Medical Sociology and Health Policy

Author(s): Aditya Bharadwaj, Paul Atkinson and Angus Clarke

Predicting susceptibility to haemochromatosis is a recent example of DNA-based population screening technologies. Haemochromatosis or genetic haemochromatosis (GH) is a common genetic disorder causing the body to absorb an excessive amount of iron from the diet. Excessive quantities of iron can cause liver damage and serious tissue damage in other organs and body parts. Haemochromatosis was first described in 1865 by Trousseau and von Recklinghausen first used its present day name in 1889. Haemochromatosis, a common disorder in populations of Northern European descent and considered relatively easy to treat by regular 'old fashioned bleeding,' remains a difficult condition to diagnose. The paper argues that though bleeding was practised a medical cure for 2500 years and up until the introduction of germ theory 130 years ago, its integration with molecular medicine is a recent example of innovative health technologies remaining relatively powerless to introduce 'new' treatment interventions. The paper draws on interviews with clinicians and affected individuals drawn from a larger research based in a South Wales teaching hospital to show the low predictive value of population screening for genetic susceptibility to haemochromatosis that remains overtly reliant on an ancient practice of phlebotomy to 'fix' iron overload.

Author(s): Anémone Kober-Smith and Isabelle Feroni

Workforce shortages and high turnover constitute a recurring and presently acute problem for nurse managers in French and British state hospitals. These phenomena have often been attributed to the difficulties of combining a nursing career with family commitments for younger nurses and of carrying on nursing for older ones. Comparing two European countries enables us to go beyond traditional gender analyses of nursing work and to highlight the impact of changes in the female labour market and of global public sector employment policies on nurse retention. Even though there are some differences between the two countries (i.e. turnover is lower in France and the proportion of older nurses is higher), a comparison of recent national statistics reveals similar trends, namely an ageing workforce as well as a diminishing pool of young people entering nursing. A comparison of national employment policies shows that these similarities are linked to healthcare cost management policies (i.e. setting up, or even reducing, training quotas in the 90s) and to the structure of the nursing profession itself (limited career prospects, lack of consideration for the needs of older nurses etc.). The analysis also highlights the importance of specific employment and social policy factors, particularly the lack of adequate childcare facilities in Britain and the difficulties linked to the setting-up of the 35 hour week in France.

Author(s): Bjørg Helene Krogh Andersen

This paper emerges from a study of doctor-nurse-patient communications in three hospital settings. The study focuses on information and communication in terms of power. It is well known from decision theory that non-decisions can be as important markers of power as actual decisions. Yet many theories of power, like Weber's or Braathen's model monopoly theory, state that power emerges with and is only visible through action. Could we draw a parallel from decision theory to theory of action, and claim that non-actions can be as revealing indicators for power in general as executed actions? Non-actions are not as easily visible, nor are they easily interpreted, thus indicating a practical- methodological problem. A comparison between organisations (here three hospitals) may help reduce the visibility problem. But the interpretation problem remains: A commonly used example about nurses claims they have the knowledge to pass information about diagnoses on to the physician, but at the same time must suppress their knowledge towards the patients. Is the non-action of not (overtly) diagnosing a sign of latent power? Or does it indicate lack of power? I will discuss this issue, both as an analysis problem and as empirical finding, using examples from my own observations for illustration.

Author(s): Catherine Déchamp-Le Roux

Patient education is becoming increasingly important in the care of chronically person, are now a social issue. This study looks at the impact of patient awareness on a new, knowledge-based balance of power between carers and the cared for. Several factors, including this proto-professionalism of patients, ill patients. Patients' rights, based on the sharing of information with the ill have contributed to the current stand with regard to patient expertise. It examines the hypothesis that the collective mobilisation of the rapidly growing number of extremely active voluntary organisations created to promote and protect patients' rights has contributed to the recognition of patient expertise.

Methodology A qualitative analysis was carried out on the content of the goals formulated by all the voluntary health organisations listed in France (1,200 in 1998). Voluntary organisation directors were then interviewed to establish their strategy with regard to patient information and to see how a new hybrid store of both medical and profane knowledge was being built up.

Results and conclusion The analysis of the data demonstrates that voluntary organisations are part of a movement to appropriate health by patients that has been on-going for over a decade. In certain cases, they contribute towards the development of a specific skill based on a global approach to the illness. They play a role in the dissemination of scientific and medical knowledge and, in some cases, build an expertise with regard to the experience of the disease that can be transmitted directly to both patients and carers.

Author(s): Clementina Rodríguez-Legido

La medida de la satisfacción de la población con la atención sanitaria es uno de los aspectos que despierta mayor interés entre investigadores y responsables de la política sanitaria. A pesar de la complejidad del término satisfacción y de los problemas de definición teórica, su relación con la calidad parece indiscutible. El método de "escalas" se ha mostrado como una herramienta potente para la medida de la satisfacción. En este trabajo se analizan los determinantes de la satisfacción con la atención sanitaria; este análisis se basa en los resultados obtenidos en dos estudios realizados en Andalucía, con un intervalo de ocho años y utilizando la misma herramienta. Las dimensiones utilizadas para la medida de la satisfacción están formadas por tres escalas: Cualidades Personales del Profesional, Competencia Profesional y Relación Coste/Comodidad. Los resultados obtenidos muestran que, en ambos estudios, la población está menos satisfecha con el área de Coste/Comodidad, es decir, con aspectos relacionados con la accesibilidad, disponibilidad y comodidad de la atención; algo más satisfecha con la dimensión de Cualidades Personales (situaciones que configuran la relación profesional-paciente); el área mejor valorada es la Competencia Profesional (percepciones de la población sobre los conocimientos profesionales y su aplicación). La satisfacción está fuertemente asociada con algunas variables sociodemográficas. Un análisis factorial (correspondencias múltiples) demostró que las mayores contribuciones a la satisfacción corresponden a la edad, el nivel de estudios, la clase social y la percepción de impuestos pagados en relación con los servicios sanitarios

Author(s): Corinne Delmas

In the continuity of reflexions on the conditions under which the handicap became the object of a public policy in the Seventies and on the construction of a policy of the handicap - as well as that of the old people -, we will be interested in the current consensus on the need for reforming the latter (and on the absence of consensus on the objectives to reach and the means to be applied), by analyzing the urgence of this debate, political, legal and civil embarrassment caused by the Perruche affair, clinical reality as well as the social reality of medicine which is not able to make its standards accepted, its operation nor its manner of seeing things, which requires us to go back to the base of this "total social fact" which medicine has become, which Michel Foucault calls the bio-capacity. We have to also study the place of handicapped people in society and professional space. We will study the stakes of this debate and expertise produced, in particular that produced by the Senate's Commission of the Social Affairs (the participation of its members, its work, the final report of Paul Blanc and its reception).

