The global use of diverse medical systems.

In 1969, anthropologist Irwin Press introduced the concept of dual use in an attempt to lay to rest the idea that individuals in the real world must choose between allopathic and alternative systems. While providers of medical traditions have a vested interest in seeing the public use one system exclusively, individuals do not. Yet, utilization research generally follows a bifurcated research agenda. thwarting our understanding of how the population uses health care resources. Here, we frame a global analysis of individuals' yearly use of different medical systems. Using the Network Episode Model (NEM), we shift the focus to patterns of care and lay out seven hypotheses, testing whether socio-demographic, cultural, access and health factors are associated with use of one, another, or both system. Data from the 2011 International Social Survey Program's Health Module, reveals that the use of alternative systems alone has virtually disappeared as a pattern of care while dual use remains relevant. Using multilevel models to take into account country differences, we find that being older or younger (i.e., curvilinear effect), female, out-group member, employed, unsatisfied with last allopathic visit; or, reporting barriers to allopathic options, chronic illness, poor health, or positive assessment of alternative options are associated with dual use. Education, income, rural residence, or reporting sufficient insurance coverage are insignificant. Thus, nearly all hypotheses reveal the complexity of contemporary utilization behavior.

Icelandic inclusion, German hesitation and American fear: A cross-cultural comparison of mental-health stigma and the media.

AIMS: Quantitative survey research findings reveal that Western countries have lower rates of public stigma surrounding mental illness than other nations. However, qualitative media research across selected Western countries reports differences in stigmatising messages. Here, we take an in-depth look at country-level data exploring both similarities and differences in this stigma across three countries. Specifically, we use previous findings on global differences in public stigma and media to examine whether there is a correspondence between themes in newspaper reporting and variations in attitudes across seven stigma dimensions. METHODS: The Stigma in Global Context - Mental Health Study provides nationally representative data from Iceland ( N=1033; response rate=71%), Germany ( N=1255; response rate=63.16%) and the USA ( N=1425; response rate=67.31%). We limit analyses to respondents who received a vignette describing an individual meeting clinical criterion for schizophrenia or depression. Exploratory data analyses are used to examine overall patterns and cross-national differences. RESULTS: Graphical analyses show patterned similarities, especially for more individuals endorsing social distance as contact becomes more intimate. However, results also corroborate cross-national differences documented in media research. More Americans endorse evaluations of dangerousness, to both self and others. Fewer Icelanders report exclusionary tendencies, whilst Germans report the most consistently moderate levels of stigma. CONCLUSIONS: While Western nations tend to report similar, lower levels of stigma globally, they each have unique areas of concern. Anti-stigma programs must take note of both similarities and differences to tailor their efforts to the local context.

Institutions, Incorporation, and Inequality: The Case of Minority Health Inequalities in Europe.

Scholars interested in the relationship between social context and health have recently turned attention further "upstream" to understand how political, social, and economic institutions shape the distribution of life chances across contexts. We compare minority health inequalities across 22 European countries ( N = 199,981) to investigate how two such arrangements-welfare state effort and immigrant incorporation policies-influence the distribution of health and health inequalities. We examine two measures of health from seven waves of the European Social Survey. Results from a series of multilevel mixed-effects models show that minority health inequalities vary across contexts and persist after accounting for socioeconomic differences. Cross-level interaction results show that welfare state effort is associated with better health for all groups but is unrelated to levels of inequality between groups. In contrast, policies aimed at protecting minorities from discrimination correlate with smaller relative health inequalities.

Gender and validity of self-rated health in nineteen European countries.

AIMS: The aims of this study were to: (1) examine the concurrent validity of self-rated health for mental and physical health in Europe; and (2) evaluate whether self-rated health predicts health problems differentially by gender. METHODS: Data are from 19 European countries surveyed in the 2014 European Social Survey. We applied ordinary least squares regression to examine the association between self-rated health and summary indicators of physical and mental health problems. RESULTS: We observed an association between self-rated health and both physical and mental health problems in all countries. Gender differences in the concurrent validity of self-rated health were documented in eleven out of 19 countries. CONCLUSIONS: Self-rated health is a valid and efficient measure of physical and mental health across the European continent, with significantly greater concurrent validity among women.

