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PubMed1986

Cross-cultural issues in the use of socio-medical indicators.

Socio-medical indicators for the assessment of physical, psychological and social conditions have become increasingly popular as adjuncts to traditional clinical and epidemiological measures. Most such indicators have been developed in the U.S.A. or Great Britain and considerable problems may arise from attempts to use them in other cultures. The ambiguity inherent in the terms "health" and "illness" is compounded cross-culturally by differences in the meaning system of cultures, their values, expectations and historical development. Consideration of cultural differences must precede any attempt to adapt already existing instruments for use in a culture or within a sub-group whose members were not included in the development process. Reliability and validity of socio-medical measures can only be assumed after the closest attention has been paid to the technical, conceptual and linguistic issues which arise from translation. This paper details some of the issues involved together with an account of the practical problems arising from the translation of the Nottingham Health Profile into Arabic and Spanish.

Cross-Cultural Comparison↗
PubMed1985

Reforming health care in Hungary.

Over the past two decades Hungary has initiated a series of social and economic reforms which have emphasized decentralization of control and the reintroduction of market mechanisms into the socialized economy. These reforms both reflect and reinforce a changing social structure, in particular the growing influence of upper class special interest groups. Market reforms are an expression of concurrent ideological shifts in Hungarian society. We examined the political significance of three recent proposals to reform health services against the backdrop of broader social and economic changes taking place. The first proposes a bureaucratic reorganization, the second, patient co-payments, and the third, a voucher system. The problems each proposal identifies, as well as the constituency each represents, reveal a trend toward consolidation of class structure in Hungary. Only one of these proposals has any potential to democratize the control and management of the heath care system. Moreover, despite a governmental push toward decentralization, two of these proposals would actually increase centralized bureaucratic control. Two of the reforms incorporate market logic into their arguments, an indication that the philosophical premises of capitalism are re-emerging as an important component of the Hungarian world-view. In Hungary, as well as in other countries, social analysis of proposed health care reforms can effectively illuminate the social and political dynamics of the larger society.

Community Participation↗
PubMed1985

The social construction of the patient: patients and illnesses in other ages.

The way individual conceptions and experiences of illnesses are socially constructed is shown through the historical analysis of diseases, particularly epidemics. For centuries, sickness did not clearly correspond to what we now call the patient status. Several factors were necessary for this social status to develop. Sickness had to cease being a mass phenomenon. Medicine had to become capable of providing efficacious treatment and of taking the sick out of the custody of religious institutions. Through social legislation, the notions of illness and of health had to be related to the world of work. Owing to the first two factors, sickness was transformed from a collective into an individual affair, from a way of dying into a way of living. Once related to production processes and medical custody, it became the individual's social condition.

Disease Outbreaks↗
PubMed1988

Healing boundaries in south Kalimantan.

In the Meratus Mountains of South Kalimantan, Indonesia, a number of intersecting discourses on the body compete to clarify and legitimize health practices and curing techniques. Meratus Dayak shamans cure through chants that metaphorically open and expand social and somatic boundaries; they open up the pores to let in healthy cosmic flows and to remove intrusive foreign objects caused by a patient's narrow-focused definition of self-interest and personal space. In contrast, neighboring Banjar Muslims fortify their boundaries against debilitating intrusions--like poisoned winds and poisoned foods--and messy extrusions--like the spilled blood of vampire's mouths and women's vaginas. In the ensuing ethnic dialog, Meratus shamans are cast as perpetrators as well as curers of the kind of illness-causing sorcery that makes Banjar most vulnerable. The contrasts, and the combinations, of these two curing systems highlight the internal logic of each as well as the social conditions of their continuing practice.

Cross-Cultural Comparison↗
PubMed1988

Advantages of breastfeeding according to Turkish mother's living in Istanbul and Stockholm.

As part of a cross-sectional study, carried out among Turkish mother-infant pairs, the mothers of 269 infants living in Istanbul and 30 living in Stockholm were asked their opinions as to the advantages and/or disadvantages of breastfeeding. The answers were categorized according to the attributes mentioned, quantified and related to the socio-economic status of the area of residence, maternal education, origin, current infant feeding practice and contraceptive method. In Istanbul, 63% of the responses stressed some advantage and 31% some disadvantage of breastfeeding. The contraceptive effect was considered the major advantage and the possibility of milk insufficiency the major disadvantage. In Stockholm, the nutritional value of breastfeeding was considered the most important advantage. No disadvantage was mentioned in Stockholm, despite the fact that breastfeeding durations among the immigrant group was shorter than that of the group in Istanbul. The implications of the responses are analyzed. It is hypothesized that mother-centered advantages, such as the birth-spacing effect of breastfeeding, may be more important motivators for continuing breastfeeding among women living under less-advantaged social conditions, and that, if this is true for some groups of mothers, the infant-centered emphasis in the breastfeeding promotional messages may need modification to include the interests of the mothers, as well.

