The last 200 years has seen substantial evolution in conceptions of health and disease. The emergence of biomedical models was vital in understanding the human body and developing evidence-informed treatments. The emergence of social health models has equally profound implications for the way that we strengthen health and wellbeing in our society.

It is no longer sufficient to base healthcare policy and service delivery on individual interventions, without considering the broader social, economic and environmental factors which influence health outcomes. How can we further build social health models to create a healthier society?

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Evolving models of health

Humankind has always sought to resolve illness and develop understandings of what it means to be healthy; this has included physical, environmental, psychological and spiritual dimensions.

Western theories of health and disease, and the beliefs and meanings ascribed to our health, have repeatedly changed over the course of millennia. These changes are the result of distinct cultural and religious beliefs, and emerging scientific and medical developments.

Conceptions of health in ancient times were linked to religious and moral beliefs. Headaches and mental illness were attributed to demons or a weakness of character that prevented adherence to moral codes or religious rituals.

In this world view gaining favour with your chosen deity through prayer and sacrifice was viewed as health promotion.

While it may seem surprising given Western society's commitment to science and evidence, some of this thinking persists today, for example in the way we continue to demonise illicit drug use in the face of an overwhelming focus on medication to manage health problems.

Biomedical models

Hippocrates and the emergence of logic and reason 2,500 years ago revolutionised approaches to healthcare. For the first time cause-effect relations were identified and diagnostic categorisations emerged.

Later enlightenment thinking introduced positivist scientific methods, leading to healthcare approaches which trialled, and embraced or rejected treatments based on real world data rather than theoretical postulations.

The biomedical or 'disease based' model was enshrined in European healthcare thinking in 1854 when Dr John Snow first demonstrated that cholera was being transmitted by shared water pumps in central London, not an ethereal 'miasma' floating through the air.

This approach shifted moral and religious ideologies. People experiencing illness were still considered diseased and deviant, but these attributions were no longer the result of angry gods.

The biomedical model has been fundamental to better understanding the human body, developing diagnostic categorisations to inform treatment, and has unquestionably improved health and longevity. We would not have vaccines or modern surgery without it. However, these approaches are framed principally around individual health and focused on treatment of illness.

Biomedical and diseased based models retain prominence today. This is evidenced through the continued resourcing of health treatments at the expense of illness prevention and health promoting activities.

For example, the Australian Institute of Health and Welfare estimates that only 1.3% of all health spending in Australia during 2013-2014 was for illness prevention initiatives despite an estimate that 83% of all premature deaths are the result of preventable chronic diseases.1

Social determinants of health

While biomedical approaches remain important, new thinking and practice has emerged which is transforming our beliefs about health and healthcare. These approaches have been developed in response to perceived gaps in biomedical models, namely the focus on individual characteristics, and treatment of illness.

Beginning with the World Health Organisation's constitutional statement2 that 'health is a state of complete physical, mental and social well-being and not merely the absence of disease' (1946), there have been repeated calls to expand the range of influences recognised to impact health, and to reorient health services to provide a stronger emphasis on prevention and health promotion. Two pivotal primary healthcare conferences led to key documents that outline these perspectives: the Declaration of Alma-Ata (1978)3 and the Ottawa Charter for Health Promotion(1986)4.

Expansion of the domains which influence health was recognised as important as it became clear that not only individual factors, but social, economic, cultural and environmental factors significantly contribute to individual and community wellbeing.

A range of health models have attempted to capture these broader health determinants. Common amongst these are bio-psycho-social models (e.g. Engel, 1977)5, ecological models (e.g. McLeroy et al., 1988)6, and social ecological models (e.g. Bronfenbrenner, 1979)7.

Image of the Biopsychosocial Model of Health

Figure 1: A biopsychosocial model of health

This recognition creates a strong case for health service reorientation. While most health funding has historically focused on acute health treatment, better outcomes can be achieved through diverting resources upstream to reduce and prevent health problems occurring.

A social model of health

These contemporary approaches highlight the influence broad social health determinants have on our wellbeing. They acknowledge the close connections between the social, economic, cultural and environmental conditions in which people live and their health.

