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Sociology of Health - Science topic

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It seems that the paradigm of the Social Determinants of Health is no longer enough to explain health - the dynamics of the disease. Is it time to propose new and better models of explanation?
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The way the initial question is posed makes me wonder if you thought that social determinants of health are supposed to explain all vulnerability to disease or all the factors needed for being healthy. The first three responses to the question all indicate that developing disease or staying healthy has multiple types of determinants. And, indeed, these can interact. Take a very simple disease such as influenza which right now is occurring in many parts of the world. The immediate cause of the disease is infection by the influenza virus. The virus potentially can infect anyone who does not have sufficient antibody to the particular strain of the virus that is "in circulation." But, the likelihood of exposure to the virus depends on the likelihood of contact with someone who is infectious. That, in turn, can be affected by the local population density - such as the number of persons who share a household. The severity of the disease can be affected by other factors such as poor nutritional status. So, even in this simple example there are multiple types of determinants of health and disease and severity, or impact, of disease.
It is also worth remembering that disease and health are not just physical states but also emotional states. There are factors that affect mental health. Furthermore, mental health and physical health can interact.
All this is well-known; and yet, I do not believe that anyone can state that we know exhaustively all the factors or possibly even the types of factors that can affect health and disease.
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Lipsky's book on Street-Level Bureaucracy is more general than the health-care sector, but applies to what I have seen in my field-study locations (public health clinics in South Africa).  Sociology of Health and Illness has articles on nurse-doctor relationships (eg Allen 1997 on Negotiated Order).  Social Science and Medicine has more relevant articles (eg Walker and Gilson 2004 use Lipsky).  But forward-chaining from these turns up very little.    
Academy of Management has articles on high- and low-status work.  Org Sci, Adm Sci Q and Organization have articles that are generally too removed from the domain to be much use.    
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Dear Brendon,
I would recommend you to read articles and books published by professor Marek Korczynski, Nottingham University. I came into contact with him when he was the key-note speaker at a seminar at Lund University in 2010. I think his speech was relevant for your questions. If you read Korcsynski you will find some other authors in this field of service workers connected to health. Examples of texts:
Korczynski, M.; Macdonald, C.(2009), ed Service Work: Critical Perspectives, Routledge, New York: USA.
Korczynski, M.; Evans, C.(2013)., "Customer Abuse to Service Workers An Analysis of Its Social Creation within the Service Economy", Work, Employment and Society, Vol.27 (5), pp. 768-784.
Best wishes
Lars Nordgren
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The work is important to the quality of life of individuals. Seniors face the difficulty of staying in the labor market. It is important in the preparation for retirement phase and participation in all spheres of social life.
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Fern Swedlove's article about OT's in retirement mirrors one aspect: Active activists - http://www.caot.ca/otnow/06Sept/WorldsHealth.pdf But there surely are many views on how to approach the transition from being an OT professional to retired life - as with other professionals going through the same process. OT's might have knowledge of meaningful and psychologically rewarding occupations but successful transition depends on so many factors such as: circumstances and settings; how professional life is experienced and valued by self and others; the range of interests except of work; contacts in social life and more. Just because we know a lot about occupation it does not mean we enact our own life led by our professional knowledge. 
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I'm doctoral researcher and I wish to understand factors influencing mental wellbeing of a community from a salutogenic perspetcive. But I'm not sure whether the salutogenic theory or is only suited to health-promoting/ protective factors. 
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Salutogenesis describes an approach focusing on factors that support human health and wellbeing, rather than on factors that cause disease. More specifically, the salutogenic approach is concerned with the relationship between health, stress, and coping (Antonovsky, 1979).
In comparison with concepts like coping or resilience (where the conditions and mechanisms are more rigid and contextual) salutogenesis has its strength in adaptability and universal use and as a life orientation always focusing on problem solving.
If a person believes there is no reason to persist and survive and confront challenges, if they have no sense of meaning, then they will have no motivation to comprehend and manage events. The essential argument is that salutogenesis depends on experiencing a strong sense of coherence and that this can lead to positive health outcomes.
Antonovsky, A. (1979) Health, Stress and Coping. San Francisco: Jossey-Bass Publishers.
Lindström B, Eriksson M. (2010) The Hitchhiker's Guide to Salutogenesis. Salutogenic pathways to health promotion. Fokhalsan Health Promotion Research Report 2. Helsinki, Finland.
