Showing papers in "Journal of Health and Social Behavior in 1995"

Revisiting the behavioral model and access to medical care: does it matter?

Abstract: The Behavioral Model of Health Services Use was initially developed over 25 years ago. In the interim it has been subject to considerable application, reprobation, and alteration. I review its development and assess its continued relevance.

Social Conditions as Fundamental Causes of Disease

Abstract: Over the last several decades, epidemiological studies have been enormously successful in identifying risk factors for major diseases However, most of this research has focused attention on risk factors that are relatively proximal causes of disease such as diet, cholesterol level, exercise and the like We question the emphasis on such individually-based risk factors and argue that greater attention must be paid to basic social conditions if health reform is to have its maximum effect in the time ahead There are two reasons for this claim First we argue that individually-based risk factors must be contextualized, by examining what puts people at risk of risks, if we are to craft effective interventions and improve the nation's health Second, we argue that social factors such as socioeconomic status and social support are likely 'fundamental causes" of disease that, because they embody access to important resources, affect multiple disease outcomes throughmultiple mechanisms, and consequently maintain an association with disease even when intervening mechanisms change Without careful attention to these possibilities, we run the risk of imposing individually-based intervention strategies that are ineffective and of missing opportunities to adopt broad-based societal interventions that could produce substantial health benefits for our citizens

Stress, coping, and social support processes: where are we? What next?

Abstract: I review existing knowledge, unanswered questions, and new directions in research on stress, coping resource, coping strategies, and social support processes. New directions in research on stressors include examining the differing impacts of stress across a range of physical and mental health outcomes, the "carry-overs" of stress from one role domain or stage of life into another, the benefits derived from negative experiences, and the determinants of the meaning of stressors. Although a sense of personal control and perceived social support influence health and mental health both directly and as stress buffers, the theoretical mechanisms through which they do so still require elaboration and testing. New work suggests that coping flexibility and structural constraints on individuals' coping efforts may be important to pursue. Promising new directions in social support research include studies of the negative effects of social relationships and of support giving, mutual coping and support-giving dynamics, optimal "matches" between individuals' needs and support received, and properties of groups which can provide a sense of social support. Qualitative comparative analysis, optimal matching analysis, and event-structure analysis are new techniques which may help advance research in these broad topic areas. To enhance the effectiveness of coping and social support interventions, intervening mechanisms need to be better understood. Nevertheless, the policy implications of stress research are clear and are important given current interest in health care reform in the United States.

Minority stress and mental health in gay men

Abstract: This study describes stress as derived from minority status and explores its effect on psychological distress in gay men. The concept of minority stress is based on the premise that gay people in a heterosexist society are subjected to chronic stress related to their stigmatization. Minority stressors were conceptualized as: internalized homophobia, which relates to gay men's direction of societal negative attitudes toward the self; stigma, which relates to expectations of rejection and discrimination; and actual experiences of discrimination and violence. The mental health effects of the three minority stressors were tested in a community sample of 741 New York City gay men. The results supported minority stress hypotheses: each of the stressors had a significant independent association with a variety of mental health measures. Odds ratios suggested that men who had high levels of minority stress were twice to three times as likely to suffer also from high levels of distress.

Lifetime traumas and mental health: the significance of cumulative adversity.

Abstract: This paper reports the community prevalence of 20 life traumas and considers their individual relevance as risk factors for psychiatric disorder. Also presented is the first evidence on the mental health significance of cumulative adversity as indexed by a count of lifetime exposure to a wide array of potentially traumatic events. The question of the importance of considering such events within efforts to assess variations in life stress is also examined. Our results demonstrate clear relationships between many traumatic events and, especially, accumulated lifetime trauma experience and both psychological distress and psychiatric disorder. That these relationships persist with temporal priority controlled - and net of the effects of parental psychopathology - suggest the causal relevance of major lifetime events and the conclusion that they represent on important dimension of increased mental health risk. From these findings and from evidence for the significance of traumas in disorder recurrence, it is contended that failure to take account of such events has resulted in the systematic underestimation of the role of stress exposure in accounting for variations in emotional distress and disorder.