Gendered health inequalities in mental well-being? The Nordic countries in a comparative perspective.

AIMS: The aims of this study were to: (a) compare gender differences in mental well-being in the Nordic countries with gender differences in 28 other countries around the world; and (b) evaluate whether gender differences in the Nordic countries remain when other social and lifestyle factors are taken into account. METHODS: Data were obtained from 32 countries around the world that participated in the 2011 health module of the International Social Survey Programme. Ordered logit regression models were used to evaluate whether gender differences remained significant when other social and lifestyle factors were considered. RESULTS: Gender differences in mental well-being in the Nordic countries are not particularly small and the four countries do not cluster together. The gender differences remain when other social and lifestyle factors are taken into account. CONCLUSIONS: There appears to be a similar Nordic health paradox for mental well-being outcomes as for physical health outcomes. Although there may be multiple reasons for this, continued gender equality, including sex segregation in the labour market and gendered expectations, are considered to play a part.

The Theory of Industrial Society and Cultural Schemata: Does the "Cultural Myth of Stigma" Underlie the WHO Schizophrenia Paradox?

The WHO's International Studies of Schizophrenia conclude that schizophrenia may have a more benign course in "developing" societies than in the West. The authors focus on this finding's most common corollary: cultural schemata are shaped by the transition from agrarian to industrial society. Developing societies are viewed as traditional, gemeinschaft cultures lacking the stigmatizing beliefs about persons with mental illness held in modern, gesellschaft cultures of developed societies. The Stigma in Global Context-Mental Health Study formalized the cultural myth of public stigma (CMPS) with propositions linking level of development to intolerant, exclusionary, and individualistic attitudes. In 17 countries, the authors find no support for the corollary; where support is found, the findings are opposite expectations, with developed societies reporting lower stigma levels. Reconceptualizing of the cultural landscape on more specific dimensions also produces null or contrary findings. This correction to nostalgic myths of cultural context in developing societies thwarts misguided treatment, policy, and stigma-reduction efforts.

Public or private? The role of the state and civil society in health and health inequalities across nations.

Social scientists have long recognized that macro-level factors have the potential to shape the health of populations and individuals. Along these lines, they have theorized about the role of the welfare state in creating more equal opportunities and outcomes and how this intervention may benefit health. More recently, scholars and policymakers alike have pointed out how the involvement of civil society actors may replace or complement any state effort. Using data from the World Values Surveys and the European Values Study, combined with national-level indicators for welfare state and civil society involvement, we test the impact of each sector on health and health inequalities in 25 countries around the world. We find that both have a statistically significant effect on overall health, but the civil society sector may have a greater independent influence in societies with weaker welfare states. The health inequalities results are less conclusive, but suggest a strong civil society may be particularly beneficial to vulnerable populations, such as the low income and unemployed. Our paper represents an early step in providing empirical evidence for the impact of the welfare state and civil society on health and health inequalities.

Contextualizing Disparities: The Case for Comparative Research on Social Inequalities in Health.

PURPOSE: Research on healthcare disparities is making important descriptive and analytical strides, and the issue of disparities has gained the attention of policymakers in the US, other nation-states, and international organizations. Still, disparities scholarship remains US-centric and too rarely takes a cross-national comparative approach to answering its questions. The US-centricity of disparities research has fostered a fixation on race and ethnicity that, although essential to understanding health disparities in the United States, has truncated the range of questions researchers investigate. In this article, we make a case for comparative research that highlights its ability to identify the institutional factors may affect disparities. METHODOLOGY/APPROACH: We discuss the central methodological challenges to comparative research. After describing current solutions to such problems, we use data from the World Values Survey to show the impact of key social fault lines on self-assessed health in Europe and the U.S. FINDINGS: The negative impact of SES on health is more generalizable across context, than the impact of race/ethnicity or gender. RESEARCH LIMITATIONS/IMPLICATIONS: Our analysis includes a limited number of countries and relies on one measure of health. ORIGINALITY/VALUE OF PAPER: The paper represents a first step in a research agenda to understand health inequalities within and across societies.

Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns.

This essay reviews and evaluates recent comparative social science scholarship on healthcare systems. We focus on four of the strongest themes in current research: (1) the development of typologies of healthcare systems, (2) assessment of convergence among healthcare systems, (3) problematization of the shifting boundaries of healthcare systems, and (4) the relationship between healthcare systems and social inequalities. Our discussion seeks to highlight the central debates that animate current scholarship and identify unresolved questions and new opportunities for research. We also identify five currents in contemporary sociology that have not been incorporated as deeply as they might into research on healthcare systems. These five "missed turns" include an emphasis on social relations, culture, postnational theory, institutions, and causal mechanisms. We conclude by highlighting some key challenges for comparative research on healthcare systems.

Health Inequalities in Global Context.

The existence of social inequalities in health is well established. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between inequality and average population health across countries. Despite the theorization of (presumably variable) social conditions as "fundamental causes" of disease and health, the cross-national literature has focused on average, aggregate population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality. We advance and redirect these debates by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from 48 World Values Survey countries, representing 74% of the world's population, we examine cross-national variation in inequalities in health. The results reveal substantial variation in health inequalities according to income, education, sex, and migrant status. While higher socioeconomic position is associated with better self-rated health around the globe, the size of the association varies across institutional context, and across dimensions of stratification. There is some evidence that education and income are more strongly associated with self-rated health than sex or migrant status.

Constructing illness: how the public in eight Western nations respond to a clinical description of "schizophrenia".

According to classic and contemporary social theory, the community is crucial to how individuals respond to the onset of health problems. Cultural response to symptoms provides the foundation for lay diagnosis; offers a gauge for marking individual and societal health literacy; and reflects the cultural embeddedness of modern medical knowledge. Using data collected between 2004 and 2007 from the Stigma in Global Context - Mental Health Study (SGC-MHS) on the recognition of schizophrenia from vignettes describing individuals meeting DSM-IV criteria, we examine the nature and correlates of lay diagnosis. Focusing on Western societies in the SGC-MHS, we ask three questions regarding problem recognition in Bulgaria (N = 255), Cyprus (N = 253), Germany (N = 382), Hungary (N = 352), Iceland (N = 291), Spain (N = 327), Great Britain (N = 289), and the United States (N = 449): (1) What is the cross-national variation in recognition of schizophrenia as a mental illness? (2) Is lay diagnosis associated with individuals' socio-demographic characteristics and/or their evaluation of underlying causes? (3) Are lay diagnoses likely to shape the nature and direction of the illness career? We find lay diagnosis of "mental illness" to be high across these Western nations with some, though modest, difference across countries. Variation for the more specific diagnosis of "schizophrenia" is greater, though fairly consistent in country ordering. Lay diagnoses are shaped most consistently by attributions, inconsistently by socio-demographics, and generally associated with respondents' treatment recommendations and expected outcomes. In light of assumptions about public beliefs and knowledge that often underlie research, community efforts, clinical programs, and health policy, these findings suggest that a greater understanding of the complexities of lay diagnosis is warranted.

The Cultural Turn in Sociology: Can It Help Us Resolve an Age-Old Problem in Understanding Decision Making for Health Care?

