Formal Medical Care Research Articles

Ethnographic Research in Medical Sociology

Medical sociology ranges from studies of formal medical care to those of health, healing, and caring practices outside the health care system. This field has had a history of ethnographic and qualitative research since its beginnings. Because few studies in medical sociology derive from immersion in a setting, the authors examine those qualitative works in which researchers and subjects had sustained contact. They focus only on major areas in which ethnographic contributions have clustered: (1) disability, chronic illness, and terminal illness; (2) caring and curing; (3) medical sociology in aging research; (4) socialization into health care professions; and (5) the ethnography of ethics. Throughout this review, the added value of ethnographic research to each specific area is noted. Ethnographic research has enriched medical sociology with its emphasis on descriptive detail, meanings, ongoing processes, and concepts. The article ends with a discussion of methodological considerations for conducting research and a summary statement.

Low utilization of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma.

Assessment of the societal importance of trauma relies, in large part, on hospital and other health service data. Such data are of limited value in developing nations if a significant proportion of injured persons do not receive formal medical care. We undertook an epidemiologic study of trauma in Ghana. Via household visits, we surveyed 21,105 persons living in 432 urban and rural sites. During the preceding year, there had been 13 fatal injuries (62 per 100,000) and 1,597 nonfatal injuries resulting in > or = 1 days of lost activity (7 per 100). Of the fatally injured, only 31% received formal medical care (hospital or clinic). Of the nonfatal injuries, 58% received formal care, but with major differences between urban and rural sites. Only 51% of rural injured received formal medical care, compared with 68% of urban injured (p < 0.001). Even among those with more severe injuries (disability time > or = 1 month), 26% of rural injured never had formal care. Overall hospital use was especially low, with only 27% of all injured persons using hospital services. Among those with more severe injuries, 60% of urban, but only 38% of rural injured received hospital care (p < 0.001). These data indicate low utilization of formal medical services by injured persons in this developing nation. Even many of those with severe injuries do not receive medical care, especially in rural areas. Assumptions that rely on health service data, especially hospital data, underestimate the importance of trauma. Appropriate commitment of health care resources might thus be affected. Population based data are needed to fully assess the extent and societal impact of injuries in developing nations.

Clinicians must lead

All NHS consultants can recall the day when the chairman of a consultant appointments committee told them that they were the successful candidate and that the hospital looked forward to their contribution to its life and development. All consultants begin their career with two major ambitions, firstly, to continue to be good doctors and provide their patients with the best possible individual care, and, secondly, to introduce new forms of medical care. These laudable ambitions have driven medicine forwards for centuries. Their prime purpose is not, or should not be, self aggrandisement or worldly riches—they are the ambitions of our profession for better medicine, the sole purpose being better patient care and human health. But the ambitions can be achieved only if each one of us has sufficient independence to introduce or develop the ways and means necessary to fulfil them. Over the past four years, while president of the Royal College of Surgeons and now chairman of the Joint Consultants Committee, I have observed a steady deterioration in hospital doctors' morale. Many …

Health care and the wayman A.M.E. church

Research conducted at the Wayman African Methodist Episcopal (A.M.E.) Church in Bloomington, Illinois, underscores the multifaceted role of the black church. Although the Wayman A.M.E. Church served as a religious center, medical artifacts from excavation suggest the church as an institution provided health care to segments of the congregation and local community during the late 19th and early 20th centuries. Historical information in combination with archaeological data illustrate a dual health care strategy was practiced by the congregation. This dual strategy was based on the use of both traditional, or folk, healing practices and formal medical care. More importantly, the health care artifacts highlight the inequality that blacks have experienced in obtaining adequate medical care. Corresponding temporally to a series of epidemics in Bloomington, the health care artifacts suggest the church congregation did not passively accept the inequality characteristic of the period.

Generational Change, Folk Medicine, and Medical Self-Care in a Rural Appalachian Community

This paper reports on a study of the potential impact of folk medicine on health care delivery in a rural community in southwestern Virginia. The intent of the investigation was to examine some commonly held stereotypical notions within and outside the medical community about rural Appalachians and medical self-care. Interviews were completed with 102 respondents aged 60 and over who were asked what they would do today and what their parents did when they were growing up to treat 65 symptoms of illness. Responses were grouped into 11 treatment categories, including botanical, non-processed natural substances, foods, home articles, proprietary medicines, other commercial medicines, magico-religious, and formal medical care and then analyzed in terms of generational change. Our findings indicate that dependence on folk medicine has declined considerably from one generation to the next, particularly with regard to the application of traditional home remedies and magico-religious beliefs and practices. Contra...