Naming and framing: the social construction of diagnosis and illness.

Abstract: This paper examines the social construction of diagnosis and illness in several ways. First, I discuss the centrality of social construction in medical sociology. Next I discuss the major role of diagnosis in social construction, leading to the need for a sociology of diagnosis. I emphasize controversial and conflictual diagnoses, as a first step toward a more general sociology of diagnosis. Then I put forth a typology of social construction, involving four combinations based on whether a condition is generally accepted and whether a biomedical definition is applied. Next I detail a series of stages in the social construction of a condition. In that process, my primary concern is the initial social discovery, which is essentially a matter of diagnosis, with a secondary emphasis on illness experience. This is followed by stages of treatment and outcome, which recursively affect social construction. I conclude by noting the health policy implications of the social constructionist perspective.

Does Employment Affect Health

Abstract: Employment correlates positively with health, but is employment cause or consequence? The social causation hypothesis says that employment improves the health of men and women. The selection hypothesis says that healthy people get and keep jobs more than unhealthy people do. We test both hypotheses using longitudinal data from a national probability sample (N = 2,436 interviewed in both years). In the equations representing social causation, full-time employment predicts slower declines in perceived health and in physical functioning for both men and women. Full-time employment has the same effect for both sexes. Among women, it also has the same effect for White and non-White, and for married and nonmarried. In the equations representing social selection, physical functioning increases the odds of getting or keeping a full-time job for both sexes. Perceived health increases the odds for women but not for men. In regard to homemaking among women, homemaking predicts significantly greater declines in health, but health has no effect on the odds of becoming or staying a homemaker.

Gender, multiple roles, role meaning, and mental health.

Abstract: This paper examines gender differences in the consequences of combining spouse, parent, and worker roles for mental health. I suggest that work and family roles have different meanings for males and females, and that differences in the meaning of these roles may be partially responsible for why the mental health advantages of holding multiple roles are fewer for women than for men. Based on qualitative analyses of follow-up, in-depth interviews with 40 employed married parents who participated in a community panel study of mental health, I find that sex differences in the perceived relationship between work and family roles may help account for sex differences in distress by contributing to male-female differences in both the extent and nature of work-parent conflicts, attributions of responsibility for marital problems, feelings of guilt, and self-evaluations as parents and spouses. By identifying gender differences in the meaning of roles among individuals who have the same multiple role configuration, and suggesting how these differences can help explain sex differences in well-being; this research may expand existing theories about the mental health consequences of multiple role involvements.

A reconsideration of parental and peer influences on adolescent deviance.

Abstract: The role of peers in fostering deviant behavior in adolescence is well-documented in the sociological literature, while support for parental influence or "control" theories of deviance is more equivocal. This paper examines the relative influences of parents and peers on adolescent delinquency and marijuana use, using data from a three-wave panel study of youths who were paired with a best friend (N = 435). Covariance structure models based upon polychoric correlations among study variables reveal that friends are indeed the primary source of influence on youths' behavior, but that estimates of influence are grossly overstated in analyses relying upon respondents' perceptions of their friends' behavior. Parental supervision and attachment are weakly related to subsequent delinquency and marijuana use, lending little support to control theories of deviance. Findings reveal that different processes account for the similarities among members of delinquent and drug-using peer groups. Although youths are socialized into delinquent behavior by peers, both selection and socialization influences play important roles in the formation of drug-using peer groups.

Economic context and the health effects of unemployment.

Abstract: Most studies of the health consequences of unemployment ignore the economic context within which job loss occurs. Using data from a subset (N = 1,252) of a national probability sample, this paper compares the effects of current and previous unemployment on depression and subjective physical health status across levels of educational attainment and local job availability. Results show that current unemployment effects among the previously unemployed are strongest in low unemployment areas, particularly among individuals with a college-level education. These findings are interpreted in terms of the two categories of unemployment-related stress most frequently identified in the literature: financial strain, which is thought to be more salient for people in lower socioeconomic statuses, and damage to sense of self, which may primarily characterize higher status victims of job loss.

