Framing Disease

An Underappreciated Mechanism for the Social Patterning of Health

Social epidemiology and population health have made enormous contributions to the ways in which health is viewed and treated. The author describes two of these contributions: 1) the recent emphasis on how mechanisms of the life course influence health, such as quality of schools, housing and health care. And 2) the role of psychosocial mechanisms, such as perception of one's relative status as an influence of health, or the role stress plays in chronic diseases or health in general.

The intention of this paper, however, is to lay out a third framework for understanding social patterning of health and disease. This framework relates to the ways in which societies recognize, define, name and categorize disease states and attribute to them a cause or causes. An example is the high prevalence of asthma diagnoses among urban poor and ethnic minorities. Several mechanisms have been generated to explain this high prevalence, including dust mites, cockroaches, stress-related immune mechanisms and others. The author posits, however, that high asthma prevalence in poor urban communities may result partially from conditioned values and social structures leading to higher rates of diagnosis in these communities. For example, inadequate access to primary care, combined with emergency room (ER) physicians' fears that children seen in the ER for wheezing might not receive good follow-up, may lead to more asthma diagnoses in these children. This is compared to diagnoses in children from higher-income groups whose parents might receive advice to practice watchful waiting. In addition, a feedback loop can operate in these situations, where the fact that asthma is perceived to be more common in these populations leads to more diagnosis of asthma in that population.

Other framing mechanisms are outlined here, including gender framing mechanisms, such as the long-held perception that migraines were a women's health issue. Most of these frameworks are complex and influenced on multiple levels related to social class, perception of risk and others. The author suggests that it would be productive to understand why some associations and not others are investigated and that understanding how these conditions are framed will help societies balance investments in health versus other spending and, within health, between curative and preventative spending.

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