…and ‘How might this be relevant to the work of the nurse’?
What do we mean by social factors? This term covers a multiple meanings, but lets start by thinking about what people and society do and the categories we place ourselves, and others, into. A social factor then is something that might have an effect on us as we go about our daily lives as social actors. Emile Durkheim in ‘The Rules of Sociological Method’ (1895) wrote about ‘social facts’ as almost having a life of their own: “treat social facts as things” existing outside of our individual consciousness. The common categories or factors include things like:
Socio economic status.
We might also want to consider social structures such as:
Leisure, Work and Occupations.
Before we proceed just consider how the above social structures have changed over time.
The following will discuss obesity and a heart attack using our sociological imagination. I will then consider the relevance for nursing.
To illustrate how any of these affect health we could take the issue of Obesity. Why are populations globally all getting fatter over the past couple of decades? A biological explanation founders in that it requires some biological mechanism that has changed for billions of people. Evolution does not work that fast. As there are differences between groups of people and individuals there is something psychological and or sociological happening.
It might be linked to one’s socio-economic status, as we know that poverty and economic and social deprivation are correlated to increased weight in populations. McLaren (2007) argues that obesity is a social phenomenon. That is to say it is just not a physical or biological condition to be explained or dealt with only in physical terms (e.g. the injunction to eat less and exercise more). Action on obesity includes targeting both economic and sociocultural factors. McLaren illustrates the varying social patterns involved in level of obesity in this review of studies.
Roberts and Edwards (2010) suggest that world-wide, over a billion adults are overweight and 300 million are officially obese. Their book ‘The Energy Glut’ suggests that how energy is both sourced, e.g. oil, and used, e.g. car driving, is directly linked to growing obesity. They suggest ‘fatness’ and climate change, are manifestations of the same fundamental cause. It is down to how oil based fossil fuel energy, after being discovered, started not only the process of catastrophic climate change, but also propelled the average human weight distribution upwards.
In addition they suggest that the food industry uses sophisticated marketing techniques to sell us mountains of energy-dense food whilst at the same time we are ‘functionally paralysed’. We just don’t move about as we used to, partly because the opportunities to do so diminish. This could be seen especially in the UK with increased car use, road building, living miles from work and the growth of retail outlets built out of town to exploit car use, poor public transport and poor cycling infrastructure. The accumulation of body fat is therefore a political, not a personal, problem.
The Information Centre has published Statistics on Obesity, Physical Activity and Diet: England 2012. The topics covered in the report include, overweight and obesity prevalence among adults and children, physical activity levels among adults and children, trends in purchases and consumption of food and drink and energy intake and health outcomes of being overweight or obese.
In 2010, just over a quarter of adults (26 per cent of both men and women aged 16 or over) in England were classified as obese (BMI 30kg/m2 or over). For the same period, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31 per cent and 29 per cent respectively).
In 2010, 41 per cent of respondents (aged 2+) said they made walks of 20 minutes or more at least 3 times a week and an additional 23 per cent said they did so at least once or twice a week in Great Britain (GB). However, 20 per cent of respondents reported that they took walks of at least 20 minutes “less than once a year or never” in GB.
In 2010, 25 per cent of men and 27 per cent of women consumed the recommended five or more portions of fruit and vegetables daily.
The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity among people of all ages was 11,574 in 2010/11. This is over ten times as high as the number in 2000/01 (1,054).
In 2010, there were 1.1 million prescription items for the treatment of obesity, a 24 per cent decrease on the previous year when 1.4 million items were dispensed. This is the first recorded decrease in seven years.
Wright Mills (1959) wrote:
‘…men (sic) do not usually define the troubles they endure in terms of historical change…’ (p3).
A middle aged man has a heart attack but he does not consider that his illness may be linked to living in the 21st century, or that the roots of his illness may lie in current society.
‘…seldom aware of the intricate connection between the patterns of their own lives and the course of world history.’ (p4).
Lying in a hospital bed, with ECG electrodes stuck to his chest, the man may curse his luck or put his condition to being overweight, his smoking habit and lack of exercise.
He does not:
‘…possess the quality of mind essential to grasp the interplay of man and society, of biography and history…’ (p4).
In addition he:
‘..cannot cope with their personal troubles (his heart attack) in such ways as to control the structural transformations that lie behind them.’ (p4).
What ‘structural transformations’ (social factors) might lie behind the heart attack, or an eating disorder or binge drinking? What is a ‘structural transformation?’
If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society ‘works’ when individuals, groups, communities and populations decide to act out their relationships one with another and in doing so create (and are created by) social ‘structures’. I have listed some structures on page 1.
In the above heart attack case what structures are there and what are those structures that lie beneath his personal trouble?
