Peculiarities of medical sociology: application of social theories in analyzing health and medicine

Summary. Objective. To reveal the peculiarities of medical sociology introducing the application of social theories in analyzing public health and medicine. Methods. Comparative and descriptive analysis of scientific references found and current situation.


Introduction
Social welfare is very much related to the better health (or morbidity) indicators of the society, thus medical sociology is one of the fundamental developing areas of the science of public health. Phenomena of urbanization, industrialization, and globalization in all over the world are about to change not only the developing direction of medicine itself, but the attitude of the society towards the disease, its curing, or the activity of institutions, ensuring health care as well.
Medical sociology becomes the new "glasses" for public health specialists, where the view looking through them seems wider, and the opportunities of tackling the health care problems (for instance, doctor-patient interactions) are higher.
In this article the meaning of medical sociology is being elaborated, social theories and their application in medical sociology are being discussed, and the importance of medical sociology and opportunities in contemporary health care context are being presented.

The meaning of medical sociology or the types of sociology applied in the analysis of phenomena of health and medicine
Sociology is the scientific study of groups, organizations, institutions, relationships, and interpersonal behavior. The field of medical sociology brings an eclectic approach to the study of health behavior, professional work roles, and medical institutions. Medical sociologist is trained to appraise how cultures, institutions, and organizations are influencing individual beliefs, behaviors and patterns of social interaction and ultimately affect the physical and mental health of individuals, groups, and organizations. Medical sociologists are especially well suited to understand practitioner-patient relationships in health care system, which is the complex of technical, organizational, economical, and ethical approaches. This multidimential perspective, coupled with knowledge about how groups and organizations are functioning, allows medical sociologist to facilitate communication among the various clinicians, researchers, administrators, and patients in health care delivery settings. Medical sociologists hold teaching positions not only in sociology departments but also in public health, medical, and nursing schools. In addition, they are employed as researchers and research directors in public and private health agencies and in health-related industries, such as insurance, pharmaceutical, and hospital management companies.
In general, sociology tends to focus on basic research, for which practical applications are not always obvious. In contrast, medical sociology has an applied focus which takes researchers into health service settings for on-site data collection and intervention. Medical sociologists utilize applied sociology methods, such as needs assessment and social impact assessment. In addition, medical sociology lends itself to formulating and testing case management options in health care settings using evaluation research methods.
The meaning of medical sociology appeared in the USA, in the second half of the 19th century, and the development of urbanization, industry, and other social issues had a significant impact on it. The term "medical sociology" was used for the first time in the paper of Ch. McIntire called "The importance of studies of medical sociology" and published in 1894.
Thus, R. Strauss in 1957, analyzing the meaning of medical sociology was paying more attention to the main terms -sociology in medicine and sociology of medicine. The mentioned two could be supposed as two different approaches in medical sociology. The meaning of sociology in medicine (in some scientific literature found as sociology of health and disease) reflects more applied approach of medical sociology and is understandable as the application of sociological (of social sciences) methods in analyzing the exact, different problems of medicine and health such as treatment of diseases and prevention, resource allocation, etc. (1). Thus sociology in medicine is under-standable as applied social researches, the main object of which is not the social, but medical-based problems or phenomena (2). In the case of medical sociology (sometimes called as sociology of health care institutions), medicine itself is supposed as social institution, pretty the same as, for instance, family, religion, education, economics, politics, and so far (3). So, the studies of social nature, which are being proceeded in investigating medicine from the social point of view, give the opportunity to develop certain providences about the social interactions, social networks, social organizations, etc., which are influencing the social problems of medicine and health (4).
J. Siegrist tried to delineate the disciplinary structure of medical sociology in terms of five important areas of knowledge: 1.Sociology of healthy lifestyles (prevention); 2.Sociology of patients' careers (rehabilitation); 3.Sociology of client-professional interaction (diagnosis, therapy); 4.Sociological (social epidemiological) studies of causes of health and disease; 5.Sociology of health care systems.
It is argued that intensified exchange according to these areas between the academic disciplines of medical sociology and social medicine is needed to generate a significant impact on future training and research both in medicine and in public health (5).

