The social construction of chronicity – a key to understanding chronic care transformations

Purpose The purpose of this paper is to argue the importance of contemporary analysis of the modern social construction of chronicity – encapsulating the world views of the chronically ill, and the medical and health system constructions of chronic disease, through the nature of care for chronic conditions. It is argued that chronic diseases are themselves, socially constructed, despite widely accepted disease classification systems. Thus, there is a need to examine how different ideas have permeated our clinical and health system developments and their social context and vice versa. Methods We examine historical ideas, theory and evidence about the tensions in social construction of chronic illness by those afflicted and the responses of society, the medical and health professions and increasingly the public and private institutions that shape health care. This is with the background of major differences in the two cultures that create knowledge: those based upon argument and intellectual logic – hermeneutic, and those based upon ‘objectivist’ empirical science, often called heuristic. Evidence‐based medicine (EBM) is the flagship of disease management, increasingly narrative‐based medicine and other similar genres are becoming the pragmatic face of social constructions, yet sit in juxtaposition without synthesis. A third culture has emerged of scientific intellectuals who straddle these cultures and in health care their public face is ‘mixed methods’. Findings Recent cases of modern ideas about improving chronic care were reviewed. We found that despite developments of social theory, the world view of the chronically ill exerts small influence in health system redesign, apparently dominated by chronic disease models. Confusion remains within health system reforms as to the social construction of chronicity – chronic disease, chronic condition or chronic illness and chronic care transformations. The role of Primary Care remains ambiguous straddling disease and illness. Radical redesign of health systems is taking place without an understanding and discourse about the nature of their construction. Ad hoc eclectism with unquestioning adoption of the dominant EBM paradigm is driving a new health culture based on disease‐based performance incentives, which is intrusive beyond the medical model and pays little attention to narratives of illness and even less to the whole social reconstruction of illness and wellness. Conclusions Health care systems cannot afford to avoid, and should actively embrace the critiques of social theory and analyses in the transformations of health systems to improve chronic care. Creative tensions between empirical and intellectual critique, and a synthetic middle ground are likely to lead to more realistic and innovative approaches spanning the nature of chronicity and the transformation of Primary Care.     

全科医生的社会性及医学社会学素养

发展社区卫生服务的关键是要大力培养全科医生,合格的全科医生必须具备一定的医学社会学素养。本文分析了全科医生的社会性、医学的社会化特征及医学社会学的内涵、研究对象和研究方法,探讨了培养全科医生医学社会学素养的意义和途径。     

Investigation of the ways in which patients' reports of their satisfaction with healthcare are constructed

A characteristic feature of patient satisfaction research is the consistently high level of satisfaction recorded. More reliable and relevant inquiry tools are constantly being developed, but underlying psychological and social pressures that could promote such a consistent and undiscriminating response have been little investigated. Williams et al. (1998) explored the phenomenon and concluded that, by considering issues of duty and culpability, patients could make allowances for poor care, and avoid evaluating it negatively. Their study was in community mental health. This study follows up their work within elective orthopaedic surgery, and investigates the pressures promoting such apparent transformation of opinion. Using a longitudinal design, and in-depth qualitative interviews, the patient's process of reflection was explored. Three psycho-social pressures were identified that appear to work together to make the transformation of opinion almost the default process. They are: the relative dependency of patients within the healthcare system; their need to maintain constructive working relationships with those providing their care; and their general preference for holding a positive outlook. It is suggested that, while it is the patient's prerogative to re-interpret the quality of their care positively, it is not the prerogative of the inquirer to accept this re-interpretation as representative of the patient's experience. Methods of inquiry are needed which access something of patients' development of opinion, and thereby something of their initial, often more negative, untransformed responses to their healthcare experiences.     

Spatial stigma and health inequality

A large body of literature has considered the way that places contribute to the health of their residents. The bulk of this research has considered the numerous risks and resources that are contained within the bounded spaces of neighborhoods and communities. Only recently have scholars begun to consider how these material and social conditions interact with the symbolic dimensions of place to further affect health. In this conceptual paper, we draw on a broad literature in order to develop a conceptual framework that connects negative representations of place, or spatial stigmas, to health. We argue that spatial stigma can affect health through three primary pathways: (1) access to material resources; (2) processes of stress and coping; and (3) processes related to identity formation and identity management. Our model suggests that spatial stigma is likely an important and understudied mechanism through which disadvantaged places contribute to multiple physical and mental health outcomes. Furthermore, by considering the larger sociocultural meanings that surround marginalized places, the concept of spatial stigma introduces new considerations for the development of effective policies to address geographic health inequality.     

