Health is an evolving rather than a static concept. A meaningful understanding of the concept of health in a cultural context requires consideration of several factors: beliefs with respect to anatomy and physiology; components of health; health cognitions and classification of disease; and health interventions. Lack of knowledge among health professionals about cultural health concepts and practices, in addition to intercultural communication difficulties, has been a major issue in health care provision in multicultural countries.
Views about anatomy and physiology are culturally determined and crucial to perceptions of health and disease. Helman (1984, 1995) has discussed the cultural definitions and the social and psychological significance of three aspects of body image on health and disease: beliefs relating to body shape, size, and adornments (e.g., clothing and body piercing); beliefs with respect to the structure of the body; and beliefs about body functioning. Beliefs about body shape, size, and adornments vary across cultures and serve as sources of social communication and social functioning (e.g., group membership and social rank). The right of Canadian women to walk topless on the beach or in the streets has drawn considerable attention across the country. Beliefs about the inner structure of the body also vary across cultures and influence perceptions and presentations of bodily complaints and responses to interventions. Finally, beliefs about the inner workings of the body show differences among cultures and have significant effects on human behavior. Helman (1984) describes at least three different lay models of the inner functioning of the body: the Balance Model, the "Plumbing" Model, and the Machine Model.
Theories associated with the Balance Model describe the healthy functioning of the body as a harmonious balance between two or more elements or forces within the body. Harmonious balance is also viewed as a function of both external (e.g., diet, environment, supernatural agents) and internal factors (e.g., hereditary weakness). The humoral theory represents the most widespread view of the Balance Model. The roots of humoral theory date back to China and India, and its elaboration into a system of medicine to Hippocrates (Helman, 1984). According to humoral medical beliefs, the basic functions of the body are regulated by the four bodily fluids or humors of blood, phlegm, black bile, and yellow bile. Excess of yellow bile is associated with chronic anger and irritability; excess of black bile with chronic sadness and melancholy; excess of blood with sanguin-ity or optimism; and excess of phlegm with calmness and listlessness. Each of the fluids or humors is also characterized by a combination of hot/cold and wet/dry: hot and wet for blood, cold and wet for phlegm, cold and dry for black bile, and hot and dry for yellow bile. The wet and dry conditions are believed to be less important than the hot and cold conditions. In fact, the hot-cold balance is considered to be the secret for good health. The Greek theory of humoral pathology was elaborated in the Arab world, imported to Spain as scientific medicine during the Muslim domination, and transmitted to the Americas at the time of the Spanish Conquest (Henderson & Springer-Littles, 1996). Needless to say, harmonious balance is a contemporary lay belief about health and illness in a variety of cultures, including those of Latin America, the Islamic world, and the Caribbean.
The "Plumbing" Model
The "Plumbing" Model of the body represents the Western conceptualization of body structure and functioning. In this model, the body is conceived of as a "series of hollow cavities or chambers connected with one another, and with the body's orifices, by a series of 'pipes' and 'tubes.' The major cavities are usually 'the chest' and 'the stomach,' which almost completely fill the thoracic and abdominal spaces respectively"(Helman, 1984, p.15). Central to the Plumbing Model is the view that "health is maintained by the uninterrupted flow of vari ous substances—including blood, air, food, faeces, urine and menstrual blood— between cavities, or between a cavity and the exterior of the body via one of the orifices. Disease, therefore, is the result of 'blockage' of an internal tube or pipe" (Helman, 1984, p.15).
The Machine Model characterizes "the body as an internal combustion engine, or as a battery-driven machine" (Helman, 1984, p.16). According to Helman, indicators for the operation of the Machine Model in Western medicine include the use of such metaphors as "Your heart isn't pumping so well," or "I need a rest, doctor—my batteries need recharging." To these can be added the "I need a tune-up" metaphor. The view of the body as a machine-like entity that operates according to principles of physics and chemistry and requires the doctor to repair the machine is embraced by both Western religion and medical science (Engel, 1977).
Health as a total state may also be viewed as encompassing two separate states—physical health and psychological well-being. In combination, the physical and psychological states result in different health outcomes: poor physical health or debilitating disease with or without concomitant poor psychological well-being; and poor physical or psychological well-being in the absence of identifiable physical disease (Downie, Fyfe, & Tannahill, 1990). Kleinman (1980) has made the distinction between disease and illness. Illness entails a subjective experience and represents a personal response to discomfort. Disease, on the other hand, refers to observable and measurable deviations in body structure and function.
In addition to the cultural determination of beliefs about anatomy and physiology, culture dictates disease classification, beliefs about etiology, and help-seeking behavior. In relation to disease classification, Western systems include the DSM-IV (Diagnostic and Statistical Manual-4th Edition) and the ICD-10 (International Classification of Diseases-10th Edition). Classification systems have also been developed in non-Western cultures with significance for Western cultures. Read (1966) has described a threefold classification system from the African cultural perspective: (1) trivial or everyday complaints that can be treated by home remedies; (2) European diseases that require Western scientific interventions; and (3) African diseases which are not responsive to modern medical treatments.
Health may be equated with curative medicine or seen as a "field concept," i.e., the product of human biology, lifestyle, environment, and the health care system (Lalonde, 1974). The curative medicine perspective views "health as just a matter of hospitals, doctors and patients" (Premier's Council on Health, Well-being and Social Justice, 1994). In contrast, the "field concept" of health allows a health promotion framework in which health-related inequities are reduced, focus on prevention is increased, and individual coping is enhanced (Health and Welfare Canada, 1986). In the health promotion framework, self-care, mutual aid, and healthy environments are emphasized. Implementation strategies that foster public participation, strengthen community health services, and coordinate healthy public policy are also supported.
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