Social Theory, Health and Healthcare

Orla McDonnell, Maria Lohan, Abbey Hyde

• Publisher: Bloomsbury Academic
• Year: 2009
• Print ISBN: 9781403989536
• eBook ISBN: 9781350311183
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Health research, education and provision have become increasingly interdisciplinary over the last few years, leading health professionals to broaden their knowledge beyond technical aspects of care. Practitioners now need a clear understanding of how society can affect health, and an appreciation of how societal structures can drive healthcare practices. In a clear, systematic and accessible style, this timely text looks at the social context of health and healthcare by:
- Analysing a wide range of classic and contemporary theories;
- Identifying the relevance of each theory to health;
- Showing how theory has been used in research
- Outlining the impact of theory on health and health provision. Specifically written for health professionals and those engaged in health studies research, this book will help students and practitioners alike understand the sociology of health and illness, and enable them to critically assess health issues, policies and practices.

CHAPTER 1

Structural Functionalism, Health and Healthcare

Introduction

In this chapter, we begin with the work of the classical theorist and one of the key founding figures of sociology, Émile Durkheim (1858–1917). His work is essentially concerned with how societies reproduce themselves through collective belief systems and practices, and how individual members are collectively bound by values and norms that govern societal practices. In turn, these practices regulate society and create a sense of social solidarity. Like other classical theorists, he was interested in understanding the transition from traditional to modern society in order to explain the impact of social change. We go on to discuss structural functionalism as a distinct body of modern social theory, which represents one particular line of influence from the classical work of Durkheim. Within the sub-disciplinary field of the sociology of medicine, Talcott Parsons (1902–1979) is the most noted of the structuralist functionalist theorists. (Robert Merton is another central figure in the development of this theoretical perspective and his work is discussed in Chapter 7 in relation to the sociology of knowledge and science). A central thread that links the classical legacy of Durkheim to structural functionalism is the idea that shared norms and values are fundamental to society functioning as a cohesive whole. This core idea became the hallmark of Parsons’ work and, more generally, has led to the characterization of structural functionalism as a ‘consensus theory’ of society. An example of what we mean by this is the emphasis that Parsons places on the function that social institutions such as medicine play in meeting the needs of society to maintain social and political stability.

While structural functionalism dominated American social theory in the 1950s and 1960s, more critical perspectives concerned with unmasking the tensions and conflicts behind apparently stable and harmonious social and political structures became more mainstream by the mid-1970s. However, some sociologists have noted a revival in Durkheimian sociology since the 1990s in the expanding field of ‘social capital’ research (Blaxter 2000, Turner 2003). In the discussion on the application of structural functionalism to understanding health, we will explore the contribution of social capital theory to debates about the pervasive problem of health inequalities, a theme that is further developed under the perspective of ‘political economy’ theories in Chapter 2 and ‘critical realism’ in Chapter 5. We then turn to the classical account of the doctor–patient relationship offered by Parsons in his ‘sick role’ theory, which has perhaps more than any other theory earned sociology a place in healthcare research. However, while the sick role remains a remarkably stable concept in medical discourse it has become less popular as an analytical concept in sociological theory and, as we go on to discuss, new lines of enquiry and new explanatory frameworks have overtaken it.

Principles of structural functionalism

Let us start with a definition of the term ‘structural functionalism’. Structuralism refers to a view of society which asserts that people’s behaviour is structured according to a set of rules or laws. Functionalism is the view that society is a system made up of interconnected parts, each of which functions in a specific way to maintain the system as a whole (Porter 1998). These ideas were developed by the nineteenth-century French sociologist, Émile Durkheim. Durkheim’s work is concerned with defining sociology as a distinct discipline that could emulate the so-called ‘hard sciences’. He describes sociology as the study of ‘social facts’ relating to social structures – the work of sociology is to explain patterns that emerge in the social world (‘social facts’) by linking the determining cause of these social phenomena to their social effect. Social structures constrain individual actions and, therefore, human deeds cannot be explained solely in relation to individual motivations or behaviours. Moreover, since society is more than simply the sum of the self-interests of individuals, the problem of how society is socially integrated (what ties its members together), particularly as it undergoes processes of change, is a central concern in Durkheim’s work.