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Hi everyone,
i am a bit confused on how to tackle the above question, do i look at the factors such as culture, religion that affect gender and then link it to public health ?
Your help will greatly be appreciated
Vimbai
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I am from Nigeria- a developing country, here the term ''Gender'' is viewed as social constructs, in other words behaviors, roles, expectations, and activities in a society. A simple approach to determine how Gender affects public health is to conduct ''Gender Analysis''. In my country Gender is impacted upon by socio-demographic (e.g. early child-bearing Age), socio-cultural (e.g. early & forceful marriages,  female genital mutilation, non-negotiation for sex) and socio-economic factors- (e.g. income, education, employment). You can consider Gender Analysis of the ''Human Resource for Health Work Force'' in the the Primary health care system of a developing country, simply determine the proportion of males and females employed in select Primary health facility(s) and comparing result to acceptable global standards by WHO. For example, in my country, evidence from recent studies suggest that we have high number of females in preservice education professions like nurses and midwifery compared to the males who feel that nurses and midwifery professions are just for females. Gender Analysis can show the effect of gender on public health.
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Currently specialization divides medical disciplines into sectors, much like slices of a cake. The results are that (i) patients with multiple morbidities are shunted from one doctor to another to another etc., (ii) it is impossible to have all the necessary specialists in one place unless that place is sufficiently large (and wealthy), (iii) emergency cover is unsustainable in all areas unless certain specialists double for others, (iv) the inevitable consequence is that a specialists, even if perfectly trained and competent, cannot deal with a patient with a malady accorded to a different specialty than his own, (v) specialists leave the simpler aspects of their field to their juniors, as they prefer to deal with the complex, "more interesting" issues (except in private practice). (vi) the system is more and more expensive to run, (vii) specialization leads to further "super-specialization" and further fragmentation of medicine, (viii) the model is exported to LMICs with catastrophic results as they cannot afford nor accommodate such a system, (ix) inevitably medical schools will be pushed to limit training of their students pertaining to their final specialty destination, (x) the specialties are themselves not defined and "turf wars" are created in bordering areas of practice, both in terms of departmental control and patient care.
There is no proper definition of the generalist, neither in medicine nor surgery. Yet, on the shoulders of this dying breed rests the burden of most "ordinary" patients' treatment worldwide.
Where therefore are we going? Is it not time to define the "Generalist" as a "Specialist" in his own right, and let him deal with the central part of the cake, leaving the periphery to be divided by the particulate specialists?
After all, everyone knows that the cherry is usually in the middle of the cake.
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My apologies for my nuanced take on your question and the accompanying elaboration Michael.
For me there needs to be clarification on various points to be sure that we are on the same page. First, by division of the medical cake do you mean total health spending by sector? Second, by "proper" division do you refer to an agreed upon allocation level bereft of value judgement?  Third, by generalist do you mean the general practitioner (GP) or primary care physician or the hospitalist - in the context of the US?  Just focusing on the third point, although the GP can be considered one and the same to the primary care physician the competencies between the two can be vary varied between health systems.
Cheers.
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Little has been written on oral culture in medical education.  However, I think it is because learners are unaware of oral culture until they begin their third or fourth year of medical education during which time  they are  going through their clerkship experiences.  It is here that you might find some literature on oral culture as medical students report becoming disillillusioned during this period of time.
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I am working on a project to show how social media can be used to improve patient outcomes, specifically in community health centers.
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There are some links to this topic. But be careful! The causal link between changes in organization of care and patient outcomes as hard endpoints is weak. Its easier to take patient satisfaction or other soft outcomes. Be also aware that this can only be investigated with observational methods. And there you always have all sorts of bias. Also there is a tendency only to look at improvements and forgetting that each intervention also produces risk and adverse events.
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Housing for health and security
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As pointed out by Vedamani Basil hans Sir, the issue of "healthy housing" is more with migrants. Similarly, as pointed out by Nikki Keene Woods Madam there are clear evidences regarding proper housing and its (positive) health implications.   
As far as developing nations like India are concerned "healthy housing" could be viewed as "affordable housing" for the masses with barest minimum facilities and amenities like adequate space, safe drinking water, ventilation etc. First of all, those living in dilapidated houses and unhygienic surroundings should be suitably rehabilitated in the above sort of "affordable" or publicly funded houses / shelters. Hence, it may be pointed out that meeting the higher end needs of the population in respect of housing, including health aspects of housing, comes only after fulfilling the above basic needs of the masses in respect of developing  as well as third-world countries.   