Author(s): Chris McLean and Andreas Hild

The oscillation between action as determined and action as determining has been a major feature of social theory and one which theorists have tried to overcome within their work. For example, rather than reducing action merely to an individual agent or member of the collective, or to the effect of the structure or system, action is viewed the performance of a specific collective (Gomart & Hennion, 1999). This is illustrated by the work of Suchman (1987) in which she describes the way in which situated action must be understood in terms of collective action. Thus, rather than viewing 'interests' and 'norms' as stable, these must be examined with regard to the local situations in which the continual process of constitution and accomplishment takes place. This focus on situated action clearly links to the ways in which boundaries and tensions relating to competing notions of practice are constituted and negotiated. For instance, Garfinkel provides an interesting illustration within his analysis of clinical practice, in terms of the tensions between the situated or everyday practices of clinicians, and practices of accounting and management, such as form-filling. This paper seeks to examine a range of problems and issues relating to the production of accounts and the constitution of boundaries by focusing on the relationship between practices, actions, subject/object positions and relations. For instance, writers such as Callon and Latour have suggested that within an ethnomethodological approach insufficient emphasis is placed on the presence of objects, as ethnomethodologists are still concerned with the interaction of subject and object, human and non-human, agent and structure (Gomart & Hennion, 1999:245). Moreover, Gomart & Hennion suggest rather than undoing the model of human action, the situated-action approach is viewed as merely allowing the cognitive capacities of humans to migrate to objects. In particular, they suggest that the focus should be upon the process of mediation and the way in which object-mediators (which are rendered as prolongations of actions already initiated elsewhere) do not merely relay and repeat actions, but also transform them in different and sometimes surprising ways. Thus, events are not limited to origins, determinants or effects… "as mediation is a turn towards what emerges, what is shaped and composed, what cannot be reduced to an interaction of causal objects and intentional persons. The network is not a black pool in which to drop, dilute, criticise, and lose the subject. It is on the contrary an opening - pried lose with a partly rhetorical liberation of things and an attentiveness to spaces, dispositions, and events - which releases us from the insoluble opposition between natural determination and human will. 'Mediation' allows the course of the world to return to the centre of analysis" (Gomart & Hennion, 1999:226). In other words, each element of the network 'relays' and 'prolongs' the action of the collective without being the source itself. Thus the capacity to be strategic should be described as the effect of an association of a heterogeneous network and not merely assigned to a human actor (Callon and Latour, 1997). In contrast, others critique this focus on processes (Button 1993) and suggest that such an approach fails to fully examine the various techniques and embedded working practices with respect to the way they emerge concurrently in relation to other elements within the network. Furthermore, this approach is criticised with regard to problems of inclusion and exclusion, the cutting of the network, and finally, the issue of how do you speak on behalf of others within these complex networks of relations and how do we understand the issue of power and politics in terms of the constitution of boundaries. In particular, this paper seeks to examine this final issue in relation to the process by which certain boundaries are presupposed and constituted with a focus upon the role of specific information practices underlying the organization and management of mental health care. For example, this will include reviewing the role of the CPA and needs assessment with regard to relations between different disciplinary groups (e.g. social workers and clinicians), and patients and clinicians. More specifically we will examine the process by which these approaches attempt to overcome a range of problems relating to disciplinary boundaries underlying mental health care and the role they play in reconstituting these boundaries, relations and practices in complex and uncertain ways. The empirical research which forms the basis for this study was performed in a local NHS hospital trust. An ethnographic style of research was conducted which involved working within the mental health department on a number of projects including the development and application of the CPA and the needs assessment process. This case study thus provides some interesting and insightful illustrations of the changing relations between various groups and individuals involved in the process of mental health care and in particular a range of issues relating to the production of credible/legitimate accounts and the constitution of boundaries. One specific aspect we wish to examine in relation to this process concerns the hierarchies of distribution and the ordering of accounts. For instance, while we may talk about the role of heterogeneous engineers in the process of network building and translation (Law 1997), heterogeneity is quite different for those who are privileged and those who are not (Star 1991). Thus, the ways in which distributions of power and a multiplicity of completing truths are recursively woven into the complex set of relations that underlie particular circulations of actors (Law 1997), is an area which requires further and more detailed examination. Rather than examining accounts as providing the 'truth' or merely telling a 'story', it is vital to examine the way in which some distributions and truths take precedence and become stable features of the setting compared to others, the different forms resistance that may emerge (see Fujimura 1991; Star 1991), and the ways in which certain object/subject positions and boundaries are presupposed and constituted. In particular, this paper will examine these questions in relation to the role of information practices in framing representations of the past and the sequencing of events in the present, especially when one group's visibility comes at the expense of another's suffering, or where what might be considered as the categories of the powerful become partially embedded within certain practices and artifacts and taken for granted as given (Bowker and Star, 1999:320). For instance, Law (1997) states that a celebration of diversity is an empty gesture without the presence of a politics that establishes the conditions for its exercise. While he may suggest that we should seek to distinguish what is right from what is wrong at a local level, how do we actually achieve this in practice? For instance, while boundaries, orderings and classifications are required in order to access the 'past', 'present' and 'future', it is important that the development and stabilization of standards and classifications are not taken as universal or given. In other words, there needs to be room to examine this process in more detail without relying on a priori notions of time, representation (see Lynch and Woolgar, 1990), and universality. One way to start thinking around this issue involves examining the way in which we live in a world of complex and partially connected orderings (Haraway 1991b; Strathern 1991) that may support, undermine and generally interfere with each other in different and uncertain ways and based on alternative notions of spacing and timing (Law 1997). Thus, it is not possible to grasp an ordering as if one singular or transparent time or flat space exists, as our world is one of multiplicities of interconnectedness and in order to recognize this within our accounts we need new ways of 'knowing' and 'speaking about' these distributions without flatterning difference into pluralism. Additionally, clearly no piece of social research can ever be amoral or apolitical. However, the way in which we either explicitly or implicitly deal with such issues is crucial, and needs to be considered further if we are to understand the implications surrounding notions of politics, ethics, distributions, and the making of judgements in our accounts (Hull, 1999). Thus, with the aid of illustrations from an ethnographic study performed within a mental health department, this paper will explore these issues in further depth. In particular, this will involve focusing on the practices of needs assessment, and the role of a specific form-filling process in constituting subject and object positions (in terms of both patients and mental health workers), the ways in which competing truths undermine, support and within complex networks of relations, and the problems relating to the production of accounts which neither rely on claims of objectivity or independence, but remain as a credible in terms of the accounting process.

Author(s): D. Secondulfo

The paper shows data from a survey held in Parma (Italy) asking to a sample of people which kind of doctors or healing therapist they had contacted during the past year. The survey dates from 1996. Results shows that a 27% of consumers contacted also a non-medical therapist, most of them omeopathy, sciatzu, and few others, with specific motivations. One of the main differences between medical and non-medical was the amount of time spent with the patient. Another interesting result of the survey was the individuation of a pattern of image of health leading consumers in the choice of the preferred kind of medecine, images built by a Likert-type scale and several factorial analysis. An ideal-tipus of the "alternative" patients were also built. Always using the informations of consumers, were also estimated the penetration of complemetary med among general pract (in italian "basic doctors") of the health service. The use on complem med among these doctors followed different patterns and, as a whole, were estimated in a 18 %. Of course the survey is much richer, but these are the core informations. Data about doctors of the health service have been updated to 2001 by a survey made by the medical professional association of Parma, the % of doctors (overall the profession) directly using compl med were about 8%, but inside the gen pract group the % were 12,7. A brief outline of the main characters of these doctors were also produced. ok, these are the informations that I think will be interesting among the many we had from the survey, the research of the medical association is very thin but doctors and not consumers were contacted. Many prof ass tried to make a research about compl med and doctors in the past 3 years, but the one of Parma is the only we can trust.

Author(s): Dani Filc

The Israeli health care system - as several health care systems along the world - has undergone a process of crisis and change during the last two decades. This process has involved contradictory trends, namely, the privatization and commodification of certain aspects of health care and the legislation of a health insurance law which guarantees health care on a universal basis. While the Israeli welfare regime as a whole went through a process of commodification along neo-liberal lines, the transformations within the health care system have been ambiguous. Due to the specificities of the Israeli society, in the health care system coexisted trends of commodification and decommodification. The present paper is an attempt to explain this contradictory process in the context of a wider transformation of the hegemonic socio-economic model, i.e., the passage from a Keynesian/Fordist to a neo-liberal/post-Fordist model. The articulation between the health care system crisis, the centrality of health care in contemporary societies, political interests, and a popular "common sense" which opposed the further commodification of health care, may explain the contradictory trends. It is the paper's contention that this contradictory result of the neo-liberal attack on the health care system responds to the fact that the hegemonic struggle is a relatively open-ended process in which politics still plays a role.

Author(s): Daniel La Parra and Miguel Ángel Mateo Pérez

Objectives- To explore the sources of inequality in health that affect individuals with Chronic Respiratory Disease and their families. Methodology - Qualitative, in-depth interviews. Setting - Rural and urban areas of Barcelona, Valencia and Alicante (Spain). Participants- 14 relatives of people with Chronic Respiratory Disease, and 95 respondents to a semi-structured mail questionnaire with open ended questions. These respondents were selected from an association for sufferers, and from services specialised in pulmonary disease in hospitals. Main outcome measures - Participant's reports about their quality of life. Results - The quality of life of patients and their relatives is dependent upon the relation between the socioeconomic situation of household members, and the patient's situation. The relationship between the household structure and the current stance of healthcare and social policies is a key element in explaining the kind of inequalities suffered by patients and their relatives. Households with a family member with Chronic Respiratory Disease may begin a process of social exclusion when there is a lack of adequate social support, or other entitlements. Conclusions - The explanatory model suggests that taking into account the household and community level is of crucial importance when planning solutions to improve the quality of life of those people with Chronic Respiratory Disease.

Author(s): Dorte Gannik

On the basis of both empirical studies and sociological theory, a situational concept of symptoms and disease was developed. This concept differs radically from a bio-medical concept. The situational concept of disease does not operate on essentialistic or etiological premises. Disease is viewed as an integrated social-physiological process which comprises the person's relation to the environment, and the way this relationship expresses itself in ongoing situations. Thus, though being of a physical nature, disease is also a relational phenomenon. Disease develops out of the omnipresence of symptoms and bodily feelings in everyday life. The disease process is reversible, corresponding to ongoing changes in the person-situation relation. Accordingly, disease is a unique phenomenon, and part of the individual's local situation, indicating that any generalisation from one person to another concerning etiology, treatment or prognosis should be made with great care. Situational disease and biomedical disease are both models, i.e. they are two different perspectives on the same real life phenomenon. The biomedical view has a concrete existence expressing itself as formally organized societal forms, e.g. hospitals, medical science, clinical routines. The view of disease as situational, on the other hand, is linked to folk everyday knowledge, experiences and actions. This paper presents empirical evidence intended to illustrate the situational nature of an array of disease processes and goes on to explore some possible implications of a situational disease model for the health care system.

Author(s): Ellen Kuhlmann

Improving the quality of care is next to cost containment the main regulatory incentive for restructuring processes in health care systems. Despite the nation-specific differences in the regulation of health care systems there are two main strategies to achieve this goal: bureaucratic procedures like guidelines and audits, and more formalised decision- making through evidence based medicine on the one hand, and organisational changes like integrated care models, teamwork and multidisciplinary qualifications, on the other hand. In this paper I will discuss the different challenges which these new regulatory strategies pose on professionalism, and explore new definitions of what counts as professional work. My analysis I based on an extensive literature review and explorative case studies in Germany. Currently, shifts in the definition of knowledge, competence and expertise can be observed, which enhance more flexible and diverse forms of professionalism, and further the introduction of new categories, e.g. gender. With regard to the impact on the power relations I will argue that bureaucratic procedures tend to strengthen the power of biomedical knowledge, whilst the new organizational forms are more open for negotiations on knowledge and professionalism. Hereby, they bear opportunities for reducing hierarchy in the field of health care.