The utilization of formal medical services for young children. The lack of impact of medical professionals in social networks.

The objective of this study was to examine the impact of medical professionals in social networks on the use of formal medical care for young children's minor illnesses. 795 Swedish mothers, with only one child 5-15 months of age, were randomly sampled. The mothers were interviewed by telephone and complete interviews were conducted with 92% of them. Of the 795 mothers, 84% had a relative or friend and 24% had a physician or nurse within their social networks whom they could contact for advice and support when their children became ill. No associations were found between the mothers' access to advice and support from medical professionals within their social networks and the number of formal medical contacts for their young children's illnesses. Similarly, no associations were found between the mothers' access to advice and support from lay persons in their social networks and the use of medical services for their children.

The cost of cancer home care to families

For the most part, previous research on costs of cancer care has focused on the formal medical care costs. Research on home care for patients with cancer has emphasized direct care costs (expenditures). Among indirect costs, only loss of income to family members has been studied. However, a major component of indirect costs, the family labor expended to care for the patient with cancer, needs to be included for a more realistic appreciation of home care costs. The costs of family labor are estimated by imputing monetary values for the time spent caring for the patient with cancer. The assigned monetary cost either is equated with income losses of the helper in question or is based on a putative market value of the expended labor time. In addition, out-of-pocket expenditures examined in this study cover all cancer care-related expenses for which the patient was not reimbursed by third parties. Data were obtained from a convenience sample of 192 patients with cancer and their families in lower Michigan. When family labor is included in the cost calculations, average cancer home care costs for a 3-month period ($4563) are not much lower than the costs of nursing home care. The substantial variation in home care costs (standard deviation [SD] = $4313) appears to be unrelated to the type of cancer diagnosis, type of treatment, or time since diagnosis but seems to be driven by the functional status of the patient and the family living arrangements. Outpatient care for patients with cancer coupled with greater reliance on home care appear to be economically attractive because costs to families usually are underestimated.

Use of self-care by Hispanics: culture, access or need?

Hispanics have often been depicted as being avid users of traditional self-care who are skeptical of the formal health care system. This study used descriptive statistics and multiple regression analyses to examine the self-care practices of Mexicans and Puerto Ricans living in Chicago. The findings provide evidence that Hispanics are not excessive users of self-care and underutilizers of formal medical care. Though both groups used non-prescribed-home-treatments, they did so at rates comparable to those reported for the general population.

Trends in use of health care services in Swedish primary care district. A ten year perspective.

In a study that covered ten years a questionnaire about use of health care facilities was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district with three health centres. Primary care was the health care form with the greatest contact area with the population studied. However, the strengthening of district physician resources at one of the three health centres did not, in the long term, lead to more people coming into contact with this form of medical care. It was more common for those who visited a private doctor or school/company doctor also to consult a district physician than vice versa. Similarly, hospital patients visited the health centre to a greater degree than patients of health centres visited hospitals. The only long-term change in the flow of patients that could be registered was a reduction in the number of patients who visited hospital emergency departments. It is concluded that the implementation of an annual survey may be considerably more helpful than more sparse investigations in distinguishing between temporary fluctuations and real changes.

Care Seeking for Musculoskeletal and Respiratory Episodes in a Medicare Population

Responses to episodes of musculoskeletal illness, musculoskeletal injury, and respiratory illness are examined separately. Data are from a 1-year longitudinal study of the illness experiences of 885 Medicare recipients. Unlike studies examining aggregate use of medical services, this study examines both episodes for which medical care was sought and episodes for which no medical care was sought. Both factors associated with the decision to seek medical care for each type of episode and the illness response patterns associated with whether medical care is sought are analyzed. The three types of episode have different characteristics and profiles of illness response. Perceived seriousness and duration of the episode are the best predictors of physician visits for all episode types. However, the relative effect of predisposing and need variables on the decision to seek medical care is greatest for musculoskeletal illness episodes. These data also bear on the relationship between self-care, informal care, and the use of formal medical care. Use of nonprescription medications is shown to substitute for medical care in a significant number of illness episodes. Lay consultation and restricted activity are often linked with physician visits; however, they cannot be assumed to precede care seeking. The analytic strategy of examining responses to specific types of episodes suggests that both characteristics of the person and characteristics of the illness affect how people respond to illnesses and that the relative importance of each type of characteristic is specific to each illness type. Implications of these findings for health education are discussed.