Dr. MANOJ P K, Faculty Member, DAE, CUSAT, Kochi, Kerala, INDIA.
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I am discussing my results for an upcoming conference presentation on the determinants of health-related quality of life (HRQoL) among adults with diabetes. My results is showing that higher levels of interpersonal sensitivity is a predictor for HRQoL. Can any one offer me some reasons why this is possible? Any previous studies will be much helpful.
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I think the phrase 'interpersonal sensitivity' needs to be defined. In your study, the target group is defined as ’adults with diabetes.' If I understood you well, you seem to be referring to the type of relations the group should have within themselves. Interpersonal sensitivity in this context indicates is the ability to understand each other and being able to appreciate the problems diabetic patients experience; and in effect to being able to support each other. A problem shared is a problem halved. This is why associations of people with the same concern get formed. In my research, I found out that associations of people infected with HIV helped HIV infected and affected people deal with stigma and discrimination--perceived and enacted. The same logic applies to people with chronic diabetes. They discuss their problems and also make collective decision on the way forward. In the first case they get encouraged to accept the illness--this is a critical stage in dealing with the illness. Then they accept practices that they should do and not do to live a better life: medical, social, psychological and physical. Such practices are reinforced through interpersonal sensitivity of members. In effect quality of life of such people improves. If reinforced by extra personal sensitivity where non diabetic members of a community appreciates the challenges that diabetic patients experience, the outcome is expected to be far more better. This is why we call health is more of social than bio medical enterprise.
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Hello,
I am researching the social determinants of health of women working in garment factories in Cambodia.
Do you know of any research of Tong Tin in Cambodia? Or about the impact of garment work on commuters villages in Cambodia?
Cheers,
Fiona
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Thanks Thomas, I have found one study but can only find a draft publication online. Any ideas how I can track the final version?
My reference for it would be: 
Prota, L & Cucco, I 2014, 'The impact of garment work on commuters' villages in Cambodia', Presented at the workshop on Globalization, Industrialization and Labour Markets in Asia: Essays in Honour of Melanie Beresford, January 2013. Chiang Mai, Thailand.
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I am interested in looking at health professionals understanding of chronic conditions. thank you
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Hi
If your conceptualization of "illness" includes chronic conditions such as Intellectual disability, there is a literature on medical professionals attitudes towards this group from Canada.  I've attached a link to one article and it can lead you to many more.
Hope that's helpful
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Poor and illiterate individuals may understand complex health related topics. However, in order to sustain the knowledge they will need to reinforce it. Handouts and pamphlets may not be useful. Illustrative pamphlets may not be adequate. Audiovisual tools will be beyond affordability. How can such a population self- reinforce and revise the education provided to them?
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Dear Ankur, your question is quite valid, because most of the illiterate belong to low socio - economic status, such people can be educated and empower them to tackle their problem. Here we can apply steps of behaviour change , start to assess about the problem they know or not, if know then how much they know about the problem, they are concerns, if they concerns , then they want to change this behaviour to healthy behaviour, if interested to change then the medium we can use for change , for this message & medium should according to the target specific. One message should be at onetime.I think if we want for sustaining effect of various methods for change, then both audiovisual medium is effective and along with we can use other methods e.g., pictorial. Other ways are we can select peer educator among the target group, then trained the peer educator. These peer educator are more effective,as they are from the same community and know the socio- cultural factors which become the barriers for communication.
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health education
can an individual self manage diabetes?
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Self-management in it most simple form is the thing that people do between medical visits--in fact most people are self-managing 99% of the time.   The Institute of Medicine has a formal definition--the skills and confidence that one needs to manage the medical, role and emotional consequences of chronic illness.
So what is the nurses role  1) helping patient gain basic knowledge about  life style chances---Not anatomy and physiology of disease and not a million things which are usually taught but the very key issues such as exercise, portion size, diabetes plate, signs of hypoglycemia and what to do about it.   How to balance exercise with food.
2) helping people to make small steps and small changes and succeed.  As nurses we tend to go for the ideal and then make people fail.  Much better to go for what is real for each person, even if not ideal and have them succeed.   Without success initial efforts will soon be lost.