Author(s): Eva Krizova

In the 90´s, the health care system transformation was implemented in the Czech Republic. New organisational rules, financial incentives, but also the overall democratisation have changed the motivation of physicians and influenced their professional identification and satisfaction. Further, the patients´ rights movement and the general context of a new emerging market economy and consumerist society have also affected their relationship to patients and vice versa. However, new obligations have not been compensated with new rewards and an increasing dissatisfaction and even frustration of certain physicians groups was observed. Even when physicians still enjoy high social prestige in the opinion polls, in fact, they feel undervalued (both financially and morally) when compared to other professions. In the core, the cultural incompatibility of the physicians´ life project and postmodern mentality may be suspected (Bauman). The paper discusses specific features of medical profession in a transition country, where paternalism based on expertise was fostered by civic helplessness against any form of power (Foucault). Changing societal expectations laid on medical role lead to many internal role conflicts that physicians have to cope with. Physicians respect the patients' rights on information and self-determination, however they lack cultural stereotypes how to meet them fully.

Author(s): Ferenc Moksony

Hungary is widely known among researchers for its high suicide rate. Behind this high overall level, however, are large variations across regions; variations, moreover, that are remarkably stable over time. Despite the profound socio- economic changes that took place in the country during the past fifty years or so, subsequent volumes of demographic yearbooks invariably tell much the same story: self-destruction peaks in the Southeast and it is least common in the West. Most researchers explain this fact by cultural differences, arguing that people in the Southeast learn, as they grow up, to regard self-destruction as a legitimate coping strategy, an acceptable way of responding to problems encountered in everyday life. I tested this explanation by looking at the longer-term impact of region of birth, controlling for current place of residence. Conducting a case-control study, I found that those born in the Southeast but moving to another region later in their life retained, as! predicted, their greater propensity to suicide. This effect persisted even after ruling out a number of alternative explanations such as differential selection and residential mobility.

Author(s): Gill Haddow

The presentation is based around findings from semi-structured interviews, carried out in Scotland over a two-year period, with nineteen donor and four non-donor relatives. Drawing heavily on the respondents' quotes, the focus is on the donor families' beliefs, attitudes and experiences of organ donation. An attempt is made to compare this with the non- donor family sample and draw out the similarities and differences therein. The presentation is in three parts: 1) obstacles to donation for donor families, 2) reasons why donation subsequently occurred and 3) reasons why donation did not occur (non-donor families). Results suggest that wider socio-cultural beliefs about gifting, death and the body are brought to the specific context of an organ donation. It is how such factors interact with the health professional communication, family dynamics and the deceased's specific beliefs about organ donation affect whether organ donation occurs or not"

Author(s): Gro Underland

Electronic patient records (EPR) have during the last years been implemented in Norwegian hospitals. The intention is that EPR will improve efficiency and productivity in patient treatment, increase safety, and be a tool for decision making. The EPR will, however also improve the accessibility of medical knowledge and information for the health personnel. It is therefore reasonable to put a question to how the EPR will take care of the safety of confidential information of the patients. Still both electronic- and paper based medical records are used at the various hospitals; the intention is, however that all paper- based records will be maculated. To hand all medical knowledge and information to EPR, implicates a broader discussion on the validity of the new technology that is concerned not only with specifications or functions. The EPR includes the interaction of the technical system and the work practice; the EPR has come to be and will still evolve. To take work practise into consideration when technology is assessed is important, especially when it is concerned about the users attitudes and future use. Accessibility of sensitive information must be considered along with the patients' safety and privacy.

Author(s): Gunnar Scott Reinbacher

The paper has two options, first to present the results of a research project, named TANDEM, Training Alternative Networking Skills for Diabetes Management, Patient-Centered Networks for Chronic Disease Management (gsr European project leader and coordinator), second, on base of the results to exhibit a new sociological model for chronic disease management in the 21 century to be disseminated in different European countries from 2003. The basic elements in the new model was the empirical findings from theoretical, methodological and empirical research done at four European universities and university hospitals on different groups of patients during 1999-2002. It was interesting, that it was the sociological framework for the research both theoretical and empirical which actually demonstrated the strength of the sociological framework in medicine. The new model to be presented in this paper demonstrates that a new treatment method in chronic disease management must be multidisciplinary, integrating medical, technological, social psychological and sociological treatment methods in a holistic context. The new model will be discussed, confronting the literature about compliance in treatment, self care and change management. The health economical evaluation model used in this project and paper demonstrates the results both in a quantitative and a qualitative triangulates method.

Author(s): Hanna Toiviainen, Lauri Vuorenkoski and Elina Hemmminki

The variety of technologies used in health care keeps growing, the patients' educational level has risen, health and drug information is increasingly available (e.g., the Internet), and today's patients are actively looking for information from different sources. The aim of the study was to investigate physicians' experiences and views concerning patients who present clear wishes for care and physicians' views on the advertising of prescription drugs to consumers (DTCA). The data was gathered as part of the annual physician survey sent to all Finnish physicians (n= 16 698) by the Finnish Medical Association in March 2002. The response rate was 85%. Of the physicians in patient care (n= 12 255), 42% reported having (very) often patients who request specific laboratory or other examinations; 30% had patients requesting specific surgical or other procedures; and 23% specific drugs. Over the past years, the proportion of physicians who reported an increase in such patients was 46% for laboratory or other examinations, 42% for surgical or other procedures, and 33% for specific drugs. One fifth of the physicians considered such requests positive for the doctor-patient relationship and 39% negative. The reasons for the physicians' opinions were many, and the same reason could be used as a ground for both a positive and a negative attitude. When asked whether the European Union should allow DTCA, 4% were for full DTCA including product names and health claims; 59% for partial DTCA with specific restrictions (mostly for drug information leaflets through patient organisations or health care agencies); 18% would not allow DTCA at all, and 19% gave no opinion. In all of the questions, answers were differentiated by sex, age, and main occupation. Consumer-patients are a reality in the Finnish health care system. Physicians have varying opinions of the active role of patients.

Author(s): Hans Neefs

In this paper, Belgian prevention policy regarding venereal disease during the interbellum period is analysed with respect to its structural and cultural context. After WWI, a public campaign against the 'venereal danger' was launched consisting of strategies of primary prevention (sex education) and secondary prevention (early diagnosis and treatment). This campaign was unparalleled in its national scope, its focus on the public at large and its explicit discussion of aspects of sexuality that were traditionally concealed in private, intimate life. It is questioned how this innovative preventive approach regarding sexual health became possible. In the aftermath of WWI, the spread of venereal disease in society was perceived as disastrous requiring governmental intervention. This however does not explain the content and the practical organisation of the national prevention campaign. It is hypothesised that venereal disease became to a certain extend medicalised (venereal disease as disease in stead of sin) due to pre-war medical innovations regarding the diagnosis and treatment of venereal diseases. These innovations were seized by the emerging medical speciality of venereology for gaining authority in the medical field as well as in the field of public health policy. In this paper it is questioned if this professionalisation hypothesis explains in a sufficient way the implementation and content of historical prevention strategies regarding the 'venereal danger' in Belgium. Historical-sociological research is carried out for the period 1900-1930 with respect to the claims made by venereologists regarding the prevention of venereal disease and their reception by the Belgian government.

Author(s): Hélène Bretin

An hormonal contraceptive implant has been on the market in France since May 2001. Contraceptive implants are well known for their effectiveness. They have been offered for a longer time in thirld world societies, US and some European countries. A controversy regarding the side effects of this contraception method on women's health and on discriminatory practices of prescription (especially when women of a deprived socio-economic background are concerned) has appeared. Our paper is part of an exploratory and qualitative study involving interviews of medical practitionners and women using contraceptive implants. Our research addresses two types of issues. First, what is at stake in and what are the social determinants of the supply and demand of contraceptive implant in France. The second aim of our research is to analyse the social representations of this technique and the way it is experienced. Our presentation is based on a preliminary analysis and will focus on the following points: - medical practices and the rationales underpinning them; - selection modes of potential users of this contraceptive method and prescription circumstances; - social representations of this technique both among women and practitionners. This research gives an opportunity, firstly to widen the knowledge of reproductive and sexual health, and secondly to assess the specificity of the French case with regard to the profile of the users and the behaviour of consultants.

Author(s): Helle Timm

In Denmark a legislation of Compassionate Leave Compensation (CLC) for people who stay at home with their very ill and dying relative or friend has existed since 1990. The CLC was evaluated in 1999; at that time the CLC had not been used by as many people as expected. In this paper the results of the evaluation are presented and the CLC is analyzed as a part of the social construct of death and dying in Denmark.Aim: To explore how people experience the options and determine the reasons to chose to take (or not to take) compassionate leave. Design and methods: The evaluation was designed as 1. a descriptive and explorative empirical study (what is the practice, which are the experiences by the people involved) and 2. a theoretical framework (a cultural sociological understanding of the space of action in relation to serious illness and death in late-modern Denmark). Results: Most of the ill persons have cancer. Most compassionate leavers are women, most are close relatives (spouses or daugthers), all social groups are represented but a relatively large proportion of the women are working in the health care sector. The reasons for choosing compassionate leave are many and complex (emotional, social, practical , economical). The empirical results are discussed in relation to the social construct of a discourse of "the good death". Furthermore it is discussed how CLC consolidates societal institutions like the family and the labour market.

