staffing village health stations (Zhang and
there were 2973 hospitals specializing in TCM Unschuld 2008). They were called “barefoot
and around half a million Chinese medicine doctors” because many of them worked as
doctors provided about 14 percent of health farmers when they were not practicing medi-
care (Ministry of Health 2010). Despite the cine. Agricultural communes, which organ-
importance of TCM in China’s health care ized collective farming, also operated the
delivery system, its legitimacy and relevance as cooperative medical scheme, in which a por-
an effective healing system have been constantly tion of the communes’ output was set aside to
challenged in a rapidly modernizing society. As partially compensate barefoot doctors and
China opened up to the rest of the world during reimburse farmers’ health care costs. The
recent decades, TCM has faced increasing com- three-tier referral system consisted of village
petition from biomedicine, and its jurisdiction health stations, township health centers, and
has become more circumscribed (Scheid 2002). county hospitals. The rural health care system
As a result, the use of TCM in the health care by no means met all the health care needs of
delivery system has declined in recent decades, rural residents, but it provided basic health
especially in urban areas (Jin 2010). care and a safety net to a vast rural popula-
tion. As such, in the 1970s, the Chinese sys-
tem was held up by the WHO and the UN as
THE EVOLUTION OF CHINA’S a model for the provision of basic health care
HEALTH CARE DELIVERY SYSTEM: in developing countries (Blumenthal and
1949–2003 Hsiao 2005).
In cities, public hospitals provided both
To understand the current configuration of inpatient and outpatient services. The health
the health care delivery system in China, and, care costs of urban residents and their families

were covered on a fee-for-service basis by government, they could no longer cover the
their workplaces under the government insur- health care costs of their workers. At the same
ance scheme and labor insurance scheme. The time, the rapidly growing private sector gen-
two schemes combined to cover around 70 erally did not offer coverage of health care
percent of urban residents (Liu 2002). costs (Liu 2002). The urban health care
The Chinese health care delivery system reform, initiated in 1997, aimed to replace
developed during the first three decades of medical insurance organized at the level of
the People’s Republic of China was credited the workplace with one organized at the level
with having contributed to tremendous of a city, called the urban employee’s basic
achievement in population health. By the end medical insurance. It was hoped that the
of the 1970s, average life expectancy reached new  scheme would cover workers in both
68 years and infant mortality rate dropped to state-owned enterprises and the private
64 per 1000 live births (Blumenthal and Hsiao sector, thereby boosting the overall coverage
2005). During this period of time, however, rate. The reform succeeded in implementing
the improvement of population health and city-wide insurance schemes, but failed to
the development of the health care system increase overall coverage. The percentage of
had also suffered setbacks. In particular, the urban residents with insurance coverage
massive famines of 1958–60, mostly caused gradually declined to around 49 percent in
by political and economic turmoil, claimed the late 1990s (Blumenthal and Hsiao 2005).
20–30 million lives. In addition, during the As the economic reforms unfolded, the
Cultural Revolution, when political factions Chinese government started to withdraw
struggled for dominance, universities and from financing the provision of health care in
medical schools were closed for five years and the mid-1980s. The share of total health care
faculty and students were sent to the country- spending paid for by the government declined
side. As a result, the training of elite medical from 36 percent in 1980 to around 16 percent
personnel and medical research were stopped. in 1999 (Ministry of Health 2010). In 1999,
In 1978, market reforms were initiated to among the general hospitals run by the
revitalize China’s stagnant state-controlled Ministry of Health, transfers from the
economy. The pre-reform health care deliv- government accounted for only 6 percent of
ery system became greatly weakened, which total outlays (Ministry of Health 2010).
exacerbated existing problems and created Consequently, hospitals and other health care
new challenges. In rural areas, as collective providers had to rely on the sales of health
farming disappeared in the early 1980s, the care services and products to cover their
cooperative medical scheme (CMS) col- expenses. To assure access to basic health care
lapsed. The 1990s witnessed several attempts services, the government continued to set the
to resurrect the CMS scheme, but these prices of routine clinical visits and standard
efforts failed to achieve widespread coverage. diagnostic tests and pharmaceuticals below
The coverage rate of CMS went down from cost. However, profits from new drugs, tests,
over 90 percent in 1978 to around 5 percent and technology were permitted, so that health
in 1984 and stayed at a low level throughout care organizations remained financially via-
the 1990s. Most rural residents were left with- ble. The financing and pricing policies cre-
out access to any form of health care insur- ated distorted incentives for health care
ance (Blumenthal and Hsiao 2005). In cities, providers, who favored prescribing costly
as a large number of unprofitable state-owned new drugs and high-technology services, at
enterprises lost the financial backing of the the expense of providing basic health care

services. Over-prescription of drugs and able. Moreover, the ability to obtain health
diagnostic tests was widespread, and hospi- care services increasingly came to depend on
tals competed to introduce high-technology a person’s economic resources, which exacer-
devices. As a result, China’s health care bated social inequality in access and utiliza-
expenditure has increased at 16 percent per tion of health care (Blumenthal and Hsiao
year since the 1990s, which is 7 percent faster 2005). For example, among those who
than the growth of its gross domestic product needed, but failed to get, an outpatient visit,
(Yip et al. 2010). the percentage who did not see a doctor
In addition to over-prescription, the profit because they could not afford it steadily
motive and lack of accountability measures increased from 5 percent in 1993 to 19 per-
led to other unethical practices, such as cent in 2003. In addition, the percentage of
accepting (sometimes exhorting) bribes individuals who could not afford outpatient
from patients, taking kickbacks from the mak- visits when needed grew at a faster rate
ers and suppliers of drugs and medical equip- among low-income groups (Ministry of
ment, and selling counterfeit or expired drugs Health 2004). It was also not unusual for
(Yip et al. 2010). These unethical practices catastrophic health care spending to push
greatly compromised patients’ trust, which households into poverty. A 2006 study esti-
resulted in escalating tension and conflicts, mated that using US$1 as the poverty line,
often violent, between patients and providers health expenditure increased poverty rates
(Zhang and Sleeboom-Faulkner, 2011). from 13.5 percent to 16.2 percent in China
Moreover, the health care delivery system was (van Doorslaer et al. 2006).
highly fragmented and lacked a functioning At the beginning of the twenty-first cen-
referral system, because providers had an tury, China’s health care delivery system was
incentive to hold on to their patients rather beset with such problems as lack of afforda-
than referring them to other levels of health bility, patient–doctor conflicts, inequality,
care organizations. Patients therefore pre- inefficiency, and wastefulness. Critics of the
ferred to seek care in top-ranking hospitals, health care delivery system have argued that
which became overcrowded, while lower-level the improvement in population health stag-
health care organizations did not have enough nated and that gaps in health outcomes
patients. The utilization of the system’s availa- between the rich and poor widened between
ble capacity was inefficient and the level of 1980 and 2000, and that the chaotic health
patient satisfaction was low (Yip et al. 2010; care delivery system was partially to blame
Bhattacharyya et al. 2011). In addition, the (Blumenthal and Hsiao 2005).
neglect of primary care and lack of a function-
ing referral system did not match the needs of
a population with an increasing prevalence of RECENT REFORMS OF CHINA’S
chronic diseases (Yip et al. 2010). HEALTH CARE DELIVERY SYSTEM
As insurance coverage and governmental
health care input declined, the burden of In the early 2000s, the Chinese government
health care costs borne by individual citizens started to put more emphasis on developing
increased. Whereas out-of-pocket spending social welfare programs, including health care
accounted for 20 percent of the total health financing and provision, as a response to rising
care spending in 1980, the share went up to public discontent. The crisis caused by severe
60 percent in 2000 (Ministry of Health 2010). acute respiratory syndrome (SARS) in 2003
As costs rose, health care became less afford- highlighted the weaknesses of the Chinese health

care system and served as a further impetus for and abuse of the system (Gu 2010). Finally, as
change (Blumenthal and Hsiao 2005). The gov- of 2010, more than 200 million rural residents
ernment significantly increased health care have migrated to cities in search of better eco-
spending (Bhattacharyya et al. 2011) and a new nomic opportunities. Although most of the
round of reforms was initiated. migrants are covered by the NCMS offered in
The most dramatic development has been their home villages, they cannot benefit from
the rapid expansion of public health care these programs in cities. In 2010, only about
insurance programs. In 2003, the Chinese 20 percent of migrants to cities had health care
government started to experiment with the insurance (Ministry of Health 2010), leaving a
new cooperative medical scheme in rural large gap in the effective coverage of public
areas. The scheme was heavily subsidized by health care insurance in China.
the government and quickly spread (Wagstaff The Chinese government has also intensi-
et al. 2009); in 2009, it achieved almost univer- fied its efforts to build the primary health care
sal coverage in rural areas (Ministry of Health capacity and a functioning referral system,
2010). In urban areas, in addition to workers, especially in urban areas. Since 2003, the gov-
the basic medical insurance was expanded to ernment has invested heavily in infrastructure
cover residents who were not employed. With and constructed a nationwide network of com-
government subsidies for the urban indigent, munity health centers and stations. However,
the program also grew rapidly to include the utilization level of community health care
between 80 and 90 percent of all urban resi- facilities remains low, primarily because of
dents in 2009. The expanding insurance pro- patients’ lack of financial incentives to seek care
grams have had positive impacts, particularly in these facilities as well as their distrust of pro-
in terms of increasing Chinese citizens’ access viders (Bhattacharyya et al. 2011). To build an
to medical care. It has been shown that the uti- effective primary health system, reform efforts
lization of health care services increased are needed to improve the financing and
(Ministry of Health 2004; Wagstaff et al. 2009), administration of, and human resources in,
and the proportion of individuals who did not community health care facilities.
seek medical care when needed because they Since 2003, the Chinese government has
could not afford it declined (Ministry of been leading a campaign to address the prob-
Health 2004). However, the insurance pro- lems in China’s health care delivery system.
grams still suffer from several problems. First, The campaign’s achievements have been
reimbursement rates are generally quite low uneven. While public health care insurance
(Ministry of Health 2009) and the expansion programs have expanded fast, efforts to build a
of insurance coverage has not led to a decrease functioning referral system and strengthen the
in individual citizens’ out-of-pocket health provision of primary care have so far been
care spending (Wagstaff et al. 2009). Second, largely unsuccessful. Moreover, little has been
inefficiency in the administration of the insur- done to eliminate providers’ distorted financial
ance schemes led to huge surpluses in the incentives. Experiments aimed to realign pro-
insurance funds; for example, in 2009, the vider incentives have produced promising
cumulative surplus of the urban basic medical results in both rural and urban areas, but they
insurance scheme was 1.16 times higher than remain isolated instances (Yip et al. 2010).
its total revenues. The huge sums of unspent China’s health care delivery system is still
money prevent enrollees from benefiting from evolving very rapidly. In 2009, in a proposal of
high levels of health care protection and comprehensive health care reforms, the State
potentially provide opportunities for fraud Council of China set the goal of providing safe,

effective, convenient, and affordable basic care Lin, W., Liu, G. G., and Chen, G. 2009. “The Urban
for all citizens by 2020. The proposal also Resident Basic Medical Insurance: A Landmark
promised the infusion into the health care Reform towards Universal Coverage in China.”
delivery system of an additional ¥850 billion Health Economics 18(S2): S83–S96.
Liu, Y. 2002. “Reforming China’s Urban Health
(US$123 billion) over a three-year period. As a
Insurance System.” Health Policy 60: 133–150.
part of the comprehensive reform programs,
Ministry of Health. 2004. Chinese National Health
the reform of public hospitals was initiated in Services Survey: 2003. Beijing, China: Union
early 2011 to realign provider incentives and Medical School Press.
improve patient experience. These recent Ministry of Health. 2009. Chinese National Health
developments in China’s health care delivery Services Survey: 2008. Beijing, China: Union
system provide reasons for optimism for its Medical School Press.
continuing improvement, but rigorous exami- Ministry of Health. 2010. Health Statistics Year-
nation is needed to assess the effects of the book of China. Beijing: Peking Union Medical
reform efforts. University Press.
Scheid, V. 2002. Chinese Medicine in Contemporary
China: Plurality and Synthesis. Durham, NC:
SEE ALSO: Complementary and Alternative
Duke University Press.
Medicine; Health Professions and Organization;
Van Doorslaer, E., O’Donnell, O., Rannan-Eliya, R.
Hospitals in the United States; Inequality and
P., Somanathan, A., Adhikari, S. R., Garg, C. C.,
Health Care; Patient–Physician et al. 2006. “Effect of Payments for Health Care
Communication on Poverty Estimates in 11 Countries in Asia:
An Analysis of Household Survey Data.” Lancet
368(9544): 1357–1364.
Wagstaff, A., Lindelow, M., Gao, J., Xu, L., and
Bhattacharyya, O., Delu, Y., Wong, S. T., and Bowen, Qian, J. 2009. “Extending Health Insurance to
C. 2011. “Evolution of Primary Care in China the Rural Population: An Impact Evaluation
1997–2009.” Health Policy 100(2–3): 174–180. of China’s New Cooperative Medical Scheme.”
Blumenthal, D., and Hsiao, W. 2005. “Privatiza- Journal of Health Economics 28(1): 1–19.
tion and Its Discontents: The Evolving Chinese Yip, W. C.-M., Hsiao, W., Meng, Q., Chen, W.,
Health Care System.” New England Journal of and Sun, X. 2010. “Realignment of Incentives
Medicine 353: 1165–1170. for Health-Care Providers in China.” Lancet
Gu, X. 2010. “On the Level of Fund Balance in Chi- 375(9720): 1120–1130.
na’s Urban and Rural Public Healthcare Insur- Zhang, D., and Unschuld, P. U. 2008. “China’s
ance.” Journal of Graduate School of Chinese Barefoot Doctor: Past, Present, and Future.”
Academy of Social Sciences 5: 53–61. Lancet 372(9653): 1865–1867.
Jin, L. 2010. “From Mainstream to Marginal? Zhang, X., and Sleeboom-Faulkner, M. 2011.
Trends in the Use of Chinese Medicine in China “Tensions between Medical Professionals and
from 1991 to 2004.” Social Science and Medicine Patients in Mainland China.” Cambridge Quarterly
71(6): 1063–1067. of Healthcare Ethics 20(3): 458–465.
Chiropractors removal of a single cause: a pathogen in the
case of biomedicine, a lesion in the case of
HANS A. BAER osteopathy, and a subluxation in the case of
University of Melbourne, Australia chiropractic.
At the therapeutic level, the development
Like osteopathy, chiropractic blended elements of US chiropractic was shaped by fierce bat-
from various healing and metaphysical sys- tles between the “straights” – those who
tems. Daniel David Palmer (1845–1913), the wished to focus on spinal adjustment – and
founder of chiropractic, opened a magnetic the “mixers” – those who wished to incorpo-
healing office in the United States in rate other modalities, such as physiotherapy,
Burlington, Iowa, and later in Davenport, hydrotherapy, electrotherapy, colonic irriga-
Iowa. He administered his first “spinal adjust- tion, dietetics, exercise, and vitamin therapy.
ment” in Davenport in September 1895 when Because of its extreme eclecticism, naturopa-
he cured an African American janitor of a thy in particular provided chiropractic mix-
deafness that had lasted 17 years. Palmer ers with a ready source from which to add a
argued that disease emanates from “subluxa- wide variety of techniques to their own treat-
tions” or spinal misalignments which result ment regimen. Indeed, until the 1950s the
in interference with neural transmission, mixer chiropractic schools in the United
which in turn trigger dysfunctions in the States offered the Doctor of Naturopathy
internal organs. Spinal adjustment restores (ND) degree along with the Doctor of
the normal “nerve force,” and health is Chiropractic (DC) degree, in large part to
restored. Palmer began to offer instruction at provide practitioners with a wider scope of
the Palmer Infirmary and Chiropractic Institute practice in states which limited chiropractic
in 1898. There is some evidence that Palmer legally to spinal adjustment. Initially, chiro-
had received treatments from Andrew Taylor practic sought to function as a form of drug-
Still, the founder of osteopathy, and had less general practice – an ambition that it
learned manipulative techniques from another retains, in both its straight and mixer forms,
osteopath. In contrast to present-day US oste- in the United States. Elsewhere, in countries
opathic medicine, spinal manipulation has such as Canada, the United Kingdom,
remained the central chiropractic modality in Australia, and New Zealand, chiropractic
both the United States and numerous other mainly functions as a musculoskeletal spe-
countries. In contrasting themselves to bio- cialty (Baer 2009).
medical physicians, chiropractors often assert In their efforts to achieve legitimacy and
that they practice a form of health care that improved status in the United States, chiro-
focuses on treatment of the whole practice. In practors adopted a wide variety of strategies.
reality, the holism of chiropractic is limited in These included establishing professional
that it relies heavily, like biomedicine and associations, colleges, patient support groups,
osteopathy, on notions such as the machine and practice-building seminars; conducting
analogy. Biomedicine, osteopathy, and chiro- lobbying campaigns; and even bringing a major
practic, at least in their original forms, are antitrust suit against both organized biomed-
based on the belief that healing involves the icine and, to  a  lesser degree, osteopathic