Professional dynamics and the changing nature of medical work.

Abstract: The organization and delivery of health care in the United States is undergoing significant social, organizational, economic, political, and cultural changes with important implications for the future of medicine as a profession. This essay will draw upon some of these changes and briefly review major sociological writings on the nature of medicine's professional status to examine the nature of professional dynamics in a changing environment. To this end, we focus on the nature of medical work and how this work impacts on and is impacted by medicine's own internal differentiation and the presence of contested domains at medicine's periphery. We trace this dynamic through a number of issues including the multidimensional nature of medical work, the role of elites in that work, and how changes in the terms and conditions of work can exert changes at medicine's technical core. We close with some thoughts on the relationship of public policy to medicine's professional status, the role health policy might take in shaping a new professional status, the role health policy might take in shaping a new professional ethnic for medicine, and the role sociologists might play in this process.

Caregiving and women's well-being: a life course approach.

Abstract: This study demonstrates the utility of incorporating a life course, role context approach in investigations of the ties between particular roles and psychological well-being, using the links between women's caregiving and well-being as a case in point. We draw on panel data from a random sample of 293 women interviewed in 1956 and 1986, considering both current role occupancy and the duration of caregiving as well as a number of factors that may moderate the effects of caregiving on well-being. We find, using ordinary least squares regression, that the effects of caregiving on women's emotional health are moderated by their previous psychological well-being, with caregivers with high prior well-being reporting high subsequent well-being. Other moderators are previous social integration (in the form of religiosity and multiple-role involvements) and other nonfamily roles (worker and volunteer) currently occupied. What women bring to caregiving (in terms of their previous social integration and psychological well-being) shapes its significance for their emotional health. Moreover, the duration and timing of caregiving in women's lives also relate to its effects on their well-being. These findings point to the importance of examining the impacts of particular social roles, such as caregiving, in the context of other roles and resources.

Work and well-being: gender differences in the psychological consequences of employment

Abstract: Differential exposure and vulnerability to social roles and role characteristics have been suggested as accounts for gender differences in well-being. This paper proposes a refinement of these models that incorporates the indirect effect of roles through intervening social and psychological resources. These reformulated models provide the framework for an analysis of gender differences in the psychological consequences of work that estimates the direct and indirect effects of two job conditions, control and complexity, on two dimensions of well-being. Results reveal patterns of differential exposure, but also suggest some gender differences in the intervening variables through which work conditions influence well-being. These differences occur primarily in the proximate effects of self-esteem and social integration on distress and happiness.

The social context of mental illness and violence.

Abstract: For years a debate existed in the literature concerning whether or not mentally ill persons were more dangerous than others. Empirical work was hampered by conceptual and methodological shortcomings, and was therefore unable to settle the debate. Recently, methodologically sophisticated studies have produced evidence which indicates a modest association between active major mental disorders and violence. While some interpret this association to mean that mental illness or particular symptoms directly cause unwarranted physical aggression, this paper examines the case for the social context establishing socializing and environmental conditions which are causal in both violence and the development of mental disorder. It reviews the literature, indicating lacunae in our knowledge base, and posits a causal model which links social stratification with both mental illness and violence through the structured types of strains, events, situations and persons an individual experiences as an integral part of life.

Identity-relevant events and psychological symptoms: a cautionary tale

Abstract: I examine the psychological impact of negative and positive events in roles that individuals view as salient or important for self-conception. Events in highly salient role-identity domains (identity-threatening and identity-enhancing events) should have greater effects on symptoms than those in less salient domains. Data come from interviews with a stratified two-wave panel sample of 532 married and divorced urban adults. Contrary to expectations, the influences of events on changes in psychological distress and alcohol/drug use were not dependent on the importance of the role-identity to the individual. Exploratory qualitative analyses suggested several reasons why. I reformulate the identity-relevant stress hypothesis in light of these observations, and argue that contextual details about events are required to test the revised hypothesis adequately. The complex influences of stressors on perceptions of identity salience need further examination as well.

Organization, management, and client effects on staff burnout.