Author(s): Ian Rees Jones, Lee Berney and Moira Kelly

Introduction: recent policy changes in Britain mean that general practitioners (GPs) are central players in the allocation of resources. These changes raise a number of questions, in particular what criteria do GPs use to prioritise and allocate? This paper reports findings from a two-year project funded by the UK Department of Health which examined patient involvement in decision-making. Methods: A total of 24 GPs and 18 patients were recruited to a qualitative study using a range of methods including in- depth interviews, focus groups and narrative vignettes. Findings: Local variations in the availability of resources had an impact on decision-making. GPs appeared to have an implicit understanding of the key ethical principles of triage, equity and explicitness. There were however, clear distinctions between their understandings of ethical principles and their interpretation in practice. GPs appeared to engage in implicit categorisation of patient encounters. The diversity and complexity of general practice appeared to legitimate this implicitness. Conclusions: If GPs are to take on new roles that accompany changed responsibilities, then there is a need for greater explicitness in the doctor and patient encounter.

Author(s): Ian Shaw and Kerry Kidd

The analysis of text and images for what they reveal about the ideals of a society, or sections of it, is a well-established tradition in studies of culture. This analysis of pharmaceutical advertising targeted at doctors, provides a window to explore the construction of madness and the value of treatment. Although there have been studies of the nature and impact of pharmaceutical advertising in mental health (Cf. Stimpson, 1975, 1977) these are now becoming dated and they also did not provide the detailed sociological analysis of the imagery utilised that is proposed in this paper. This paper is based upon a wide range of pharmaceutical adverts in mental health. The analysis focuses upon the: Image - the sorts of focus are used (doctor, patient, symptom or drug) and the perspectives. The object that the readers gaze is directed towards. Differentiation between the portrayal of the patients character, behaviour social identity and/ or illness. Any social stereotypes in play (e.g. ethnic minorities an schizophrenia, women and antidepressants etc) Verbal - the vocabulary of mental illness introduced and the terms in which the drugs effects are described. Where the `gaze' is primarily focused. Any disjunction between the message of the headline and the scientific information and code of visual imagery and the text. Also the paper will generally analyse the signals sent about mental illness (as alarming, dangerous, frightening etc) and the ways in which the patient is presented (dehumanised, bothersome, suffering in silence). The ways in which lifestyle and personality is presented as factors in mental health will also be considered. In addition the paper will show how the images compare with figures of patients in advertising for other conditions (for example HRT). The paper is also concerned about the ways in which the advertisements may impact upon doctors prescribing habits. To explore the ways in which the adverts play upon professional irritations, and stereotypical imagery. Also within the rhetoric of professionalism, to explore the self-interested impulses the advertisements are designed to appeal. In this respect the ways in which the drugs are presented as a means to either control symptoms, calm a bothersome patient or (rarely) provide a cure provide another strand of analysis. This analysis will be placed in the context of the rising concern over mental illness. It will also consider the contribution of the pharmaceutical industry in the construction and management of mental illness (for example: depression as we know it was unknown 40 years ago - now 1 in 4 people are reported to need medication for the condition (Shaw and Middleton, 2001).

Author(s): Ine Van Hoyweghen

The rise of DNA-technology to diagnose so-called genetic disorders has generated much public debate on the use of genetic information by private insurance companies. The arguments put forward in this debate are however rather speculative and abstract. As such, for example, insurance principles and technologies are considered as invariable facts, both by insurers and their opponents. This paper presents a PhD-project in which we suggest to consider insurance principles and risk selection as real, empirical processes instead of abstract entities. Ethnographic fieldwork in the medical underwriting departments of several Belgian insurance companies illustrates this approach. By analysing the frames underwriters use in medical risk assessment, we hope to contribute to the idea that insurance - even private insurance - is a negotiated domain, which is not governed by abstract statistical or economic laws, but is made by human beings. Provisional findings of our research will be described which highlight the existence of some leeway within the process of boundary making of insurability. As to predictive health information, normative frames concerning the disease's causes are framing risk probabilities and put their stamp on the medical risk assessment. It seems that underwriters insert a kind of fault/no fault logic into their business. Predictive health differences can be made social differences, or not. That way, risk selection is neither a technical procedure nor a neutral application of insurance principles - it is far more a social and normative business. From these observations, some reflections will be made on the consequences of these insights for deliberation, negotiation and a widening of the public agenda on genetics and insurance.

Author(s): Inna B. Nazarova

The database of research includes respondents who took part in each of five waves of the Russian Longitude Monitoring Survey (RLMS) in 1994, 1995, 1996, 1998, and 2000. The sample is: 1114 - men and 1371 - women. The logistic regression was used. The dependent variables are: self-rated physical and emotional health (five-step scale is transferred in binary variable) and binary variable of physical health: the health problems for last 30 days. The independent variables, as a rule, are results of panel research years. Rural respondents estimate the health highest and more rarely tell about health problems. Nonslavic respondents 2,5-3 times more often highly estimate the health, and on 45-31% have problems with health less likely. A poor and more than a year unemployed woman is not satisfied of life, but she improves a situation are using behavioral and social factors. Men from poor households remain unsatisfied as well, and unemployed men become even more unsatisfied in the same conditions, as women are. Education has the largest feedback only for women and is the consistent factor in physical health self-estimation and in case of health problems in 30 days before interview. Three years of smoking is bad factor for men health from last five ones. The research showed the effect from physical exercises and sports, shortage of sleeping, and belief in God. We have two different models: male and female in a trio "emotional health - economic situation - behavior": men endure economic problems with more difficulty, as they do not use (or use in a smaller measure) cultural and social factors effect.

Author(s): Isabelle Feroni, Alain Paraponaris and Anne-Déborah Bouhnik

In 1996, the French Health Ministry allowed General Practitioners (GP) to prescribe Buprenorphine as a maintenance treatment of heroin dependence. This decision permitted drug users to access to general primary care for their addiction problems. Opiate maintenance treatments were not allowed in France before, except for methadone in outpatient treatment clinics since 1995. The development of this new medical practice in physicians offices encountered some resistances because of GP's lack of experience in drug maintenance treatments and low confidence in drug users. In 2002, we realized a cross-sectional study among a GP's sample (n=700) in a South-Estearn French province. The first aim was to determine the GP's social-demographic and professional characteristics associated with buprenorphine prescription. The results showed that buprenorphine prescription was statistically significantly associated with gender (more male than female) and high activity level. Specific characteristics such as training in maintenance treatment and previous prescription (before 1997) were also related to prescription. The second aim of our study was to identify the different types of medical practice in opiate maintenance treatment. Our results significantly showed that GP's who had received training were less likely to interrupt treatment when they faced problematic patient behaviours (such as illegal drug use or buprenorphine injection) than untrained GP's. They more often choose therapeutic responses, such as increasing treatment doses, or networking with psychiatrists or pharmacists who delivered treatment, in order to improve patients follow-up. In conclusion trained GP's more often try to maintain 'deviant' patients inside medical treatment boundaries instead of excluding them.

Author(s): Ivy Lynn Bourgeault

One of the key intersections between medical sociology and health policy exists in the literature on health professions. Specifically, the health professions literature is heavily saturated with accounts of the professional projects (a la Larson, 1977, 1979 & Witz, 1990, 1992) of various professions within the health care division of labour. Many of these accounts point to the importance role that the state plays in these projects either as an audience (consistent with Abbott's (1988) systems theory) or as a focus of legalistic social closure strategies. A more thorough analysis of the role of the state, its interests and the strategies directed towards it, however, could be informed by the health policy literature. In this paper, I will present a model which begins to undertake that very task. I specifically focus on merging the conceptualization of a system of professions with related concepts of policy communities and policy networks, as well as unpack the various forms of legalistic closure strategies that the theory on the policy-making process helps to inform.

Author(s): Joanne Mc Carthy

Within the last four decades the field of disability research has undergone significant changes. Both in Ireland and abroad the issue of disability is no longer conceptualised as an individual tragedy, but rather presented as a discourse of social exclusion. According to this critical approach 'disability' is a product of economic, material and social inequality. Within this framework the individual experience of disability in itself becomes political, offering a critique of social barriers that deny people with impairments full integration into the social world. This paper examines the implications this contemporary discourse has on the lives of Irish people with disabilities. Specifically, this work considers the tensions created in the interface between this new political discourse and the traditional practices of disability management. Conventionally, people with disabilities were either cared for in the home or provided for within State institutions. According to such responses, people with impairments were segregated from 'the normals' in the areas of education, employment and social life. Predicated on the ideology of individualism disabled people were viewed as dependent and tragic. By drawing on data generated from interviews with participants from a sheltered workshop program this paper questions how the politics of social exclusion has effected the lives of people with impairments within these remaining traditional enclaves of the disability community.