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

medicine. US  chiropractic history has seen and politicians (including Bill Clinton),
the rise and fall of rival associations at both chiropractic has managed to achieve semi-
state and national levels. With the exception legitimacy within US society. Moore (1993,
of the College of Chiropractic at the University 138) argues that chiropractic “has moved into
of Bridgeport, which is owned by the position as the orthodox, non-traditional
Unification Movement, all other 17 US chiro- approach to health – a type of orthodox unor-
practic schools are freestanding, private insti- thodoxy … [that] … now occupies a unique,
tutions. The National University of Health middle ground between regular medicine
Sciences (formerly the National College of and the harmonial-type therapies of the
Chiropractic) in Lombard, Illinois, which holistic health movement.” Conversely, it
was established in 1906, now offers a could be argued that osteopathic medicine, at
Naturopathic Medicine doctoral program. It least in the US context, which has enjoyed full
also has master’s programs in acupuncture practice rights in all 50 states and the District
and in Oriental medicine. The International of Columbia since the early 1970s, occupies a
Chiropractors Association estimated in 2011 middle ground between biomedicine and
that there are more than 10,000 chiropractic chiropractic. In contrast to the United States,
students and about 60,000 practicing chiro- osteopathy occupies a sociopolitical and ther-
practors in the United States. apeutic status as largely a manual medical
Licensing laws played a crucial role in the system in the various other countries where it
legitimization of US chiropractic. In 1913, exists, much like chiropractic. Unlike MDs,
Kansas became the first state to enact chiro- who more and more have become employees
practic legislation. As a professionalized of hospitals, medical schools, and health
heterodox medical system, chiropractic has maintenance organizations, most chiroprac-
offered upward social mobility for thousands tors continue to function as independent
of lower-middle-class and working-class entrepreneurs, either working as solo practi-
individuals (Baer 2004, 32). Despite vigorous tioners or practicing in small groups. A few
opposition historically by biomedicine, chi- chiropractors are on the staff at a number of
ropractic in the United States has undergone hospitals.
considerable legitimatization since the early Globally, chiropractic is much more wide-
1970s. The US Office of Education recog- spread than its rival, osteopathy. Formally
nized the American Chiropractic Association’s accredited chiropractic colleges exist not only
Council on Chiropractic Education as an in the United States and Canada, but also the
official accrediting agency in 1974. In 1975, United Kingdom, Australia, New Zealand,
the National Institutes of Health (NIH) Denmark, Norway, France, Brazil, Japan,
organized a Workshop on the Research Status South Korea, Mexico, and South Africa.
of Spinal Therapy that included biomedical While chiropractic colleges have not yet
physicians, osteopathic physicians, and chi- attained affiliations with public tertiary insti-
ropractors. Chiropractic is covered under tutions in the United States, they have done
Medicare, Medicaid, Federal Employees so in Canada (one program in Quebec),
Health Benefits Programs, Federal Employees’ Denmark (one program), Australia (three
Compensation, and all state workers’ com- programs), and South Africa (two programs).
pensation programs. As a result of intensive Although it has made efforts to become
efforts and support from satisfied patients linked with a public university, the Canadian
and patient support groups, labour unions, Memorial Chiropractic College in Toronto

remains a private institution. The reasons Parliament committee report in 1977 that
why chiropractic has managed to gain entrée recommended registration for both chiro-
into public universities in some countries and practors and osteopaths, although not
not others need to be further explored. One naturopaths and homeopaths. Between 1978
issue may be the fact that private chiropractic and 1991, chiropractic obtained statutory
colleges in the United States and Canada offer registration in  all Australian states and
doctoral degrees, whereas in Australia, for territories. Chiropractic education shifted
instance, chiropractic programs offer only from private colleges to three public tertiary
bachelor’s and master’s degrees, thus making institutions. The first chiropractic training
them less of a status threat to biomedicine. program at a public tertiary institution in
North American chiropractors often view the world was established in 1980 at the
themselves as the equals of their biomedical Preston Institute of Technology, which was
counterparts, while Australian chiropractors renamed the Phillips Institute of Technology
view themselves primarily as manual medi- in 1982 after it merged with a teachers’
cine specialists with a more humble status college. Phillips was eventually absorbed by
within the larger plural medical system. the Royal Melbourne Institute of Technology
Chiropractic enjoys legal status of one University in 1992. Since then, chiropractic
sort of other in numerous countries, includ- training programs have been created at two
ing developing countries such as China, the other public universities, namely Macquarie
Philippines, Jordan, Saudi Arabia, Nigeria, University in Sydney and Murdoch
and Zimbabwe. While space does not University in Perth. Both chiropractors and
permit giving attention to the sociopolitical osteopaths out-earn general practitioners
status of chiropractic in the many countries and physiotherapists in Australia (Baer
where  it exists, the Australian scenario 2009, 95–6). Ironically, general practitioners
provides an interesting contrast to the serve as the port of entry for patients to
American scenario, which has received qualify for five chiropractic or osteopathic
considerable attention in the social scientific treatments per annum under Medicare, the
literature. Willis (1989, 170–91) delineates national health plan, thus testifying to the
four periods in the development of Australian ongoing dominance of biomedicine in
chiropractic: (1) the establishment period Australia, like in all other countries around
(1918–53), in which a group of chiroprac- the world.
tors emerged in Victoria from the practice The drive for professionalization has pro-
of  osteopaths in the UK- and US-trained vided chiropractic with semi-legitimacy
chiropractors and the establishment of vari- within many of the societies where it now
ous chiropractic associations; (2) the period exists and may have evolved into what
of expansion (1954–61), which witnessed Wardwell (1992) termed a “limited profes-
a  considerable increase in the number of sion” similar to dentistry, podiatry, optome-
chiropractors trained both in Australia and try, and psychology. Nevertheless, whereas
overseas; (3) the period of agitation (1963– these latter limited professions tend to be
73), which resulted in the passage of the accepted by biomedicine as junior partners,
Western Australian Chiropractic Act in 1964 chiropractic still finds itself by and large out-
and the  inclusion of chiropractic under side its corridors.
private health plans; and (4) the period of
legitimatization, which began with a federal SEE ALSO: Osteopaths

Moore, J. S. (1993). Chiropractic in America. Balti-
Baer, H. A. 2004. Toward an Integrative Medicine. more, MD: Johns Hopkins University Press.
Walnut Creek, CA: AltaMira Press. Wardwell, W. I. (1992). Chiropractic. St. Louis,
Baer, H. A. 2009. Complementary Medicine in Aus- MO: Mosby-Year Book.
tralia and New Zealand. Maleny, QLD: Verdant Willis, E. (1989). Medical Dominance. Sydney:
House. Allen & Unwin.
Osteopaths organs. He strongly opposed the use of drugs,
vaccines, serums, and modalities such as
HANS A. BAER electrotherapy, radiology, and hydropathy. In
University of Melbourne, Australia partnership with William Smith, a British
regular physician, Still established the
Osteopathy was created in the United States American School of Osteopathy in Kirksville,
during the 1870s by Andrew Taylor Still Missouri, in 1892.
(1828–1917), a disenchanted regular physi- Despite Still’s eschewal of drugs and sur-
cian. In the early twentieth century it began gery, except in extreme circumstances, US
to diffuse to other Anglophone countries, osteopathy began to incorporate more and
such as Canada, the United Kingdom, more aspects of regular medicine or biomed-
Australia, and New Zealand, and later to icine. The early history of US osteopathy
other countries, including non-Western entailed spirited debates between the “lesion
ones. While osteopathy started out as pri- osteopaths,” who wished to adhere closely to
marily a manual medical system, and remains the principles delineated by Still, and the
so in most countries, it evolved during the “broad osteopaths,” who favored incorporat-
twentieth century in the United States and ing elements from regular medicine, as well
some Canadian provinces into osteopathic as from other medical systems such as natur-
medicine and surgery. This constituted a opathy and electrotherapy (Gevitz 2004). At
parallel medical system to biomedicine, roughly the same time that regular medicine
gaining full practice rights in all 50 US states was evolving into biomedicine, osteopathy
by the early 1970s, followed by some began to accommodate itself to its parent by
Canadian provinces, where spinal manipula- adopting surgery and the administration of
tion became an adjunct modality rather than drugs, vaccines, and antibiotics. By the
a central one. 1930s, US osteopathy had evolved into osteo-
Still developed osteopathy in response to pathic medicine and surgery, a parallel medi-
what he considered to be the inadequacies of cal system to biomedicine with an emphasis
allopathic medicine. He became disen- on primary care. DOs (Doctors of
chanted when regular medicine failed to pre- Osteopathy) referred to themselves as osteo-
vent the deaths of three of his children from pathic physicians rather than osteopaths.
meningitis. Based upon detailed anatomical The osteopathic profession began to create
investigations, Still asserted that many, if not its own hospitals and established the
all, diseases are caused by faulty articulations American Osteopathic Hospital Association
or “lesions” in various parts of the musculo- in 1934. Today, only a small minority of
skeletal system. Such dislocations produce American osteopathic physicians specialize
disordered nerve connections that in turn in OMT, despite the centrality of this modal-
impaired the poor circulation of blood and ity in Still’s original system. The vast majority
other body fluids. Still began to rely more use it, if at all, as an adjunct therapeutic
and more on osteopathic manipulation ther- modality. As the majority of American bio-
apy (OMT), not only for musculoskeletal medical physicians vacated primary care
problems but also for ailments in other for  various specialties, many osteopathic

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

physicians found a niche as primary care heterodox manual medical system, most
providers. In contrasting themselves to bio- entrants eventually came from groups who
medical practitioners, osteopathic physicians did not specifically want to practice osteopa-
often assert that they treat the “person rather thy. They wanted to become physicians, but
than the disease.” In reality, this assertion has found admission to biomedical schools
not been empirically demonstrated, but does closed to them for structural reasons, rang-
serve as a rhetorical device by which they ing from a class bias favoring upper- and
distinguish themselves from their biomedi- upper-middle-class students over lower-
cal counterparts. middle- and working-class students to quo-
While biomedicine made staunch efforts tas on the number of Jewish students, which
to legally contain osteopathy in the United were once widespread in biomedical schools.
States (Baer 2001, 55–7), the latter managed Ironically, as US osteopathic medicine
to obtain full practice rights in about a quar- increasingly abandoned its therapeutic birth-
ter of states by 1960. As a result, biomedicine right, chiropractic emerged as the foremost
embarked upon a partially successful effort promoter of manual therapy in the United
to co-opt osteopathic medicine, particularly States. Despite efforts to maintain its distinc-
in 1961 when the California Medical tiveness, US osteopathic medicine continues
Association absorbed 86 percent of the DOs to suffer from what Gevitz (2001, 176) terms
in the state. The leadership of the osteo- an “osteopathic invisibility syndrome,” in
pathic profession, however, managed to that the general public tends to be unaware
counter the effort to absorb additional state of the profession.
bodies into organized biomedicine, initially With the partial exception of Canada,
by creating a new private osteopathic college where osteopathic physicians have achieved
in Michigan. In 1969, this became the full practice rights in some provinces, oste-
College of Osteopathic Medicine at Michigan opathy is practiced in more than a dozen
State University after state legislators had other countries, including South Africa and
been convinced that osteopathic physicians ones in Europe and Asia, as a manual medi-
served an important role in primary care. cal system, positioned between heterodoxy
This victory prompted legislatures in six and orthodoxy (Gevitz 2004, 234). In the
other states – Texas, Oklahoma, West remainder of this entry, I briefly review the
Virginia, Ohio, New Jersey, and New York – sociopolitical status of osteopathy in the
to fund osteopathic medical colleges. Since United Kingdom, Australia, and New
1976, numerous private osteopathic colleges Zealand.
have been added to a low of five colleges John Martin Littlejohn (1865–1947)
reached after the demise of the osteopathic served as the most important link between
college in Los Angeles in 1961. At the time American and British osteopathy. After
of writing, there are 29 osteopathic medical receiving his DO in 1900, he founded, with
schools in the United States, 7 of them state his brothers, the American College of
and 22 private. There are currently more Osteopathic Medicine in Chicago. In the
than 78,000 practicing osteopathic wake of the creation of the British Osteopathic
physicians in the United States. Association, Littlejohn established the
Although US osteopathic medicine British School of Osteopathy (BSO) in
initially attracted regular physicians and London in 1917. Various osteopathic schools
other individuals who wanted to practice a and associations were formed in Britain

during the 1920s, including the Osteopathic and homeopathy. A federal parliamentary
Association of Great Britain (OAGB) which inquiry in the 1970s proposed statutory regis-
evolved into the alumni association of the tration for both chiropractors and osteopaths
BSO. The BSO, however, initially admitted and the creation of chiropractic and osteo-
only graduates of US osteopathic medical pathic training programs in public tertiary
schools. It later established the British institutions, but emphasized that such recog-
College of Osteopathy, which today trains a nition should not indicate that they constitute
small number of biomedical physicians in alternative medical systems. Between 1978
OMT. As naturopathy or nature cure lost and 2001 the  Australian osteopathic profes-
some of its appeal following the advent sion achieved   tatutory registration in all
of  “wonder drugs,” some naturopaths states and territories. Osteopathic training
turned  to osteopathy (Baer 1984). In 1961 programs to the level of master’s degree exist
the British Naturopathic Association was at the Royal Melbourne Institute of
renamed the British Naturopathic and Technology, Victoria University, the
Osteopathic Association (BNOA). The University of Western Sydney, and Southern
Society of Osteopaths emerged in the early Cross University.
1970s as a result of a schism in the College of As had been the case in Australia, oste-
Naturopathy and Osteopathy. Many opathy in New Zealand appears to have
biomedical general practitioners have con- developed alongside the chiropractic pro-
tracted with osteopaths to provide OMT fession. After a prolonged lobbying pro-
for  their National Health Service (NHS) cess, New Zealand osteopathy finally
patients. Some NHS hospitals employ obtained statutory registration when oste-
osteopaths to work at community health opathy was included under the provisions
centers. In 1993, Parliament passed the of the Health Practitioners Competence
Osteopaths Act, which finally provided the Assurance Act, which came into law in
British osteopathic profession with the 2004. Since February 2002, Unitec New
statutory registration it had long sought. Zealand, a tertiary education institution in
With the introduction of statutory registra- Auckland, has offered training in osteopa-
tion, the British Osteopathic Association thy. The Master of Osteopathy degree is the
proposed a merger that resulted in a new only registrable qualification, apart from
BOA, incorporating the former OAGB, Australian qualifications in osteopathy, for
the BNOA, and the Society of Osteopaths. In practitioners applying for registration in
addition to various private osteopathic col- New Zealand.
leges, an osteopathic training program exists The development of osteopathy has been
at the North East Surrey College of shaped by sociopolitical events in the vari-
Technology. ous countries where it exists. While in the
In Australia, the development of osteopa- United States and some Canadian provinces,
thy has been closely intertwined with that of osteopathic medicine in large part consti-
chiropractic. The path to statutory registra- tutes a parallel medical system to biomedi-
tion for both osteopaths and chiropractors cine; in other countries and other parts of
was paved by parliamentary investigations Canada it still functions as a manual medical
into the status of various complementary and system, albeit one that has been biomedical-
alternative medicine (CAM) systems, partic- ized both in terms of its research and
ularly chiropractic, osteopathy, naturopathy, practice.