Culture has long affected individuals' response to problems. A classic puzzle in the sociology of health and illness is discrepancy between theory and research regarding cultural beliefs and knowledge of medical care service use. "Utilization research," examining individuals' responses to the onset of health problems, has not consistently affected culture on the uptake of formal treatment. First, while ethnographic research often describes how culture shapes illness behaviors, survey-based studies rarely find significant beliefs or predispositions once "need" is controlled. Second, in quantitative studies, individuals report supportive treatment beliefs or predispositions to use services but low utilization levels, reinforcing claims about lack of utility of cultural ideologies in health-care decision making. We ask whether innovations in the sociology of culture and cognition provide theoretical scaffolding to conceptualize and measure culture in health service utilization. Rather than estimating effect of cultural beliefs on health-care decisionmaking, we question the measurement of cultural beliefs in understanding service use. Examining data from the General Social Survey, we focus on how approaches to culture might explain the paradox of high cultural predispositions and low actual use. Children with mental health problems provide a comparison between suggestions and endorsements. Suggestions, sources of care offered by individuals in response to a case description without any other social cues, align with new cultural approaches, and are measured by responses to open-ended questions about what should be done for the child described (with clinical criteria for ADHD, major depression, asthma, or "daily troubles"). Endorsements, requiring less cognitive work and cultural resistance, align with traditional conceptualizations of culture, and are measured by closed-ended questions that ask respondents to agree or disagree with seeking help from different treatment options placed later in the survey. Suggestions reveal cultural predispositions to use services corresponding closely to reported utilization levels; endorsements reveal high, unrealistic cultural predispositions to use services. Further, suggestions are associated with sociodemographics that proxy culture (e.g., race), while endorsements are associated only with perceived need.

Drawing the line: the cultural cartography of utilization recommendations for mental health problems.

In the 1990s, sociologists began to rethink the failure of utilization models to explain whether and why individuals accessed formal treatment systems. This effort focused on reconceptualizing the underlying assumptions and processes that shaped utilization patterns. While we have built a better understanding of how social networks structure pathways to care and how disadvantaged sociocultural groups face substantial barriers to treatment, we have less understanding of the larger cultural context in which individuals recognize and respond to symptoms. Drawing from recent innovations in the sociology of culture, we develop the concept of "cultural mapping" to describe if and how individuals discriminate among different available sources of formal treatment. Using data from the 1996 Mental Health Module of the General Social Survey, we compare Americans' willingness to recommend providers in the general medical and specialty mental health sectors. The results indicate that, despite unrealistically high levels of endorsement, individuals do discriminate between providers based on their evaluation of the problem, underlying causes, and likely consequences. While perceived severity leads individuals to suggest any type of formal care, problems attributed to biological causes are directed to general or specialty medical providers (doctors, psychiatrists, and hospitals); those matching symptoms for schizophrenia or seen as eliciting violence are allocated to the specialty mental health sector (psychiatry, mental hospital); and those seen as being caused by stress are sent to nonmedical mental health providers (i.e., counselors). These findings help to explain inconsistencies in previous utilization studies, and they suggest the critical importance of maintaining a dialogue between medical sociology and the sociology of culture.

Rethinking theoretical approaches to stigma: a Framework Integrating Normative Influences on Stigma (FINIS).

A resurgence of research and policy efforts on stigma both facilitates and forces a reconsideration of the levels and types of factors that shape reactions to persons with conditions that engender prejudice and discrimination. Focusing on the case of mental illness but drawing from theories and studies of stigma across the social sciences, we propose a framework that brings together theoretical insights from micro, meso and macro level research: Framework Integrating Normative Influences on Stigma (FINIS) starts with Goffman's notion that understanding stigma requires a language of social relationships, but acknowledges that individuals do not come to social interaction devoid of affect and motivation. Further, all social interactions take place in a context in which organizations, media and larger cultures structure normative expectations which create the possibility of marking "difference". Labelling theory, social network theory, the limited capacity model of media influence, the social psychology of prejudice and discrimination, and theories of the welfare state all contribute to an understanding of the complex web of expectations shaping stigma. FINIS offers the potential to build a broad-based scientific foundation based on understanding the effects of stigma on the lives of persons with mental illness, the resources devoted to the organizations and families who care for them, and policies and programs designed to combat stigma. We end by discussing the clear implications this framework holds for stigma reduction, even in the face of conflicting results.

Public knowledge and assessment of child mental health problems: findings from the National Stigma Study-Children.