Abstract: Employee burnout is perceived to be a serious problem in human service organizations serving persons with severe mental illness. There has been considerable investigation of burnout and many of its possible causes, but little investigation of the role of client severity in relationship to burnout. Furthermore, theoretical models linking environmental context, organization structure, and management processes to burnout have seldom been proposed or examined. Building on our previous work, we employ a theoretical framework that conceptualizes environmental context, organization structure, management processes, client severity and staff characteristics as influencing work satisfaction and burnout. We examine this in a survey of 311 staff in 42 community mental health service organizations. Controlling for individual staff characteristics, results suggest that organization structure, culture, and management process are important to work environment and in turn to satisfaction and subsequently to burnout. Contrary to the literature, client severity was not associated with burnout nor to work dissatisfaction.

Work alienation and problem alcohol behavior

Abstract: Using a sample of production workers from union, nonunion, producer cooperative, and employee stock ownership plan (ESOP) wood products mills in the Northwest, we test the general proposition that work alienation, defined as low job autonomy, low use of capacities, and lack of participation in decision-making in the workplace, is associated with heavy drinking and negative consequences from drinking. We find that the general proposition is supported, but that the pathways tend to be indirect rather than direct, mediated by feelings of job satisfaction and respondents' beliefs about the utility of drinking as a means of coping.

Ethnic differences in caregiving duties and burdens among parents and siblings of persons with severe mental illnesses.

Abstract: The policy of community care for the seriously mentally ill increases the caregiving duties and resulting burden on families with members who have a mental illness. Ethnicity is one factor that might have an important impact on the caregiving duties family members perform and the burden that results from these duties. This study uses interviews with 78 parents and 70 siblings of patients scheduled for imminent release from a state mental hospital. The findings indicate that Black and White parents have equivalent caregiving duties, but White parents report substantially more caregiver burden. Black siblings report more caregiving duties than White siblings but report less caregiver burden. These ethnic differences remain after controls for income, gender, age, diagnosis, perceived stigma, and coresidence. The results indicate that ethnicity can be a critical factor affecting levels of informal caretaking for persons with serious mental illnesses.

Two views of risky sexual practices among northern Thai males: the Health Belief Model and the Theory of Reasoned Action.

Abstract: We apply the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) to an analysis of unsafe sexual practices (inconsistent condom use with commercial sex workers) among men living in a high HIV-prevalence area. The empirical analysis is based primarily on a survey of sexual practices that was conducted by the authors during the fall of 1991. The survey sample includes university undergraduates, soldiers, clerks, and laborers living in Chiang Mai, Thailand. There is much overlap between the two theories, and both provide useful frameworks for examining condom use in this population. However, the Bayes Information Criterion (BIC) approach provides very strong evidence that TRA is the more plausible model, given the data. The success of TRA appears to be due to its more adequate incorporation of peer group effects. Other covariates positively associated with consistent condom use in the multivariate models include knowledge about the consequences of HIV infection, knowledge about the benefits of condom use for preventing infection, and positive attitudes about condoms.

Work and family roles and psychological well-being in urban China.

Abstract: A theoretical framework that delineates the relationships between work and family roles and psychological well-being is derived from U.S. research and utilized to examine the relationships of work and family stress with psychological well-being in urban China. Data from a sample of 733 married and employed individuals in urban Shanghai confirm the general model of the link between work and family stress and psychological distress. Due to the centrality of work roles for the Chinese, work stress exerts a stronger relationship on psychological well-being than does family stress. Furthermore, the Chinese are more vulnerable to stress arising from interpersonal conflicts than from role demands. In addition, gender differences are found in the relationship between role stress and distress. Women tend to experience more family demands than men. Women's mental health status is tied similarly to stress arising from work and family roles, whereas men are more vulnerable to work stress than family stress. However, Chinese women do not report significantly greater generalized distress than men.