Author(s): José Manuel Peixoto Caldas

Para estudiar las trayectorias institucionales y socio-familiares de la persona con VIH/sida se utiliza la noción de "carrera moral descrita" por Goffman y se conjuga con elementos de la concepción del proceso asistencial. El VIH/sida, al ser una enfermedad crónica, continúa representando una situación especial en el ámbito de las demás enfermedades cotidianas. Debido a su carácter simbólicamente contaminante, y por estar conectada con las conductas sexuales de los actores sociales. La red social informal intenta expulsar a la persona afectada hacia el sistema de asistencia formal. Pero este no dispone sino de situaciones puntuales. El resultado es que la persona VIH/sida es víctima de un juego de ping-pong entre sistemas asistenciales, siendo devuelta hacia la red social informal. Esa red informal de origen que en la mayoría de las ocasiones no lo acepta, principalmente si el afectado es homosexual o drogodependiente. De ahí, la necesidad de arbitrar mecanismos de apoyo social, que desde el sistema formal de asistencia, permita a las redes sociales de parentesco y amistad realizar cuidados, apoyo social y emocional a las personas afectadas por el síndrome de la mejor manera posible. Debe poder utilizarse el entorno de la persona para su rehabilitación bio-psico-social en vez de los pisos de acogida hasta ahora empleados. Dos nociones teóricas articulan el desarrollo de este proceso. Primero, está el concepto de "proceso asistencial", y segundo, el de noción de "carrera moral". Por proceso asistencial se entiende el conjunto de mecanismos que la sociedad pone en marcha para atender a aquellas personas que lo necesitan: en nuestro caso personas portadoras de VIH o enfermas de sida. La noción de proceso asistencial incluye los procesos formales (itinerario institucional ¿Y ahora quién me ayuda?) e informales de asistencia (itinerario sociofamilar ¿Qué hago en el futuro?). Suele ser la persona y su red social quienes deciden gestionar, los medios disponibles para garantizar la atención personal. El concepto de carrera moral permite reconstruir los procesos asistenciales desde la perspectiva de la persona asistida y contemplar el proceso asistencial como un todo: incluyendo lo formal y lo informal. Desde una perspectiva sociológica se puede entender la estructura interna de los itinerarios y procesos asistenciales: saber qué papel desarrollan en ellos los profesionales y de qué modo actúan los profanos en el proceso de aprender a vivir y de "empezar de nuevo".

Author(s): Katie Ainsworth-Vizenor

Medical Students are taught to look for explanations of illness and "surface phenomena" such as chronic pain and fatigue at finer and finer levels of resolution, or as Byron Good states "ever more fundamental orders of material reality." This presentation argues that physicians trained in this way of seeing are ill equipped to handle issues of chronic pain and fatigue because these phenomena occur at the intersection of the human body and its social environment. Chronic pain and fatigue, in the words Elaine Scarry, "unmake" and "remake" the patient's relationship with his or her body and its interaction with the environment at every moment, so that the pain of today is not the same pain as that of two days ago. Viewing the body at greater biological and cellular depth ignores this intersection between the body and its environment. My present research seeks to incorporate and extend philosopher Barry Smith's granular partition theory and anthropologist Margaret Lock's work on local biologies to the subject of chronic pain and fatigue. My goal is to forward medical education about the experiences of individuals in pain and to help physicians understand the chronic pain and fatigue complaints of patients, consequently developing more sensitive, holistic, and less invasive therapies that do not compound such problems.

Author(s): Katie Featherstone, P. Atkinson and A. Clarke

New genetic technologies potentially have major consequences for social relations and self-identities. The identification of a genetically inherited disease, or a risk of disease, constructs a context in which health, illness, risk and susceptibility to disease are subject to definition and re-definition. We examine how new genetic technologies are transforming everyday practical understandings of inheritance, relatedness and disease and the consequences of these developments for our definitions of kinship, pathology and risk. This paper is based on wider ethnographic fieldwork within a large UK clinical department of medical genetics. We have carried out a series of ten retrospective and prospective family case studies with individuals who are the recipients of genetic test results for a wide range of conditions and other members of their kindred who may also be affected. We identify the emergence of surveillance of the self and other family members as a key issue. Lay beliefs about inheritance and the specific genetic conditions affecting families lead to the inspection of one's self and other family members, and do not necessarily follow the biomedical definitions of inheritance patterns. Family members (as well as clinical staff) look for patterns within the kindred (past, contemporary and future generations) that indicate that certain members are particularly likely (or unlikely) to be affected or carriers of the condition. It is all too easy for professionals to assume that the dynamics of family interactions and the disclosure of information about family members are relatively straightforward. Similarly, it is equally easy to assume that the contents of professional advice - such as genetic counselling - are passed on within family networks unproblematically. Our research suggests otherwise. Among the families we studied, there exist complex dynamics of information-exchange and the disclosure or withholding of genetic information. Families are sites of mutual surveillance and scrutiny; they are also sites for complex patterns of belief and understanding of genetics, inheritance, health and illness. Genetic research into the molecular basis of the common, "complex" (i.e. multifactoral) diseases promises to transform the practice of medicine. For the foreseeable future, however, we will have to live with information about disease risk while remaining relatively powerless to intervene. New genetic technologies therefore have potential major consequences for social relations and self-identities. Biomedical phenomena are endowed with new social meanings; social phenomena are endowed with biological significance. The identification of a genetically inherited disease, or a risk of disease, constructs a context in which health, illness, risk and susceptibility to disease are subject to definition and re-definition. New genetic technologies may thus transform everyday practical understandings of inheritance, relatedness and disease. These will have consequences for our definitions of kinship, pathology and risk. We describe how lay beliefs of inheritance and risk inform disclosure to others and examine the social construction of genetic risk. In addition, we propose the emergence of surveillance of the self and other family members as key concepts. Geneticised families that have become aware of their inherited disorder over some generations can thus become sites in which members of different generations inspect one another. Older generations look for signs of emergent illness in younger generations; members of younger generations may equally look at older kin in order to gauge what their own future fate may be. These patterns of mutual surveillance follow lines of practical kinship and relatedness, and do not necessarily follow the biomedical definitions of inheritance patterns: for instance, all members of a younger generation may be inspected, irrespective of whether they are equally at risk of inheritance.

This paper is based on fieldwork with individuals and families who are the recipients of genetic test results for a wide range of conditions. We describe: how lay beliefs of inheritance and risk inform disclosure to others; the social construction of genetic risk; the sense of impaired body-identity. We thus explore how the interventions of medical genetics can render selves and identities both vulnerable and risky.

Author(s): Kirsi Vainionpää

In Finland new solutions are called for because of aging population; aging has more and more become a social concern during the last decades in our youth-oriented society. The aim of this study is to investigate the treatment of male menopause as a possible medical solution to the social problem 'aging society'. It has even been suggested that governments may welcome some of society's problems being redefined as medical with the possibility of new solutions. In Finland, the Finnish Medical Association approved the new subspecialty of andrology in 2001 and one point of view to support educating andrologists was to improve eldering men's care. The data of this study come from Finnish professional information about male menopause and its treatment during 1982-2002. I follow the development of male menopause by examining education material and handbooks for physicians and Finnish medical magazines. The theoretical background comes from theories of medicalization and governing people by medical social control. I am asking if treatments for 'male menopause' might be regarded as an individualized, biologically reduced and medicalized solution to the social problem 'aging Finnish society'

Author(s): Kristine A. Hirschkorn

The challenges that the rapid growth in the use of natural health products (NHPs) poses for both "alternative" and "conventional" health care professionals in Western nations is the focal point of this paper. Of particular interest are the roles that practitioners play in mitigating the risks associated with medicinal herbs, in ensuring accessibility, in bridging or resolving the discrepancies of knowledge between conventional and alternative medicine, and in fostering an informed public. With this in mind, I will report on interview and documentary data regarding the practices and regulation of herbalists in the Canadian context. This will be contrasted with data of the roles and views of mainstream health care providers -- namely pharmacists, physicians and nurses -- in regards to herbal medicine. The second part of this paper involves a comparative lens on health policy and professional perspectives in the United Kingdom and Germany. Particular attention will be given to trends and models that inform the integration of herbal medicine into the provision of mainstream health care services.

Author(s): Larissa Remennick and Gila Shakhar

This article is based on 28 in-depth interviews with Russian immigrant physicians (11 men and 17 women, age range 30-53) who decided not to seek Israeli medical license and converted to physiotherapy. This research was theoretically informed by the literature on physicians' professional commitment. It explored the case of conversion from a perceived higher to lower status medical occupation and the ensuing changes in former doctors' professional self-image, relations with the patients and colleagues, and adjustment to the new work role. Informants were recruited among the graduates of the re-training courses sponsored in the mid-1990s by the Israeli Ministry of Health in order to provide jobs for immigrant doctors and to fill in existing vacancies in physiotherapy. The stories of former MDs - novice physiotherapists indicate that most are well adjusted to their new role, maintain positive professional self-image, and are satisfied with the terms of their employment. At the same time, most informants admitted that their mode of thinking and relation to patients remained those of physicians rather than paramedics. Some informants gave medical advice to the patients (especially to their co-ethnics) when asked and discussed treatment options with physicians whenever the work context allowed. Ostensibly good re-adjustment of this group may reflect the interplay of their actual success in the new role, reluctance to disclose problems in the interview, and self-selection of this group (i.e., doctors who were ready to trade their higher status for pragmatic work benefits). We conclude that complete occupational make-over of immigrant physicians is hardly possible; their professional socialization leaves deep imprint on the mindset and conduct, regardless of subsequent career change.