SEE ALSO: Chiropractors Institutions.” Journal of the American Osteo-

pathic Association 101(3): 174–179.
Gevitz, N. 2004. The DOs: Osteopathic Medicine
in America, 2nd ed. Baltimore, MD: Johns
Baer, H. A. 1984. “The Drive for Professionaliza- Hopkins University Press.
tion in British Osteopathy.” Social Science and
Medicine 1: 717–726.
Baer, H. A. 2001. Biomedicine and Alternative
Healing Systems in America. Madison: Univer-
sity of Wisconsin Press. Baer, H. A. 2009. Complementary Medicine in
Gevitz, N. 2001. “Researched and Demonstrated: Australia and New Zealand. Maleny, QLD: Ver-
Inquiry and Infrastructure at Osteopathic dant House.
Health, Self-Rated SRH measures have been used in numerous
studies from around the world from many dif-
M. CHRISTINE SNEAD ferent disciplines since 1996, including several
Centers for Disease Control and Prevention, USA large-scale studies (e.g., the Canadian National
Population Health Survey, the Oslo Health
Self-rated health, or self-reported health Study, the Danish National Cohort Study
(SRH), is a measurement of a respondent’s (DANCOS), and the US Bureau of the Census’s
subjective sense of health. The SRH measure National Health Interview Survey). A recent
is commonly used to capture a general sense web of knowledge literature search using the
of health from the perspective of the respond- keywords “self-rated health” resulted in more
ent, and is assessed by one simple global than 4000 articles. There are several themes in
question about overall health. There are many the SRH literature. Some of these include: (1)
phrasings of this question, including “In gen- international applications and or comparisons
eral, would you say your health is …” “How of health; (2) using SRH as an outcome, predic-
would you rate your overall health?” or “How tor, or in relation to morbidity, mortality, aging/
is your health, compared with others your life cycle, lifestyle, or social capital; (3) use of a
age?” Response items for these questions are SRH measure as an aspect of specific types of
point scales typically in the range 1–5 (excel- health (e.g., dental health, mental health, occu-
lent, very good, good, fair, poor) or, for the pational health, etc.); and (4) measurement-
comparative question, 1–3 (better, same, related issues of SRH such as bias or SRH as
worse). Methodologically, SRH is often compared to biomedical measures.
described as both a reliable and a valid meas- There is a growing body of literature in
urement of health (Lundberg and which studies using a SRH measure have
Manderbacka 1996). demonstrated differences in health by various
The SRH question is purposely ambigu- social categories. Examples of categories for
ously framed so as not to specify what is which such health differences have been iden-
meant by health. While “health” is generally tified include, amongst others: geographic
thought of as, but certainly not limited to, location or place, education, socioeconomic
physical health, respondents do not all use status (SES), income, occupation, race and
the same frame of reference. Some research- ethnicity, gender, marital status, age/historical
ers place this question at the beginning of a cohort, and ideology. For example, Cockerham
questionnaire so that respondents will not be and colleagues (1999; 2002) investigated
influenced by questions that precede it. Other health lifestyles and declining health in Russia,
investigators deliberately place the SRH ques- revealing that social characteristics as well as
tion at the end of their questionnaire so that it ideology are related to SRH. Other studies
is framed by earlier questions. Some surveys demonstrate relationships between SRH and
even have framing vignettes related to physi- specific socio-demographic characteristics,
cal, emotional, or social well-being that inten- such as education (Martinez-Sanchez and
tionally set the stage for the appropriate Regidor 2002), marital status (Williams and
framework for SRH. Umberson 2004), and SES or income (Pu et al.

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

2011). For example, Williams and Umberson NOTE

(2004) used a SRH measure in their analyses The SRH scale is free to use without permission
of marital status, marital transitions, and and can be found at http://patienteducation.
health, and found that life course stage and For
more information, please refer to the source of
gender moderated the effects of marital
Psychometric Data, Stanford Chronic Disease
status  and marital transitions on health. Self-Management Study, and the psychometrics
Socioeconomic factors in particular seem to report in Lorig et al. 1996.
have strong associations with SRH, but this
finding has not been consistent in cross- SEE ALSO: Health; Inequality and Health
national comparisons (Knesebeck et al. 2003). Care; Social Capital; Stress Outcomes,
While SRH is a powerful and useful meas- Measuring; Surveillance
urement, it is not without limitations.
Language differences in reporting have been
found especially among Spanish-speaking REFERENCES
adults in the United States. There seems to be
Pu, C., Tang, G.-J., Huang, N., and Chou, Y.-J.
bias toward fair and poor health based on the
2011. “Predictive Power of Self-Rated Health
language of the interview. This bias has been
for Subsequent Mortality Risk During Old Age:
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a response in Spanish language instruments tive Survey of Elderly Adults in Taiwan.” Journal
(Viruell-Fuentes et al. 2011). In addition, dif- of Epidemiology 21(4): 278–284.
ferent social groups may interpret health in Cockerham, W. C. 1999. Health and Social Change
different ways. Gender differences, for exam- in Russia and Eastern Europe. London: Routledge.
ple, have been noted in several studies exam- Cockerham, W. C., Snead, M. C., and Dewaal, D.
ining SRH as a predictor of mortality (Idler F. 2002. “Health Lifestyles in Russia and the
2003). Women tend to rate their health lower Socialist Heritage.” Journal of Health and Social
but actually have longer life expectancies Behavior 43(1): 42–55.
Idler, E. 2003. “Discussion: Gender Differences in
when compared to men (Ross and Bird 1994),
Self-Rated Health, in Mortality and in the Rela-
suggesting that men and women differ in
tionship Between the Two.” The Gerontologist
their perceptions of health. 43(3): 372–375.
The SRH measure is subjective and because Knesebeck, O. von dem, Lüschen, G., Cockerham, W.
of this there will be differences in interpreta- C., and Siegrist, J. 2003. “Socioeconomic Status and
tions by respondents. The extent and ramifi- Health among the Aged in the United States and
cations of differing interpretations of what is Germany: A Comparative Cross-Sectional Study.”
meant by health and how respondents answer Social Science & Medicine 57(9): 1643–1652.
the SRH question are not fully understood. A Lorig, K., Stewart, A., Ritter, P., González, V., Lau-
variety of explanations have been used to rent, D., and Lynch, J. 1996. Outcome Measures
describe such differences, but there is no con- for Health Education and other Health Care Inter-
sensus as to why most of these occur. There ventions. Thousand Oaks, CA: Sage Publications.
Lundberg, O., and Manderbacka, K. 1996. “Assess-
is, however, consensus that health is a multi-
ing Reliability of a Measure of Self-Rated
dimensional phenomenon that can be meas-
Health.” Scandinavian Journal of Social Medicine
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widely used and, despite issues of subjectivity Martinez-Sanchez, E., and Regidor, E. 2002. “Self-
and differing interpretations, is an excellent Rated Health by Educational Level in Persons
predictor of future health (Lundberg and with and without Health Problems.” Journal of
Manderbacka 1996; Pu et al. 2011). Health Psychology 7(4): 459–469.

Ross, Catherine E., and Bird, C. 1994. “Sex Strat- Interview, Self-Rated Health, and the Other
ification and Health Lifestyle: Consequences Latino Health Puzzle.” American Journal of
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D. R., and House, J. S. 2011. “Language of Health and Social Behavior 45(1): 81–98.
Concordance not explicitly concerned with medicine taking
decisions, and which also grew out of the
NICKY BRITTEN debate about patient-centeredness (Armstrong
University of Exeter, UK 2005). Definitions of concordance and shared
decision-making were both strongly norma-
Although the term “concordance” has a tive in their rejection of a paternalistic model
generic meaning, its use in the context of of the patient–professional relationship. A sys-
medicine taking was stimulated by the publi- tematic review of the empirical literature
cation of a report entitled “From Compliance found that there was little published research
to Concordance: Achieving Shared Goals in examining the occurrence of concordance or
Medicine Taking” (Royal Pharmaceutical its outcomes, which served to emphasize its
Society of Great Britain 1997). The report was normative nature (Stevenson et al. 2004).
written by a working party tasked with Since 1997, the term “concordance” has
reviewing the causes and consequences of gained currency in the medical literature,
“non-compliance” and making recommenda- although not always as originally intended.
tions about how to improve the taking of For many writers, concordance appears to be
medicines. In this document, concordance a politically correct substitute for compliance.
was described as follows: Others have criticized the term on a range of
The clinical encounter is concerned with two sets grounds, from the medico-legal point of view
of contrasted but equally cogent health beliefs – to repudiation of the assertion of the central-
that of the patient and that of the doctor. The task of ity of the patient’s role.
the patient is to convey her or his health beliefs to
From a sociological point of view, the debate
the doctor; and of the doctor, to enable this to
happen. The task of the doctor or other prescriber
about concordance can be located within a
is to convey his or her (professionally informed) long literature about patient–professional
health beliefs to the patient; and of the patient, to communication. Much of this literature has
entertain these. The intention is to assist the patient taken the patient’s perspective as its point
to make as informed a choice as possible about the of  reference. Social scientists have long
diagnosis and treatment, about benefit and risk and criticized the notion of “non-compliance”
to take full part in a therapeutic alliance. Although (Donovan 1995) on the grounds that it
reciprocal, this is an alliance in which the most
ignores the patient’s crucial role in medical
important determinations are agreed to be those that
are made by the patient. (Italics in original) decision-making. Patients make their own
reasoned decisions about treatments based
This definition was radical in the sense that it on their own beliefs, personal circum-
explicitly repudiated the professionally formu- stances, and the information available to
lated problem of “non-compliance,” and recast them (Pound et al. 2005).
the balance of power in the relationship Sociologists have analyzed the role of lay
between patient and professional. It has reso- expertise in relation to that of professionals.
nance with the definition of shared decision- Freidson’s (1970) analysis of the social organ-
making (Charles, Gafni, and Whelan 1997) ization of illness drew attention to the
which emerged at much the same time but was inevitable conflict (if only latent) underlying

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

interactions between patients and professionals. in  subtle ways (Stivers 2005). Thus the
Other sociologists have examined tensions empirical work shows that the ways in
between lay and professional expertise in which professional and patient agendas are
other settings (Williams and Popay 1994). negotiated in practice are more complex
The growing burden of chronic disease has than abstract definitions of concordance
drawn attention to the crucial role played by and shared decision-making allow for.
patients’ management of their own condi- The nub of the issue is whether concord-
tions within their lifeworlds, away from any ance is a model of communication in which
consultation. Most medicine taking for patients’ perspectives are taken seriously
chronic illness occurs within the lifeworld. In and their concerns addressed, or whether it
the consultation context, Mishler (1984) ana- represents a sophisticated way of achieving
lyzed the way in which the voice of the life- professional goals, particularly compliance.
world was marginalized by the voice of The common misuse of concordance as a
medicine, making it more difficult for synonym for compliance in the medical lit-
patients to raise concerns arising from their erature suggests that, for many professionals,
attempts to manage their problems. The the latter is an attractive option. Sociologically,
notion of concordance can be seen as a way of the questions are about the extent to which
promoting consultations in which lay exper- patients’ knowledge and preferences should
tise and the patients’ concerns are no longer and can be addressed by professionals, and
marginalized. whether diminution of the asymmetry of
Stevenson and Scambler (2005) argued knowledge as a result of the information
that the paternalistic model of compliance revolution will alter power relationships
corresponded to Jürgen Habermas’s notion between patients and professionals.
of open strategic action (see Scambler
1987), in the sense that professionals SEE ALSO: Disability and Chronic Illness;
openly imposed their authority on patients. Health Care, Communication in; Lay
They conceptualized concordance in terms Expertise; Patient–Physician Communication
of Habermas’s concepts of communicative
action. However, they acknowledged the
possibility that, in practice, concordance REFERENCES
could result in systematically distorted Armstrong, D. 2005. “The Myth of Concordance:
communication, arising from professionals’ Response to Stevenson and Scambler.” Health:
and patients’ differing goals. Professionals’ An Interdisciplinary Journal for the Social Study
goals are likely to represent the means to an of Health, Illness and Medicine 9: 23–27.
end, which is often compliant medicine Charles, C., Gafni, A., and Whelan, T. 1997.
taking, while patients’ goals may be good “Shared Decision-Making in the Medical
communication and discussion of their Encounter: What Does It Mean? (or It Takes at
Least Two to Tango).” Social Science and Medi-
concerns. Much of the empirical evidence
cine 44: 681–692.
suggests that professionals are oriented to
Donovan, J. L. 1995. “Patient Decision Mak-
compliance in consultations with patients ing: The Missing Ingredient in Compliance
and in the information they provide about Research.” International Journal of Technology
medicines (Raynor et al. 2007). But it has Assessment in Health Care 11: 443–455.
also been shown that some patients are Freidson, E. 1970. Profession of Medicine: A Study
able to resist professional agendas, and that of the Sociology of Applied Knowledge. New York:
they can influence prescribing decisions Dodd, Mead and Company.