Family cohesion as a buffer against the effects of problem-drinking fathers on psychological distress, deviant behavior, and heavy drinking in adolescents

Abstract: In this paper we examine the degree to which family cohesion buffers the effects of fathers' problem drinking at Time 1 (T1) on adolescent distress, deviance, and heavy drinking at Time 2 (T2), one year later. Data from a representative sample of 658 families were used to test the hypotheses. Mothers, fathers (if present), and adolescent children were interviewed in the home. Fathers who were present completed self-report scales measuring problem drinking. When fathers were not available, mothers' reports on fathers' drinking were used to measure fathers' problem drinking. Results from regression analysis indicate that after controlling for the effects of race, SES, age, gender, and family structure: (1) the more cohesion in the family and the fever stressful events, the less distress, deviance, and heavy drinking shown by adolescents; (2) the fathers' problem drinking affects adolescent distress and deviance when cohesion is low; but as cohesion increases, the effects of the fathers' drinking are reduced. The findings support the hypothesis that cohesion in families buffers the effects of fathers' problem drinking on adolescents. Language: en

Health, illness, and healing in an uncertain era: challenges from and for medical sociology

Abstract: The current situation in health care organizations, among providers and for people, dramatically challenges the "business as usual" roles of medicine, government, insurance companies, the community, and the university. Health care reform marks the first attempt in a century to consider a reconstruction of the social contract between society and medicine. While sociology stands as one of the earliest social sciences to systematically study the health care arena and create a health-focused subfield, there is a perception, not without support, of a desertion of identity from within, an encroachment by other areas from without, and abandonment by the parent discipline. We argue that these situations in medical arenas and in research fields require serious rethinking. The key lies in understanding how these phenomena are related to each other and to larger social forces, and how they offer opportunities, rather than signal limitations, to medical sociologists. We turn to the theoretical tools of sociology to help unravel the complicated challenges that face both policymakers and researchers. After framing these issues in a sociology of knowledge perspective, we use the case of "utilization theory" to illustrate the connections between society and systems of care (as well as studies of them) and to create a future agenda. We end by raising three basic questions: (1) Why is a sociological perspective critical to the understanding of change and reform in health care? (2) Why is medical sociology critical to the survival of the general sociological enterprise? and (3) Why is general sociology critical to the research agenda in medical sociology?

The psychological consequences of multiple roles: the nonnormative case.

Abstract: Occupying multiple roles has been shown to be a major predictor of psychological well-being. We investigated the effects of multiple roles in the nonnormative case: a sample of aging mothers of adult children with mental retardation. These women have been in the role of caregiver for up to five decades, in addition to occupying the range of roles normatively held in adulthood and old age. We found, using longitudinal analyses, that holding multiple roles in significantly and negatively related to depression in this sample, as in the general population. The effect of multiple roles remains significant even after the previous level of depression is controlled. These results support the role accumulation hypothesis predicting positive consequences of multiple roles on psychological well-being, even in this sample of older women who have had lifelong caregiving responsibilities.

Body weight and self-ratings of health.

Abstract: Does body weight affect self ratings of health? If yes, are health ratings affected by being overweight, underweight, or both? These questions are examined in this research note with data from a national sample of adults surveyed in 1986 (N = 3, 497). Obesity is associated with lower ratings of health among persons with similar levels of morbidity and functional limitation; being underweight does not independently influence health ratings. The effect of being overweight is similar for Black and White adults as well as for men and women. Finally, health ratings for older people were more positive than anticipated regardless of body weight.

Through the lenses of organizational sociology: the role of organizational theory and research in conceptualizing and examining our health care system.

Abstract: This paper reviews various theoretical perspectives on organizational change which have been and could be applied to medical organizations. These perspectives are discussed as both filters influencing our observations (research) and mirrors of the shifting dynamics of delivery system reform (policy). We conclude with an examination of how such theories can provide useful insights into our rapidly changing health care system.