Author(s): Lee Berney, Ian Rees Jones and Moira Kelly

The drive for greater patient involvement in all aspects of healthcare has profound implications both for health service planning and the nature of general practice (GP) consultations. Patients are being encouraged to take greater responsibility for their health and practitioners are being encouraged to develop a more 'patient-centred' approach to service delivery. What are the factors that will influence GP consultations in the coming years? How far do patients want to be involved in the decision-making process? A total of 24 GPs and 18 patients were recruited to a qualitative study. The aims of the study were to determine what criteria GPs used when allocating scarce resources; how they involved patients in this process; and what level of involvement did patients themselves desire? GPs expressed frustration at not always being able to provide the level of involvement that they felt was wanted. This was mainly due to time pressures. Most expected that as patient knowledge of health issues increases, patients will begin to expect longer consultations. Patients reported a strong desire to receive more information from their GPs but were ambivalent about taking a greater role in the decision-making process.

Author(s): Line Melby

A patchwork of different information and communication systems exist in Norwegian hospitals today. Computerized information systems, like the electronic patient record (EPR), diverse local paper systems and face-to-face communication coexist and are used in a mix by the health personnel. These different systems, or mediums for information retrieval, have their respective advantages and disadvantages, tied to intrinsic qualities in the mediums themselves and to infrastructures and social norms for their usage. Furthermore, there exist different types of information and the different mediums are in varying degree suited for transferring the various information types. For instance the EPR is not very well suited for providing patient information during doctors' morning conference, if there are no computers in the conference room. Drawing upon experiences from participant observation in a Neurological dept. in a University Hospital I want to elaborate on one overarching quality in information systems, the concept of mobility. Mobile information systems in hospitals are getting more widespread, and may be seen as the remedy for problems like poor availability of information. This paper consequently addresses questions such as how might mobile information systems affect patient care? And how might doctor-doctor or doctor-nurse communications be affected?

Author(s): Lorella Palazzo

This study offers a United States perspective on the integration of complementary and alternative medicines (CAM) into mainstream health care. I focus on two factors: (1) state-level health policies as they emanate from the federal and, especially, individual states' governments; and (2) managed care markets, whose powerful forces have shaped US health care for nearly three decades. The government's role in the surge of CAM remains largely unexplored in the American context. This work examines the evolution of individual state policies toward CAM since the 1970's and their interface with Federal governance by exploiting analytically the significant variations existing across states and regions of the country. My second focus is on health insurance and managed care companies structuring the economic conditions for the delivery of, and access to both conventional and CAM services. I study how these entities regulate the supply and availability of CAM care, affect its legitimacy, and define its role within the overall system both independently and through interaction with state policy and laws. Drawing from institutionalism, new institutionalism, and Light's theory of countervailing powers, this work adds to the sociology of CAM and gives insights into the dynamics of change in mixed market/state health care systems.

Author(s): Louise Woodward and Julie Killingbeck

Depression accounts for 30 per cent of all primary care consultations and 50 per cent of all consecutive attendances (Kessler et al, 1999), with one in four adults experiencing this condition during their life. However a high rate of those referred to specialist mental health services do not attend and there is a substantial drop out from drug therapy (Coppock & Hopton, 2000). Treatment strategies may offer limited help to individuals as they attempt to make sense of the experience of a 'loss of self' through depression. The aim of this paper is to examine the precarious nature of a depression diagnosis on an individual's sense of identity and to reflect on how the tensions between self and medical diagnosis are negotiated by individuals. Such a diagnosis may offer individuals an attempt to find meaning in confusion (Braken, 2002), the extent to which this transgresses into a new identity will be explored. This may witness individuals both becoming aware of a 'self' that is lost but also a recognition of a 'new' emerging identity which makes the depression experience less threatening and more affirming. This may be a crucial period which influences the subsequent path an individual chooses, in terms of treatment and self-identity, as they negotiate their way through the depression experience.

Author(s): Malin Bolin

Research on work and health has mainly focused the individual with measurements and interpretations done at an individual level in organizations, based on the idea that health risks originate from occupational activities as such. In recent years it is has been suggested that factors of importance for occupational health also are rooted in the organisational conditions with support of several empirical studies. It is known that establishments organise work differently even within the same branch and similar production or service obligations which generates differences in the work environments and health risks. Still little knowledge exists about how working conditions vary between organisational forms or how work could be organised to minimise health risks. The field of work and health research has also an individual focus theoretically. The three main factors in the definition of psychosocial work environment are work content, work organization and the social relationships at the workplace, but the organisational context in which these factors are created is not systematically analysed. Instead occupational titles, classifications of industries have been used as a substitute for exposures at an aggregated level. The organisational research on the other hand, has mainly focused on the organizational level given us a broad knowledge about the relation between the establishment and its environment, its structure and management technologies and about causes to organizational change. Since both the individual level and the organizational level constitute the individuals work environment, the field of work and health research should be expanded to include aspects of organisational conditions. That is, to link dimensions, concepts and categories from organisational theories to working conditions and health of the workers. This would improve the knowledge about at which level risk and health promoting factors occur and how they interact with each other thereby facilitating prevention. In this paper a sample of organizational theories will be analysed from a set of criterias, such as definition of actor, context and possibility to be tested in empirical studies.

Author(s): Manuel Hernández Pedreño

In this communication the results of the last surveys about health carried out in Spain are analysed. The objective is to observe differences in health according to sex, keeping in mind social variables related to social structure (age, educational level, incomes, economic activity, etc.). There have been important advances in Spain in social and sanitary matter. Nevertheless, it is verified that social inequalities still persist because of variables as education and income generate important differences in health according to sex. Those results are obtained from the analysis of perceived health, behaviours and habits related with health and the access and use of the sanitary services. Those differences are related, in great measure, with different social roles assigned to gender.

Author(s): Marcelo Puttini and Pedro Jabur

This paper analyzes how the contemporary societies present a tendency marked by an exacerbated individualism. This idea proposes to social groups the notion that individuals as masters of their destinies; whose social condition is settle from a system of compensations to the personal and capital merit. The idea of the "Universal Man" presupposes, that this individual has his equality reaffirmed in their differences, depending on his capacity and freedom to define their destinies and therefore, the competence and the universal duty of answering directly to the concepts and social norms in an absolute and individual way. Associating to the posture strongly individualist, the scientific knowledge presents a moment of redefinitions in the knowledge on the body and the man. In a period marked by the surprising progress of the biotechnologies and scientific knowledge regarding the conditions and peculiarities of life, the society started to try new sensations regarding the human being. The deep knowledge of the living systems allowed a new definition of the individual aspects of the organism. With the development of this new knowledge, the organisms are recognized as biologically unique. The recent development of sciences and techno- sciences enables a progressive colonization of the body and their organs. In this scenario, appeared new regulations involving the human condition from other references that try to be capable to deal with the insurgent paradigms of biosciences. In the level of the application of biotechnologies to man, having as its greater objective reducing the mortality and increasing the life expectancy - aiming to reach the desirable coefficient for the individual, in a point of view exclusively technical - situations unprecedented are created for the medicated body.

Author(s): Margrethe Nielsen

The paper presents the results of a project about evaluation of maternity care. The central questions of the project are how maternity care is evaluated and what consequences it has for practice. There seems to be a growing demand about evaluation within the public sector, and therefore also within the health system of which maternity care is a small part. This makes it relevant to focus on the ways evaluation is done and how an evaluation method can make the field appear. Maternity care is characterised by individual human processes and only to a small degree by evidence based treatments. This should be reflected in the evaluation method. The project is looking into four evaluation projects, which have taken place in four different maternity wards in Denmark. The project is containing two parts. The first part is inspired by Foucault´s discourse process of thought. Through a textual analysis four different meaning rooms are build up - one for each evaluation report. Building up meaning rooms is a way of understanding Foucault´s discourse process of thought. An analysis method is build up in the project, to get the overall understanding of the single evaluation. In the second part of the project interviews are done with representatives from the maternity wards. The interviews are analysed with inspiration from Corbin and Strauss with

Author(s): Marieluise Baur

The paper analyze miscellaneous datasets in order to understand why physical stature, health, and longevity in the U.S. population are lower than in Europe; although the U.S. features the highest per capita gross national product. Several indicators of health status such as physical stature, weight, and the body-mass-index, as well as individual episodes of illnesses will be used as dependent variables. A hundred years ago Americans were about 7 cm taller than most populations in Western Europe and Scandinavia, whereas today Americans are 5-7 cm shorter and have a higher percentage of uninsured people. That implies, in turn, that their health status has not kept pace with European standards. In order to get some insights into this phenomenon regional characteristics and urban/rural differences of these variables will be examined, as well as the impact of such variables as dietary habits, government expenditures on public health and welfare programs, inoculation, medical services, income inequality, and several proxies for social status, including the health status of the "working poor".