Mishler, E. G. 1984. The Discourse of Medicine: Medical Sociology, edited by G. Scambler, 165–
Dialectics of Medical Interviews. Norwood, NJ: 193. London: Tavistock Publications.
Ablex. Stevenson, F., Cox, K., Britten, N., and Dundar, Y.
Pound, P., Britten, N., Morgan, M., Yardley, L., 2004. “A Systematic Review of the Research on
Pope, C., Daker-White, G., and Campbell, R. Communication Between Patients and Health
2005. “Resisting Medicines: A Synthesis of Care Professionals About Medicines: The Con-
Qualitative Studies of Medicine Taking.” Social sequences for Concordance.” Health Expecta-
Science & Medicine 61: 133–155. tions 7: 235–245.
Raynor, D. K., Blenkinsopp, A., Knapp, P., Grime, Stevenson, F., and Scambler, G. 2005. “The Rela-
J., Nicolson, D. J., Pollock, K., Dorer, G., Gil- tionship Between Medicine and the Public: The
body, S., Dickinson, D., Maule, A. J., and Spoor, Challenge of Concordance.” Health: An Interdis-
P. 2007. “A Systematic Review of Quantita- ciplinary Journal for the Social Study of Health,
tive and Qualitative Research on the Role and Illness and Medicine 9: 5–21.
Effectiveness of Written Information Available Stivers, T. 2005. “Parent Resistance to Physi-
to Patients about Individual Medicines.” Health cians’ Treatment Recommendations: One
Technology Assessment 11: 1–178. Resource for Initiating a Negotiation of the
Royal Pharmaceutical Society of Great Britain. Treatment Decision.” Health Communication
1997. From Compliance to Concordance: Achiev- 18: 41–74.
ing Shared Goals in Medicine Taking. London: Williams, G., and Popay, J. 1994. “Lay Knowledge
RPSGB. and the Privilege of Experience.” In Challenging
Scambler, G. 1987. “Habermas and the Power of Medicine, edited by J. Gabe, D.  Kelleher, and
Medical Expertise.” In Sociological Theory and G. Williams, 118–139. London: Routledge.
Mental Health and percentage of owner-occupied dwellings, and
the percentage of residents who have lived for
Neighborhoods fewer than five years in the neighborhood).
Neighborhood social organization refers to
University of Utah, USA the density of social ties and the level of collec-
CATHERINE E. ROSS tive efficacy. The density of social ties is defined
University of Texas at Austin, USA by the number of social relationships and the
frequency of social interaction in the neighbor-
hood. These can be indicated by the average
WHAT ARE NEIGHBORHOODS? number of friends and relatives that residents
have living in the neighborhood and how often
Neighborhoods are distinct geographical neighbors talk to and visit each other. Collective
areas within cities and towns where groups of efficacy refers to the degree of neighborhood
people live and interact with one another. cohesion and the willingness of residents to
Neighborhoods are defined by particular exercise informal social control. Neighborhood
boundaries and conditions. Boundaries are cohesion is indicated by the degree to which
established informally by history and land- residents get along with each other, trust and
marks, the judgments and movements of help each other, and share common values.
residents and non-residents, and formally by Informal social control is indicated by the will-
administrative classifications like ZIP codes, ingness of residents to intervene under various
postal codes, and census tracts. Conditions conditions of crisis, incivility, and crime (e.g.,
refer to unique physical, social, cultural, keeping the local fire station open, children
economic, and political environments. showing disrespect to adults, and someone
In practice, neighborhood context is meas- being beaten or threatened).
ured with objective and subjective indicators. Neighborhood disorder refers to a range of
Objective indicators include measures of objective social and physical conditions that
neighborhood structure, neighborhood indicate the breakdown of social control in
social organization, and neighborhood disor- the community. Signs of social disorder
der. Neighborhood structure refers to the include people hanging around on the streets,
demographic attributes of neighborhoods open alcohol consumption and drug use,
and is primarily indicated by neighborhood- prostitution, and other criminal activity.
level socioeconomic disadvantage (e.g., the Indicators of physical disorder include the
percentage of residents with less than a high presence of abandoned buildings, vandalism,
school degree, the unemployment rate, and graffiti, garbage, and ambient noise. These
the percentage of residents living below the objective conditions are measured indepen-
poverty line), racial and ethnic composition dently of neighborhood residents, through,
(e.g., the percentage of residents classified as for example, systematic social observations
black, Hispanic, or immigrant), and residen- (e.g., researchers traveling through neighbor-
tial instability (e.g., the percentage of resi- hoods filming and recording social activities
dents living in apartment buildings, the and physical features).

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Subjective indicators measure how residents tend to exhibit higher levels of depression than
perceive or experience the residential environ- residents of more advantaged neighborhoods.
ment. The neighborhood experience is defined Ross (2000) provides an excellent study of
by the perceptions and personal encounters of neighborhood structure and depression. Her
residents within neighborhoods. Common analysis of data from the Community, Crime,
indicators emphasize personal experiences and Health (CCH) survey shows that adults
within the neighborhood (e.g., personal vic- who live in disadvantaged neighborhoods
timization and relationships with neighbors) (indicated by the percentage of households
and subjective assessments or ratings of the below the federal poverty line and female-
neighborhood environment (e.g., perceptions headed households with children) tend to
of neighborhood disorder and collective exhibit higher levels of depression than resi-
efficacy). Because objective indicators of dents of other neighborhoods. This associa-
collective efficacy and neighborhood disorder tion persisted with comprehensive adjustments
are conceptually distinct from individual for age, gender, race/ethnicity, education,
perceptions and experiences, it is possible to employment status, household income, marital
estimate associations between objective and status, the presence of children, household
subjective indicators. For example, residents crowding, and urban residence. Almost any
of neighborhoods with higher crime rates (an association between neighborhood context
objective indicator of social disorder) may be and mental health could simply reflect the fact
more likely to report that crime is a problem in that disadvantaged individuals often live in
the neighborhood (a subjective perception of disadvantaged neighborhoods (i.e., the com-
the objective condition) than residents of position of the neighborhood). These findings
neighborhoods with less crime. clearly suggest that neighborhood context
matters for mental health over and above a
range of individual attributes.
DO NEIGHBORHOODS MATTER FOR Consistent with studies of depression,
MENTAL HEALTH? research suggests that residents of disadvan-
taged neighborhoods tend to exhibit higher
More than 70 years ago, Faris and Dunham levels of anxiety. Aneshensel and Sucoff
(1939) examined the spatial distribution of (1996) sparked a great deal of contemporary
mental disorders in Chicago neighborhoods. research in the area of neighborhood con-
Their analyses of data collected from more text and mental health. Using data collected
than 34,000 psychiatric patients showed that from adolescents in Los Angeles County,
“high insanity rates appear to cluster in the they demonstrate that youth who perceive
deteriorated regions in and surrounding the high levels of “ambient hazards” (signs of
center of the city” (1939, 35). Since this semi- neighborhood disorder indicated by apprais-
nal work, studies have consistently shown als of, for example, violence, crime, and the
that neighborhood context is associated with physical appearance of the neighborhood)
various indicators of individual mental health tend to report higher levels of anxiety than
status, including, for example, depression, youth who perceive fewer problems in the
anxiety, and psychological distress. environment. These patterns held with con-
Most studies of neighborhood context and trols for  age, gender, race/ethnicity, family
mental health focus on depressive symptoms. structure, living arrangements, perceptions
Research in this area demonstrates that of neighborhood social cohesion, neighbor-
residents of disadvantaged neighborhoods hood stability, and the combination of

neighborhood socioeconomic status and danger in the environment (Aneshensel and

race/ethnic composition. This analysis is Sucoff 1996; Ross, Reynolds, and Geis 2000).
especially influential because it is among the The association between the neighborhood
first to consider the psychological conse- experience and mental health status can be
quences of the “subjective neighborhood.” further explained by several classes of second-
Given the patterns for depression and anx- ary mechanisms, including socioeconomic
iety, it should come as no surprise that resi- status, biological factors, psychological dispo-
dents of disadvantaged neighborhoods also sitions, social resources, and health behaviors.
tend to exhibit higher levels of overall psy- Neighborhoods could undermine mental
chological distress. Ross, Reynolds, and Geis health by limiting opportunities for socioeco-
(2000) present an intricate analysis of the nomic status. Research suggests that poorer
psychological consequences of neighborhood neighborhoods are characterized by restricted
stability. Their analysis of CCH data shows that access to community resources and opportu-
higher levels of residential stability (indicated nities, including quality schools and employ-
by the percentage of people who lived in ment opportunities (Jencks and Mayer 1990).
the  respondents’ census tract over a defined Because poorer neighborhoods are defined by
five-year period) tend to favor lower levels of the concentration of poorer residents, tax rev-
psychological distress in lower poverty neigh- enue and consumer bases are often limited.
borhoods and higher levels of distress in higher Under these unique economic conditions,
poverty neighborhoods. These results persisted funding for schools is restricted and businesses
with adjustments for age, gender, race/ethnic- are less viable. Studies provide indirect support
ity, education, employment status, household for these explanations, showing that residence
income, home ownership, marital status, the in a disadvantaged neighborhood is associated
number of children, household crowding, with poorer educational outcomes (Jencks
urban residence, and personal social ties with and  Mayer 1990). Neighborhoods could also
neighbors. The truly distinctive feature of this undermine socioeconomic status through
study is the interaction between unique dimen- processes related to the neighborhood experi-
sions of neighborhood structure (i.e., the effect ence. Perceptions of low collective efficacy in
of residential stability across levels of neigh- the neighborhood could increase the probabil-
borhood socioeconomic disadvantage). ity of absenteeism by reducing the perceived
costs associated with skipping school. When
residents attend school, perceptions of disorder
WHY MIGHT NEIGHBORHOODS in the environment could undermine learning
MATTER FOR MENTAL HEALTH? through biological, psychological, and behav-
ioral mechanisms. For example, research
Research suggests that disadvantaged neigh- shows that chronic stress can impair memory
borhoods undermine mental health by expos- function, the sense of control, and sleep quality
ing residents to conditions that they define as (Mirowsky and Ross 2003).
stressful (Ross 2000). Residence in neighbor- The neighborhood experience could also
hoods characterized by socioeconomic disad- undermine mental health through biological
vantage, the concentration of racial and ethnic mechanisms, including physiological. Residents
minorities, residential instability, weak social of disadvantaged neighborhood environments
ties, low collective efficacy, and visible signs of are likely to experience allostatic load or
disorder clearly increases the probability of chronic activation of the physiological stress
perceiving or experiencing disadvantage and response and overexposure to stress hormones

(Ross and Mirowsky 2001; Hill, Ross, and changing or improving their living conditions,
Angel 2005). Chronic exposure to stress hor- they are likely to develop a general sense of
mones can be sufficient to disrupt or even powerlessness.
damage the hypothalamus, hippocampus, and Neighborhood context might also contribute
amygdala – regions of the brain that play to mental health by shaping social resources,
important roles in the development of anxiety including social ties and social support (Cutrona,
and depression (Mirowsky and Ross 2003). Wallace, and Wesner 2006). Residence in a
The association between the neighborhood disadvantaged neighborhood may undermine
experience and mental health could be the formation and maintenance of social ties in
explained by various psychological disposi- various ways. Residential instability (i.e., people
tions, including mistrust, self-esteem, and the frequently moving in and out of the neighbor-
sense of control. When residents experience hood) would clearly limit opportunities for
neighborhood disorder (e.g., criminal activity) social interaction. If perceptions of disorder
as a way of life, they learn that people in the contribute to negative dispositions toward
environment can be threatening and danger- humanity (e.g., mistrust and misanthropy), it is
ous (Mirowsky and Ross 2003). Under these reasonable to expect that residents of disadvan-
conditions, residents are likely to develop neg- taged neighborhoods might go out of their way
ative dispositions toward humanity (e.g., gen- to avoid social interaction (Ross and Mirowsky
eralized mistrust and misanthropy) in the 2009). Restricted opportunities for social inter-
interest of survival. Because places are imbued action would obviously constrain network size
with social significance and social value, the and, by extension, limit the availability or receipt
self-concept can be intimately tied to the places of social support. Even under the conditions of
we inhabit (Fitzpatrick and LaGory 2010). extensive social networks, negative dispositions
What is the symbolic value of living in a disad- toward humanity (e.g., mistrust) could under-
vantaged neighborhood? Mirowsky and Ross mine perceptions of the availability of social
(2003, 151) argue that perceptions of neigh- support (Ross and Mirowsky 2009).
borhood disorder suggest to residents that “the Health behaviors represent the final class
people who live around them are not of secondary mechanisms. The idea is that
concerned with public order, that the local the neighborhood experience could under-
agents of social control are either unable or mine mental health by promoting risky
unwilling to cope with local problems, and health-related behaviors, including, for
that those in power have probably abandoned example, poor sleep quality and substance
the neighborhood.” If residents feel this way use. Because sleep is an adaptive behavior,
about their neighborhoods, their self-esteem neighborhoods that are characterized by
or self-worth is likely to suffer as a conse- noise, dilapidation, and crime might directly
quence of negative social comparisons and undermine the ability of residents to initiate
reflected appraisals. Stable conditions of and/or maintain sleep (Hill, Burdette, and
neighborhood disadvantage and disorder can Hale 2009). Disadvantaged neighborhood
be overwhelming. When residents are repeat- environments may also encourage the use
edly exposed to dilapidation, crime, and low and abuse of alcohol and illicit drugs.
levels of social control, they come to view the Residents of disadvantaged neighborhoods
neighborhood environment as unpredictable have more opportunities to purchase alcohol
and chaotic (Mirowsky and Ross 2003). If resi- and drugs. For example, research suggests
dents perceive that these conditions are that alcohol outlets are more prevalent in dis-
inescapable and that they are incapable of advantaged communities (Nielsen et al. 2010).

Due to diminished mechanisms of social variations in the effects of perceived disorder

control, disadvantaged neighborhoods may on depression (Gary, Stark, and LaVeist 2007).
provide a normative context in which heavy Other studies of depression show no race or
drinking and illicit substance use is not sanc- ethnic variations in the effects of perceived
tioned as strongly as within other neighbor- disorder (Ross 2000). Why might the associa-
hoods. It is hypothesized that residents may tion between neighborhood context and
use substances to cope with the stress associ- mental health status vary according to race and
ated with the experience of neighborhood ethnicity? “Compound disadvantage” could
disorder (Hill and Angel 2005). help to explain the susceptibility patterns of
certain groups (e.g., blacks and Hispanics), but
it is unclear why subgroup variations by race
ARE CERTAIN GROUPS OF PEOPLE and ethnicity are apparently less common than
MORE VULNERABLE THAN OTHERS those by socioeconomic status.
TO THE MENTAL HEALTH Research concerning the buffering role
CONSEQUENCES OF of social resources is less consistent than
NEIGHBORHOODS? variations by socioeconomic status and
race and ethnicity. Some work on depres-
Research suggests that similar neighborhood sion finds that neighborhood social ties
environments can influence individuals more and general social support are protective
or less depending upon the personal charac- against perceived neighborhood disorder
teristics of residents, including, for example, (Kim and Ross 2009), while others show no
their socioeconomic status, race/ethnicity, variations according to levels of general
social resources, psychological dispositions, social integration and social support
and health behaviors. Studies consistently (Latkin and Curry 2003). Although some
show that individual socioeconomic status anxiety research suggests that the effect of
is  protective against the mental health perceived neighborhood disorder is attenu-
consequences of living in a disadvantaged ated by neighborhood social ties (Ross and
neighborhood. Research indicates that per- Jang 2000), perceived neighborhood cohe-
sonal wealth may attenuate the effects of sion is not effective in this way (Aneshensel
neighborhood socioeconomic disadvantage and Sucoff 1996). Social ties are important
on depression (Wight, Ko, and Aneshensel as sources of social support, which may
2011). These patterns have been attributed to help to reduce the psychological conse-
“compound disadvantage” processes. The idea quences of stressful neighborhood condi-
is that disadvantaged individuals (e.g., people tions by encouraging positive psychological
of low socioeconomic status) may be especially dispositions (e.g., self-esteem) and stress
vulnerable to the psychological consequences appraisals (e.g., from knowing that one has
of stressful neighborhood conditions because help, that one is not alone) (Kim and Ross
they tend to have fewer stress-buffering 2009). Through these general mechanisms,
resources (e.g., a sense of personal control). social support (e.g., knowing that people
Variations by race and ethnicity are some- are available to listen to problems) could
what mixed. Studies show that neighborhood attenuate the impact of social and physical
industrial waste production and perceptions disorder in the environment. However,
of disorder may be especially depressing research clearly suggests that neighborhood
among Hispanics (Downey and Van Willigen conditions can be sufficient to overcome
2005). Some research reports no black–white personal social resources.

