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Biomedical model

Social model

Definition of health

Absence of disease

Holism

Health care provider

Physician, specialist

Multidisciplinary team or professional

Focus of care

Body

Whole person

Knowledge base

Biomedical

Social sciences, traditional wisdom

Locus of care

Hospital with walls

Hospital without walls, clinic

Nature of illness

Acute

Chronic

Goal of intervention

Cure

Well-being

Role of consumer

Passive

Active

terns of subjective experiences of illness and recovery are affected interactively by psychosocial factors, the immune system, stress and social support, and quality of helper-helpee relationship (Reynolds, 1996). Psychosocial factors include personality, coping skills, and lifestyle.

Numerous empirical studies, both human and animal, have supported the biopsychosocial perspective by demonstrating the somatic effects of social and psychological factors. The personality and psychosocial attributes that have been examined include Type A behavior, stress, social isolation, hostility, and perceived locus of control (Carmody & Matarazzo, 1991). The biopsychosocial approach, however, has been criticized on three major grounds (Sadler & Hulgus, 1990; Reynolds, 1996). First, it is more relevant to the science of health than to the practice of health. Second, it overestimates the influence of social and psychological factors in disease. Third, it stigmatizes sick people for the chronicity of their condition or for their presumed engagement in health-jeopardizing lifestyles.

The Prevention Approach

An alternative to the biomedical approach to health care is the prevention or public health model. Several factors provided the impetus to the prevention approach. The first relates to the recognition of the link between lifestyle and health. The second is the increased awareness that disease could be caused by unhealthy conduct. The third relates to the success in reducing the onset and spread of communicable diseases (e.g., typhus, tuberculosis, cholera) by systematic implementation of public health measures, i.e., improvements in diet, housing, quality of air and water, public sanitation, and personal hygiene.

According to the 1994 Statistical Abstract of the United States, the health profile of the United States is such that the top 10 killers or causes that lead to death are heart disease, cancer, cerebrovascular disease, pulmonary diseases, accidents, pneumonia, diabetes, suicide, AIDS, and homicide. Similarly, malignant neoplasm, diseases of the heart, cerebrovascular diseases, chronic obstructive lung disease and allied conditions, accidents and adverse effects, pneumonia and influenza, diabetes mellitus, suicide, and HIV infection are among the 11 highest mortality rates in Canada (Statistics Canada, 1994). An understanding of "behavioral pathogens" (e.g., smoking, high-fat diet, and physical inactivity) that produce these diseases, with a view to devising strategies to tackle them before they affect individuals adversely, is within the purview of preventive health (Carmody & Matarazzo, 1991).

Western societies are increasingly recognizing the critical role that sociocul-turally based belief systems play in health behavior, including initiatives dedicated to "keeping healthy people healthy" (Engel, 1977; Kleinman, Eisenberg, & Good, 1978). Culturally based belief systems or explanatory models (Klein-man, 1980) exist among lay individuals and health care providers for a variety of illnesses (e.g., cancer). Kleinman (1980) has described five basic elements associated with explanatory models: cause of illness, circumstances surrounding the onset of sickness, how sickness produces its effects, the course of illness, and pos-

sible illness treatments (Kleinman, 1980). Landrine and Klonoff (1992) have identified five major etiological agents of illness that are universal across a variety of cultures: (1) violations of interpersonal norms; (2) social role violations; (3) emotions associated with social norms and role violations; (4) moral and religious transgressions; and (5) quasi-natural agents (e.g., hot-cold foods or weather) and blood "states" (e.g., weak, thin, bad). Lack of understanding of cultural explanatory models in pluralistic cultures precludes culturally competent health care, disease prevention, and health promotion. Cultural explanatory models are likely to be reflected in a variety of forms. These include communication patterns and routines, and expressions, phrases, and metaphors with respect to health and illness. The role of cultural explanatory models in response to illness and coping is illustrated by two case reports (Eisunbruch, 1990; Saykao, 1990; both cited in Pauwels, 1995). In the first case, the parents of a Turkish boy who were desperate about their son's worsening condition decided to give him back blood—and, so they hoped, life. Their son had been admitted to the hematology ward of a hospital and diagnosed as having lymphatic leukemia. Despite being placed on powerful cytotoxic medications, his health was gradually deteriorating. His condition was requiring constant withdrawal of blood, leaving him in a state of physical weakness. The parents arrived at the hospital on a wintry day with bulging overcoats. In their son's room, they opened up the coats to reveal two live squawking roosters. They cut off the heads of the roosters and sprinkled the blood over him.

In the second case, a Hmong woman arrived at a hospital for an operation for a ruptured ectopic pregnancy. The woman's condition was so severe that failure to receive the operation would result in her bleeding to death. Doctors informed her that the operation would mean "tying" one of her fallopian tubes. When she heard this, she and her family flatly refused the operation. For this woman, it was important which fallopian tube would be tied, as one tube is involved in producing boys and another in producing girls. The woman had only one son, and she wanted to have more. She believed that tying the "boy tube" in the operation might leave her unable to have any more boys.

The Health Promotion Approach

An important extension of the prevention approach, which can be argued to include prevention approaches, is the health promotion model (Evans, 1994, 1997). The focus of the health promotion model is on those factors and behaviors that enhance an individual's health and quality of life. As such, the focus is on positive behaviors (e.g., exercise, a healthy diet, and good interpersonal relations). On the other hand, the focus of many prevention programs is on the management of negative behaviors (e.g., smoking cessation, control of diet, reducing alcohol consumption). Many companies are working to develop wellness programs for their employees (Evans, 1997). While the emphasis in health promotion programs to date has been on physical factors, there is a growing belief that psychological and social factors are equally important. The health promotion approach is discussed in more detail in Chapter 4.

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