Author(s): Matilde Panadero Díaz

The german physician Samuel Hahnemann (1755-1843) was the founder of Homeopathy. The word homeopathy is a term which origin comes from the greek root homoios or "similar" and pathos or "disease". This philosophy is based on the principles Similia similibus curantur, doses minima y unitas remedii. More than 150 years after Hahnemann's discover, homeopathy still stands in a second place on the spanish medical scenery. However, in the last years the number of patients of homeopathy has increased as a consecuence of social and cultural changes on the meaning of health. This paper tries to explain the concepts of health and illness of the homeopathic physicians and research in social and cultural factors on health. This is evidenced by the emergence of new social values and new life styles in advanced societies.

Author(s): Mimmi Barmark

Not to long ago the concept of "sick buildings" was developed, and along with it the "sick building syndrome" (SBS). The latter is the collective name of a series of quite common symptoms (e.g. headache, tiredness and skin problems) that sometimes are associated with a poor indoor environment. So far most of the research in this area has been done within the fields of building technology and medicine. Previous research has shown that SBS-symptoms are more frequently reported from tenants then from home owners, from apartment blocks than from single family houses and from buildings constructed during certain periods of time. However, enough attention has not been given to the fact that different types of dwellings are inhabited by different types of people in terms of socio-economic background. One purpose of this study is to examine to what extent such differences (which are known to be associated with inequalities in health status) can explain the above mentioned differences found between types of dwellings regarding the number of reported SBS-symptoms. The overall aim of the study is to examine how people experience their housing situation in terms of safety and control and how that may be related to their experience of well-being, and to whether potential symptoms by the individual are associated with the indoor environment. In order to answer these questions a survey has been conducted in one of Sweden´s larger cities, Malmö, and the material is now being analysed. The first results from this analysis will be ready to be presented in Murcia in September.

Aim of the study is to find out what forms of activity the Finnish occupational health care has had in a past few decades and has its action been equivalent to the health policy (law and health programs). It has been noticed that there are some difference between these two. Another aim is to find out what areas are seen to be the top priority in the field of developing health care. This is examined in employee, employer and occupational health nurses point of view but also in health policy point of view. The area of work life itself is going through changes. This has affections to the requirements of professional activity. More and more is demanded from the employees - how does this affect to their health and can occupational health care recognise these new demands? Has the legislation reacted to this change of demands?

The data of this research consist of three regularly repeated surveys, which are directed to employees, employers and occupational health nurses and Finnish legislation and health programs which concern occupational health care.

Author(s): Ossi Rahkonen, Helen Sweeting2, Sakari Karvonen and Patrick West

This study investigates health inequalities among 15-year- olds in two cultures (Scotland and Finland), which we suggest differ in the extent to which late modern influences have replaced those associated with traditional social structures such as occupational social class. We hypothesise that since Scotland represents late modern society more strongly than Finland, there will be fewer health inequalities among Glasgow youth than their Helsinki counterparts. The comparative data come from two similar surveys conducted in Glasgow (n=2196) and Helsinki (n=2420). Several health indicators were used (self-rated health, GHQ and symptoms); independent variables were parental social class and education, and own educational achievements. Health differences by parental class and education were generally few and inconsistent in both countries, the exception being among Glasgow girls where there was a reverse class gradient in respect of psychological distress. The results partly support our hypotheses, in Finland hardly any health differences by class of origin, but in Glasgow perhaps an equalisation in health and girls from higher social class of origin showed poorer mental health than their counterparts.

Author(s): P. Åsbring and A. L. Närvänen

CFS and fibromyalgia are two illnesses that are distinguished by an unclear aetiology, few uniform treatment possibilities and uncertainty regarding the prognosis. In other words, there are much uncertainty connected to the illnesses that can cause problems among the patients, the caregivers they encounter as well as other people in their social surroundings. The study is based on interviews with 25 women with CFS (12) and fibromyalgia (13) as well as 26 interviews with some of the physicians they had encountered. The interviews were semi-structured and analysed by grounded theory analysis procedures. The aim with the patient study was to investigate what consequences the illnesses were perceived having for the womenÆs identity, if the illnesses were experienced as stigmatising, which strategies that were developed to gain control over their overall situation and in relation to health caregivers. The aim with the physician study was to investigate how they experienced the patients and which strategies they developed to handle them. Theoretical focus in the studies is directed toward the biographical disruption and biographical work in relation to identity, stigma and power and control in relation to uncertain illness trajectories. Also, illness and disease are central concepts, especially in the physician study.

Author(s): Paula Black

Beauty therapists make claims about their own status in relation to medical professionals. They frequently compare themselves to nurses in the level of training they receive and in the types of duties they perform. Drawing upon qualitative research with beauty therapists and their clients, this paper will examine the overlap between beauty therapy and the health profession. Beauty therapy lies at the inter-section of practices and discourses relating to notions of well being. Here it is examined for its role in widening notions of health, away from absence of illness, and towards a more generalised sense of well being. This discourse of well being is linked to the concept of 'lifestyle' and I interrogate the extent to which the notion of a 'healthy lifestyle' is classed and gendered. The issue of to what extent the medical and 'beauty' professions are inter-dependent will also be addressed. The beauty therapist is aware that although most of her business comes from 'looking' treatments (leg waxing, eye brow shaping, manicures), in order to boost her own professional status, she must draw upon a discourse of 'feeling' treatments (massage, reflexology). This tension affects the professional status of the beauty therapist, disagreements within the industry as a whole, and the every day working life of the therapist. Key words: beauty therapy; professional status; health; well-being; lifestyle

Author(s): Peggy McDonough and Amanda Sacker

The question of how poverty harms health has been the subject of considerable debate for many years. It is argued that poverty structures the material and social conditions of everyday life by restricting access to the fundamental conditions of health, such as adequate housing, good nutrition, and opportunities to participate in society. Despite these seemingly self-evident links, the relationship remains poorly understood, partly because poverty and health are usually conceptualized and empirically investigated in static terms; that is, they are treated as categories rather than as processes with stable and dynamic components. This paper examines patterns of change in individuals' self-rated health over time and the ways in which such patterns are structured by continuity and change in poverty experiences. We ask three main questions: (1) What is the shape of individual health trajectories? (2) Does poverty history affect health trajectories? and (3) What is the impact of poverty dynamics on health? Data, collected for adults aged 25 and older in 1984 (N=7,258), are from the 1968-1996 annual waves of the Panel Study of Income Dynamics. Because of our interest in individual change over time, we employ hierarchical linear modeling to examine health trajectories and then to systematically link differences between individuals' health trajectories with heterogeneity between individuals across patterns and sequences of poverty. Results are interpreted in light of their substantive implications and the ongoing challenges of mapping the dynamics of poverty and health experiences.

Author(s): Piet Bracke

Stigmas tend to stick to persons with a history of psychiatric treatment for severe mental illness. Furthermore, research has shown that, although rehabilitation programs effectively improve the quality of life of persons with chronic mental illness net of their experience of stigma, psychiatric labels still have detrimental consequences. Hence, reducing stigma should be an aim in its own right of rehabilitation services and mental health services. Although the link between characteristics of service organizations and their ability to invoke stigmatization on their clients is at the core of labelling theory, few empirical studies have investigated their capacity to reverse this process. Using information of 583 clients in 52 rehabilitation centres in Flanders (Belgium) the present study tries to fill this gap by examining which organizational characteristics determine the experience of stigma in persons with chronic mental health problems. Following Fife and Wright (2000) and Link et al. (1997) stigma is defined as a multidimensional phenomenon including the experience of isolation, rejection and secrecy. We hypothesize, that, net of individual characteristics such as present mental health complaints, and a history of psychiatric treatment, (a) rehabilitation centres can diminish the experience of stigma by providing normalizing activities such as work related activities, (b) the provision of treatment related activities will enhance the experience of stigma, and finally, (c) the composition of the client population can elicit self labelling. Multilevel analyses are used to estimate and separate the effects of organizational, compositional and client characteristics. The results are discussed.

Author(s): Richard Holliman

This paper examines UK television and newspaper coverage of the scientific/medical and political controversy over the existence, symptoms, causes and responses to a new illness; "Gulf War syndrome" (GWS). The paper presents the results of content analysis of two years (January 1996-December 1997) of media coverage of GWS. The media sample includes eight UK national newspapers and news bulletins from four UK terrestrial channels. The results show that media coverage GWS was dominated by political controversy over how best to deal with this issue and by anecdotal evidence of the symptoms and causes of GWS. To a lesser extent, the scientific debate about whether GWS could be proven to exist and the potential causes was a further important issue. This debate over the scientific/medical explanations for GWS is dominated by physical explanations over discussions of psychological factors, often denigrating the latter. The paper concludes by reviewing the role of the media in representing a new illness given the highly contested and often controversial nature of the evidence involved. In doing so, it raises issues relevant to how health and illness is defined, by whom and for what purposes.

Author(s): Seppo Poutanen

Foucauldian concepts and analytical tools, such as 'liberal government' and 'bio-politics', for example, have had a growing influence in the critical sociology of health and illness over the last two decades or so. Recently, sociologists who apply Foucauldian ideas have tried to capture some essential changes in western health care systems by introducing the concept of 'neo-liberal government', which is associated with the following features at least: (a) stress on individual choice, personal responsibility and control over one's own fate, (b) extension of 'market rationality' to all spheres of life, and (c) understanding life as a project of security against risks. In my paper I will analyse how this neo-liberal government might become realised in genetic screening and related genetic counselling, and my concrete case of illustration is the first genetic screening in Finland. I will try to demonstrate a social logic, which is derived from properties of this kind of screening and counselling. In my view, the outlined logic would be operative in constructing very 'pure' neo-liberal human subjects in the kind of context I speak of. However, because in reality Foucauldian neo-liberal discursive processes do not seem to be working as effectively and 'logically' as my demonstration suggests, I take this to implicate some problems in the very idea of Foucauldian neo-liberal government.