Structural functionalism
Structural functionalism looks at the role the sick person plays in society. The focus is on how being ill is given a specific form in human societies so that the social system's stability and cohesion can be maintained. Talcott Parsons is often considered the father of Medical Sociology because of his description of the "Sick Role." This describes the difference between the role of a sick person as opposed to the "Social Role" of a healthy person. He defines the sick role as defining the motivation of the patient. Curiously enough, T. Parsons makes no mention of the role of the doctor or other medical institutions. The sick role comprises four aspects: exemption from normal social role responsibilities, the privilege of not being held responsible for being sick, the desire to get better, and the obligation to find proper help and follow that advice. A pivotal event occurred in 1951 that oriented medical sociology towards theoretical concerns and initiated the establishment of its academic credentials.
This was the publication of T. Parsons' long-anticipated book "The Social System," which established the author at the time as the dominant figure in American sociology. Anything T. Parsons published attracted great attention because he was supposed to be charting a course for all of sociology. T. Parsons was interested in the different roles of professionals in capitalistic and socialist societies and decided to include physicians and their relationship with their clients/patients in his analysis, because this topic was an area of long-standing interest and one in which he felt he had familiarity (6, 7).
T. Parsons' concept of the sick role is a clear and straightforward statement of four basic propositions outlining the normative pattern of physician utilization by the sick and their respective social roles. T. Parsons not only constructed the first theoretical concept directly applicable to medical sociology, but by utilizing the work of E. Durkheim and M. Weber, he did so within the parameters of classical sociological theory. His formulation was recognized as "a penetrating and apt analysis of sickness from a distinctly sociological point of view," which indeed it was. T. Parsons also influenced the study of professions by using the medical profession as the model for professions based on expertise and a service orientation (7).
E. Durkheim's only work that had a direct application to medical sociology was his theory of suicide in which the act of taking one's life was determined by the individual's ties to his or her community or society. This is seen in his typology of three major types of suicide: 1) egoistic (social detachment); 2) anomic (state of normlessness); and 3) altruistic (a normative demand for suicide). The merit of his concept is that it shows the capability of the larger society to create stressful situations where people are forced to respond to conditions not of their own choice. Thus, E. Durkheim helps us to not only understand the social facets of suicide, but to recognize that macro-level social events (like economic recessions) can affect health in a variety of ways through stress and that the effects of stress can be mitigated through social support (7).
Structural functionalism, with its emphasis on value consensus, social order, stability, and functional processes at the macro-level of society, had a shortlived period as the leading theoretical paradigm in medical sociology.

Conflict theory
Conflict theory is concerned with the relationship between health and illness and capitalist social organi-zation. The focus is on how the definition and treatment of health and illness are influenced by the nature of economic activity in a capitalist society. Conflict theory is based on the assumption that society is composed of various groups struggling for advantage that inequality is a basic feature of social life, and conflict is the major cause of social change. C. Marx's perspective in conflict theory is seen in the rejection of the view expressed by structural functionalism that society is held together by shared norms and values. Conflict theory claims that true consensus does not exist; rather, society's norms and values are those of the dominant elite and imposed by them on the less privileged to maintain their advantaged position. Since all social systems contain such inequality, conflict inevitably results, and conflict, in turn, is responsible for social change (7). Whereas the Marxian-oriented features of conflict theory have emphasized class struggle, other theorists have moved toward emphasizing conflicts that occur between interest groups and the unequal distribution of political power. According to B. Turner, modern societies are the best understood as having a conflict between the principles of democratic politics (emphasizing equality and universal rights) and the organization of their economic systems (involving the production, exchange, and consumption of goods and services, about which there is considerable inequality). Therefore, while people have political equality, they lack social equality. This unresolved contradiction is relatively permanent and remains a major source of conflict. Ideologies of fairness are constantly challenged by the realities of inequalities, and they influence governments to try to resolve the situation through politics and welfare benefits (7).
This situation represents one of conflict theory's most important assets for medical sociology; namely, the capacity to explain the politics associated with health reform. Conflict theory allows us to chart the maneuvers of various entities, like the medical profession, insurance companies, drug companies, the business community, and the public, as they struggle to acquire, protect, or expand their interests against existing government regulations and programs and those under consideration. Other conflict approaches are connected more directly to classical Marxism by relying on class struggle to explain health policy outcomes and the disadvantages of the lower and working classes in capitalist medical systems where the emphasis is on profit. While a major focus of conflict theory in medical sociology is on the role of competing interests in health care delivery and policy, other interests concern the sources of illness and disability Raimundas Kaminskas, Žilvinas Darulis in work environments, working-class health, differences in health lifestyles, and capitalist ideologies supportive of physician-patient interaction (7). However, there are inherent limitations in the use of conflict theory in medical sociology. While some health situations are affected by conflict-related conditions, others are not. People may maintain their health or become sick, and these outcomes can have little or nothing to do with conflict, politics, interest-group competition, class struggles, and the like.
The greatest potential of conflict theory for medical sociology thus lies in its non-Marxist aspects, as interest-group competition in welfare states proves more relevant for health concerns than class struggle.