To help answer that question Wright Mills argued that:
‘what they need…is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves…this quality…(is) the sociological imagination.’ (p5).
So we need to use information and reason to start making the links between society and illness. A heart attack results from a variety of sources. Some may be genetic, but others are patterns of living which are subject to social structure. The middle aged man just happened to have been born in the 1950’s into a working class background in Liverpool. His father worked as a docker and he in turn followed in his father’s footsteps.
Social class is a form of social structure. Living in working class Liverpool during the 1950’s to the 1970’s means engaging in certain eating habits, wearing certain clothes, taking holidays in certain places (in the UK) and following certain football teams. And, of course, smoking. Smoking is as natural an activity as breathing, even Division One footballers smoke. The ‘metrosexual’ man does not exist yet, there are no ‘Men’s Health’ magazines, cigarettes are cheap, there are no laws banning smoking in public places. The idea of working out in a gym does not feature except in the working class boxing clubs. Olive oil and the Mediterranean diet exist only in the Mediterranean. Eating (saturated fat) red meat is masculine. ‘Jogging’ has not entered into the English language yet, exercise is for athletes or only takes place when playing Sunday football for the local pub team. Car use is becoming more common and cycling is in decline. Margaret Thatcher was soon to say that a 30 year old man on a bus is a failure so public transport is only for those who have to.
The social structure of this man’s early years involve lifestyles that increase his chance of a heart attack but he was not aware of all the connections. He thinks all his choices are his own, but he is unaware that choice is limited and results from those chances handed out to him. His choices are also based on imperfect information and also upon the wishes of others who want him to make certain choices (e.g. the cigarette manufacturers). If the society in which he lives offers him the choice of A, B and C and he chooses A, he may think he has made a real choice. But what if there is choice F, G and H that he is not aware of through circumstance or that history has not yet provided?
in 1950, one could choose to smoke anywhere and the lack of a strong public health campaign and research evidence did not point to the deadly nature of the practice. The personal trouble of smoking has to be seen in the context of that history.
Fast forward to 2010 and a new historical period. The public issue of millions dying of lung cancer has affected change in society and now impacts differently upon the individual. Social structures have been transformed since the 1950’s. For example, we now think of smoking not as glamorous but as a ‘filthy habit’. Men no longer congregate in pubs where everyone smokes inside.
‘The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life….’ (p5).
Thus, the middle aged heart attack victim who has this ‘quality of mind’ would understand his present trouble as linked to the context of 1950’s Britain where working class life took smoking for granted. He knows that all his friends smoke and that the likelihood of him smoking is high, given the social context and the time in which he lives.
This depends on where the nurse works. In an intensive care unit or in many acute settings, it is irrelevant to the everyday clinical practice of giving physical care. In primary care however, understanding how social factors impact on people’s lives may suggest strategies for mitigating them and for engaging in health promotion and health education. The obvious is knowledge for healthy eating habits or exploring personal physical activity levels.
However, certain issues will require action at the community or political level. This calls into question the social and political role both for the individual nurses and for nursing as a profession. Public health is a core part of nurse education and thus understanding social causes for ill health is part of the public health role for nursing. Wright Mills argues that it is the job of the social scientist or the liberal educator to foster the sociological imagination so that people become aware of how social factors (in our case) affect health and illness. We could argue that this applies to nurses in that once we know what causes disease we might have a duty to do something about it at the social level if it is caused by social factors (i.e. the ‘Social Determinants of Health’).
At the very least we should be very wary of victim blaming or accepting wholesale simplistic arguments over personal responsibility, see for example Wind Cowle (2012), while at the same time we do very little to curb fast food outlets, regulate the food industry, curb car use through urban planning or encouraging active travel alternatives such as cycling.
Nursing has various elements to it: giving direct patient care, working in a team, managing oneself and personal development. To that we could add the need for networking and political awareness to exercise nursing leadership. Therefore I suggest that developing an understanding of the social factors involved in health and illness can assist a nurse in developing in these various elements to various degrees regardless of where one works.
Benny Goodman 2012
McLaren, S. (2007) Socioeconomic status and obesity. Epidemiological Reviews 29 (1): 29-48.http://epirev.oxfordjournals.org/content/29/1/29.abstract
Roberts, I. and Edwards P (2010) The Energy glut. The Politics of fatness in an overheating world. Zed Books
Wind Cowle, M (2012) The NHS needs people to be more responsible http://www.guardian.co.uk/society/2012/sep/25/nhs-needs-people-be-more-responsible
World Health Organisation (2008) Closing the Gap in a generation. The Social Determinants of Health. http://www.who.int/social_determinants/en/
Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.