To the best of our knowledge, very few CONCLUSION

studies have tested whether the association
between neighborhood context and mental The pioneering work of Faris and Dunham
health might vary according to psychologi- (1939) and numerous subsequent studies
cal dispositions. Nevertheless, research by show us that mental health varies systemati-
Cutrona and colleagues (2000) suggests that cally across neighborhoods, with the most
the effect of high neighborhood disorder disadvantaged neighborhoods having the
(aggregate ratings) on psychological distress greatest burden of psychological distress.
can be buffered by a positive outlook (indi- Taken together, these patterns are of socio-
cated by the combination of the sense of logical interest because they emphasize the
control and optimism). Schieman and social origins of mental health. Neighborhoods
Meersman (2004) also find that, among are socially structured conditions that are
older men, the positive association between external to individuals. Such contextual effects
neighborhood disorder and anger is attenu- cannot be explained by the dominant psychi-
ated by a greater sense of mastery; however, atric model that locates the causes of psycho-
this moderation pattern did not extend to logical distress within individuals.
depression or anxiety in older men or
women. Disadvantaged neighborhoods SEE ALSO: Geographies of Health Inequality;
should be less threatening to people who feel Geographies of Health and Well-Being;
in control of their own lives and to those Geographies of Space, Place, and Population
who are generally optimistic about the Health; Neighborhood Disadvantage and
Well-Being; Stress and Mental Illness
future. For example, when individuals have
a strong sense of control, they believe that
life is manageable and controllable REFERENCES
(Mirowsky and Ross 2003). Under these
Aneshensel, Carol, and Sucoff, Clea. 1996. “The
conditions, life events are less uncertain and
Neighborhood Context of Adolescent Mental
discouraging, and symptoms of anxiety and
Health.” Journal of Health and Social Behavior
depression are less common. 37: 293–310. doi:10.2307/2137258.
Like psychological dispositions, there is Cutrona, Carolyn, Russell, Daniel, Hessling, Rob-
very little evidence to support health behav- ert, Brown, P. Adama, and Murry, Velma. 2000.
iors as viable moderators. One study by “Direct and Moderating Effects of Community
Hill, Burdette, and Hale (2009) indicates Context on The Psychological Well-Being of
that the positive association between per- African American Women.” Journal of Per-
ceived neighborhood disorder and psycho- sonality and Social Psychology 79: 1088–1101.
logical distress is attenuated among doi:10.1037//0022-3514.79.6.1088.
residents with higher levels of sleep quality. Cutrona, Carolyn, Wallace, Gail, and Wesner,
Kristin. 2006. “Neighborhood Char-
They explain that sleep is fundamental for
acteristics and Depression: An Exami-
physiological restoration. Under the condi-
nation of Stress Processes.” Current
tions of restful sleep, the brain down-regu- Directions in Psychological Science 15: 188–192.
lates the sympathetic nervous system and doi:10.1111/j.1467-8721.2006.00433.x.
activates the parasympathetic nervous sys- Downey, Liam, and Van Willigen, Marieke. 2005.
tem. Because sleep deprivation tends to “Environmental Stressors: The Mental Health
prolong the sympathetic stress response, the Impacts of Living Near Industrial Activity.”
body is especially vulnerable to the effects Journal of Health and Social Behavior 46: 289–305.
of stressors in the environment. doi:10.1177/002214650504600306.

Faris, Robert E. L., and Dunham, H. Warren. Journal of Health and Social Behavior 44: 34–44.
1939. Mental Disorders in Urban Areas: An doi:10.2307/1519814.
Ecological Study of Schizophrenia and other Mirowsky, John, and Ross, Catherine. 2003. Social
Psychoses. Chicago, IL: University of Chicago Causes of Psychological Distress, 2nd ed. Haw-
Press. thorne, NY: Aldine de Gruyter.
Fitzpatrick, Kevin, and LaGory, Mark. 2010. Nielsen, Amie, Hill, Terrence, French, Michael,
Unhealthy Cities: Poverty, Race, and Place in and Hernandez, Monique. 2010. “Racial/Ethnic
America. New York: Routledge. Composition, Social Disorganization, and Off-
Gary, Tiffany, Stark, Sarah, and LaVeist, Thomas. site Alcohol Availability in San Diego County,
2007. “Neighborhood Characteristics and California.” Social Science Research 39: 165–175.
Mental Health among African Americans and doi:10.1016/j.ssresearch.2009.04.006.
Whites Living in a Racially Integrated Urban Ross, Catherine. 2000. “Neighborhood Dis-
Community.” Health & Place 13: 569–575. advantage and Adult Depression.” Journal
doi:10.1016/j.healthplace.2006.06.001. of Health and Social Behavior 41: 177–187.
Hill, Terrence, and Angel, Ronald. 2005. “Neigh- doi:10.2307/2676304.
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Heavy Drinking.” Social Science & Medicine 61: borhood Disorder, Fear, and Mistrust: The
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Hill, Terrence, Burdette, Amy, and Hale, Lauren. American Journal of Community Psychology 28:
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Epidemiologic such as classical social determinants like
poverty and lack of social services.
(Observational) Studies This interest in downstream causes explains
why so much of epidemiologic methodology
University of California, Los Angeles, USA (including theory of study designs) does not
closely parallel social science methodology,
apart from questionnaire design and use of
EPIDEMIOLOGY AND ITS GOALS general statistical abstractions such as regres-
sion and structural models. Downstream
Epidemiology is sometimes defined as the events are often much more bound up with
study of the distribution and determinants of individual decisions (e.g., surgical options
health-related states and events in populations chosen by a medical practice, the use of a par-
(which generalizes to some extent the defini- ticular food-handling procedure) than are
tion given in Rothman, Greenland, and Lash upstream social events (e.g., mandates to use
2008, 32). Thus, epidemiologic studies focus on disposable rather than reusable needles, or to
measurement or estimation of properties of post hand-washing notices in facilities used
populations. This focus is shared with social by food handlers).
sciences, so it should come as no surprise that The distinction is brought to the fore in the
the boundary between epidemiology and those somewhat legendary story of abatement of the
sciences is a blurry one, embracing territory 1854 London cholera epidemic by removing
covered in medical sociology and social epide- the handle of a pump that supplied contami-
miology. What may be surprising, however, is nated water (Johnson 2006). While there is
the limited overlap in study methods and their much of interest in studying the social factors
related conceptualizations and terminology. behind epidemics, in this story the key knowl-
The divergence of epidemiology from edge was purely mechanical breaking of the
social sciences may be explained by the needs transmission of the infectious agent into the
of other epidemiologic specializations in population. Elements of social change that
which the connection to social sciences is eventually led to the end of waterborne epi-
weak or of secondary interest. These include demics in developed countries – such as man-
the majority of clinical epidemiology (which datory protocols for sewage disposal and
overlaps heavily with medical research on disinfection of public water supplies –
patients), infectious disease epidemiology, emerged only later and on a longer time scale.
disease surveillance, and outbreak investiga- For the physician or public health official
tion, topics which dominated epidemiology faced with a situation in dire need of rapid ame-
until the mid-twentieth century and remain lioration, social change is not a feasible option.
important today. The chief interest in these And yet, for a public health official looking over
specialties is identifying and eliminating the long term (such as the US Surgeon-General),
downstream (proximal or immediate) causes social and psychological factors will enter into
of disease such as microbes, toxins, and play when trying to reduce disease and
vectors, or mechanisms of transmission or improve the health of populations. Reducing
exposure, rather than upstream (distal) causes the acceptability of cigarette smoking and

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

encouragement of exercise are two prominent comparison to that expected based on rates
examples in which social manipulation is an seen in a reference population, such as the sur-
expressed goal. Thus there is a tension between rounding general population (after adjustments
the short-run need to identify outbreaks and to for demographic differences between the popu-
quickly identify their immediate causes, versus lations). Case reports may be entered into case
the long-run need to identify upstream causes series studies, wherein the cases are checked for
and produce long-term improvements in the unexpected or unusual distributions of certain
social environment that lead to disease. These factors (e.g., clustering in location or population
differing needs can lead to different study subgroup, again possibly signaling an outbreak).
designs, which are reviewed next. Time clustering is gauged relative to the nature
of the disease; gastrointestinal disease outbreaks
unfold relatively quickly, over hours, days, or
POPULATION SURVEILLANCE weeks, whereas cancer outbreaks unfold over
AND CASE SERIES STUDIES years or decades (e.g., Kaposi’s sarcoma in
young gay men in the early 1980s). Similarly,
Monitoring the health status of populations spatial clustering may be in a very small area
requires relevant data on the frequency of (e.g., that served by a particular restaurant) or a
health-related states, events, and factors, and very large one (e.g., that served by a large con-
forms the initial component of much epide- taminated body of water).
miologic research. Surveillance is the process A common fallacy is to claim that case
of acquiring and analyzing these data to iden- series studies are especially incapable of
tify patterns (Buehler 2008). This process determining causes of the case disease, espe-
may be passive, awaiting reports from rele- cially when neither temporal nor spatial clus-
vant sources (e.g., tracking physician reports tering is evident or when surveillance is
of adverse events), or active, in which person- passive. This is not so when key factors are
nel seek information from relevant sources measured that uniquely link the monitored
(exemplified by registries sending abstractors events (here, disease cases) to a cause, and
to obtain information from health care pro- there is a surveillance system in place in the
viders, and by vital statistics registration). source population (the population from which
Passive reports may of course be actively the cases arose) that does not use these fac-
followed up if that appears warranted. Health tors as a diagnostic or reporting criterion.
surveys are active surveillance studies of a As an example, roughly half the cases of
form most akin to the surveys familiar to Salmonella dublin reported in California in the
social scientists. Such surveys may include early 1980s were identified as having exposure
questionnaires, record abstraction, physical to raw milk. This fact alone should raise suspi-
examinations, or biological sampling (e.g., cion about raw milk as a major infection source,
blood sampling and analysis, as in serosurveys given that under 1 percent of the state’s milk
for antibody status). Analogies in social sales were unpasteurized (Richwald et al. 1988).
research include passive monitoring of crime A crucial objection, however, is that there must
statistics and active social surveys. be severe underreporting of cases, given the
Reports of disease cases are typically moni- fact that probably most S. dublin infections go
tored for unusual increases or spikes over time, undiagnosed as such. Indeed, a key concern in
which are possible signals of outbreaks. Special studies based on surveillance data (especially
populations (such as occupational groups) may passive) is the degree of underreporting or
be monitored for elevated disease frequency in under-ascertainment of disease, which, if high

enough and related to exposure, could create or to various artifacts collectively referred to as
obscure relationships. Nonetheless, countering ecologic or aggregation biases (Greenland
this concern in the example is that the same 2004; Morgenstern 2008). These studies and
pattern is seen among reported S. dublin deaths, their biases have long been recognized in
which are arguably far more thoroughly social science research (e.g., see Borgatta and
reported than non-fatal cases. The connection Jackson 1980) but are often misunderstood in
was cemented by the fact that the S. dublin anti- health research.
biograms found in raw milk matched those The most common misunderstanding of
found in the exposed cases (Werner et al. 1984). these problems equates them all to confound-
Thus, merely labeling a study as based on ing (mixing) of group effects with factor
case series or surveillance does not automat- effects, but other sources of artifacts exist,
ically imply the study results are suspect or including nonlinearity of factor outcome
inconclusive; strong associations and bio- relations among population members
logic details (as common with infections (Greenland 2004). The logical limit of eco-
and highly toxic exposures) must be consid- logic studies is a deeper problem of non-
ered and may permit strong inferences. This identification, in that observed marginal data
fact is illustrated by the case-only studies in are mathematically compatible with too many
genetic epidemiology, in which gene fre- possibilities, even if they cover the entire
quencies seen in case series can be compared population and are free of all errors and biases.
to population distributions computed Table  1 provides a transparent numeric
directly from laws of inheritance (Khoury, example showing this problem for a population
Millikan, and Gwinn 2008). On the other divided into two groups (e.g., regions or time
hand, without very strong associations or periods). Disease frequency increases along-
such crucial biologic detail, inference from side exposure frequency as one moves across
surveillance data should be highly circum- the groups (see Table 1a), but that fact does
scribed. For example, if case diagnosis (as not by itself imply that exposed persons are
opposed to etiology) and reporting have getting the disease more than the unexposed.
influenced the exposure factor under study, Only by obtaining data on individual expo-
there will be an elevated exposure frequency sure and disease status can we pin down
among reported cases relative to what might whether this positive association in aggregate
be expected from their source population, corresponds to exposure associated with a
even if the exposure is harmless. doubling of the disease rate (see Table 1b) or
a halving of the rate (see Table 1c).
Contrary to popular lore, the same logical
ECOLOGIC STUDIES problem remains operative even with unlimited
numbers of regions (Greenland 2004).
The limitations of surveillance data are illus- Furthermore, the observed results can be very
trated in ecologic or aggregate studies, in sensitive to the degree of grouping, and very
which data on frequency of health outcomes large bias can be produced by very small
over time or across locations (e.g., vital statis- group effects. In Table 1c, group A only increases
tics) are related to separate (marginal) data the disease rate by an eighth over group B, yet as
on possible factors in these outcomes seen in Table 1a this group effect obliterates the
(Morgenstern 2008). If there are no data sup- apparent exposure–disease association.
plying the factors and outcomes on the same Despite these limits, ecologic studies can pro-
persons, these sorts of studies are vulnerable vide valuable clues about population relations if

Table 1 Example showing how ecologic analyses (analyses based only on marginal summaries
of exposure and disease frequencies) cannot identify the effect of exposure (X = 1) on the disease
rate. Panel 1a exhibits hypothetical ecologic (aggregate or marginal) data exhibiting no associa-
tion of exposure and disease. Panel 1a may have arisen from panels 1b or panel 1c, which show
opposite exposure effects (doubling vs. halving of rate from exposure within groups) and oppo-
site group effects. N = denominator (in thousands of person years); RRA is the rate ratio for the
true effect of group A versus B; RRX is the rate ratio for the true effect of exposure (X = 1) vs. no
exposure (X = 0).
1a. Ecologic (marginal) data:
Group A Group B
X=1 X=0 Total X=1 X=0 Total
Disease ? ? 560 ? ? 560
N (1000 s) 60 40 100 40 60 100
Rate* ? ? 5.6 ? ? 5.6

1b. Possibility 1 (RRX = 2, RRA = 7/8):

Disease 420 140 560 320 240 560
N (1000 s) 60 40 100 40 60 100
Rate* 7.0 3.5 5.6 8.0 4.0 5.6

1c. Possibility 2 (RRX = ½, RRA = 8/7):

Disease 240 320 560 140 420 560
N (1000 s) 60 40 100 40 60 100
Rate* 4.0 8.0 5.6 3.5 7.0 5.6