3) helping patients to find other patient role models.   One of the best way to learn is from someone like you who understands your life experiences.
4) give up on doing for people and instead move to a coaching, doing with mode.
All of this is taken from being a nurse with 30 plus years of experience in helping people live with diabetes and other chronic diseases.   Our website might be of help patienteducation.stanford.edu
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I am normally using discussion and focus groups with patients but I would like to go further and learn more about projects, methods and techniques that are properly applied in the healthcare and medicine domain from a sociological perspective. Thank you!
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Patients are reporting issues such as poor access to care, availability of socio-economic resources and time; knowledge; and emotional and physical energy. (Bee et al. 2014)
The work patients must do to care for their health; problem-focused strategies and tools to facilitate the work of self-care; and factors that exacerbate the burden felt (Eton et al 2014)
Capacity, responsibility, and motivation: a critical qualitative evaluation of patient and practitioner views about barriers to self-management in people with multimorbidity. BMC Health Services Research (Impact Factor: 1.77). 11/2014; 14::536. DOI: 10.1186/s12913-014-0536-y
Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Related Outcome Measures 2012:3 39–49 http://dx.doi.org/10.2147/PROM.S34681
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Have you considered the first tool within the Flinders Program - Chronic Condition Care Planning? You'll find details about it at:  http://www.flinders.edu.au/medicine/sites/fhbhru/self-management.cfm
It's called the 'Partners in Health Scale' and it's a 12 item measure that the person self-rates re their knowledge, relationship with health professionals, access, monitoring and responding, physical, social and emotional impacts, lifestyle, etc. The tool has been validated and used in many research trials and in practice as either a standalone to measure change over time, determine client groupings, determine for services which clients would benefit from care planning, etc.
It has been adapted into other languages and used in the US, NZ, Australia, Hong Kong and some other countries.
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A very good question - which I hope will inspire a much needed debate. An article of interest may be: Ascuntar, J.M et al (2010): Fear, infection and compassion: Social representations of tuberculosis in Medellin, Colombia, 2007. INT J TUBERC LUNG DIS 14(10):1323–1329. Another is van der Walta, H. and Swartz, L (2002): Task orientated nursing in a tuberculosis control programme in South Africa: where does it come from and what keeps it going? Social Science and Medicine.
A colleague in Norway, Mette Sagbakken, has done a lot of qualitative work on TB in Ethiopia and Norway, and published widely - google her, and you find some good articles. I was working in the TB field till 2009, and have a lot  of good resources on training of health providers in communicating about TB (plus research to assess the effect of the training) - am in the process of publishing the training materials, and articles. The model has been developed with nurses and physicians, and implemented in 7 countries - now going broader than "only" TB. I also have conducted research to develop patient centered materials on TB, but - have focused on making it available for implementers, rather than on writing academic articles. The TB field is extremely dominated by medical professionals, and social scientists are much needed to answer the question you raise.
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I'm seeking any texts that have looked at goal framing theory in the context of healthcare use, ideally screening compliance behaviours.
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Perhaps there are some examples arising in the UK (with their Nudge approach to improving health behaviours)? I suspect that the Goal Framing Theory might be applied under different names, and may more likely to be published in Behaviour Economics or Sociology of Medicine journals. My files of GFT include these two:
Cheers,
Janet
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I work in a rural town in Kenya and my heart bleeds each time there's a delay to patient care, either due to patient delays or because the hospital is not well equipped.
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There is no limit for financial requirements to meet the unmet needs of the poor. In this context, the government should plan the use of its resources better in such a way that the resources are spent on cost-effective services. Often, this is not the case. Governments allow their resources flow into developed places to serve the better-off even while keeping their policies targeted at the poor and primary healthcare. Unless there is a positive correlation between the policy priorities and budget spending, this kind of scenario is unfortunately unavoidable. The private not-for-profit sector attempts to bridge the healthcare gap to some extent in some areas in Africa, but they too face resource constraint.
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I am interested in conducting a sexual network mapping exercise with men living in a rural community as a means of bringing about/contributing to sexual behaviour change (reduction in multiple concurrent partnerships or at least consistent condom use).