The social division of labour

Like other classical social theorists, Durkheim is concerned with the way in which the modern processes of urbanization and industrialization break down traditional ways of living. In The Division of Labour in Society ([1893] 1964), Durkheim explains that traditional and modern societies are integrated differently. Traditional societies (e.g., agrarian subsistence societies where the family is the dominant economic unit) are structured by a simple ‘division of labour’, meaning that people perform similar functions to each other, which creates a shared bond within society based on common experiences and shared beliefs (Ritzer and Goodman 2003). He refers to this form of social integration as ‘mechanical solidarity’. Modern society, on the other hand, is characterized by a more complex division of labour where people perform specialized tasks in an ever-widening range of structures and institutions. Here we need only to think about the growth in institutions associated with the welfare state in the twentieth century and the important role that these play in social protection, education and health, functions previously associated with the traditional institution of the family. Durkheim characterizes the social integration that arises from mutual dependency created by the more complex division of labour in modern society as ‘organic solidarity’.

In modern society social bonds based on a shared way of life are inevitably weaker and social integration is a function of the mutual dependency of people’s needs and ‘the mutual relationships between [specialized] functions’ (Durkheim in Calhoun et al. 2002: 145). For Durkheim, this interdependency is consolidated through the ‘network of ties’ that becomes institutionalized in society over time. As society undergoes rapid social and economic change, the norms, values and beliefs that guide people in the conduct of their everyday lives and that reproduce a sense of collective belonging are weakened. This gives rise to a state of ‘anomie’ – a concept that Durkheim uses to explain the breakdown in traditional social norms. In this situation, individuals are set adrift and isolated from the kind of common bonds that are formed in, for example, family and kin networks, community and in the work place. Durkheim suggests that the complex division of labour in modern society, which has the potential to create new forms of solidarity based on the interdependency of needs and specialized functions, also has ‘pathological’ tendencies in the sense of producing unhealthy societies evidenced, for example, by rising rates of suicide.

Conceptualizing suicide as a problem of social integration

Durkheim develops his argument on the problem of social integration in modern society in his study of suicide ([1897] 1951). In this study, which best illustrates his concept of anomie, Durkheim offers an important sociological insight that suicide, more commonly understood as an individual act of self-destruction, can be explained in relation to underlying social factors. In explaining the differential rates of suicides cross-culturally and over time, he argues that too little or too much social integration and social regulation creates the social conditions for different patterns of suicide (Ritzer and Goodman 2003). To this end, he identifies four types of suicide. The two dominant types of suicide in modern societies are ‘egotistic’ and ‘anomic’ suicide. Durkheim associates these patterns of suicide with low levels of social integration and regulation in societies marked by individualism and disruptive social change. In the case of the former pattern, suicide is the result of the weakening of social bonds, whereas the latter is associated with the kind of social disconnection that arises from radical social and economic change, which weakens the hold that traditional norms have in regulating individual behaviour. Durkheim identifies ‘altruistic’ and ‘fatalistic’ suicide as the dominant patterns in traditional societies, which are more highly integrated and regulated. In traditional societies where individual members are tightly bound by a single belief system, individuals are more likely to sacrifice their lives (as in the case of the martyr) for the greater good of the community, whereas fatalistic suicide occurs when traditional norms and belief systems operate as oppressive structures of regulation.

Durkheim suggests that modern societies are marked by a rise in egoistic and anomic suicides reflecting a breakdown in social bonds and traditional norms following certain social trends such as political apathy, hyper-individualism, the prevalence of nihilistic philosophies, and the widening of social choices at the same time that the norms and moral reference points on how we should live are loosened. Although Durkheim was making these observations over a hundred years ago, they remain pertinent to contemporary commentaries on the social causes of rising suicide rates. A central theme in his approach to the problem of social integration and regulation is the idea that associational forms of social organization are necessary to counter-balance such tendencies. This idea is re-emerging in social capital theory marking what Blaxter (2000) and Turner (2003) describe as a ‘neo-Durkheimian’ turn in social theory, which is discussed more fully under the application of structural functionalism to health in the following section.