OBJECTIVE: Child and adolescent psychiatry confronts help-seeking delays and low treatment use and adherence. Although lack of knowledge has been cited as an underlying reason, we aim to provide data on public recognition of, and beliefs about, problems and sources of help. METHOD: The National Stigma Study-Children is the first nationally representative study of public response to child mental health problems. A face-to-face survey of 1,393 adults (response rate 70.1%, margin of error +/-3.5%) used vignettes consistent with diagnoses of attention-deficit/hyperactivity disorder (ADHD) and depression. Descriptive and multivariate analyses provide estimates of the levels and correlates of recognition, labeling, and treatment recommendations. RESULTS: Respondents do differentiate "daily troubles" from mental health problems. For the cases that meet diagnostic criteria, 58.5% correctly identify depression and 41.9% correctly identify ADHD. However, respondents are less likely to see ADHD as serious, as a mental illness, or needing treatment compared with depression. Moreover, a substantial group who correctly identifies each disorder rejects its mental illness label (ADHD 19.1%, depression 12.8%). Although women are more knowledgeable, the influence of other sociodemographic characteristics, particularly race, is complex and inconsistent. More respondents see general practitioners, mental health professionals, and teachers as suitable sources of advice than psychiatrists. Behaviors and perceived severity seem to drive public responses. CONCLUSIONS: Americans have clear and consistent views of children's mental health problems. Mental health specialists face challenges in gaining family participation. Unless systematically addressed, the public's lack of knowledge, skepticism, and misinformed beliefs signal continuing problems for providers, as well as for caregivers and children seeking treatment.

Similar pressures, different contexts: public attitudes toward government intervention for health care in 21 nations.

Health care systems worldwide are experiencing similar pressures such as rising cost, aging populations, and increased burden of disease. While policy makers in all countries face these challenges, their responses must consider local pressures, particularly the implicit social contract between the state, medicine, and insurers. We argue that public attitudes provide a window into the social context in which policy decisions are embedded. Using data from the International Social Survey Programme (ISSP), we compare public attitudes toward government involvement in health care in 21 countries, testing the associations between various national-level variables (e.g., health care expenditures, aging of population, health care traditions) and public opinions. Specifically, we posit four national-level hypotheses ("health care traditions," "expenditure crisis," "demographic crisis," "changing disease profile crisis"), one individual-level hypothesis ("individual vulnerability"), and two cross-level hypotheses ("cultural socialization" and "health care need"). Our findings indicate that public attitudes cluster around the historical organization of health care, but also relate to current economic and demographic realities. Individuals in countries adopting the "National Health Service Model" (the state directly provides health care but complete state control is absent) or the "Centralized Model" (the state directly provides health care and has much control) are more supportive of government involvement in health care than those in the "Insurance Model" (the state is limited to maintenance of the system) countries. However citizens in countries currently spending more on health care and having a greater burden of chronic illness are less supportive. Our results cast doubt on arguments that increased cost will result in a questioning of the contract between the state and citizens in the social provision of health care. We end by discussing implications for recent work in political sociology that highlights the importance of public attitudes.

Fundamental causes of health disparities: stratification, the welfare state, and health in the United States and Iceland.

Research has established that those with higher social status have better health. Less is known about whether this relationship differs cross-nationally and whether it operates similarly across different institutional arrangements. To examine the relationship between stratification and health, two Western, industrialized societies at opposite ends of an equal/unequal continuum are compared: the United States and Iceland. Using data from the 1998 General Social Survey and the 1998 Health and Living Standards of Adult Icelanders survey, I draw from two theoretical perspectives. First, I explore the notion of fundamental causes of disease by examining whether stratification has similar effects on health. Second, I examine whether the organization of welfare states affects this relationship. The results show that education, employment, and relative poverty have similar effects on health in both nations, thus supporting the notion of a fundamental cause. However in Iceland relative affluence has a weaker relationship with health. Further, being a parent, regardless of marital status, has a stronger positive relationship with good health in Iceland. Welfare state intervention may be most successful in equalizing health outcomes by supporting families and by removing advantages traditionally accumulated by the wealthy in capitalist societies.