The Social Sciences and Public Health

Dawn Miller, M.A.

"...there is a need to utilize behavioral and social science and research

methods now to address emerging public health problems.”1

Introduction

            There is a growing interest in utilizing theories and methodologies from the behavioral and social sciences in the study of health and disease.  Medical researchers and health care personnel are increasingly confronted with complex disease conditions that can not be addressed solely with medical treatments.  Furthermore, the World Health Organization and subsequently other institutions have defined health in a holistic manner that not only includes the absence of disease, but also emphasizes social, emotional, and physical well-being.  In response, more emphasis has been placed on the contextual aspects affecting health, including social, behavioral, political, and economic factors.  The social sciences, particularly medical anthropology, have a rich research history focused on social relations and human behavior. The theories and methodologies employed in disciplines such as medical anthropology offer tools for understanding the social and behavioral factors underlying health and disease, illuminating options for health interventions and for shaping public health policy. 

This chapter summarizes the relationship between the social sciences and public health. First the historical relationship between the social sciences and public health will be reviewed.  Then, contemporary approaches to public health research from a social science perspective will be presented through health research examples combining social science and epidemiological methods. Finally, directions for future research will be suggested that combine quantitative and qualitative approaches in a complementary manner.

Historical perspective on public health and the social sciences

Public health has at various times throughout its history adopted a social science perspective in the study and control of disease. For example, in the 1800s, Rudolf Virchow emphasized the social and cultural causes of disease in his public health work.2  Epidemiologist William Farr pointed out social factors, such as class differences, that were related to differential patterns of disease. John Snow, another 19th century epidemiologist, utilized behavioral type research to illuminate the transmission of cholera long before the causal agent was identified.  Finally, sociologist Emile Durkheim also influenced the behavioral focus in epidemiological research with his studies on suicide.2

While a social and behavioral focus on disease remained popular in public health until the late 1800s, that focus shifted with the isolation of pathogenic organisms as disease causing agents.3  Social and behavioral factors in health lost their relevance as antibiotics and other treatments were developed that specifically targeted disease conditions. The bacteriological paradigm was dominant in research and public health throughout the late 19th and into the early 20th century.3, 4

Around this time, the epidemiological profile in the United States began to change.  As morbidity and mortality from acute infectious diseases decreased, chronic and degenerative conditions in the population increased, a change that has been referred to as the epidemiological transition.5  The correlation between causative agent and disease was no longer as clear as it once was.  Chronic conditions such as coronary artery disease, stroke, and cancer presented more complex challenges to researchers and public health officials.  Individual lifestyles and risk behaviors began to receive more attention in the search for successful health interventions.

The recent emergence of infectious diseases, such as HIV/AIDS, and the resurgence of others such as tuberculosis, have compelled public health researchers and policy makers to re-conceptualize the way in which they study and treat disease. Researchers have begun to examine a variety of factors in addition to behavior patterns—the physical environment, socioeconomic status, and political influences—looking for correlates to disease in a complex web of causation.4, 6  Researchers are taking into account not only population level incidence and prevalence rates but also the ways in which individuals conceive of and experience disease.  Thus, “[t]raditional public health focused on disease and its causes and on the behaviours of individuals; the new public health is also concerned with how people experience diseases and how economic, social and other environmental factors affect health.7

This new focus in public health requires an expansion of theories and methodologies to accommodate a more complex study of health and disease.  While traditional epidemiological theories and methods have been well-suited to describing disease trends across and within populations and for identifying single causative agents linked to disease, they have been less successful in illuminating the larger context in which health is situated.  The social sciences are particularly well-suited to provide tools for research that can help to identify more complex links to health and disease. 

Application of social science theories and methods to public health research

Social sciences, such as medical anthropology, have much to offer public health in understanding the structural and behavioral determinants of health.  First, these theories are often meaning centered; in other words, they privilege individual experience of health and disease.  This emphasis on individual meaning can illuminate barriers to seeking and receiving health care, and clarify behaviors that stand in opposition to the improvement of health.  These theories often take as their starting point the cultural and social construction of health and disease.8, 9  This is useful, for example, in accounting for differences between ethnic groups in their conceptualization of disease and desired medical treatment.  Political economy approaches within the social sciences examine the role that larger structural factors—local, regional, and national political and economic policies—play in shaping public health policy and health care services.  The intersection of meaning, behaviors, and structural determinants of health in the social sciences, then, offers a much more complex picture of health that can lead to more effective policies and interventions.