Welfare and psychological distress : a longitudinal study of African American urban mothers

Abstract: This paper examines the psychological impact of receiving welfare. The prospective longitudinal data are from a cohort of African American mothers (N = 833). Four explanations structured the analyses: social selection; chronic burdens; a failure hypothesis; and earlier life conditions of welfare recipients. Psychological distress was assessed by women's reports of depressed and anxious moods. Women were categorized into one of four welfare conditions by receipt of welfare when their children were first-graders and 10 years later. Concurrent and longitudinal relationships existed between the women's welfare status and reports of psychological distress. Welfare recipients had more chronic burdens--including perceived ill health--which helped to explain these relationships. Measures of failure did not "explain'' the greater psychological distress. Women who grew up receiving welfare were more likely to report psychological distress and lower self-esteem later in life. The women's education influenced welfare and physical and psychological well-being.

Women's health research: public policy and sociology.

Abstract: In the space of just a few years, the amount and nature of scientific research on women's health has emerged as a major policy issue being addressed at the highest levels of the federal government and in the mainstream media. This debate has engaged members of Congress, the National Institutes of Health, and other federal agencies, and medical, scientific, health, and women's organizations. Sociologists have made significant contributions to both the process by which the women's health research issue has ascended to public awareness and the content of its agenda. Many of these contributions go unrecognized and other potential contributions by medical sociologists remain unrealized. In order to advance both science and practice in women's health--by ensuring the inclusion of the sociological perspective--we encourage sociologists to participate more directly in the policy debates.

Epilepsy and children's social and psychological adjustment.

Abstract: This research investigates the effects of epilepsy on the social and psychological adjustment of the children studied in the National Health Interview Survey of 1988. Analyses examine the effect of epilepsy on four measures of adjustment - home behavior problems, school behavior problems, depressed mood, and impulsiveness. For each outcome, we address five questions : (1) Do children with currently active epilepsy have poorer adjustment than children with inactive epilepsy ? (2) Do children with epilepsy fare worse than other children ? (3) Do demographic background and family structure moderate the apparent effects of epilepsy ? (4) Do family processes mediate the apparent effects of epilepsy ? and (5) Do cooccurring conditions produce the apparent effects of epilepsy ? Generally, we find that : (1) Children with active and inactive epilepsy fare about equally ; (2) Children with any history of epilepsy fare worse than children without epilepsy ; (3) Demographic and family background moderate only a small part of epilepsy's effect ; and (4) A combination of family processes and cooccurring conditions appears to produce epilepsy's apparent effects.

Medical Sociology and the Study of Severe Mental Illness: Reflections on Past Accomplishments and Directions for Future Research*

Abstract: Over the past 40 years, the mental health care system has been radically transformed from one focused on institutionalized care to one centered on treatment in community settings. While medical sociology has played a prominent role in the study of psychiatric hospitalization and the deinstitutionalization process, the systematic exploration of the sociological dimensions of community-based mental health care is only just beginning. This essay reflects on past disciplinary contributions and explores some important empirical and theoretical directions in the field of mental illness research that could benefit from more extensive sociological analysis. The central argument is that the shift to a community-based mental health system has increased the need for the sociological perspective and that medical sociologists, in particular, have the theoretical and analytical perspective essential for developing a more complete understanding of the current conditions impacting the lives of people with severe mental disorders. Drawing on recent work in medical sociology, we illustrate some important topical areas at the center of controversies over treatment, social change, and public policy regarding severe mental illness. We conclude with a discussion of the barriers to this type of sociological research and suggestions for ways medical sociologists might contribute to the study of severe mental disorders in the future.

Playing by the rules and losing: health insurance and the working poor.

Abstract: Using a sample of 7,734 employed adults from the National Medical Expenditure Survey, this research compares the sources of health insurance coverage and the antecedents of employer-sponsored insurance among the working poor to those at higher income thresholds. Concern with the working poor is warranted because they constitute the majority of the uninsured, they do not qualify for public health programs, and their health insurance benefits have eroded substantially. The data reveal that (1) the working poor are only one-third as likely to receive insurance from their employer as are the non-poor, and are over five times as likely to be without insurance from any source ; (2) employment characteristics are critical antecedents of employer-sponsored insurance and, as a set, explain variation in coverage beyond that provided by human capital/socioeconomic factors ; and (3) most employment characteristics have a similar effect on the odds of coverage across income categories, except for unionization and minimum wages. Implications for health care reform are addressed.