‘Plausible uncertainty’: The negotiated indeterminacy of pandemic influenza in the UK

Policymakers in the UK (and worldwide) are preparing for what is said to be an inevitable and imminent influenza pandemic. However, aside from its inevitability, there is a considerable amount of uncertainty surrounding the pandemic. Public health policy is flexible and ad hoc, and this, the public is told, is a direct result of the natural unpredictability of the influenza virus, This article argues that we should not uncritically accept policymakers’ assertion that the uncertainty surrounding pandemic influenza public health is simply a result of this natural unpredictability. Uncertainty in public health policy must be understood in terms of its socio-political, as well as its scientific, context. Uncertainty is seen to occupy two separate but related levels: basic scientific uncertainty and public health policy uncertainty. This study shows how the former, which to an extent is real uncertainty, is translated into the latter which is (re)constructed and politicised as ‘plausible uncertainty’. The actors are seen to displace accountability onto the influenza virus through a naturalistic account of uncertainty which fails to include a public discussion of those socio-political factors, such as funding and licensing, which also help to shape both scientific research and policy formulation, and which subsequently have an impact on how well prepared we are for coping with a pandemic. The danger, it is suggested, is that the existence of a ‘culture of precaution’ too easily allows for a naturalistic account of uncertainty to be seen as a justifiable solution to a difficult policy problem, in instances where the full social and political context of the issue may not have been openly discussed.     

刍议护理语言的应用及作用

从临床护理语言在疾病康复中的作用出发 ,探讨了护士的社会角色、融洽护患关系等问题。提出临床护理语言是一个广义的概念 ,护患沟通中语言交流与非语言交流同等重要 ,是影响病人身体康复的重要社会因素。     

The sociology of risk and uncertainty: A response to Judith Green's ‘Is it time for the sociology of health to abandon “risk”?’

This article responds to Judith Green's (2009 Green, J. 2009. Is it time for the sociology of health to abandon ‘risk’?. Health, Risk & Society, 11(6): 493–508. [Taylor & Francis Online], [Web of Science ®] [Google Scholar], p. 493–508, this issue) contribution ‘Is it time for the sociology of health to abandon “risk”?’ It agrees with some of Green's criticisms of risk studies, but argues that rather than abandoning the concept of risk it should be refined and developed. Even though Green is right to have concerns about narrow approaches to social reality she follows a narrow perspective herself, which is atypical for sociological approaches to risk. She starts with criticism of the overemphasis on risk in research on the sociology of health but seem to shift to a general critique of risk research and focuses on one particular approach. Sociological risk research, I would argue, provides a critique of precisely those reductionist approaches to risk which Green sees as narrowing the focus of risk to concepts of rational decision making, technical calculation and risk assessment. Her examples, however, indicate a range of problems, but less with the concept of risk but rather methodological weaknesses, issues of operationalisation of macro theory and a technical understanding of risk which are altogether problematic not only in the realm of risk but for sociological approach to social reality in general. Instead of questioning risk I point to ways in which sociological risk research can be systematised. I show that Green's analysis has weaknesses that are conceptually important. In particular, she does not clearly distinguish between several levels of analysis such as institutional self representation and everyday practice, the risk society as a specific theory and the sociology of risk and uncertainty as an area of research and risk as an analytical approach and a research object. I argue that sociological approaches to risk already work with other distinctions than rational/subjective and some research even shows how such distinctions can be overcome to open further perspectives for risk research.     

Dignity in health‐care: a critical exploration using feminism and theories of recognition

ARANDA K and JONES A. Nursing Inquiry 2010; 17 : 248–256
Dignity in health‐care: a critical exploration using feminism and theories of recognition Growing concerns over undignified health‐care has meant the concept of dignity is currently much discussed in the British National Health Service. This has led to a number of policies attempting to reinstate dignity as a core ethical value governing nursing practice and health‐care provision. Yet these initiatives continue to draw upon a concept of dignity which remains reliant upon a depoliticised, ahistorical and decontexualised subject. In this paper, we argue the need to revise the dignity debate through the lens of feminism and theories of recognition. Postmodern feminist theories provide major challenges to what remain dominant liberal approaches as they pay attention to the contingent, reflexive, and affective aspects of care work. Theories of recognition provide a further critical resource for understanding how moral obligations and responsibilities towards others and our public and private responses to difference arise. This re‐situates dignity as a highly contested and politicised concept involving complex moral deliberations and diverse political claims of recognition. The dignity debate is thus moved beyond simplistic rational injunctions to care, or to care more, and towards critical discussions of complex politicised, moral practices infused with power that involve the recognition of difference in health‐care.