Social science disciplines offer methodologies that are complementary to those currently utilized in epidemiological research.  While quantitative methods traditionally employed in public health research are useful for identifying trends in the population level health, measuring incidence and prevalence rates of disease, and correlating some causative agents with disease conditions, a qualitative approach provides for a richer understanding of health.  Qualitative data often reveal the reasoning underlying non-protective health behaviors and the less than successful outcomes of many health interventions.  The two approaches can be utilized in a complementary manner, illuminating both what is going on within a particular population, and why a certain trend may exist resulting in a much more complete picture of health and disease.10

            Qualitative methods differ from more quantitative approaches in several ways.  First, qualitative methods, by the nature of their structure, involve in-depth study of fewer individuals than quantitative approaches.  Researchers often administer semi-structured interviews to respondents in a conversational format.  These interviews consist of the same questions posed to each respondent, yet are open-ended meaning that respondents can elaborate on their answers without being restricted to pre-determined choices.  Qualitative interview instruments are generally subjected to the same type of reliability and validity tests as scales and surveys, to ensure that questions tap the intended domains, are valid for the population under study, and produce data that can be collated across individuals.8, 9, 11

            Observation is another commonly used qualitative data gathering method.  It has been well-documented in the behavioral literature that incongruence exists between what people say they will do in a particular situation versus how they actually behave when faced with that situation.8  Related to health, it has been demonstrated that having information about a disease does not necessarily translate into taking preventive action related to that disease.12  Therefore, simply asking a person what he or she may do in relation to treatment and health prevention may reveal very different information than observing what that person does in a particular situation.  Research on child and adolescent health, for example, is one area in which observation may reveal more than the administration of interviews. 

            Conducting focus groups is another useful method for gathering qualitative information related to health behaviors, interventions, and policy.9, 13  Generally, eight to ten people are gathered together in a group facilitated by a moderator who poses questions for the participants to discuss over the period of an hour or two.  In this manner, researchers can gain quick insight into health issues.  Data from focus groups can be utilized in conducting a preliminary needs assessment for a community, in helping to design research instruments that will be utilized in later research, and for assessing conceptions and experiences of disease.

While qualitative approaches yield more varied and complex information than quantitative methods, data analysis often presents a challenge to researchers.  While scales and surveys can be coded and statistically analyzed in a rapid manner, qualitative data analysis is more time consuming.  Observational notes and transcripts from tape recorded interviews must be analyzed for their content before anything can be said about the data.  Qualitative data analysis software packages such as Atlas.ti and Nudist streamline this process, and can interface with quantitative software such as SPSS.14  Interviewee responses are grouped according to narrative themes that repeat themselves across interviews, and are analyzed for both their frequency and their context.  In this manner, variables for analysis are not necessarily determined beforehand, but are compiled based upon the data.15  This is not to say that the researcher begins data collection without hypotheses and variables in mind for analysis; rather, salient variables derived from qualitative data often illuminate unanticipated domains which may not have been part of the original research question.  This is extremely useful in investigating behaviors related to health, particularly when survey instruments and scales often do not capture the full range of possible responses.  Finally, narrative data from qualitative methods can be linked back to theoretical concepts within a body of literature, using the grounded theory approach.16

Health research examples

            Social science theories and methods have been utilized in numerous studies of health and disease to both better understand social, behavioral, and structural factors and to contribute to the design of health interventions and public policy.  Three examples—HIV/AIDS, adolescent psychosocial health, and mental illness—will be presented here.  These examples illustrate the ways in which behaviorally focused research can complement epidemiological studies in delineating aspects that contribute to complex  health issues, along with suggesting options for interventions that improve health outcomes. 

            Research on sexually transmitted infections is one area in which social science research has contributed much to the understanding of disease transmission and to the design of intervention programs.  This is a salient issue as the United States has the highest rates of sexually transmitted infections in the developed world and higher rates than some developing countries.17  The study of behavior has been particularly important in the case of HIV/AIDS.  For example, “HIV prevention research using approaches grounded in behavioral and social science theory has been shown to be effective in reducing risk behaviors among a number of high-risk populations."18  Theoretical paradigms such as the Health Belief Model posit that a person must feel personally threatened by disease, and furthermore, must believe that the benefits of prevention outweigh the costs.12  Qualitative research has in many cases illuminated the reasons underlying the hesitance to engage in health protective behaviors related to HIV/AIDS.  Often this hesitance relates to cultural and social conceptions about the disease itself and the meaning derived from engaging in protective behaviors. 

