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Week 3 Health and Maladies: Concepts of Well-Being and Disease, Illness, Sickness and the Sick Role

From Winkelman Culture and Health Chapter 2

Overview
What is Health? Personal Conceptions of Health What are determinants of health?
Health maintenance behaviors

Concepts of maladies
Disease, Illness, and Sickness/Sick Role

Mediating Across Maladies


Health Beliefs Model Explanatory Model

What is Health?
Etymological perspectives
Heal, Ill, Sick, Disease and Medicine

Medical Perspectives
Mortality and Morbidity

Nursing education and research relies on abstract analytical definitions of health rather than people actual concerns and experiences

Biomedical Health Perspectives


Life expectancy Span of Health Life Reserve Health Social Support Birth rate and population growth?

All a function of cultural and social context

What is Health?
World Health Organization definition:
state of complete physical, mental, and social well-being, not merely the absence of disease

Health as symbolic of wellness, a value term defined by culture or individual

Public Health Concepts


Community resources Organizational Concepts
Community Involvement

Planning- Healthy Communities 2010 No single definition of health as comprehensive and exhaustive What does health mean to you? See selfassessment Values and Health

Personal Conceptions of Health


Unlocking
self-assessment process as revealing the personal and experiential aspects of health

Reveals the importance of following for health


Experiences-- Feeling of well-being Homeostasis Physical, mental, and social well-being Mental and subjective states Activities of daily living Harmony of body, mind and other important aspects of life

Cultural Views of Health


Desirable traits Views of normal conditions Preferred emotional and psychological states Illness concepts Moral states Spiritual conditions Why important for doctors to know?

Many factors affecting health


Major causes of Death
Which have to do with germs? Which are fundamentally behavioral?

Sociogenic disease
Caused by social and cultural conditions

Cultural-Ecological Systems Models

Determinants of Health Status


Diet Behavior Physical activity Injury Weight/Obesity Sexual behavior Tobacco and other drug use Social relations Environmental quality Immunization status Health care access

Environment of Health Force Field Paradigm


Physical Environment Social Environment Personal Behavior/Lifestyle Medical Care Services Genetics and Biology

Health Maintenance Behaviors


What do you do to stay healthy? Importance of understanding patients views for establishing preventive care services Diet and behavior as fundamental aspects

M1L3.2 Concepts of Maladies


Disease presumed biology Illness- personal experience Sickness- socially induced effects Sick Role- social expectations for behavior Consequences of differences miscommunication, noncompliance, untreated conditions, lack of confidence

Biomedical Assumptions About Disease


The Biological Basis of Disease Deviation from Normal Functioning The Doctrine of Specific Etiology The Assumption of Generic Disease The Scientific Neutrality of Medicine

The Biological Basis of Disease


Assumption that maladies are basically biological conditions
Abnormal physiological conditions

Effects of cultural context


Dyslexia Consequences of others responses Sociogenic conditions Case Study: Leprosy

Doctrine of Specific Etiology


Etiology = cause;
Biomedicine specific biological causes alone Problem: many infections without disease Causation within a system:
Necessary causes Sufficient causes Remote/distal causes Contributory causes: Direct and indirect Case Study: Cardiac arrest biology or interpersonal?

Deviation from normal functioning


Problems of what is normal
mean? Median? Mode?

Normal for which segment of population


Male vs female, age, ethnic group, diet

Conditions as culturally assessed


Spirit possession vs epilepsy

Conditions as personally/culturally variable

Assumption of Generic disease


Identical universal diseases Nosology universal classification systems
ICD- International Classification of Disease DSM- Diagnostic and Statistical Manual

Presume universal criteria for disease Different systems of classification/causation Political and cultural criteria
Homosexuality changing classification Now emphasizes unwanted feelings Why no unwanted heterosexuality?