Author(s): Sharon Wray and Nicki Latham

There is substantial evidence to suggest that the symbolic significance of the female body as a keeper of religious ethnic and cultural territory has an important effect on women's health (Pettman 1996, Yuval-Davis 1997). Indeed, encounters with diet and exercise regimes often directly impact on women's health and well - being. Diet is closely linked to the construction and maintenance of ethnic, cultural and gender identities. It signifies values, territories and rituals and enables individuals to distinguish themselves from others (Hargreaves 2000). Additionally, control over diet, appetite and physical activity may be influenced by, or used to convey, religious and spiritual beliefs, beauty norms and notions of moral responsibility for health. This paper draws on two qualitative research studies. The first examines the health experiences of British Pakistani African Caribbean and white women at mid life. The second explores the meaning of exercise and health for women at mid life with Type 2 diabetes. Both reflect on the meanings that these women give to diet and exercise and the extent to which these are influenced by ethnic background and the politics of identity and belonging. The findings from this research, suggest ethnic and cultural background have a significant impact on perceptions of medical discourse: it's reliability and accuracy. The implications of this for health policy and practice are discussed in the final section of the paper.

Author(s): Sibyl Anthierens, Mieke Van Driel and J. De Maeseneer

This paper investigates by a review of the literature whether there is a health information gap between the information rich and information poor in our 'information society'. The persistence of health knowledge inequalities can have a sever impact on those groups excluded by society. Accessible and understandable health information of high quality is an important factor to improve quality of care. An important development in medicine, is 'Evidence Based Medicine' (EBM) which led to a paradigm shift in the scientific basis of medicine. Patients have to understand why some procedures are worthwhile and other are useless. We have argued that there is an information gap especially amongst the groups most negatively affected by socio- economic changes. Evidence Based Medicine should be in principle a concept of equity and not cost-containment, however the way the messages are transmitted or being communicated are leading to an information gap especially amongst the poorer groups in our society. It is especially important for the media, public health and health professionals to be aware of these health information gaps in order to overcome the gap and to prevent that EBM becomes an element that widens the gap.

Author(s): Sirkka Komulainen

As part of my PhD research project, I have observed multi-disciplinary assessments, where a team of health and social work practitioners attempt to diagnose young children's 'communication difficulties' and special needs. This paper focuses on the epistemological clash between 'clinical' and 'sociological' ways of 'knowing' about 'reality'. My sociological stance toward a multi-disciplinary setting draws from social constructionist notions of fact and account making in interactional contexts: I have wanted to explore the 'sociological' in the 'clinical' (see e.g. Smith, 2002). In this paper I will, firstly, outline a clinical account of a 'communication difficulty' called 'Asperger's Syndrome': I have chosen to describe this 'condition' since the possibility of this diagnosis frequently arose in the assessments that I observed. Secondly, I will analyse a sample of my field data drawing on social constructionist notions of 'fact-making'. Thirdly, I will step back and look at the epistemological dimensions of both clinical and sociological accounts: how we make sense of the world from within our own disciplines. Instead of trying to resolve a realism/relativism dichotomy within sociological thought, I want to extend the epistemological discussion to considerations of disciplinary power, social research ethics, and the integrity of sociological knowledge.

Author(s): Stephanie D. Short and Valentin D. Hadjiev

Since its transition to a market economy in 1991, Bulgaria has seen a decline in health spending accompanied by a decline in the quality of health care. The governments of Bulgaria have committed themselves to rapid structural reform in the health sector, including the introduction of a national health insurance system, modelled in part on Medicare in Australia. These changes required the introduction of new legislation to facilitate the reform process with a view to improving the efficiency of the public health facilities; strengthening essential services, including primary care; and restructuring the medical profession. The introduction of the national health insurance scheme occurred in conjunction with the reform of wider social insurance, including reform of the taxation system. Data were collected from official and non-governmental documents and statistics, validated and augmented by key informant interviews with health care governors, managers, providers and citizens. The key conclusions to emerge from the analysis relate to the differential impact on client groups and providers within a fractured and under-resourced reform process.

Author(s): Susanne Wurm

The impact of social inequality on health was examined in a number of studies already. They found consistent evidence that people with lower socio-economic status have higher morbidity and mortality rates. There has been an increasing interest in identifying psychosocial variables related to health outcomes in recent years. These variables may contribute to the understanding of the specific relationship between socio-economic status and health. The concept of control beliefs is among the most extensive bodies of research linking psychosocial variables with health. However, little attention has been paid to the interplay of socio-economic status and control beliefs. There is some empirical evidence that people with lower socio-economic status have lower levels of perceived control beliefs. Moreover, control beliefs play a moderating role, with even greater benefit for people with lower socio-economic status. The interaction of socio-economic status and control beliefs is examined in more detail using data from the German Ageing Survey. This survey is a nationally representative longitudinal survey of the German population aged 40 to 91 that was conducted in 1996 and 2002 respectively (nt1,t2 = 1524). Thereby, the focus is on the following questions: Does the extent of individual control beliefs vary depending on socio-economic status? Are there specific patterns of the interplay of socio-economic status and control beliefs and can they predict health outcomes? And finally: do these patterns vary by age?

Author(s): Taina Kinnunen

The presentation deals with my study under consideration, in which I will trace the embodied meanings of cosmetic plastic surgery or "esthetic surgery". The research material will consist primarily of interviews and, hopefully, of videotapes of the office hours in which the doctor and the patient discuss the forthcoming and performed operations. The interviewees will include patients, surgeons and professors of plastic surgery answering for specialist training. The interviewees will be gathered from Finland and the United States. In my study, the starting point is that the subject based study should be deepened in the study of cosmetic surgery. I assume that a strong paradigmatic emphasis on social constructionism, and analyzing interviewees narratives for example in the light of discourse (power) analysis that has been widely used in former studies of plastic surgery, cannot reach meanings that patients as well as doctors give to the operations. Studying the lived body is necessary as well. This is not to say that the body of the cosmetic surgery should be traced in a cultural vacuum. Instead, the body should be understood simultaneously as a body-subject and a representation of cultural beliefs and practices. In this context, the plastic surgery as a discipline itself (with specific "body culture" and social hierarchies), and as a part of a wider western body culture, must be traced as a cultural "frame" for surgical operations. In addition, the interactionist methodology of medical sociology is of use in this study when analyzing the interaction between the patient and the doctor during the office hour. Epistemologically, this "two-dimensional" approach to the body has been widely accepted in social-cultural studies of the body in recent years. However, in my study, I will critically trace the methodological possibilities of combining these two approaches.

Author(s): William Magee

Sociologists of mental health in North America have begun to recognize that the construct of distress is too narrow to capture all of the mental health consequences of social arrangements that are of sociological interest. Critiques of reliance on distress as the outcome of interest in sociological research is important, because strong arguments have been made against adopting more medicalized outcomes, such as psychiatric diagnoses. Some researchers have argued that that assessment of behaviors, such as family violence, may help compensate for some of the problems associated with assessing distress as an outcome. In sum, the argument is that family violence and other behaviors are indicative of masked distress. This paper reviews the logic of utilizing behavioral measures of distress, and the implications of expanding definitions of mental illness and distress in this way. Proposals for the widespread adoption of behavioral indicators of distress are weighed in relation to! criteria that sociologists of mental health might adopt for defining illness. These criteria go beyond the avoidance of reification of psychiatric categories, and concerns with the distribution of affective experience. For example, I argue that sociologists should incorporate information about context in the definition of mental illness and distress. However, many North American sociologists of mental health adopt a statistical approach in which contextual factors are relegated to the independent variable side of the equation. Thus, the incorporation of information of context in the definition of mental illness challenges the dominant research paradigm. I outline how a paradigm shift might be accomplished.

Author(s): Yelda Ozen

For at least two decades, the concept of body has become important focus of interest in sociological theory, women studies and sociology of health and illness. The rise of feminism, the growth of consumer culture and influence of post- structuralism have focused new attention upon the body. At recent times, mass media plays a key role to give this idea to shape social experiences of people towards their own bodies. Many social scientists criticize representations of women's body in media texts because firstly, they favor cultural traditional norms on gender roles in society, secondly, the body has become a market issue as a commodity in capitalist market. There is a close relationship between conception of health and of the body. Change in discourse on health interacts with change in discourse on the body. At recent times, people's experiences with their body have begun to change. Now, health is often conceptualized in terms of the body maintenance such as exercise, diet, and avoidance of unhealthy products. Moreover, during the last few decades there has been a shift in emphasis of health care from cure to prevention. In this paper, the role of media texts in reinforcing the dominant ideology towards the body and health is examined in order to reveal the relationship between conception of the body and changes in health policies. Therefore this study analyzes women's body representations and media conception of women's health issues in two Turkish magazines from 2000 to 2001: Cosmopolitan and Elele.