What implications do the differences between a social and medical model of health have for the nursing profession?

What implications do the differences between a social and medical model of health have for the nursing profession?

 

(note the hyperlinks in the text)

 

This short paper will address biomedical, social and ecological models of health.

 

Medical model:

First of all we need to be clear what we mean by these terms. A medical model (sometimes called a biomedical model) is based on knowledge about the biological causes of disease. This approach uses the sciences such as physiology, pathophysiology, pharmacology, biology, histopathology and biochemistry. A detailed knowledge of the human anatomy is required as well as detailed knowledge of:

·         Aetiology (in the United States  they spell it Etiology).

·         Epidemiology.

·         Signs and Symptoms.

·         Diagnosis.

·         Investigations and clinical examinations.

·         Treatment options and management plans

for a very wide range of conditions and diseases.

The focus is often on the individual ill patient, and it seeks to cure through the application of medications and/or surgery.

Many doctors in practice however adapt and supplement this basic approach to consider issues such as lifestyle, patient preferences and wishes in their treatment options. This might be termed a biopsychosocial model. Options for treatment also include referral to other professionals such as physiotherapists and dieticians and some doctors refer to complementary therapists.

“While disease dominates biomedical thinking, the biopsychosocial model incorporates social, psychological and emotional factors in diagnosis and treatment. It recognises that illness cannot be studied or treated in isolation from the social and cultural environment. Whereas the biomedical model prioritises professional knowledge, the biopsychosocial model expects health carers and doctors to acknowledge and take into account users’ circumstances.

Medicine practised within a biopsychosocial framework acknowledges the links between socioeconomic deprivation and adverse health. It also considers issues such as improving access to health services and reducing health inequalities as a legitimate and appropriate function of health service provision.”

(source: http://openlearn.open.ac.uk/mod/oucontent/view.php?id=398060&section=1.7)

Thus a biopsychosocial model is a link between the medical approach and the social model of health.

Box 1: This extract is taken from the Open University.

Models of healthcare delivery: the biomedical model:

Biomedicine is also known as allopathy, conventional medicine or modern western scientific medicine).  In the UK biomedicine dominates contemporary and official understandings of health and forms the basis of the NHS and other western health care systems. While the biomedical model is considered the epitome of scientific, objective, reproducible medicine, the actual delivery of health care may be somewhat different in practice. The following statements about biomedicine thus represent an idealised, necessarily artificial version of this model.

·         Health is predominantly viewed as the ‘absence of disease’ and as ‘functional fitness’.

·         Health services are geared mainly towards treating sick and disabled people.

·         A high value is put on the provision of specialist medical services, in mainly institutional settings, typically hospitals or clinics.

·         Doctors and other qualified experts diagnose illness and disease and sanction and supervise the withdrawal of service users from productive labour.

·         The main function of health services is remedial or curative – to get people back to productive labour.

·         Disease and sickness are explained within a biological framework that emphasises the physical nature of disease: that is, it is biologically reductionist.

·         Biomedicine works from a pathogenic (origins of disease) focus, emphasising risk factors and establishing abnormality (and normality).

·         A high value is put on using scientific methods of research and on scientific knowledge.

·         Qualitative evidence (given by lay people or produced through academic research) generally has a lower status as knowledge than quantitative evidence.

(Source: adapted from Jones, 1994 in http://openlearn.open.ac.uk/mod/oucontent/view.php?id=398060&section=1.6)

 

The Social Model

The social model of health focuses on the social distribution of health and illness between different groups (e.g. death rates which vary between social classes).  The social model is interested in the social causes of ill health best illustrated by the Social Determinants of Health (World Health Organisation 2008) approach.