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I'm assuming that by low-income you are referring to not necessarily having the resources to buy expensive mapping software. With that in mind, there is Epi Map - free from the CDC (http://wwwn.cdc.gov/epiinfo/), which is part of their Epi Info suite. And ArcGIS (from ESRI; http://www.esri.com/software/arcgis/explorer) has a free version with limited capabilities, but fine for relatively simple mapping/analysis. I haven't used it, but there is also a free, open-source GIS software called GRASS GIS (http://grass.osgeo.org/). I don't do much GIS work so that's all I'm familiar with at the moment. Good luck!
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I would like to know if there exists some questionnaire for assessing the oral health needs in children.
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Aubrey or Paulina, is there a similar questionnaire specific for children with neurodevelopmental disroders? I am lookinf for one that may be used as a guide to reduce the number of General anaesthetics needed to be given to children with moderate to severe intellectual disability in order to monitor their dental health.
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Mainly for rural communities.
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You can use the three combinaison of MeSH terms to do your research
(("Questionnaires"[Majr]) AND "Oral Health"[Majr]) AND "Health Knowledge, Attitudes, Practice"[Majr]
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Is it possible to apply the model considering the particular characteristics of the Mexican population?
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yes, ıt is one way to classify the potential predictors of health care services. I applied this model to two different datasets. I can give you further information
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Do we need to learn more from looking into the minutia of everyday interactions between people and their social and physical environments? What are the implications?
Recent years has seen an escalation and variation in the application and scope of social ecological frameworks with the common intent of wishing to effectively interpret factors that influence human behaviour (Holt, Spence, Sehn, & Cutumisu, 2008; O’Connor, Alfrey, & Payne, 2011; Sallis, Owen, & Fisher, 2008; Stokols, Misra, Runnerstrom, & Hipp, 2009). To date the dominant discourse for social ecological research in the scholarly community has been heavily located in conducting large scale studies, the employment of gross markers and distant analysis with a key outcome of finding the big macro levers that aim to achieve a population shift in human behaviour.
References
Holt, N., Spence, J., Sehn, Z., & Cutumisu, N. (2008). Neighborhood and developmental differences in children’s perceptions of opportunities for play and physical activity. Health & Place, 14, 2-14.
Krieger, N. (1994). Epidemiology and the web of causation: Has anyone seen the spider? Social Science & Medicine, 39(7), 887-903.
O’Connor, J., Alfrey, L., & Payne, P. (2011). Beyond games and sports: A socio-ecological approach to physical education. Sport Education and Society, 17(3), 365-380.
Sallis, J., Owen, N., & Fisher, E. (2008). Ecological models of health behavior. In K. Glanz, B. Rimer & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (pp. 465-482). San Francisco, California: Jossey-Bass.
Stokols, D., Misra, S., Runnerstrom, M., & Hipp, A. (2009). Psychology in an age of ecological crisis: From personal angst to collective action. American Psychologist, 64(3), 181-193.
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Dear Alice
Thanks for your question about the type of research we are doing at St Andrews. We spend a lot of effort on trying to understand the links between the expression of emotion in conversations between health providers and patients. As I think
I mentioned previously the way in which health providers respond to open, frank or hidden emotive content in a patient's speech is of importance to outcome. I have been impressed by the late Peter Maguire from Univ of Manchester UK and his work with staff at Christie's Hospital with cancer patients. If emotional concerns in diagnostic interviews expressed by patients were 'blocked' by clinicians then lowered mood in patients was detected at follow up.
Do look at examples of my work with the talented Research Fellow - Yuefang Zhou in a couple of recent papers we have published (the PLoS-One article and the paper in Annals of Behavioral Medicine). The former is about medical students' responses to simulated patient emotional expression and the later about reassurance producing counter-intuitive effects in young children receiving a preventive intervention). Both papers show the importance of timing and investigating contextual factors. The later article has been captured nicely in a piece now on Reuter's Health web-site page.
Hope this is of interest and adds to the discussion.
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I'm looking some strategies for expand the coverage and quality of dental services in marginalized communities.
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get in contact with the dental department of the Ministry of Health. They just published a paper on the use of ART in marginalised population groups in Mexico as part of a oral health strategy. Free to be downloaded from PubMed.
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I've read theToni Schofield's paper on Health sociology review journal about health inequities and its social determinants. In the paper, the author did mention that health inequities and health inequalities or differences are not the same. I do not get this point. What is the difference b/w health inequities and health inequalities? Could you give me an example to understand the difference, please? Thank you so much
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inequities are unjust inequalities, or in other words, inequalities produced as a result of societal arrangement rather than personal health decisions.