Symbolic interaction
How we interact in the society? What is the way we understand each other? What determines the success of our social interaction? Symbolic interaction is one of the social theories, which is attempting to answer to the questions above. This is theory of modern sociology and social psychology, which analyzes the social interactions and appeals on their symbolic content. The sense of symbolic interaction is based on the look at the interaction among people as continuous dialog, where the participants are observing each other and thinking about each other's intentions and react on them differently. Social meanings are being created and changed during this dialog. Human behavior is social and based on the communication. Individuals are responding both to the behavior of others and to the other's intentions.
Symbolic interactionism is concerned with examining the interaction among the different role players in the health and illness drama. The focus is on how illness and the subjective experience of being sick are constructed through the doctor-patient exchange. The argument is here that illness is a social accomplishment among actors rather than just a matter of physiological malfunction.
J. Elinson raises somewhat rhetorical questions about the value of medical care and medical sociology. Behind them is a serious concern with the type and scope of medicalization in modern society as well as its sociological criticism. This raises the issue of whether the various theoretical images of medicine and the patient which sociology provides are able to account for the effect of the social environment upon morbidity and mortality as shown, for instance, by the Alameda County Study. Three theoretically distinct approaches are discussed in detail, structural functionalism, symbolic interactionism and conflict theory. These characterize medical sociology over the last 30 years (8).
The theory of symbolic interactionism is widely used in the investigations of population health (9, 10). Traditionally, symbolic interactionism has been viewed as one perspective underpinning qualitative research, but it is also the basis for quantitative studies. Rooted in social psychology, symbolic interactionism has a rich intellectual heritage that spans more than a century. Underlying symbolic interactionism is the major assumption that individuals act on the basis of the meaning that things have for them. Symbolic interactionism can serve as a theoretical perspective for conceptually clear and soundly implemented multiple method research that will expand the understanding of human health behavior (11,12).

Feminist theory
Feminist theory explores the gendered nature of the definition of illness and treatment of patients. Its main concern is the way in which medical treatment involves male control over women's bodies and identities. Feminist theory in medical sociology also has poststructural roots, especially in regard to social constructionist accounts of the female body and its regulation by a male-dominated society. Social and cultural assumptions are held to influence our perceptions of the body, including the use of the male body as the standard for medical training, the assignment of less socially desirable physical and emotional traits to women, and the ways in which women's illnesses are socially constructed. Other feminist theory is grounded in conflict theory or symbolic interaction and deals with the sexist treatment of women patients by male doctors and the less than equal status of female physicians in professional settings and hierarchies. There is, however, no unified perspective among feminist theorists other than a "woman-centered" perspective that examines the various facets of women's health and seeks an end to sexist orientations in health and illness and society at large. Regardless of its widespread influence on many facets of contemporary theory in medical sociology, poststructuralism has its critics. Some argue that poststructuralism has been overtaken and surpassed by postmodern theory or, at best, cannot be easily distinguished from postmodernism. Others suggest that the perspective does not take limits on power into account, nor explain relations between macro-level power structures other than dwell on their mechanisms for reproduction; moreover, there is a disregard of agency in poststructural concepts, especially those of M. Foucault.

