Care for Major Health Problems and Population Health Concerns: Impacts on Patients, Providers and Policy: Volume 26

This chapter provides an introduction both to some major issues and concerns in the area of population health and major health problems, especially chronic health problems, and to the overall volume. The topic of population health is reviewed, beginning with the more public health approach of Kindig and that attempt to define the term and the outcomes of interests. The chapter will then move to an examination of the linkages between population health from a more specifically sociological perspective, and especially to relationships between social structure, including socioeconomic status, and health. The last part of this introductory chapter briefly discusses the other sections in the book and each of the chapters within those sections.

Although much is known about inequalities in the prevalence of CHD, less is known about the barriers experienced in self-managing it. Questionnaires, focus groups, and Internet forums were analyzed to explore obstacles in self-managing CHD. Most people found it difficult and costly to maintain a healthy lifestyle. Gender inequalities included women being more likely to live on their own and with a lower income. Marital status was an issue as several were either caring for an ill spouse or were coping with their recent death. Socio-demographic factors played a key role in influencing people's ability to manage their CHD.

Arthritis is the most prevalent chronic condition in persons ages 65 and older and is projected to increase substantially as the population ages. The purpose of this research is to assess if age, duration of arthritis, and severity of arthritis exert independent effects on various aspects of the disability process: functional limitations, activities of daily living (ADL) limitations, and instrumental activities of daily living (IADL) limitations. Type of arthritis, socio-demographic factors, behavioral factors, and additional health statuses are also examined. Using longitudinal data from the Health and Retirement study, results show age and severity of arthritis are related to the number of functional limitations one has and to the odds of having ADL and IADL limitations. Duration of arthritis is positively related to functional limitations and to the odds of reporting ADL limitations. Duration of arthritis is not significantly related to IADL limitations, which are strongly linked to performing social roles and have less to do with physical functioning compared to ADL tasks and functional tasks. There is no difference between those with established arthritis compared to those who have had it for a shorter time period, suggesting those with arthritis adapt to social tasks better than physical tasks. The resources used to cope with IADL limitations may be more effective over time compared to those used to cope with functional limitations and ADL disability. Understanding the context of functional limitations and disability among those with arthritis may lead to improved support and care for those living with arthritis.

In this chapter I explore how conflicting discursive claims made by the medical community are consequential for bariatric weight loss surgery patients. Bariatric surgery has become increasingly common in the United States since the 1990s, with over 177,000 Americans undergoing surgery in 2006. Despite the surgery's growing popularity, the US medical community does not wholeheartedly endorse the surgery. Rather, different members of the medical community espouse contradictory evaluations of weight loss surgery. I broadly characterize this intra-medical community controversy and, then, discuss how conflicting claims have helped shape the bariatric surgery industry's discursive conception of an “ideal patient.” Next, I analyze actual patients’ negotiations of the ideal patient archetype, and find that patients’ responses follow three paths: embracing the ideal, having a mixed response to the ideal, and strategically complying with the ideal. As patients are compelled to grapple with the ideal archetype in order to access surgery, I conclude that the ideal archetype acts as a discursive frame connecting individual patients to broad bariatric surgery discourses.

Medical encounters are interactional/interpersonal processes taking place within contexts shaped by macro-level social structures. In the case of sexually transmitted diseases (STDs), medical encounters occur at a stigmatized crossroads of social control and gendered norms of sexual behavior. When women are diagnosed and treated for chronic STDs, practitioner demeanor has an important impact on how patients will view not only their health status but also their moral status. This chapter draws on in depth interviews with 40 women diagnosed with genital infections of herpes and/or human papillomavirus (HPV – the cause of genital warts) to explore three models of patient–practitioner interaction. The analysis focuses on the relationship between gender, construction of illness, and practitioner interaction style. In a broader context, the health risks posed by particular interaction styles to female STD patients shed light on larger public health implications of combining morality with medicine for the broader range of patients with stigmatizing diagnoses.

Women with HIV have increased longevity and the potential for decreasing mother to child transmission with the use of antiretroviral therapy. Since the beginning of the AIDS epidemic in 1980, the disease has evolved from an acute condition to a chronic one. How have women long-term survivors transitioned from a “death sentence” to living with HIV/AIDS as a chronic illness? In this study, we investigate the reproductive, mothering, and living experiences of HIV positive women 10 years after their participation in a study of their reproductive decisions. The sample was taken from two groups of women living with HIV (n = 60), one in Oakland, California (n = 30) and one in Rochester, New York (n = 30). Both groups participated in the initial study (1995–2001). The inclusion criteria for this study are women with HIV who are living and well enough to participate in a face-to-face interview. Of the original 60 women, 52 women are living. Two and one half years into this 4-year study, the author has completed interviews with 25 women from Oakland (n = 10) and Rochester (n = 15). An unexpected life with HIV challenges participants to live a viable life different from their pre-diagnosed life. It involves a life of defining normalcy in everyday experiences and building a legacy of a life worth living. Participants’ issues and concerns of living with HIV/AIDS identify what kinds of cultural notions, and medical and social interventions support or undermine women's reproductive, mothering, and long-term living with HIV/AIDS.