Parsonian functionalism

For our present purpose, we now turn our attention to the development of structural functionalism (sometimes referred to simply as ‘functionalism’) as formulated in the work of the American sociologist, Talcott Parsons. Parsons is considered a central figure in the development of modern social theory and his work has left a deep imprint on the development of medical sociology. Influenced by the psychoanalytical theory of Freud, Parsons is interested in the motivations behind illness behaviour and how this is managed in the doctor–patient relationship (Turner 1992). However, Parsons’ analytical framework extends beyond the therapeutic encounter to understanding the doctor–patient relationship in terms of the functional needs of society. Therefore, much of the commentary on Parsons’ contribution to the sociology of health and illness has focused on his structural analysis of the illness experience. For Parsons, the structures of society (social roles, norms and values) are organized on the basis of its functional needs. In other words, they have a purpose and that purpose is to make society run smoothly. The core of his work is concerned with the problem of social order – how society reproduces and maintains an ordered structure or a state of balance between the different parts of the social system. Unlike the social interactionalist theorists discussed in Chapter 3, Parsons does not take the micro-level of individuals interacting with one another as the basic unit of analysis in the study of society. Instead, his work is concerned with the large-scale structural components of the social system and its functional imperatives, including the necessity to maintain social order. It is important to note, however, that Parsons does not dismiss the importance of the micro-level of social interaction; his seminal work The Social System (1951), for example, is based on the interactions between doctors and patients in a Boston hospital. However, in understanding the relationship between actors and social structures, Parsons is interested in the way that people are socialized into the norms and values of a given social system and appropriate social roles.

Parsons is not just concerned with explaining individual action but with how that action may be determined by the way the social environment is organized. This idea is developed in his ‘action system theory’. In this schema, there are four interrelated action systems – the social, cultural, behavioural and personality systems. The ‘social system’ consists of four subsystems (Parsons was very fond of the number four), which perform different but interrelated functions in maintaining the system as a whole. The economy serves the function of adapting the external environment to the needs of society through the organization of labour, production and distribution. The political system performs the function of defining common goals and mobilizing society to that end. The socialization system consists of the main institutions for socializing actors into the dominant norms, values and expectations of society, such as the family and educational system. The societal community serves the function of integrating and regulating the other components of the social system through formal legal codes and informal social control (Layder 1994, Ritzer and Goodman 2003). Balance between the various sub-systems of the social system, which is necessary for social stability, is achieved through the exchange of various forms of what Parsons calls ‘symbolic media’, such as money in the economy, power in the political system and influence and commitment in the societal community and socialization systems, respectively. The ‘cultural system’ refers to the stock of resources (knowledge, ideas and shared symbols such as language) available within a given society that individuals draw on to help them make sense of their interactions with others. The cultural system is embodied in the norms and values of the social system and the orientations and motivations of individual actors. For Parsons, the ‘behavioural organism’ (the body) is shaped in interaction with the social environment through processes of learning and socialization, as is the ‘personality system’ (see Ritzer and Goodman 2003 for a more detailed discussion).

Parsons, therefore, is best described as a macro-theorist in that he understands large-scale social and cultural systems as exerting a determining influence on individual motivations and behaviours. When compared to Marxist theory in the next chapter, which also offers an overarching theory of society, structural functionalism ignores the role that material factors, such as money and power, play in the way that the social system is structured. Moreover, the role that core values and norms play in terms of social integration is seen as operating outside of material interests. But what concerns us here is the emphasis that Parsons places on socialization and social control as mechanisms for maintaining social stability. As Ritzer and Goodman (2003) note, Parsons’ overarching concern with social order and the assumptions that he makes about the passivity of social actors in his strong version of socialization theory (the idea that people internalize norms, values and role expectations) have become major targets of criticism of his work.