Peculiarities of medical sociology: application of social theories in analyzing health and medicine
Oppression based on gender exists in all aspects of women's lives and transcends contemporary cultures, economic systems, and even health care services. Radical feminism provides an alternative philosophic framework of health care that is based on a womencentered viewpoint, with the experiences of women as its unifying philosophy. Midwifery is a means to apply this new philosophic approach to the health care of women. A partnership between midwifery and feminist philosophy will allow women's voices to be heard, while guiding research in women's health care in new directions and illuminating new approaches to current health problems. The new millennium provides an opportunity to explore an alternative framework and philosophy that will change the current paradigm of women's health care (13).
By its very nature, the field of medical sociology has considerable potential for incorporating a consideration of gender in its research. After approximately a generation of the women's movement, women's studies, and the study of gender in sociology, now is an appropriate time to assess the impact of feminism on the mainstream of the field. Such an assessment is distinct from a feminist critique of medical sociology, with its implication that the field has many shortcomings, and also from a review of the growing sociological study of women's health and their role in providing as well as receiving care. The purpose to examine a representative research in mainstream medical sociology for evidence of the extent and nature of feminism's influence is necessary. Overall, one may argue that by the 1990s mainstream medical sociology has been significantly affected by feminism, but that this effect is qualified in important ways (14).

Poststructuralism
Poststructuralism concentrates on the dominant medical discourse, which has constructed definitions of normality (health) and deviance (sickness). This discourse provides subjects in modern societies with the vocabulary through which their medical needs and remedies are defined. The source and beneficiary of this discourse is the medical profession. Poststructuralism theorists also argue that medical discourse plays an important role in the management of individual bodies (what M. Foucault called "anatomopolitics") and bodies en masse (bio-politics). Medicine is not just about medicine as it is conventionally understood, but also about wider structures of power and control. The leading representative of poststructuralism is M. Foucault, who focused on the relationship between knowledge and power. M. Foucault provided social histories of the manner in which knowledge produced expertise that was used by professions and institutions, including medicine, to shape social behavior. Knowledge and power were depicted as being so closely connected that an extension of one meant a simultaneous expansion of the other. In fact, M. Foucault often used the term "knowledge/power" to express this unity. The knowledge/power link is not only repressive, but also productive and enabling, as it is a decisive basis upon which people are allocated to positions in society. A major contribution of M. Foucault to medical sociology is his analysis of the social functions of the medical profession, including the use of medical knowledge as a means of social control and regulation, as he studied madness, clinics, and sexuality. M. Foucault found two distinct trends emerging in the history of medical practice: "medicine of the species" (the classification, diagnosis, and treatment of disease) and "medicine of social spaces" (the prevention of disease). The former defined the human body as an object of study subject to medical intervention and control, while the latter made the public's health subject to medical and civil regulation. The surveillance of human sexuality by the state, church, and medicine subjected the most intimate bodily activities to institutional discourse and monitoring. Thus, bodies themselves came under the jurisdiction of experts on behalf of society (7).
Another area of investigation is the social construction of bodies, illness, and emotions. In medical sociology, the social constructionist approach is closely tied to M. Foucault and analyzes the body as a product of power and knowledge (12). It focuses on examining the manner in which people shape, decorate, present, manage, and socially evaluate the body.