            Once these meanings are understood, bringing about behavioral change, both on an individual and often on a community or even national level, presents a challenge.  Educational programs aimed at providing information about the transmission and prevention of disease have often produced few results, again because of the relation between perceived risk and the benefits of prevention.  Thus, "[w]hat the behavioral sciences have to offer to those interested in developing effective interventions is a clearer understanding of the types of information that people need for changing or maintaining a given behavior.”19  Changes in self-reported sexual behaviors have been documented at the individual and community level; many of these changes have been directly attributable to behavioral interventions produced from social science research.17  Finally, major institutions involved in research and prevention of HIV/AIDS have recognized the benefits of social science research: “At the Centers for Disease Control and Prevention, we agree with the Institute of Medicine's assessment that a solid understanding of the comparative effectiveness of behavior interventions is essential to control the epidemic of HIV infection and AIDS, and that this knowledge will require a long-term commitment to behavioral research related to HIV-AIDS prevention.”20

            Adolescent psychosocial health research is another area that has benefited from a social science perspective.  Psychosocial health has been found to explain as much as 77% of the variance in physical health of adolescents.21  Underlying adolescent psychosocial health status are factors such as willingness to seek help from social support networks and medical professionals.  Social science research has illuminated gender differences in seeking help, and the sources from which an adolescent is likely to seek assistance.  For help with emotional and behavioral problems, for example, females tend to seek assistance from friends and family, while boys often rely on their fathers for problem solving.22, 23  In both cases, family and friends tend to be the first source for help rather than health professionals.  And while quantitative methods can document aspects of the social network, such as density, geographic location, and how often a person interacts with those in his or her network, qualitative methods can reveal the quality and influence of these relationships on health outcomes. While social networks were once assumed to be health protective and adaptive on the basis of more social support equaling better health outcomes, behavioral research has demonstrated that social networks often contribute to negative health outcomes.24, 25

             Finally, social and behavioral research can contribute to a better understanding of mental illness and the medications utilized in treatment.  By combining a meaning centered qualitative methodology with more traditional quantitative approaches, a more holistic picture can be obtained both of the experience of mental illness and the efficacy of treatments related to that experience.  For example, in an on-going study of schizophrenia, culture, and atypical antipsychotic medications, researchers are using a combination of quantitative and qualitative methods to document medication adherence and to understand the experiences of medications and illness among out-patients.26 Quantitative instruments are used to gather data on prevalence by gender, ethnicity, and socioeconomic status, for example.  In-depth semi-structured interviews conducted with the patients reveal their perceptions about the illness and the medications used for treatment. 

In these interviews, participants have elaborated on their experiences with various medications, their strategies for coping with mental illness, and their progress with recovery.  These reasons for adherence and non-adherence to medication regimes are often not revealed in the clinical encounter to physicians and are not well understood by pharmaceutical manufacturers.  Semi-structured interviews, along with observations, reveal much more of the context in which patients are making decisions about their treatment and ultimately their recovery.  Themes in this data about medication adherence, which often form repeating patterns across patients, can be integral in designing better treatment programs and medications that are more congruent with patient expectations for their lives.   

Future research

            One emerging area of public health research in which behavioral and social science perspectives will be crucial is that of health disparities possibly resulting from social inequalities.  Recent epidemiological research has begun to focus on disparities in health related to relative income levels within populations.27, 28  It is hypothesized that social inequalities based on income and ethnicity/race may produce differential health status and outcomes through psychosocial pathways.27  Researchers have also begun to focus on the concepts of social cohesion and social capital both within communities and within nations as factors underlying health status.27, 29, 30  Preliminary research indicates that there may be a positive relation between the sense of community that individuals perceive and their health status.  Further research is needed, however to more fully assess the possible linkages between social inequalities, social cohesion, and social capital and health to better understand how they may be related.  Again, a mix of epidemiological and social and behavioral theories and methodologies will be necessary to present a more comprehensive picture of how these concepts may impact health.   

Conclusion

            The relationship between the social sciences and public health has been one of varying degrees throughout the past two hundred years.  Early in public health, much emphasis was placed on the social and behavioral determinants of health.  As the bacteriological paradigm gained currency, social approaches to health waned.  In response to a changing epidemiological profile, however, researchers in public health have once again become interested in the numerous contextual factors related to health status to include structural, political, and economic aspects in addition to individual behavior.  The re-emergence of infectious diseases as contributors to mortality, in addition to the increase of chronic and degenerative diseases, have led to a changing focus in public health research, intervention programs, and policy.  Furthermore, hypotheses about the relationship between social inequalities and health, and community or social cohesion and health, require a much more complex approach to research.  The social sciences, with theories focused on human behavior and structural constraints, along with methodologies that elicit in-depth contextual data on the social and cultural constructions of health and illness, offer a necessary complement to more traditional epidemiological approaches in addressing urgent contemporary health issues.

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