Attitude to Health↗
PubMed1990

Doctors and the state: lessons from the Biko case.

The death of the well-known black leader, Steve Biko, in detention in South Africa in 1977 has continued to generate debate in the international medical literature. The three doctors who examined him during his terminal illness made a diagnosis of malingering in spite of overwhelming evidence suggesting that he had suffered extensive traumatic brain injury while in detention. The inquest into his death provided a rare insight into the manner in which state doctors function in relation to the police of a repressive regime. This article documents the relevant testimony from the inquest and explores the reasons for the doctor's mismanagement of Biko. It is suggested that failures in the doctors' judgement were a result of complex influences including the effects of their own social conditioning, the risk of habituation by state doctors to degrading prison conditions, the inroads that Apartheid has made into medical practice, the possibility of reprisal if state doctors oppose the wishes of the police, and, more speculatively, the possibility that the doctors' obedience and passivity were exploited by the Security Police who wished to absolve themselves from responsibility of Biko's injuries. Most importantly, it is argued that the repeated failure of the major medical organizations in South Africa to provide clear guidance and leadership to state-employed doctors increases the risk that individual doctors will continue to succumb to hierarchical pressures to condone acts of state-sanctioned violence against detainees.

Dissent and Disputes↗
PubMed1991

AIDS and the social side of health.

The presence of AIDS in epidemic proportions in the African context can directly and indirectly affect the health of the majority of people. AIDS highlights the social side of health, those factors of a social nature that enhances or potentially weakens the health status of individuals and whole communities. Attention solely on a limited range of social behaviors or health activities may obscure this fact with the consequence that the spread of HIV/AIDS is not controlled. Focus is turned in this paper to the stress in AIDS policies and programs on terminal illness more than on terminal life. This approach, if not altered, can increase the vulnerability of persons who live with AIDS. The influence that the subordination of women exerts on the spread of HIV infection calls into question the traditions of male sexuality. The adverse effects of HIV on the health of men as well as women suggest the urgent need for re-assessment of the concepts of maleness held in the region. Change in male attitudes and behavior may require change in legislation and a resocialization to a new orientation in male/female relationship. The health of family members may be endangered because of the demands of the care-giving role. Traditional community mechanisms for coping with illnesses may be inadequate in the face of an epidemic. Rather than the pursuit of strategies to assist categories of selected persons, such as widows or orphans, whole affected communities will need to be approached as weakened families. It is questioned whether the health care system can adequately respond to the health requirements of the many when resources are drained, health care providers are overburdened, and primary health care is fragmented because of AIDS. The social dimension of health makes it imperative that policy and program measures to stop AIDS be a collective, balanced social and biomedical scientific effort.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Bringing social structure back into clinical decision making.

Although research in the past twenty years has resulted in an increasingly sophisticated understanding of clinical decision making processes, the dominant approach in this area of inquiry remains limited. Most studies emphasize normative models of how decisions ought to be made, others attempt to describe physicians' thinking, but few take the social context of decision making systematically into account. Research models typically assume that physicians are autonomous professionals practicing in socially insular clinical settings--an approach that is consistent with classic formulations of the social structure of medical practice, but they ignore 30 years of sociological research on research on patient-physician relationships and major historical changes in the structure of medical practice. Eisenberg's still timely advice to students of clinical decision making--that they need to describe decision making in the context of 'sociologic influences' (including patient, physician and practice setting characteristics)--is expanded in the present discussion. Recent studies are reviewed, highlighting important dimensions of social structure impinging on physicians' decision making. Findings indicate that the process of clinical decision making is likely influenced by patients' age, gender, socioeconomic status, and race, physicians' professional training and experience, as well as by larger structural features of organized clinical settings. Our review of these studies on the social context of clinical decision making, however, reveals major methodological limitations including those inherently imposed by secondary data analysis, normative approaches, written case vignettes, small, non-random samples and the inadequate control of confounding influences. We present a feasible, alternative research strategy, built on a factorial experimental design. Illustrative findings indicate how complex social structural influence on clinical decision making may be disentangled in an unconfounded manner.

Age Factors↗
PubMed1993

Social disintegration and the spread of AIDS--II. Meltdown of sociogeographic structure in urban minority neighborhoods.