This chapter explores how primary care physicians deliver mental health treatment for Medicaid patients in one county in the United States, and how treatment may have changed after HMO enrollment with a mental health carve-out. We utilize Lipsky's theory of street-level bureaucracy to better understand how primary care physicians treat Medicaid patients for depression and what types of insurance arrangements support or inhibit that treatment. Exploratory interviews with 20 physicians revealed that the patient's status as a non-voluntary client, service system barriers and physicians’ commitment to treatment caused them to bear primary responsibility for the majority of depression care. Physicians were willing to act as advocates for their clients and viewed such advocacy as ethical given the lack of mental health parity. In general, primary care physicians were not familiar with new policies dictating mental health carve-outs for Medicaid patients, nor were they concerned with how mental health care was reimbursed for their patients. However, they were willing to provide mental health care even if they were not reimbursed. Physicians rely upon medication management to treat depression, and reimbursement plays a role in the amount of time spent with patients and in the coding used for the visit. Lipsky's (1980) theory of street-level bureaucracy provides a useful framework for understanding how physicians will act as advocates for their clients in the face of structural as well as resource constraints on health care.

Objective: Our study examines the association between social support and use of mental health services in Asian American men and women. Specifically, we report on the association between types of social support and types of health services used (general medical care and specialty mental health care).

Method: We use data from the National Latino and Asian American Study, a nationally representative survey of the US household population of Latino and Asian Americans. Our present study is based on data from the sample of Asian Americans (N = 2,095).

Results: Overall, our findings suggest that Asian Americans use general medical care services more than specialty mental health care. Our findings also showed variations in levels of social support, and the use of health services among different Asian subgroups (Vietnamese, Filipino, Chinese, and Other Asian) and nativity status (US-born versus foreign-born Asians). Specific types of social support influenced the use of specialty mental health care services, while other types of social support inhibited use of specialist services.

Conclusion: Compared to using generalist services, Asian Americans demonstrated lower rates of using specialist services. Our results emphasize the importance of considering other social factors to explain between group differences as well as factors contributing to the underutilization of specialty mental health services by Asian Americans.

The homelessness of those 50–64, older homeless people, is a growing problem in the United States. This chapter seeks to understand the unique healthcare issues faced by this population. Data in the city of Chicago was collected and analyzed through a variety of qualitative and quantitative methods. Data included answers to survey questions by older homeless individuals, interviews with providers and older homeless individuals, focus groups with older homeless individuals, and agency data from homeless service organizations. Findings agree with previous research that shows a growth in the homeless population, the greater number and severity of health problems in the population, the significant number of barriers that the population encounters in obtaining health care, housing, and jobs, and the concern with preventative health that the older homeless have. After outlining these findings, this chapter offers policy and program recommendations for the larger health care and homeless service systems.

The urbanization of poverty is a structural trend embodied in the sprawling urban slums of the developing countries. It remains a largely unacknowledged dynamic. This is particularly true in terms of the population-level patterns of social well-being derived from urban slum prevalence or proportion of the total population living in urban slum conditions. In particular, there is increasing evidence of an “urban penalty” wherein urban slum dwellers exhibit poorer health outcomes than non-slum urban residents and even rural populations. We articulate the proposition that urban slum prevalence is a key factor shaping population-level rates of social well-being in the developing countries, measured at the national level. Further, we develop the proposition drawn from political economy of health theorization suggesting cross-national dependency relations substantially influence urban slum conditions. In turn, the structural dynamics of the world economy underlie urban slum prevalence which itself has a direct influence on population-level patterns of social well-being as measured by infant and under-five mortality, maternal mortality, and life expectancy at birth. We conclude by arguing for greater empirical attention focusing upon the consequences of dependency relations as expressed in the built urban environment and the impact of urban slum prevalence as a key social condition impacting well-being in the less developed countries.

Health care has become one of the paramount issues of the 21st century as governments and individuals grapple the complex problems associated with contemporary medical care such as cost, affordability, and shifting demographic trends. One response has been the growth of medical tourism (sometimes called health tourism or global healthcare). Medical tourism is an example of how the forces of globalization are re-shaping what has previously been a relatively stable localized service, medical treatment, in the face of changes to health care. While traveling to distant locations in search of health restoring locations is not new as the affluent have long traveled to spas or exotic locales to derive health benefits. What has changed is who is doing it and why they are doing it as insurers and patients alike become eager participants in the outsourcing of medical care. The rising number of uninsured and underinsured Americans, particularly in the middle class, has been coupled with effective marketing by medical tourism companies to produce growing numbers of Americans traveling to foreign countries for healthcare. China, India, Korea, Malaysia, the Philippines, South Africa, and Thailand are only a few of the competitors for overseas patients as a source for economic development. Using analytic frameworks of Immanuel Wallerstein and Anthony Giddens to provide a social analysis of this phenomenon yields an exploration of this trend.