Legal Issues in Surgical Care of Elderly Persons

ABSTRACTSurgical care of elderly persons focuses many of the difficult legal and ethical dilemmas that have arisen in modern medicine. Such issues arise at both macro and micro levels. This paper explores four micro level areas involving physician-patient interaction. These are: informed consent, dying patients, pain relief treatment and medical research, when the patients involved are elderly persons.The discussion of informed consent includes consideration of refusal of treatment, scope of information, voluntariness, coercion and competency. In particular, the basic presumptions are articulated and variations in the application of these concepts, when aged persons are involved, and justification of such variations, are considered. Within the topic of dying elderly persons, the “living will” and “durable powers of attorney” are discussed. The obligation to provide pain relief treatment can be particularly important in the context of terminally ill and dying persons and it is suggested that there should be a legal obligation to provide such treatment, including in some circumstances, where the treatment could possibly, or even is likely to, shorten life. Finally, aged persons' participation in medical research and the special problems that can be involved in this are addressed.In conclusion, it is suggested that the greater visibility and identification of old persons needing surgery than of those needing some other forms of medical care is likely to make this an important arena for setting far-reaching precedents regarding humane approaches to, and human rights in, access to and provision of medical care.

Substitution between prescribed and over-the-counter medications.

Using data from the Health Insurance Experiment (HIE), this article examines use of over-the-counter drugs (OTC) in a general, nonelderly population. Families from six areas of the country were assigned to health insurance plans that varied in the amount of medical care cost sharing. Thus, the out-of-pocket prices of OTC relative to prescription drugs were experimentally varied. The sites were chosen to represent markets with differing access to physician services. Multivariate methods were used to relate OTC use (collected from bi-weekly health diaries) to cost sharing and demographic variables. The empirical results do not support the expectation that people assigned less generous insurance for prescription drugs substitute OTC for prescriptions. People with complete insurance coverage purchased more of both types of drugs, suggesting OTC are an adjunct to formal medical care, rather than a substitute for it. Better educated and more knowledgeable consumers used more OTC drugs and spent more of their drug budget on OTC products. That there was greater OTC drug use in HIE sites with poorer access to formal medical care suggests there was some substitution between formal care and self-care with OTC drugs. Overall, however, better financial access to formal care promotes rather than substitutes for OTC use.

Informed Consent in the Post-Modern Era

The doctrine of informed consent' is intended to get physicians to talk to their patients so that patients can make reasonably knowledgeable choices about whether to undergo particular forms of medical care. Although the law has long prohibited treatment without the patient's consent,2 physicians have resisted the idea that treatment decisions ultimately are for the patient to make. Only recently have physicians been willing to disclose information about the benefits and risks of recommended thera-

Family size, illness and use of medical services among preschool Colombian children.

There is a paucity of information about the role of family size and other predisposing and enabling factors in the decision to use medical services among Latin American families. This report presents further findings from a Colombian study in which such characteristics of pre-school children are related to use. A case-comparison study was designed in which ‘cases’ were those mothers of children 0–4 years old who did not use medical services for their pre-school child within the last year. The comparison group was user mothers. There is no statistically significant independent association between illness and use of medical services when both family size and child's age are controlled in analysis. Findings have implications for the style of the delivery system and suggest house-to-house visits by health workers is the most useful way to overcome the non-user mother's tendency not to enter the formal medical care stream.

Do-Not-Resuscitate Orders for Critically III Patients in the Hospital

We studied compliance with do-not-resuscitate (DNR) orders at a university hospital where a DNR protocol has existed since 1979. Documentation of DNR status in patient progress notes and chart orders increased through 1983. During a 12-month period (March 1983 through April 1984), we studied in detail the medical records of 521 patients who had a cardiopulmonary arrest in the hospital. Seventy-five percent (389 of 521) of these patients were designated DNR. Patients who were designated DNR were significantly more likely to be older, to have malignancy or an abnormal mental status, and to be less likely to have acute myocardial infarction, stroke, or chronic obstructive pulmonary disease than patients in whom resuscitation was attempted. Eighty-six percent of families, but only 22% of patients, were involved in the decision to designate a patient DNR. The decision to designate a patient DNR occurred late in the course of a patient's illness, often when the patient was in coma. For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR. These data suggest that use of the DNR protocol requires changes if patients are to participate in the decision not to undergo cardiopulmonary resuscitation.