An elementary model of sociogeographic network structure in an urban minority community suggests externally applied stress, particularly that which triggers frequent individual or family moves of increasing distance, may cause a sudden 'phase change' resulting in disconnection of previously integrated subgroups from the community. Such 'community meltdown' would seriously disrupt mechanisms for social control, economic opportunity and socialization of youth, while intensifying substance abuse and indiscriminate and frequent sexual activity, particularly among the very young. 'Phase change' of this nature would seem to preclude success of programs to control spread of HIV infection, particularly in heterosexual populations. The possibility is explored that programs of 'community recrystalization' in disintegrated urban area might likewise need to exceed some threshold of investment and organizing activity before becoming effective. However, if supported to levels above threshold, this work implies such programs might have very great impact in a very short time. The possibility of interaction between behavioral pathologies resulting from the initial meltdown and further consequent deterioration in sociogeographic network structure leads to speculation that the threshold for recrystalization may become significantly and progressively greater than for meltdown. Implications of these matters for diffusion of HIV into the general population are discussed.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care.

This study asked how patients and doctors process self-destructive behaviors that warrant preventive action, such as smoking, substance use, and sexual practices. Although many suggestions have appeared about how physicians should encourage health promotion and disease prevention by counseling patients about self-destructive personal habits, few studies have examined actual encounters to assess how patients and doctors communicate about these matters, and prior research rarely has considered the social context of self-destructive habits. The present research has been influenced by a growing recognition of narratives, embedded in the sociocultural context of medical encounters, as an important analytic focus in the study of patient-doctor communication. Our conceptual work extended perspectives from literary criticism, critical theory, and narrative analysis in the humanities and social sciences to focus on elements of sociocultural context, ideology, social control, underlying structure, and superficially marginal features of discourse in medical encounters. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by two illustrative encounters, the discourse of health care reinforces ideologic principles of professional surveillance and individual control in dealing with patients' self-destructive tendencies. Contextual issues remain largely marginal features of the discourse, despite their pertinence to the goal of prevention. Narrative analysis provides a useful method to study the processing of self-destructive behavior in medical encounters. Future studies should continue to assess the variability of discourse in dealing with self-destructive behavior and should begin interventions to test the efficacy of differing discourse styles. Meaningful improvements in health-care discourse depend partly on difficult changes in the social context of medicine, including policies that address social conditions contributing to substance abuse and other forms of self-destructive behavior.

Adult↗
PubMed1994

The social impact of aging populations: some major issues.

Demographic trends regarding the issue of aging underscore the fact that both current situations and future trends directly concerns all of us. Aging is the reality for the future world. The pace at which demographic transition develops varies among countries and regions of the world, but most of the developed and developing countries will be challenged by increasing numbers of dependent individuals. This is particularly critical in the less-developed countries where older populations will increase substantially faster. It is expected that by the year 2000, Latin America and the Caribbean will have 41 million elderly, 7.2% of the total population. By 2025 this percentage will increase to 10.8%. The stunning growth of the elderly demands special attention of policy and decision-makers. The total dependency ratio will decrease in the Americas between 1980 and 2025 due to a marked decrease in the fertility rate, whereas old age dependency ratios will show a marked increase in all countries except Haiti and Surinam. Most of the elderly populations, predominantly women, are living in urban centers. This fact is one of the most important characteristic of the socioeconomic picture in Latin American and Caribbean countries: urbanization with poverty. Women are bearing mainly the burden. It is obvious that, from a cultural perspective, the social impact of aging populations is a complex issue. The wide range of possible future programs will be the result of differences and similarities in social values, relationships, and dynamics within each society. It is important to recognize that since modern industrialized societies live in a culture emphasizing competition for economic wealth, that values economic over social productivity, and where inequities based on class, gender, and race are accepted, that these are the issues influencing the parameters of aging populations. Social policy development for the elderly needs to be critically examined in order for society to adapt to aging as well as for older populations to adapt to a charging society. The major political challenge is the need for redistributive policies. Developing countries must add new priorities to their scarce resources, for social programs for elderly, while still having to deal with the problems of their younger populations. Women issues are extremely important in considering social policies for elderly population. Feminization of poverty and ill-health during old age is a result of exacerbated risks for women across the life course. Appropriate care and support for this vulnerable group is a priority.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1991

The age incidence of childhood acute lymphoblastic leukaemia.

A mathematical model of childhood acute lymphoblastic leukaemia (ALL) is presented which is based on the assumptions that: 1) malignant clones of lymphoblasts arise by spontaneous mutation; 2) this is normally prevented by repair systems which either cause intracellular DNA repair or eliminate the malignant clone; and 3) the repair systems are fallible and their performance decays at random with time. If the major drive to lymphocyte division is microbial antigens then the model produces a reasonable fit to published data on the age distribution of ALL. Furthermore the model offers an explanation for the apparent increase in the incidence of ALL which is associated with improved social conditions.