*Annual disease-incidence rate (new cases per 1000 persons per year)
Source: Greenland 2004

supplemented by data that allow exclusion of case series studies. Given a case series for which
certain within-group possibilities. For example, (unlike the raw milk example) it is not obvious
information that exposure could only have whether the exposure distribution is unusual,
harmful effects (e.g., as with a toxin) would the straightforward solution is to obtain infor-
eliminate Table  1c. Unfortunately, many eco- mation on the exposure distribution in the
logic studies provide results based on implicitly source population from which those cases
excluding possible artifacts via assumptions arose.
(e.g., linearity, bivariate normality) that have no Usually this information is obtained from a
supporting data. (See Morgenstern 2008 and control series that is presumed or hoped to
Greenland 2004 for further discussion.) represent the source population distribution
(such control data should be distinguished
CASE CONTROL STUDIES from experimental data produced by actual
physical control of exposure – e.g., placebo
An enormous variety of study designs can be controls). The most limited data of this sort
placed under the “case control” heading, with arise from existing survey data. Among the
considerable variation in the definitions and concerns using such data is that artifacts may
criteria for placement. Historically, case control arise from differences between the case series
studies were treated as a direct extension of and survey in how exposure information was

obtained (e.g., from medical records for cases The accuracy of the case control odds
vs. from questionnaires for control subjects), ratio in representing the population rate ratio
or how subjects were recruited (e.g., from hinges on the case control sampling ratio
record requests for cases vs. from interview being unrelated to exposure. If, instead, the
requests for survey participants, which entail sampling ratio varies with exposure, the odds
quite different cooperation levels). ratio will be distorted (biased) for estimating
Before the 1970s, such studies were called the population rate ratio, a type of selection
“retrospective studies,” reflecting the implicit bias which is of special concern in case control
assumption that pre-disease exposure status studies. Another concern arises if data are
was determined after the disease occurred (in obtained retrospectively from subjects after the
retrospect). To deal with the aforementioned disease has occurred, for it raises the possibil-
concerns, by the 1960s these studies began to ity that knowledge of the disease or the disease
be reconceptualized as outcome-dependent process itself may have altered responses or
sampling designs (choice-based designs in the measurements. Rothman, Greenland, and
econometric literature, where the outcome is Lash (2008, Chs. 8 and 9) describe these issues
often a purchase or sale choice or decision). and many others in some detail.
The term “case control study” was introduced A common fallacy is to claim that case
to reflect this conceptual shift. In this concep- control studies are intrinsically incapable of
tualization, the study begins with a source determining causes of the cases. In reality, as
population rather than a case series; study with case series, there can be such strength
cases are then viewed as a sample of popula- and biologic detail in the study that the evi-
tion cases and the study controls are a sample dence is compelling; for example, the rela-
of the population. tion of prenatal diethylstilbestrol exposure to
An ideal case control study will employ the vaginal adenocarcinoma was established pri-
same selection and measurement procedures marily through case control research (Herbst,
and criteria to cases and controls, differing Ulfelder, and Poskanzer 1971). Even without
only in the sampling fractions used for these features, there are many settings in
each outcome group. Table 2 illustrates the which concerns about selection bias and
concept in a source population in which the disease-influenced measurement do not
disease rate is 5.6 cases per 1000 per year arise, for example when the study is based on
and  the rate among the exposed (X = 1) is direct sampling of records from a database or
twice that of the unexposed (X = 0). It then surveys covering the entire population (e.g.,
samples 50 percent of the cases as they occur as in studies within health maintenance
(for a net case sampling rate of 2.8 cases per organizations).
1000 per year) for a year and in parallel sam- There are many variations on this idea
ples controls from the population at large at a (most commonly, in which cases are not
rate of 1 percent (10 per 1000 persons) per allowed in the control group) (see Rothman,
year. In the resulting sample, the ratio of cases Greenland, and Lash 2008, Ch. 8). Sometimes
to controls (the sample odds of disease) is a study can bypass the need for separate con-
50/1 = 50 times the population disease rate in trol subjects entirely, as when the population
every category. Upon taking ratios, however, distribution can be computed from theory or
this 50-fold sampling ratio cancels, leaving an case data. Examples include case-only studies
odds ratio comparing exposed to unexposed of genetic factors mentioned above, and case
equal to the rate ratio of 2 seen in the crossover and case specular studies, in which
population. for each case temporal or spatial exposure
Table 2 Example of case control study with 50% case sampling, 1% population sampling over a year
Population Study

X=1 X=0 Total X=1 X=0 Total

Disease 420 140 560 Cases 210 70 280

N 60 000 40 000 100 000 Controls 400 600 1000
Rate* 7/1000 3.5/1000 Odds 21/40 7/60
Rate ratio 2 Odds ratio 2

*Annual incidence rate (new cases per 1000 persons per year)

data are used to estimate a matching popula- VALIDITY ISSUES: OBSERVATIONAL

tion exposure distribution (Rothman, VERSUS RANDOMIZED STUDIES
Greenland, and Lash 2008, 125–6).
The above study descriptions have alluded to
COHORT STUDIES a number of potential sources of study biases,
most of which should be broadly familiar to
Cohort studies identify and recruit a popula- those in survey and social science research.
tion that will be classified on past, current, Measurement error (including misclassifica-
and perhaps future exposure status, then fol- tion) is a potential problem for all but a few
lowed up for subsequent disease incidence conceptually simple variables (birth date, bio-
(hence they are often called follow-up studies). logical gender), and the variety of distortions
Such studies are in some ways conceptually such error can produce is staggering, even
the simplest, but can be tremendously lengthy, when that error is independent of other study
difficult, and expensive, and are severely lim- variables (Rothman, Greenland, and Lash
ited in statistical precision and power by the 2008, 137–46). Selection bias (here subsum-
number of cases that occur during follow-up. ing response bias, differential loss, and
Their simplicity arises because the design informative censoring) can be more limited
almost always entails data collection before to the extent that study inclusion and exclu-
disease occurrence, thus eliminating concerns sion criteria are applied uniformly to all sub-
that the disease might influence the data. jects and are based only on pre-exposure
Their chief vulnerability to selection bias characteristics, but it becomes a concern
(shared by randomized trials) is via differen- when there is poor cooperation or tracing of
tial loss to follow-up (informative censoring in subjects or their physicians.
the clinical trial literature), wherein failure to Each of these bias sources can be serious
ascertain the final outcome (disease status) of whether the study is considered purely
subjects is related to both the exposure and descriptive (associational) or has explicitly
the disease. The potential for selection bias is targeted a causal effect for study. Confounding,
limited to the extent that ascertainment failure however, is a bias uniquely affiliated with
is small. (For further discussion of cohort causal inference. It is variously defined as
studies and their problems, see Rothman, mixing of exposure effects with extraneous
Greenland, and Lash 2008, Chs. 7 and 9.) effects (due to baseline association of expo-
Historical cohort studies are conducted after sure with other causal factors, which become
cases have occurred by forming cohorts from confounders of the exposure effect); as a dis-
records – e.g., from a medical practice or health crepancy between true population associa-
maintenance organization database. These tions (the association free of measurement
studies are sometimes called “retrospective error and selection bias) and true effect; and
cohort studies,” although their measurements as association of potential outcomes with actual
and their selection criteria might be determined exposure or treatment assignment (Rothman,
entirely before disease or the process leading to Greenland, and Lash 2008, Chs. 4 and 9).
it begins. Cohort studies with real-time follow Regardless of the definition of con-
up are then distinguished by being called “pro- founding, another common myth is that
spective cohort studies.” In either type of study, randomization of a treatment or other
however, bias can result from use of data that intervention prevents confounding in esti-
could be influenced by the outcome (e.g., ques- mating the intervention effect, and thus
tionnaires administered after disease occurs). inevitably results in a more reliable or

more valid estimate of effect than do human data for both the detection and con-
observational epidemiologic studies. In firmation of hazards. Again, when these data
reality, however, there is no universal or are coupled with affiliated biologic informa-
reliable rule for ranking the reliability or tion, the resulting inferences may be clearly
level of evidence provided by the different certain to all but those strongly invested
types of study. There are several reasons against the results (as illustrated in the pro-
for this lack. tracted public health battles against the ciga-
First, randomized trials can suffer from rette industry).
bias, including confounding and selection On the other hand, the fact that rand-
bias due to treatment non-adherence and omized trials themselves have limits (and are
loss-to-follow-up, which are especially likely often impractical) does not imply that feasi-
in long-term trials. These biases are not ade- ble observational studies can always answer
quately addressed by typical analysis methods pressing questions. The limits of observa-
for censored data, which assume the biases tional studies become clearest when effects
are absent and only allow for differences in are too small to estimate accurately with
length of follow-up. To the extent that factors observational studies and the degree of con-
responsible for these biases are measured, founding and other bias is expected to be
they can be adjusted for in observational as high. For example, the extensive correlation
well as in randomized studies. among nutrients, other dietary factors, and
Second, while there is no question that health-related behaviors led to observational
randomization confers potentially large associations of estimated nutrient intakes
advantages, these advantages can be nullified with improved health that have not been
by several problems inherent in randomized borne out in randomized trials of supple-
studies. Most randomized trials are too small ments (β carotene and vitamin E being classic
and too short to detect or accurately estimate examples).
harmful long-term effects. Compounding Such mistaken inferences have arisen in
this problem is that trials are often conducted part from failing to appreciate that all statisti-
in persons quite different from the general cal methods in common use are based on
population in which the treatment will be assuming that exposure was randomized at
used (e.g., they are often done in low-risk the level of stratification or covariate adjust-
patients, making adverse effects hard to ment employed. Apart from exceptional “nat-
detect), leading to severe uncertainty about ural experiments,” exposures in observational
generalizability. In these situations only studies are not randomized, and randomiza-
observational studies can bridge the gap tion is often broken in randomized trials (e.g.,
between trials and everyday reality. due to non-adherence and loss). Thus, in
Third, randomization is often neither ethi- observational as well as in many randomized
cally nor practically feasible for exposures or trials, conventional inferential statistics
treatments already considered to have more should be interpreted as hypotheticals (e.g.,
harm than benefit potential, such as indus- “If this study had been randomized within
trial chemicals, or for rare or very long-range levels of adjustment variables, P would be
outcomes. Thus claims that randomized 0.03”) rather than as direct inferential state-
experiments are necessary to prove causation ments, and as such are insufficient for infer-
can become tools to evade responsibility for ence about underlying effects (Rothman,
harmful exposures. In these situations, obser- Greenland, and Lash 2008, Ch. 19; Greenland
vational studies may be the only source of and Poole 2011).

CONCLUSION Statistical Principles and Methods for Public

Health Surveillance, edited by D. F. Stroup and
Observational epidemiologic studies often R. Brookmeyer, 315–340. New York: Oxford
supply essential and sometimes the only rel- University Press.
Greenland, S., and Poole, C. 2011. “Problems in
evant information for the evaluation of treat-
Common Interpretations of Statistics in Scien-
ments and other health interventions. Most
tific Articles, Expert Reports, and Testimony.”
statistical methods were developed for the Jurimetrics 51: 113–129.
analysis of randomized studies, however, and Herbst, A. L., Ulfelder, H., and Poskanzer, D.
so focus on the impact of random error. This C. 1971. “Adenocarcinoma of the Vagina.
focus severely limits the utility of these meth- Association of Maternal Stilbestrol Therapy
ods for analysis of observational studies, in with Tumor Appearance in Young Women.”
which concerns about non-random errors New England Journal of Medicine 284:
(biases) predominate. Furthermore, rand- 878–881.
omized studies are often infeasible or severely Johnson, S. 2006. The Ghost Map: The Story of
limited in relevance. Methods that go beyond London’s Most Terrifying Epidemic – and How It
conventional statistics will often reveal that Changed Science, Cities and the Modern World.
London: Riverhead Books.
single studies (whether observational or
Khoury, M. J., Millikan, R., and Gwinn, M. 2008.
experimental) can make only small contribu-
“Genetic and Molecular Epidemiology.” In
tions to knowledge. Thus, perhaps even more Modern Epidemiology, 3rd ed., edited by K. J.
than in experimental science, inferences from Rothman, S. Greenland, and T. L. Lash, 564–
observational studies will have to rely heavily 579. Philadelphia, PA: Lippincott Williams &
on synthesis of diverse evidence. Wilkins.
Morgenstern, H. 2008. “Ecologic Studies.” In
SEE ALSO: Disease Clusters; Epidemics; Modern Epidemiology, 3rd ed., edited by K. J.
Health; Medical Geography; Pandemic Rothman, S. Greenland, and T. L. Lash, 511–
Preparedness and Response; Public Health; 531. Philadelphia, PA: Lippincott Williams &
Surveillance; Vital Statistics Wilkins
Richwald, G. A., Greenland, S., Johnson, B. J.,
Friedland, J. M., Goldstein, E. J. C., and Plichta,
D. T. 1988. “An Assessment of the Excess Risk
of Serious Salmonella dublin Infection Associ-
Borgatta, E. F., and Jackson, D. J., eds. 1980. Aggre- ated with the Use of Certified Raw Milk.” Public
gate Data: Analysis and Interpretation. Beverly Health Reports 103: 489–493.
Hills, CA: Sage. Rothman, K. J., Greenland, S., and Lash, T. L. 2008.
Buehler, J. 2008. “Surveillance.” In Modern Epi- Modern Epidemiology, 3rd ed. Philadelphia, PA:
demiology, 3rd ed., edited by K. J. Rothman, Lippincott Williams & Wilkins.
S. Greenland, and T. L. Lash, 459–480. Philadel- Werner, S. B., Morrison, F. R., Humphrey, G. L.,
phia, PA: Lippincott Williams & Wilkins. Murray, R. A., and Chin, J. 1984. “Salmonella
Greenland, S. 2004. “Ecologic Inference Prob- dublin and Raw Milk Consumption – Califor-
lems in Studies Based on Surveillance Data.” nia.” Morbidity and Mortality Weekly Reports 33:
In Monitoring the Health of Populations: 196–198.
Health Inequalities, Work, musculoskeletal disease. Ergonomic hazards
such as repetitive movements and heavy lift-
and Welfare ing are connected to musculoskeletal disease,
CLARE BAMBRA stress, and anxiety. Those working in lower
Durham University, UK occupational jobs are more exposed to these
adverse physical working conditions.
It is well established that the work environment European Survey data show that profession-
is an important social determinant of health als have at least 50 percent less exposure to
with hazardous working conditions resulting the major physical hazards (exposure to dan-
in poor health (Marmot, Siegrist, and gerous chemicals, noise, vibrations, repetitive
Theorell 2006; Bambra 2011a). Similarly, the work, shift work, and heavy lifting) than the
negative association between unemployment bottom occupational groups (European
and health has been subject to intensive Working Conditions Observatory 2005). This
scrutiny (Bartley, Ferrie, and Montgomery results in a higher prevalence of work-related
2006; Bambra 2011a). However, what is less health problems amongst manual than
established is the contribution of the work amongst non-manual workers. For example,
environment or unemployment to socioeco- industrial injury rates in the United Kingdom
nomic inequalities in health (Bambra 2011a; exhibit significant – tenfold – occupational
2011b). “Health inequalities” is a term used to inequalities, with professional occupations
refer to the systematic differences in health having a fatal injury rate of 0.2 per 100,000
between social classes whereby morbidity compared to a rate of 1.9 per 100,000 for the
and mortality are inversely associated with lowest grade occupations (Health and Safety
occupational grade, educational level, or per- Executive 2010).
sonal income. This entry examines the con- The health effects of the psychosocial work
tribution that work and unemployment play environment have most commonly been ana-
in determining health inequalities and the lyzed using the demand-control model
mediating impact of the broader political and (Bambra 2011a). This has shown that high
economic context – “welfare state regimes.” strain jobs (where the worker has low control
Particular hazards in the physical work over their work tasks, and high job demands)
environment are associated with adverse result in higher rates of stress-related diseases,
health outcomes (Bambra 2011a). For exam- including cardiovascular disease and mortal-
ple, chemical hazards including exposure to ity, musculoskeletal pain, mental ill health,
toxic substances used in industrial processes and adverse health behaviors (Marmot,
(asbestos, silica, coal dust, and lead) are asso- Siegrist, and Theorell 2006). The distribution
ciated with respiratory diseases, cancers, and of adverse psychosocial working conditions is
hypertension. Environmental factors such as also socially patterned, with jobs at the lower
noise are associated with acoustic shock inju- end of the socioeconomic class scale more
ries, tinnitus, hypertension, stress, and likely to entail a higher exposure to adverse
fatigue, while exposure to vibration is associ- conditions than those toward the higher end.
ated with vibration-induced white finger and For example, European survey data show that,