Generic Disease cont


Cross-cultural differences in schizophrenia
Manifestations of symptoms Differences in severity & prognosis

Case Study: Depersonalization vs detachment


Buddhist perspectives nonattachment, liberation Differences in response to experiences of hopelessness, meaninglessness Importance of cultural & personal perspectives

Scientific Medicine?
Is Biomedicine Culturefree?
CultureS of medicine shows not

Lack of scientific evidence no double blind clinical studies for many (most?) treatments Politics of medical practice, education & funding hospitals for CVD vs. PHC

Illness Accounts
Emphasis on sufferers personal experiences of a malady Also affected by social factors Emphasis on undesirable experiences
Consequently emphasizes personal, cultural preferences

Includes effects of beliefs, personal consequences, personal limitations, personally valued activities, ADL,

Illness sources
Internal sensations Emotions Bodily functions Feared/actual limitations Culturally stigmatized conditions Social responses

Illness Implications for Biomedicine


Cultural conceptions of disease conditions Social implications affecting treatment\ Case Study: Caida de mollera Case Study: High-Pertension vs hypertension
High-pertension and high blood nerves & excitability; emotional & dietary contributions High blood pressure as blood pressure high blood treated with salty & pickled foods Can contribute to high blood pressure

The Sick Role and Sickness Career


Focus on social consequences & expectations Sick Role expectations of the ill & diseased Focus on role behaviors of a position Classic Formulations of Sick Role
Exemption from normal responsibilities Release for personal responsibility if compliant Obligation to follow medical orders Temporary legitimization

Limitations of Classic Sick Role Concepts


Not accepted for certain Disease AIDS, STD, Mental Illness Culture of Blaming for Disease Life style not forgiven Some conditions uncurable Need to expand Sick Role conceptualizations

Sequences in Illness Experiences


Experiences of Symptoms Assumption of sick role Medical care contact Dependent stage Recovery or rehabilitation All have major cultural components

Culture & Sick Role: Case Studies


African American Culture
Not available, fear of discrimination, psychological effects Spiritual coping & crises responses

Mexican American Culture


Economic and political limitations Cultural expectations machismo, marianismo

AIDS as Disease, Illness and Sickness AIDS as Disease: HIV


Cultural variation in incidence, susceptibility

AIDS as Sickness
Social responses and effects

AIDS as Illness
Factors affecting personal experience

M1L3.3 The Challenge of Crosscultural Medicine


Mediating across conceptions Maladies Culture Communication Clinical relations

Strategies for Mediating among Conceptions of Maladies


Clinical Adaptations to Illness & Sickness Health Beliefs Model Explanatory Model

Clinical Adaptations to Cultural Aspects of Maladies


-- understanding 'illness and sickness -- improve communication -- increased cultural self awareness -- treating disease, illness and sickness -- assessing social and cultural effects

Health Belief Models


Public health origins Recognition that decision-making models shape preventive actions and treatment responses. Based in theories regarding perceived risks and benefits

Original emphasis of Health Beliefs Model


A tool for examining differences in lay and professional beliefs regarding a condition Focusing upon patients perceived: -- susceptibility to disease -- likelihood of contracting a condition -- severity of that condition -- benefits of action -- barriers to care

Expansion of Health Beliefs Model


Corrective to the original cognitive orientation Also addresses Modifying Factors
Demographic/Cultural Availability of services Cost-benefit analyses of changing behaviors or accessing services Cues to action,
billboards or public service announcements that stimulate peoples thinking about needed health behaviors; and

self-efficacy
the individuals belief in their personal ability to take actions to achieve changes.

The Explanatory Model


Originated by physician-anthropologist Arthur Kleinman Examines how patients interpret causes and progress of a malady and how they think it should be treated. Use patients perspectives to enhance medical care

Explanatory model elicits the patient's view of


etiology or cause of the condition, that is, what has happened and how or why timing of symptom onset, why has this occurred now pathophysiological processes, what the condition does to the organism the natural history of the malady, its anticipated course and effects if left untreated appropriate treatments, what the patient thinks should be done

Conclusions
Basis for understanding health behaviors Adaptations to patients behaviors Basis for negotiated outcomes
see lecture 6.3