The Artificial Heart's Threat to Others

A member of the two federal advisory panels on artificial hearts reflects that the nuclear-powered artificial heart, had it been developed, would have posed a physical threat to others. Today's artificial heart poses a different threat. Because of the high costs, many people may be deprived of access to other forms of medical care and other social goods.

Self-care

This article examines the relationship between selected self-care practices during an episode of illness and the use of formal medical care. Stimulated by conflicting evidence and assertions, the general question addressed is: "Is self-care a substitute, a supplement, or a stimulus for use of formal medical care services?" Multiple Classification Analysis was used in a secondary data analysis of a 1976 nationwide study on access to medical care. The results suggest that self-care users may visit the physician less often and stay fewer days in the hospital, and thus they are expected to have lower expenditures for hospital and physician services. Therefore, the self-care activities examined appear to be substitutes for, rather than supplements or stimuli to, health services utilization. The results must be viewed with some caution due to limitations in the data. However, the results also argue for a greater research emphasis on self-care.

Nutritional intervention among rural pre-school children--an evaluatory study.

Nutritional intervention in the package form of medical care, supplementary feeding and education was offered to 82 severely malnourished children in two villages of rural health training centre, Naila, for 8 months. Normal weight was restored in 6.09 per cent of children respective to their age; 18.3 per cent improved to grade-l and 40.2 per cent to grade-11, 25.3 per cent remained refractory. The maximum weight gain was 2.5 Kg and 3.02 kg in grade-III and grade-IV malnourished children, respectively. On an average, it took 140.5 days for grade-Ill and 180 days for grade-IV severely malnourished children to return to road-to-health with respect to their weight for age.

The Right to Health Care: Building on Traditional Self-Reliance in Village Java

Some of the beliefs and practices in maternal and child health care among rural Javanese women are described and important changes which are occurring as new forms of medical care are introduced are reviewed. In terms of both specific practices and an underlying philosophy an understanding of the 2 approaches to health care is critical to the formulation of effective programs aimed at improving the health and welfare of women and their families. A health program which recognizes the right to effective self-care could be developed from a combination of the best features of modern and medicine. Overall the practices of health imvolve a considerable amount of self treatment support from family and the larger social group and in some instances healers who are also a part of the community. In Javanese society it is primarily the women who hold and apply knowledge of a wide range of home remedies to prevent and treat illnesses among family members. The wisdom in this form of health care lies in the principle of self help health care. The women are following a basic organized medical procedure i.e. identifying symptoms selecting the appropriate cure which has been shown to be effective previously and applying the remedy. There are also many harmful practices which are a part of tradition but these must be viewed in the context of the beliefs and knowledge upon which they are based. The important issue is that harmful practices are not based on irrational assumption but on reasons within the womens perceptions of risk and causality. Attempts to change such behavior could be more meaningful if they were based on an understanding of these reasons. Although the concept of traditional health care has been defined broadly there is considerable diversity within Javanese society according to social class. The Indonesian government under its 5-year plan ending in 1973-1974 established more than 2500 rural health centers and programs of expansion have continued under the 2nd plan. Most modern health care programs work toward removing health care from the responsibility of the woman and her family and placing it in the hands of professionals.

Children's health care and the changing role of women.

The pivotal role of women as wife, mother or adult daughter in performing health-related activities for family members has received little attention from health researchers or policymakers. Yet the majority of health problems do not reach the medical care system, but are dealt with informally or through other social systems. This article discusses the impact of family health care responsibilities on women's market and nonmarket roles in two areas: home nursing care for children's illnesses and escorting children to sources of formal medical care. National data on the incidence of children's illnesses provide the basis for an analysis of the contribution to absenteeism among employed women represented by care of an ill child. Similarly, data from the National Ambulatory Care Survey form the basis for estimates of the economic value of escort time involved in children's medical care. The analysis suggests that policies directed to assuring adequate health care for children take account of the informal, nonmarket health services in which women now play the major role. It must also be recognized that women's changing labor market roles are affecting the availability of these services and increasing their costs to the women who provide them.