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

in terms of demands at work, monotonous welfare state capitalism (Bambra 2007).

work was around 50 percent higher amongst Following comparative social policy research,
the lowest occupational groups. The United advanced welfare states can be divided into at
Kingdom’s Whitehall cohort studies demon- least four different types: social democratic
strated the importance of the psychosocial (Nordic countries), conservative (Continental
work environment in explaining the social Europe), liberal (English speaking countries),
gradient in health (Marmot et al. 1997). and southern (Mediterranean European
There are clear relationships between countries) (for an overview, see Bambra
unemployment and increased risk of poor 2007). International research on the social
mental health and suicide, higher rates of all- determinants of health has increasingly
cause and specific causes of mortality, examined how population health and health
self-reported health and limiting long-term inequalities vary by welfare state regime type.
illness, and, in some studies, a higher preva- These studies have invariably concluded that
lence of risky health behaviors, including health is better in the more egalitarian social
problematic alcohol use and smoking democratic welfare states (Bambra 2007).
(Bartley, Ferrie, and Montgomery 2006; Research into the work environment,
Bambra 2011a). Unemployment is concen- unemployment, and health-related workless-
trated in lower socioeconomic classes, with ness also suggests important variation by
employment rates consistently higher welfare state regime. In terms of the psycho-
amongst more educated groups (Arber 1987). social work environment, studies have shown
The importance of unemployment to health important variation in work-related stress
inequalities was demonstrated in an English and the health effects of adverse psychoso-
study carried out in 2010 which found that, cial working conditions (Salavecz et al. 2010).
for both men and women, not being in paid For example, the relationship between job
employment accounted for up to 81 percent insecurity and poor health is less evident in
of the inequalities in the prevalence of those countries with more extensive social
self-rated poor health between the most afflu- security systems which improve the ability of
ent and the least affluent socioeconomic individuals to cope with stressful events
classes in the English working age popula- (Bartley and Blane 1997). Similarly, relation-
tion. As an example, the study revealed that ships between stressful work environments
5.6 percent of men living in owner occupied and health differ by welfare state regime with
housing did not have good general health, a lower prevalence of work-related stress in
compared to 19.1 percent of men in social social democratic countries that have more
rented housing, an age-adjusted difference of comprehensive welfare states and where the
13 percentage points. After further adjust- psychosocial work environment is more reg-
ment for unemployment, this difference ulated (Dragano, Siegrist, and Wahrendorf
reduced to 2.5 percentage points, a reduction 2011; Sekine et al. 2009). These same studies
of 81 percent. Adjusting for employment have also found that the effects on health and
status reduced the prevalence of poor self- health inequalities of adverse psychosocial
reported health in all socioeconomic classes, work environments are lessened in these
thereby substantially reducing the social countries.
gradient (Bambra and Popham 2010). Social protection (particularly wage
“Welfare state regimes” is a term used to replacement rates) during unemployment
refer collectively to the different political and varies by welfare state regime. A compara-
economic arrangements of particular types of tive study examined the extent to which

relative health inequalities between unem- Bambra, C. 2007. “Going Beyond the Three
ployed and employed people varied across Worlds: Regime Theory and Public Health
European welfare state regimes (Bambra Research.” Journal of Epidemiology & Commu-
and Eikemo 2009). It found that in all coun- nity Health 61: 1098–1102.
Bambra, C. 2011a. Work, Worklessness and the
tries, the relative health of the unemployed
Political Economy of Health. Oxford: Oxford
was consistently worse than that of those in
University Press.
work, and that these relative inequalities Bambra, C. 2011b. “Work, Worklessness, and the
were largest for both men and women in the Political Economy of Health Inequalities.” Jour-
liberal welfare states where benefit levels nal of Epidemiology & Community Health 65:
were lowest and where means-testing was 746–750.
more common. Bambra, C., and Eikemo, T. 2009. “Welfare
This entry has outlined the health effects State Regimes, Unemployment and Health:
of the physical and psychosocial work A Comparative Study of the Relationship
environment as well as the relationship Between Unemployment and Self-Reported
between unemployment and health. It has Health in 23 European Countries.” Journal
demonstrated how the uneven socioeco- of Epidemiology & Community Health 63:
nomic distribution of these risks contrib-
Bambra, C., and Popham, F. 2010. “Workless-
utes to inequalities in health. Finally, it has
ness and Regional Differences in Educational
examined the importance of welfare state Inequalities in Health: Evidence from the 2001
regimes and public policy in mitigating Census.” Health Place 16: 1014–1021.
these adverse health impacts, showing that Bartley, M., and Blane, D. 1997. “Health and the
health and safety regulation and welfare Lifecourse: Why Safety Nets Matter. British
safety nets do matter. Medical Journal 314: 1194–1196.
Bartley, M., Ferrie, J., and Montgomery, S. 2006.
“Health and Labour Market Disadvantage:
ACKNOWLEDGMENT Unemployment, Non-Employment, and Job
Insecurity.” In Social Determinants of Health,
edited by M. Marmot and R. G. Wilkinson,
This entry is adapted from C. Bambra 2011.
78–96, Oxford: Oxford University Press
“Work, Worklessness and the Political
Dragano, N., Siegrist, J., and Wahrendorf, M. 2011.
Economy of Health Inequalities.” Journal of “Welfare Regimes, Labour Policies and Workers’
Epidemiology and Community Health 65 Health: A Comparative Study with 9917 Older
(2011): 746–750, with the permission of BMJ Employees from 12 European Countries.” Journal
publishing group. of Epidemiology & Community Health 65: 793–
799. doi:10.1136/jech.2009.098541
SEE ALSO: Health Inequalities; Health and European Working Conditions Observatory. 2005.
Welfare Systems; Occupational Health and Fourth European Working Conditions Survey
Safety; Public Health; Socioeconomic Status (2005).
and Health; Socioeconomic Status and Stress veys/ewcs/2005/index.htm. Accessed April 16,
Health and Safety Executive. Health and Safety
Statistics. Accessed
April 16, 2013.
Arber, S. 1987. “Social Class, Non-Employment, Marmot, M., Bosma, H., Hemingway, H. et al.
and Chronic Illness: Continuing the Inequali- 1997. “Contribution of Job Control and Other
ties in Health Debate.” British Medical Journal Risk Factors to Social Variations in Coronary
294: 1069–1073. Heart Disease.” Lancet 350: 235–240.

Marmot, M., Siegrist, J., and Theorell, T. 2006. Comparison Study.” Journal of Epidemiology &
Health and the Psychosocial Work Environ- Community Health 64: 57–62.
ment.” In Social Determinants of Health, edited Sekine, M., Chandola, T., Martikainen, P., et al.
by M. Marmot and R. G. Wilkinson, 97-130. 2009. “Socioeconomic Inequalities in Physical
Oxford: Oxford University Press and Mental Functioning of British, Finnish, and
Salavecz, G., Chandola, T., Pikhart, H., et al. 2010. Japanese Civil Servants: Role of Job Demand,
“Work Stress and Health in Western European Control, and Work Hours.” Social Science &
and Post-Communist Countries: An East–West Medicine 69: 1417–1425.
Mental Health and supernatural entities – is associated with better
mental health across a range of indicators,
Religion including anger, depression, anxiety, psycho-
logical distress, and cognitive functioning
University of Utah, USA (Ellison, Burdette, and Hill 2009; Hill et al.
ANDREW H. MANNHEIMER 2006; Idler and Kasl 1997; Krause 2005,
Florida State University, USA McFarland 2009). McFarland (2009) provides
an excellent study of religion and mental
Religion is a prevalent and powerful social health among older adults. His analyses of
force in the lives of American adults. According national longitudinal data from the Religion,
to national estimates from the 2010 General Aging, and Health Survey shows that older
Social Survey, a large percentage of adults men who report high levels of organizational
aged 18 and older affiliate with religious religiosity (indicated by attendance at Bible
groups (82 percent), attend religious services study groups, prayer groups, and religious
weekly or more (30 percent), pray at least services) tend to exhibit lower levels of
once per day (58 percent), and believe that depression than older adults who report
the Bible is the actual word of God and is to low  levels of organizational religiosity. This
be taken literally (34 percent). These figures association persisted with comprehensive
are remarkable in their own right. They also adjustments for age, race, education, marital
inspire countless questions concerning the status, non-organizational religiosity (indi-
outcomes of religious involvement. For exam- cated by frequency of Bible reading, prayer,
ple, does religion matter for mental health? religious media use), and initial levels of
More than a century ago, Émile Durkheim depression, physical health, and functional
(1858–1917) examined regional variations in limitations. Almost any association between
religion and suicide rates (1951 [1897]). His organizational religiosity and mental health
analyses of vital statistics across Western could simply reflect the fact that healthier
Europe showed that suicide rates were lower individuals are able to attend religious meet-
in predominantly Catholic and Jewish regions ings and services. However, McFarland’s
than in predominantly Protestant regions. study clearly suggests that organizational
Durkheim explained that Catholic and Jewish religiosity matters for mental health over and
rituals were more likely to provide an “intense above initial health status.
collective life” that could integrate and regulate Koenig, McCullough, and Larson (2001)
behavior (e.g., suicide) than the more individ- argue that religious involvement benefits
ualistic religious practices of Protestants. Since mental health by promoting social (e.g.,
Durkheim’s seminal work, studies have con- social support) and psychological resources
sistently shown that religion can be both good (e.g., optimism and a sense of meaning and
and bad for mental health status. purpose). Healthy lifestyles (especially lower
Religious involvement – indicated by levels of substance use) are also likely to play
observable feelings, beliefs, activities, and an important role (Hill, Burdette, and Idler
experiences in relation to spiritual, divine, or 2011). Religious attendance may be especially

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

important for indicators of cognitive func- religious faith), are associated with higher
tioning. Religious attendance in particular levels of psychological distress (indicated by
involves a number of activities that are likely symptoms of depression and anxiety). These
to stimulate cognitive faculties, including results persisted with adjustments for age,
singing, prayer/meditation, sermons, scrip- gender, race, education, family income, mari-
tural study, philosophical discussions, and tal status, religious attendance, frequency of
general socializing. If social ties and activities prayer, and frequency of meditation. The truly
stimulate cognitive faculties, they may delay distinctive feature of this study is the exami-
the deterioration of cognitive performance in nation of so many unique indicators of reli-
old age, presumably through the maintenance gious involvement and spiritual struggles.
of dense neocortical synapses in the brain Religious struggles may directly undermine
(Hill et al. 2006). mental health. Religious involvement might
Although most studies emphasize the contribute to discomfort associated with
health benefits of religious involvement, reli- cognitive dissonance when religious beliefs
gious struggles may also undermine mental (e.g., strict morality standards) and behaviors
health. Religious struggles include religious (e.g., moderation in life) conflict with other
doubts, feeling abandoned by God, negative personal beliefs (e.g., a pro-choice view) or the
interactions within the church, negative reli- broader norms of society (e.g., liberal attitudes
gious beliefs (e.g., believing that human nature toward premarital sexual activity) (Exline
is fundamentally perverse and corrupt), high 2002). Failing to meet religious standards
levels of extrinsic religiosity, and the combina- could also contribute to feelings of guilt and
tion of strong religious beliefs and low reli- shame (Abu-Raiya, Pargament, and Magyar-
gious attendance. Indeed, research indicates Russell 2010). Religious doubts are likely
that religious struggles are associated with associated with anxiety (especially fears and
poorer mental health, including higher levels worries concerning divine retribution), while
of guilt, shame, anger, anxiety, paranoia, strained relationships with God and coreli-
depression, and psychological distress gionists might relate to feelings of anger and
(Ellison, Burdette, and Hill 2009; Ellison and hostility (Abu-Raiya, Pargament, and Magyar-
Lee 2010; Exline, Yali, and Sanderson 2000; Russell 2010). Religious struggles may also
Krause and Wulff 2004; Pargament et al. undermine mental health indirectly by
2004). Ellison and Lee (2010) present an intri- reducing social and psychological resources.
cate analysis of the psychological conse- The loss of meaning and purpose could
quences of spiritual struggles. Their analyses contribute to anxiety (especially fears and wor-
of national General Social Survey data shows ries concerning the meaning and significance
that several indicators of spiritual struggles, of life events) (Abu-Raiya et al. 2010; Ellison
including troubled relations with God (indi- and Lee 2010). The loss of social support and
cated by feeling that God is punishing you for self-esteem might also elevate depression
your sins or lack of spirituality and wondering levels (especially feelings of sadness and hope-
whether God has abandoned you), negative lessness) (Abu-Raiya et al. 2010; Exline, Yali,
interaction (indicated by how often people in and Sanderson 2000).
your congregation make too many demands The pioneering work of Émile Durkheim
on you and are critical of you and the things (1951 [1897]) and numerous subsequent
you do), and religious doubts (indicated by studies show us that mental health varies
how often evil in the world and personal systematically according to religion. While
pain and suffering cause doubts about your general religious involvement tends to promote