Adolescent↗
PubMed1976

A sociological theory of the diffusion and social setting of opiate addiction.

The theory presented here is intended to apply to socially deprived areas where heroin addiction is endemic, narcotics are available, and adolescents are not naive about the consequences of heroin use. In such settings rapid epidemic changes occur in which within a short period of time large numbers are involved. The transition of heroin use is a conversion-type phemonenon which is facilitated by the basic belief system, the network of social circles and the social and psychological inducements for compliance.

Communication↗
PubMed1995

Gender differences in disability: a comparison of married patients with schizophrenia.

Gender differences in disability constitute a fertile area of research, as disabilities need to be measured and evaluated in the social context which defines role expectations and consequently the role performance. This paper reports on the differences in disability in married patients with schizophrenia, as marital status is an important determinant of role expectation. The study sample constituted 30 married patients, of both sexes, who satisfied DSM-III criteria for schizophrenia, and were living with their spouse at the time of assessment. Disability was evaluated using the DAS (modified version). The findings indicated that women were more disabled than men on many of the evaluation parameters (p < 0.05); there was also a strong correlation between negative symptoms and disability variables in both the sexes. While a correlation between PSE syndromes and disability variables was seen in the case of males, the relationship was not seen in females. Stepwise regression also revealed that negative symptoms predominated among the factors associated with global disability in both sexes. Most of the reports in the literature reveal that women are less disabled than men. The findings of this study, that women are more disabled than men, is discussed in the context of the social conditions prevailing in India.

Adult↗
PubMed2006

Predictors of recurrence in veteran patients with umbilical hernia: single center experience.

BACKGROUND: Different medical and social conditions have been associated with primary and recurrent hernias. Possible predictors of recurrence after elective umbilical hernia repair have not been defined clearly. The aim of this study was to determine factors that predict recurrence in patients after elective repair of umbilical hernias. METHODS: A 6-year retrospective review of patients with elective umbilical hernia repair at the Dallas VA Medical Center was performed. Clinical and pathologic data were evaluated by univariate analysis to identify predictive factors for recurrence. RESULTS: A total of 244 patients underwent elective hernia repair within the study period (male, 96%; mean age, 56 y; Caucasian, 74%; African American, 14%; Hispanic, 8%). Because 15 patients were not compliant with follow-up requirements, 229 were eligible for the study. Ninety-seven underwent suture repair (42.4%) and 132 underwent mesh repair (57.3%). Eleven recurrences were identified (4.8%): 7 in the suture repair group (7.7%) and 4 in the mesh repair group (3%). Univariate analysis showed that patients likely to develop recurrences were as follows: African American (15.6% vs. 3.5%; P = .017), type II diabetics (14.2% vs. 2.6%; P = .002), patients with hyperlipidemia (9.2% vs. 2.6%; P = .028), and human immunodeficiency virus-positive patients (66.6% vs. 3.9%; P = .000). CONCLUSIONS: Smoking, obesity, size of hernia, type of repair, or chronic obstructive pulmonary disease do not seem to predict recurrence of hernias in our VA population. African Americans, patients with type II diabetes, hyperlipidemia, and positive for human immunodeficiency virus, may have a higher risk for recurrence after elective umbilical hernia repair.

Adult↗
PubMed2005

Changes in number of synapses and mitochondria in presynaptic terminals in the dentate gyrus following cerebral ischemia and rehabilitation training.

Damage to the adult brain can result in adaptive plasticity in regions adjacent to the site of the principal insult and that the plastic changes may be modulated by post-injury rehabilitation training. In this study, we examined the effects of rehabilitation training on synaptic morphology in the dentate gyrus following transient global cerebral ischemia and the metabolic correlates of the ultrastructural changes. Forty adult male Wistar rats were included in the study and assigned to either ischemia or sham group. Following ischemic or sham surgery, rats were randomized to either complex environment housing (EC), exercise (EX), or social condition (SC, paired housing) group. Electron microscopy and unbiased stereological methods were used to evaluate synaptic plasticity and the number and size of mitochondria in synaptic axon terminals. Increased number of granule neurons was seen in all ischemic groups and in the sham EC rats. Changes in the number of synapses per neuron in the outer and inner molecular layers of the dentate gyrus parallel those seen in granule neurons. Similarly, ischemia and behavioral experience in EC independently increased the number of synaptic mitochondria in presynaptic terminals in both the outer and inner molecular layers; however, no significant changes were seen in mitochondrial size. These data suggest a link between behavioral training and synaptic plasticity in the region adjacent to the injury and that the likely metabolic correlate of this synaptic plasticity is increased number of mitochondria at synaptic axon terminals.

Animals↗