Opportunities of development of medical sociology in Lithuania
In paradigmatic -basically directions of social theories -attitude contemporary medical sociology is rather differentiated and in some aspects fragmented. From the other hand, investigations, especially sociological, are usually deeper integrated in sociopolitical, socioeconomical, and sociocultural environment of certain social structure. Medical sociology in Lithuania as other social sciences as well should combine two things, which are far from each other: inherited conservative tradition of quantitative methods and more often interdisciplinary qualitative principals of social health coming from the Western world of science. The processes of international Raimundas Kaminskas, Žilvinas Darulis integration of science raise very important questions: what is the perspective of Lithuanian medical sociology in integrating in the wider and more dynamic context of directions of biomedical researches or different directions of public health researches? Should Lithuanian medical sociology remain as only passive watcher of processes running around? It is obvious that to answer to this question it would be necessary to evaluate the heritage of traditions of conservative quantitative researches and modern opportunities of development of qualitative researches. Any tradition creates certain pyramidical and hierarchical structures, which have the independent power as dominating norms and further support the existing and institutionalized meaning of science (15,16). Thus, the problems of differentiation of medical sociology are related not only to the possible administrative changes, but to the real relations of power and questions of institutionalization as well. The last mentioned are important because the definitions of medical sociology are substantially changing today -medical sociology is acquiring the peculiarities of multiparadigmatic academic activity. All this allows forming different, sometimes even alternative theoretical and empirical strategies of researches, which in overall orient towards the wider interpretation of the directions of contemporary medical sociology. While discussing the theories of medical sociology and proportion of methodology and methods, it is crucial to understand that social theories, which are based on the certain theoretical paradigm, are not the final consequence of academic investigations or approximately set collection of truth which covers the direct historical perspective. The latter attitude pays an important role for methodology, which helps to understand that social theoretical paradigms as systems of reading and the choice of certain methods of researches are not set once for ever. Medical sociology and its branch, sociology of health and medicine, are not only the sciences of accumulative nature as, for instance, nature sciences but the science of critical thinking and interpretational nature as well. One of the main aims of medical sociology is to understand, evaluate, and forecast the social problems of health in different levels of the analysis of society (for instance, levels of community, regional, societal, and global levels), which come from their general source -experience. It is vital to combine aspects of experience and thinking. Theoretical activity is also both observing and taking part in analytical (interpretational) researches. That is why it is important for medical sociology to participate in investigating intellectual, ethical, or political health problems of Lithuanian society. It is important to note that strategy mentioned promotes critical evaluation of methodological problems of researches, especially too much pretentious tradition of positivism, which was dominating during the 20th century and is still dominating in contemporary Lithuanian medical sociology. Thus, the question whether we should think about the training of professionals of medical sociology in Lithuania comes. Recent graduate of high medical school in Lithuania is very much familiar about the cells, human organs, biochemical structures, and so on, but seeing the offered list of subjects to study, there is a doubt whether graduate is aware enough about at least core peculiarities, interactions and relations of individual, as social being and society, as the system, whether graduate is able to analyze these questions in certain level? This doubt comes to the statement that high medical school in Lithuania should paid more attention to the place of different sociological disciplines in the context of both study and research programs. Besides, it is vital today to reorient medical thinking in Lithuania in the direction of sociologization within the society and medicine itself; it is important to develop not only researches of medical sociology but theory as well and construct certain Lithuanian terminology using the Western standards and experience. It is the time to think about the establishment of the association and specialized scientific journal of medical sociology (sociology of health), which would stimulate the development of medical sociology in Lithuania and would help to tackle the retardation of it from the Western part of the world related to the past experience and events. Thus, it is logically to think that in the present and in the future, it would be purposive to work systematically in developing the studies and researches of medical sociology in Lithuania. The attempts of looking for the reasons and explanations of medical phenomena not only using demographical approaches but sociocultural contexts as well show that medical sociology has very good opportunities to develop and reflect the strivings to explore the winnings and achievements of public health science more effectively and oriented towards the improvement of human well-being in every country (17)(18)(19)(20).

Conclusions
More and more attention in various areas of medical activities is being paid to the social aspects (both individual and society levels) of these activities, and there is a shift from applied sociology towards medical one being asserted. Despite the cessations of the development of medical sociology as separate branch of sciences, the researches of recent years are demons-Peculiarities of medical sociology: application of social theories in analyzing health and medicine trating obvious approaching modern research issues and methods, which do exist in contemporary world. Such tendencies show the prompt approaching of the academic community of Lithuania the general scientific standards which are dominating in the globalization-effected world.