Having outlined the key ingredients of Parsons’ complex theoretical framework, we go on to look more closely at how he develops these insights in relation to healthcare, particularly his analytical model of the sick role (1951) in explaining key features of the doctor–patient relationship, and how he links these to the wider system problem of social stability.

Applications to understandings of health

The neo-Durkheimian turn and social capital theory

Since the mid-1990s there has been a growing literature linking social capital to a variety of outcomes including better health. In this section, we are particularly concerned with tracing the ‘neo-Durkheimian’ thread in the way the concept of social capital is applied in understanding the social determinants of health. As is often the case with other classical theories presented in this book, we find only a cursory mention to Durkheim in the contemporary research field on social capital and health, which also largely ignores his work on suicide. However, the link between the classical theoretical precepts outlined in the previous section is suggested by the way that social capital is used as an umbrella term encapsulating the ideas of social integration, social cohesion and social support (Almedom 2005). The key bodies of work that have shaped social capital theory in the field of health research are Robert Putnam’s Bowling Alone: The Collapse and Revival of American Community (2000) and Richard Wilkinson’s Unhealthy Societies: The Afflictions of Inequality (1996), and the application of their theories in the much-cited research of Kawachi et al. (1997, 1999a). This body of work may be interpreted as neo-Durkheimian in the sense that social capital is understood as a property of social structures and social relationships whose function is to promote social support through norms and values of trust and reciprocity and that, at the same time, regulate deviant behaviour. This conceptualization of social capital proves to be the major point of contention in Marxist materialist analyses in which the link between social inequalities and health inequalities is bound up with the social relations of production in capitalist societies (Muntaner and Lynch 1999, Navarro 2002; see also Chapter 2). We will now consider how social capital theory is applied to understanding the social determinants of health by exploring the following:

• Definitions of social capital based on its relational dimensions (emphasizing the norms and values that connect people to one another) and its material dimensions (emphasizing social capital as a resource that is determined by an individual’s socio-economic or class position);

• How the links between social capital and health outcomes are conceptualized in the key social capital literature, and finally;

• Empirical evidence of the link between social capital and health outcomes.

Defining social capital: The relational dimension

The relational dimension of social capital includes norms, values, social networks, trust and reciprocity, social integration, social cohesion and social support. The core elements of the relational definition are encapsulated in Putnam’s (1995, 2000) theory of social capital, which dominates the health research literature (Moore et al. 2005), and these may be summarized in the following way:

a) Membership of social groups or networks (personal or primary social networks such as family, friends, neighbours, co-workers; and secondary, formal networks such as voluntary organizations and statutory organizations).

b) The norms and values that confer obligations and benefits on individual members of the social network (such as trust, reciprocity, access to strategic resources, sense of belonging and social control).

c) The outcomes (and function) of social capital (such as social support, civic participation, social cohesion).

Putnam’s (1993) original thesis is based on the idea that social capital as a measure of civic participation is a prerequisite to democratic culture, effective political governance and economic development. In ‘Bowling Alone’ (1995), he equates the demise in the American sense of community with a perceived loss of quality of life. The public health literature draws on Putnam’s concept of social capital as a ‘civic’ property of communities, which he defines as ‘…features of social organization such as networks, norms, and social trust that facilitate action and cooperation for mutual benefit’ (1995: 67). An important feature of Putnam’s definition of social capital is that he understands it as a collective property of society rather than as a property of individuals. The ‘stock’ of social capital available in a given community is measured by a number of predictive indicators, including membership in voluntary organizations (social capital networks), democratic participation (newspaper consumption, voting patterns and preferences) and expressions of...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Introduction: Social Theory, Health and Healthcare
• 1 Structural Functionalism, Health and Healthcare
• 2 Political Economy Theory, Health and Healthcare
• 3 Social Interaction Theory, Health and Healthcare
• 4 Poststructuralism, Health and Healthcare
• 5 Critical Realism, Health and Healthcare
• 6 Feminist Theory, Health and Healthcare
• 7 Science and Technology Studies, Health and Healthcare
• References
• Index