The Social determinants of health

The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission’s final report was launched in August 2008, and contained three overarching recommendations:

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission’s final report was launched in August 2008, and contained three overarching recommendations:

1. Improve daily living conditions

2. Tackle the inequitable distribution of power, money, and resources

3. Measure and understand the problem and assess the impact of action

The WHO Conference Secretariat has now put together the full Report of the World Conference (66 pages with color pictures). A 16 page summary Report is also available. World Health Assembly adopts the Rio Political Declaration on Social Determinants of Health. A resolution endorsing the Rio Political Declaration on Social Determinants of Health was adopted in May 2012 by WHO Member States at the Sixty-fifth World Health Assembly (WHA) in Geneva, Switzerland.

http://www.who.int/social_determinants/en/

 

 

Barton and Grant (2006) have developed  a ‘health map’ which illustrates the global, environmental as well as the social antecedents for health:

 

http://eprints.uwe.ac.uk/7863/2/The_health_map_2006_JRSH_article_-_post

Barton, H. and Grant, M. (2006) A health map for the local human habitat. The Journal for the Royal Society for the Promotion of Health, 126 (6). pp. 252-253.

 

Note that the outer ring includes the ecosystem so this firmly locates human health within the ecology of the planet. Therefore health stems from the biogeophysical environment in which humans live and are an inescapable part of. This perspective which sees no separation of humanity from ecology suggests that no one can be healthy in an unhealthy environment. This might take the position that if the oceans are increasingly acidic, resulting in fish species loss, then by definition human populations are not healthy either.

Health is then social and ecologically determined, experienced within the social relationships in a material world. No one lives alone and so it is in the coming together in communities and societies that we fashion the determinants of health. There is a biological basis for some individuals, however genetic determinants (e.g. in cystic fibrosis) operate at this individual level and are manifest in a relatively minor way. This is not to deny that for the individual the medical condition is anything but minor, but health on population levels are not determined thus. Even genetic manifestations are at times made worse or better by the social conditions in which the individual finds themselves. Poverty has a knack of making underlying biological problems much worse. Climate change may also make both poverty and the health status of populations worse.??

Social Conditions??

If health is socially determined by social relationships, what are the current forms of social relationships that give rise to certain patterns of health, illness and disease? We know from studying inequalities in health that socio-economic conditions and relative social status determine populations’ health status including measurable outcomes such as life expectancy and the under 5 mortality rate. Other social relationships such as gender and ethnicity also affect health status. I would argue that major influences upon global health are the socio-economic relationships which are based on a certain forms of political economy, i.e. capitalism.

Implications for Nursing:

The following is a gross simplification, a continuum if you like, of the two typologies. In practice a nurses will develop their own mix of the two approaches:

Biomedicine focuses on the ill individual, social models focus in healthy populations. A biomedical nurse would use mainly the medical sciences to help cure the individual , A social model nurse would draw from various disciplines (sociology, psychology) to promote health and well-being of populations. A biomedical nurse would be drawn to acute care, especially critical care while a social model nurse may be drawn to primary care and public health. A biomedical model seeks to change the individual,  A social model nurse would seek to change society. A biomedical nurse has little need for history and politics, a social model nurse understands her history and political action.  A biomedical nurse has little need to use a sociological imagination, a social model nurse needs to develop her sociological imagination.

A biomedical nurse may ignore ‘non-scientific’ approaches to cure, a social model nurse might value alternative and complementary approaches. A biomedical nurse wants to cure, a social model nurse wants to care. Biomedical nurses implicitly positively acknowledge higher stuts of medicine, a social model nurse gives no privileged status to medical practice. biomedical nursing mirrors male ways of thinking, social models open themselves up to female and post-colonial ways of thinking.

 

 

 

 

A note on ‘econursing’ or an ecological model of health.

Taking on board Barton and Grant’s health map, acknowledging for example the health impacts of climate change,  and the building upon a social determinants approach, an ecomodel would emphasise that human experience cannot be understood as separate from nature. Philosophically it critiques the dualist assumptions that see nature separate from humanity, what has been called ‘human exceptualism’. This is the position that sees us as exceptions from nature, we are separate from it, and nature is open for domination and control for the benefit of humankind. From an eco-perspective, this is extremely damaging to human health and to the health of the planet, more than that, they are the same thing.

Benny Goodman 2012

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