mental health, religious struggles tend to Hill, Terrence D., Burdette, Amy M., Angel,
undermine it. Taken together, these patterns Jacqueline L., and Angel, Ronald J. 2006. “Reli-
are of sociological interest because they empha- gious Attendance and Cognitive Functioning
size that the mental health of individuals and among Older Mexican Americans.” Journal of
Gerontology: Psychological Sciences 61B: P3−P9.
groups is intimately tied to involvement in
doi: 10.1093/geronb/61.1.P3.
institutions of religion.
Hill, Terrence D., Burdette, Amy M., and
Idler, Ellen L. 2011. “Religious Involve-
SEE ALSO: Durkheim, Émile; Health and ment, Health Status, and Mortality Risk.”
Culture; Health and Religion; Mental Health; In Handbook of Sociology of Aging, edited
Mental Illness and Suicide; Stress and Religion by Richard A. Settersten and Jacqueline L.
Angel, 533−546. New York: Springer. doi:
Idler, Ellen L., and Kasl, Stanislav V. 1997. “Reli-
Abu-Raiya, Hisham, Pargament, Kenneth I., and gion among Disabled and Nondisabled Persons
Magyar-Russell, Gina. 2010. “When Religion I: Cross-Sectional Patterns in Health Practices,
Goes Awry: Religious Risk Factors for Poorer Social Activities, and Well-Being.” Journal of
Health and Well-Being.” In Religion and Psy- Gerontology: Social Sciences, 52B: S294–S305.
chiatry: Beyond Boundaries, edited by Peter doi: 10.1093/geronb/52B.6.S294 DOI:10.1093%
J. Verhagen, Herman M. Van Praag, Juan J. 2Fgeronb%2F52B.6.S294.
Lopez-Ibor, John L. Cox, and Driss Moussaoui, Koenig, Harold G., McCullough, Michael E., and
389–412. Chichester, UK: Wiley-Blackwell. doi: Larson, David B. 2001. Handbook of Religion
10.1002/9780470682203.ch22. and Health. New York: Oxford University Press.
Durkheim, Émile. 1951 [1897]. Suicide: A Study in Krause, Neal. 2005. “God-Mediated Con-
Sociology. New York: Free Press. trol and Psychological Well-Being in Late
Ellison, Christopher G., Burdette, Amy M., and Life.” Research on Aging 27: 136–164. doi:
Hill, Terrence D. 2009. “Blessed Assurance? 10.1177/0164027504270475.
Religion, Anxiety, and Tranquility among US Krause, Neal. 2010. “Religion and Depression
Adults.” Social Science Research 38: 656–667. Symptoms in Late Life.” In Religion, Families,
doi: 10.1016/j.ssresearch.2009.02.00. and Health: Population-Based Research in the
Ellison, Christopher G., and Lee, Jinwoo. 2010. “Spir- United States, edited by Christopher G. Ellison
itual Struggles and Psychological Distress: Is There and Robert A. Hummer, 229–247. New Brun-
a Dark Side of Religion?” Social Indicators Research swick, NJ: Rutgers University Press.
98: 501–517. doi: 10.1007/s11205009-9553-3. McFarland, Michael J. 2009. “Religion and Mental
Exline, Julie. J. 2002. “Stumbling Blocks on the Health among Older Adults: Do the Effects of
Religious Road: Fractured Relationships, Nag- Religious Involvement Vary by Gender?” Jour-
ging Vices and the Inner Struggle to Believe.” nal of Gerontology: Social Sciences 65B: 621–630.
Psychological Inquiry 13: 182–189. doi: 10.1207/ doi: 10.1093/geronb/gbp112.
S15327965PLI1303_03. Pargament, Kenneth, Koenig, Harold, Tarakesh-
Exline, Julie J., Yali, Ann Marie, and Sanderson, war, Nalini, and Hahn, June. 2004. “Religious
William C. 2000. “Guilt, Discord, and Alienation: Coping Methods as Predictors of Psychological,
The Role of Religious Strain in Depression and Physical and Spiritual Outcomes among Medi-
Suicidality.” Journal of Clinical Psychology 56: cally Ill Elderly Patients: A 2-Year Longitudinal
1481–1496.doi:10.1002/1097-4679(200012)56:12< Study.” Journal of Health Psychology 9: 713–730.
1481::AID-1>3.0.CO;2-A. doi: 10.1177/1359105304045366.
Patient/User Associations clinical research since the 1980s (Paterson
and Barral 1994; Rabeharisoa 2006). When
BRIGITTE CHAMAK it created the Telethon in 1987, the aim was
Université Paris Descartes, France to collect donations for fighting genetic dis-
eases. The first Telethon took place in the
In most Western countries, the history of United States in 1954 and the main national
patient associations began with the creation telethon was created in 1966 to raise money
of associations of disabled civilians in the for the Muscular Dystrophy Association
1920s, following the social rights and meas- (MDA). Recently, the MDA has been criti-
ures established for war casualties (Barral cized by disability rights activists for its
2007; Cohen 2001; Gerber 2000). During charity mentality, and the tendency to paint
the same period, associations for people disabled people as “pitiable victims who
disabled after accidents in the workplace want and need nothing more than a big
were also founded. They claimed the right charity to take care of them. Or, better, to
to work and created rehabilitation centers. cure them” (Ervin 2005). The disability
These developments introduced the main rights movement is keen to secure equal
concepts for public and associative action in opportunities and rights for people with dis-
concrete legislative form. In the 1940s and abilities (Linton 1998). The movement argues
1950s, the first organizations for people that focusing the public’s attention on medi-
with chronic diseases were founded. cal cures to “normalize” disabled people fails
Patients with the same disease became to address issues like accessible buildings,
aware of the similarity of their individual transportation, employment opportunities,
experiences, and considered their shared and other civil rights.
experience essential for understanding, and The comparison between claims from
improving, their condition. With specific parent associations and user associations
concerns about their disease, they claimed a shows striking differences. User associations
say in decisions concerning their situation often reproach parent associations for
(Rabeharisoa 2006). speaking on their behalf. In particular, deaf
In the same period, the emergence of new activists accuse the hearing parents of deaf
associative actors emerged: the parents of children of depriving their children of
disabled children. For the families, creating opportunities to participate in deaf culture
associations allow them to voice their (Lennard 1995; Blume 2010). In the same
demands and to take initiatives on behalf of way, associations of autistic people decry the
a user group (Paterson and Barral 1994). attention on treatment and focus instead on
The parent associations have contributed to their human rights. Parent associations want
a public awareness and taken on an ever- to treat autism and are more aligned with a
increasing role in the shaping of public pol- medical model of disability, while associa-
icy and actions in the field of disability. The tions of autistic people subscribe to a social
example of the French Muscular Dystrophy model of disability. Their members no
Organization, founded in 1958, illustrated longer want to be considered as patients, but
its crucial role in organizing biological and as individuals with a different cognitive

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

mode of functioning (Chamak 2008; Orsini (Chamak 2008; Gillett 2003). In the field of
and Smith 2010). Self-advocates have mental health, Crossley and Crossley (2001)
adopted the notion of “neurodiversity” to have identified a shift from personal com-
frame their claims that the society needs to plaints about specific experiences in the
accommodate cognitive difference, rather 1950s toward a sense of collective identity
than try to cure or treat people with autism and a generalized critique of the mental
(Baker 2011; Ortega 2009). health system today. This social movement
These associations, such as self-help groups emerged within more general social con-
(Katz and Bender 1976; Emerick 1991) or the texts. Associations of mental health users,
disability movement (Shakespeare 1993; in conjunction with civil rights groups, have
Shapiro 1993), formulate themselves in terms sought to change public images of mental
of identity politics and want to be recognized illness, and to establish a right to advocacy
as equal partners by doctors and scientists. In for people with mental health problems.
the 1960s and the 1970s, different forms of Political activism represents a collective
action were introduced by disability associa- alternative to the previous individualistic
tions, and, in the 1980s, by AIDS associations. responses and may be seen as the collective
Many studies demonstrated the construction form of a more diffuse strategy of redefini-
of lay expertise and changes in the relation- tion to attain a favorable conception of self
ship between doctors and patients (e.g. (Anspach 1979).
Barbot 2006; Epstein 1995). Barbot (2006) Patient/user associations are included in
described patients as managers of their own the broader category of “social movements,”
illness, the empowerment of patients, the defined as organized challengers to the social
sciences-wise patient, and the experimenter. order, which constitute one of the principal
Orsini and Smith (2010) defined three differ- social forms through which communities
ent ways in which social movements mobilize voice their grievances and attempt to pro-
knowledge in public policy: instrumental, mote or resist change in a society (Snow,
contesting, and embodied. The first type of Soule, and Kriesi 2004). Social movements in
relationship is characterized by the instru- the field of health are an important political
mental use of expert knowledge by social force for health care access and quality of
movements to advance their specific claims. care, as well as for broader social change
The second type shows social movements (Brown and Zavestoski 2004). The study of
interested in policy change contesting science health social movements (HSMs) enables us
and expertise. The third orientation is illus- to understand how collective action develops
trated by the AIDS movement. Epstein (1995) around a health issue and what strategies
studied how people with AIDS put their bio- these HSMs employ to impact public policy.
logical bodies on the line to advance AIDS
research. AIDS activists fought and won a SEE ALSO: Health Social Movements; Illness
battle to ensure that the rules governing clini- Experience; Mental Health; Patients
cal trials were changed to include patients
who would otherwise have been excluded for
failing to follow proper protocols. As with the REFERENCES
disability movement, the slogan “nothing for Anspach, Renée R. 1979. “From Stigma to Identity
us without us” has been adopted. Politics: Political Activism Among the Physi-
The Internet plays a crucial role in the cally Disabled and Former Mental Patients.”
development of activism and new communities Social Science & Medicine 13: 765–773.

Baker, Dana L. 2011. The Politics of Neurodiversity: Gillett, James. 2003. “Media Activism and Internet
Why Public Policy Matters. Boulder, CO: Lynne Use by People with HIV/AIDS.” Sociology of
Rienner. Health & Illness 25: 608–624.
Barbot, Janine. 2006. “How to Build an ‘Active’ Katz, Alfred H., and Bender, Eugene I. 1976. “Self-
Patient? The Work of AIDS Associations in Help Groups in Western Society: History and
France.” Social Science & Medicine 62: 538–551. Prospects.” Journal of Applied Behavioral Science
Barral, Catherine. 2007. “Disabled Persons’ Asso- 12: 265–82.
ciations in France.” Scandinavia Journal of Dis- Lennard, Davis. 1995. Enforcing Normalcy: Dis-
ability Research 9: 214–236. ability, Deafness and the Body. London: Verso.
Blume, Stuart. 2010. Artificial Ear: Cochlear Linton, Simi. 1998. Claiming Disability: Knowledge
Implants and the Culture of Deafness. New Brun- and Identity. New York: New York University
swick, NJ: Rutgers University Press. Press.
Brown, Phil, and Zavestoski, Stephen. 2004. Orsini, Mickael, and Smith, Miriam. 2010. “Social
“Social Movements in Health: An Introduction.” Movements, Knowledge and Public Policy: The
Sociology of Health & Illness 26: 679–694. Case Study of Autism Activism in Canada and
Chamak, Brigitte. 2008. “Autism and Social Move- the US.” Critical Policy Studies 4: 38–57.
ments: French Parents’ Associations and Inter- Ortega, Francisco. 2009. “The Cerebral Subject
national Autistic Individuals’ Organizations.” and the Challenge of Neurodiversity.” Biosociety
Sociology of Health & Illness 30: 76–96. 4: 425-445.
Cohen, Deborah. 2001. The War Come Home: Dis- Paterson, Florence, and Barral, Catherine. 1994.
abled Veterans in Britain and Germany, 1914– “L’Association Française contre les Myopathies:
1939. Berkeley: University of California Press. Trajectoire d’une association d’usagers et con-
Crossley, Michele L., and Crossley, Nick. 2001. struction associative d’une maladie.” Sciences
“Patient’s Voices, Social Movements and the Sociales et Santé 12: 79–111.
Habitus: How Psychiatric Survivors ‘Speak Rabeharisoa, Vololona. 2006. “From Represen-
Out’.” Social Science & Medicine 52: 1477–1489. tation to Mediation: The Shaping of Collec-
Emerick, Robert E. 1991. “The Politics of Psychi- tive Mobilization on Muscular Dystrophy in
atric Self-Help: Political Factions, Interactional France.” Social Science & Medicine 62: 564–576.
Support, and Group Longevity in a Social Move- Shakespeare, Tom. 1993. “Disabled People’s Self-
ment.” Social Science & Medicine 32: 1121–1228. Organization: A New Social Movement?” Dis-
Epstein, Steven. 1995. “The Construction of Lay ability, Handicap & Society 8: 249–264.
Expertise: Aids Activism and the Forging of Shapiro, Joseph P. 1993. No Pity: People With Dis-
Credibility on the Reform of Clinical Trials.” Sci- abilities Forging a New Civil Rights Movement?
ence Technology & Human Values 20: 408–437. New York: Times Books.
Ervin, Mike. 2005. “The Kids Are All Right.” http:// Snow, David, Soule, Sarah, and Kriesi, Hanspeter. Accessed April 17, 2013. 2004. “Mapping the Terrain.” In The Blackwell
Gerber, David, ed. 2000. Disabled Veterans in Companion to Social Movements, edited by
History. Ann Arbor: University of Michigan David Snow, Sarah Soule, and Hanspeter Kriesi,
Press. 3–16. Oxford: Blackwell.
Fat Studies methodologies, performance art, and the
staging of events which enable the creation of
BETHAN EVANS alternative spaces in which fatness is
University of Liverpool, UK celebrated.
In contrast to dominant discourse on obe-
Fat studies is an interdisciplinary field which sity, those working within fat studies prob-
has its roots in feminist, fat activist, and size lematize the term “obesity” either by directly
acceptance movements (Louderback 1970; critiquing it or by using alternative terms. In
Schoenfielder and Wieser 1983). While some particular, there is a move within this litera-
researchers would interchangeably use the ture, especially for those steeped in or over-
terms “fat studies,” “critical obesity studies” lapping with activism, to reclaim the word
(Gard and Wright, 2005) – often used to refer “fat” so that it may be used as a marker of
to work which directly challenges the science/ pride rather than as a means to stigmatize fat
politics of “obesity” interventions – and “critical bodies (Cooper 2010). Drawing on feminist,
weight studies” (Rich et al., 2011) – used to poststructural, corporeal/critical realist,
refer to work which interrogates body weight queer, and disability theories, several impor-
more broadly than fatness – for others “fat tant texts and edited collections have been
studies” provides a more radical name, avoid- published in recent years which consolidate
ing the reduction of fatness to pathology the critical scholarship in this area.
(obesity) or to weight. Fat studies therefore First, work closely aligned with the HAES
encompasses research which challenges the movement questions the “science” through
dominant ways in which fat bodies are medi- which bodies of a particular size are patholo-
calized (as “obese”) as well as research which gized, highlighting, for instance, that life
does not start from this point but which seeks expectancy is longer in groups classified as
to explore the multiple and intersectional overweight and shortest in groups classified as
lived experiences of fatness. The field is underweight. This work also challenges both
closely related to fat activist, size acceptance, the science and the ethics of interventions
and health at every size (HAES) movements, which assume that weight loss is achievable in
and often involves collaboration with other the long term and that it improves health
radical theoretical approaches and grassroots (Bacon and Aphramor 2011).
movements (such as queer, crip, and feminist Second, work in this field critically ques-
theory/activists). Researchers working within tions the measures (such as body mass index
this field often, therefore, have strong (BMI) and waist–hip ratio) used to classify
connections with, or work simultaneously bodies as overweight or obese. This work
as,  activists or practitioners attempting to highlights the irrationality of such measures,
disrupt fat phobic practices or spaces and since, in the quest for efficiency, they do not
create alternative spaces and practices distinguish between different types of body
through which bodies of all sizes are mass. This means, for example, that people
respected. Fat studies researchers and activists with high levels of muscle mass are likely to
adopt a range of mainly qualitative method- be classified as obese. The inadequacies of the
ologies, including mainly qualitative research BMI to deal with different body types also

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

include variations across ethnic, gender, and Fifth, work in this field has challenged the
age groups (Gard and Wright 2005; Monaghan absence of a thinking, feeling, “fat subject”
2008). In addition, this work also questions within dominant obesity discourse by work-
some of the assumptions about the relation- ing with, and drawing attention to, the lived
ship between different population groups and experiences of sized embodiment (LeBesco
body size, suggesting, for example, that any 2004). Work here can be divided into two
correlation between poverty and body mass broad areas: first, that which does not begin
may not be one in which poverty causes with obesity policy or discourse, but instead
weight gain, but that the stigmatization of fat explores the experiences of bodies who iden-
bodies may cause those who are bigger to tify as fat, big, or corpulent in everyday and/
have poorer chances of gaining employment or activist spaces. This includes work which
(Rothblum and Solovay 2009). explores the intersections between fat and
Third, studies have questioned the inter- other forms of embodied experience and
sections between “scientific” and media/pop- politics – for example, queer/transgender,
ular understandings of fatness/obesity. This feminist, and disability politics (see, e.g.,
includes work which has interrogated the role chapters in Rothblum and Solovay 2009).
of moral, or lay, understandings of fatness in Second, in this area there is work that
the production of “scientific” knowledge on considers the embodied experiences of those
obesity, challenging the assumed objectivity implicated in attempts to tackle obesity. This
of this knowledge (Gard and Wright 2005) includes (auto)ethnographic work on slim-
and the roles of various claims makers or ming and weight-loss surgery (e.g., Longhurst
“obesity epidemic entrepreneurs” (e.g., obe- 2012; Murray 2010; Throsby 2008), and
sity researchers, politicians, clinicians, the important work on the implications of school
person in the slimming club) in the produc- cultures and weig