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What the impact of current work-life balance policy may be having on dementia care, as care homes are mainly being staffed by part time care staff.
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Have you looked at the Cochrane Library ?
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We see that the health of the black/african american population have the worst health as a whole in comparison to the white population, in the United States of America. I am hearing more and more that the circumstances that blacks faced during slavery have had a toll in the health of the population today. Examples being that black babies less than 1 years of age have a higher death rate than white babies and this is being linked to the stress black women endured during life and it effecting the child before birth. Stress that have been inheritated from generations and generations and a lifetime of discrimination, rooted from slavery. I am simply curious if there are any more articles or research being done on this topic and the thoughts of others.
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I certainly believe there is support for Dr. Joy DeGruy Leary's theory. I didn't want to assume you had read her book entitled Post Traumatice Slave Syndrome: America's Legacy of Enduring Injury and Healing. So I would like to offer it for starters. Also, Dr. Kenneth Hardy's work on trauma and oppression and his book entitled The Psychological Residuals of Slavery provides a good foundation to begin to research your question. I'd be interested to know what you think. Thanks. Norma Mtume
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I am looking for studies that take on a discourse analysis approach that focus on the use of traditional medicine. Suggestions for studies that conducted discourse analysis on medicine using tout court are also welcomed.
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Hi, you may look at the French anthropologist Laurent Pordié's researches:
He is specialized in the social study of science and medicine in South Asia. Some of his publications are in english...
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Did you include some findings related to this topic in your thesis?
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I published a mother-daughter case analysis that had essentially four generations, the mother who was one of the US's first diagnosed cases of anorexia (now in her 70s) and her daughter, her mother, and granddaughter. You might find it interesting as it focuses on the ways in which the two respondents resisted eating disorders and you find the effect over four generations.
Cwikel, J. (2011). Strategies for resisting eating disorders over the life course – A mother-daughter case analysis. Women & Therapy. 34(1): 1-36.
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Educating health professionals
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....and of course, Flip, Wright Mills does a right hatchet job on Parsonian grand theory in 'The sociological imagination' . Nonetheless, I find it a useful debating point with students. healthcare students to state the obvious are not sociologists and so the finer nuances of sociological theory and paradigms critiques are often out of place in their education. However, This should not be an excuse to dumb down and debating competing explanations around the patient experience and health seeking behavior. Has the SR relevance in contemporary healthcare? if you mean education students then yes, but as a description of current practices it is partial at best as Flip implies.
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Is it possible to explain the persistence of high maternal mortality in developing countries sociologically?
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One useful approach to this question is getting the facts straight. Look at several of Hans Roslings lectures (mainly on TED). In this one http://girlsglobe.org/2012/05/23/religions-and-babies-hans-rosling-does-it-again/ he shows the relationship worldwide over time between birthrate and income per capita. (Birthrate being directly relevant to maternal deaths, of course.) The correlation is strong, but generally the birthrate went down before the incomes rose. Which is not to say prosperity wouldn’t help: with strong poverty people tend to get more children, so they can work (and replace the children who died, that too). He also shows religion has little to do with birthrates, in spite of all the rightful anger at the Catholic Church opposing birth control.
In http://thesocietypages.org/socimages/2009/09/18/uncertainty-in-measuring-maternal-mortality/ he gives an overview of maternal deaths around the world in the course of the years and its relation to per capita income, which is again strong but not the most important causal factor. The most important factor, these data show, is access to medical facilities.
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Social capital improvement takes a long time and some times it might be like learning from history and changing the future, but can we really improve social capital in a short duration (e.g. months)?
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Can I ask for clarification here on the form of social capital you are referring too? I work in education, specifically at risk students and theorize 3 possible scenarios where social capital influences their success in formal education
a) that in their social fields they have social capital, which works to hinder their access to membership, and therefore success, in alternate social fields, ie formal education
b) they lack effective networks that allow the development of social capital
c) a combination of both scenarios exist, thereby denying movement within and between fields - limited access to new groups with simultaneous hindrance in departing from existing fields
Regardless of scenario, and I am leaning towards c), there is a requirement for Social Capital growth through pedagogical and curricular innovation.