Social health models extend earlier thinking by acknowledging that social inequalities impact health. This perspective helps us recognise that things like social inclusion, stable housing, and racial and gender equality all have a fundamental impact on our health.

A social health approach therefore highlights the important role of advocacy for social change as a key tool in improving health outcomes8 and broadens the range of services considered to be health focused.

Using this conceptual frame, we can understand how a lack of access to secure housing could have multiple negative health consequences. For example, making it harder to maintain a healthy diet, remain connected to school or work, or undertake activities which support physical and psychological wellbeing.

Image of the Social Determinants of Health Model

Figure 2: Social determinants of health model (Whitehead & Dahlgren, 1991)9

Figure 2 illustrates how these broad social health determinants extend inward to affect individual health choices like smoking or exercise.

Furthermore, social health approaches advocate for more illness prevention and health promotion activities which address the social and environmental conditions in which people live.

They also recognise personal agency and control for health decision making is an important contributor to health outcomes. People need to make health choices for themselves.

Example - Resolving drug problems

Moral and religious approaches to substance use problems have focused on a weakness of will or moral character. They also typically linked drug use to other socially unacceptable behaviours, for example sexual promiscuity (see Figure 3). 'Treatments' highlighted the need to build moral will or improve character. Fear was typically used to prevent uptake of drug use, for example by linking drug use to 'hell' or social exclusion.

Bio-medical approaches to resolving substance use problems have historically focused on treatments for drug withdrawal or substitution therapies like methadone; they haven't considered precursors to developing problems or support following treatment.

Social health responses expand this to help us understand why someone would choose to use drugs as well as how they resolve their problematic use. They recognise that drug use is tied to the social and environmental conditions in which people live (e.g. family and peers, living conditions, access to substances, employment and education opportunities, access to information and services).

This perspective recognises that stigma and discrimination against drug users can contribute to poorer health, for example by reducing access to services. As such, social health approaches recognise that broader structural factors including service accessibility, community attitudes and availability of economic opportunities must be addressed alongside treatment of the presenting condition. Individual factors such as genetic pre-disposition or early life trauma also need to be considered to assist sustained recovery from substance use.

Image of American Public Health advertisement from 1938 warning of the dangers of marihuana

Figure 3: Moral approaches to health promotion (American public health advertisement, 1938)

The foundations of social health

Social health approaches:

  • Include a wellness focus - 'health is more than the absence of disease'
  • Recognise that health is impacted by a wide range of social, cultural and environmental factors
  • Acknowledge that economic and other inequalities negatively impact health
  • Have capacity to intervene across the prevention to rehabilitation spectrum
  • Reduce discrimination, stigma and individual blame for health choices, placing them in a broader context
  • Tailor responses to unique individual circumstances, using intersectional and culturally safe approaches
  • Encourage greater individual control of health decision making

What must happen next?

While social health models are now well accepted our healthcare system remains biomedically based with a focus on resolving problems, rather than preventing them. It also continues to view professionals as 'experts' who direct and control health decision making for others.

As our population continues to grow and age, we must reorient health resources toward greater health promotion and illness prevention activities.

Despite evidence for their effectiveness primary prevention and health promotion initiatives attract only a small fraction of health system investment.

We need stronger recognition across the health system, and from government, of the importance of addressing structural factors that impact health. Policy, legislation and discourse need to take into account the health effects of social, economic and environmental conditions.

These changes are necessary in order to achieve better health outcomes for all, irrespective of race, gender, socio-economic and cultural pre-conditions.

Conclusion

Socially constructed health models have been important in identifying the broad range of factors that influence health and wellbeing. They provide guidance about how we should reorient services and partner with service users to create better health outcomes. They also provide guidance about where we should be investing scarce health resources for greatest impact.

Social health approaches have stimulated important changes in thinking and practice related to healthcare, for example by recognising the role of inequality, stigma and discrimination, and personal agency in health outcomes.

We need stronger recognition across the health system, and from government, of the importance of addressing structural factors that impact health.

In order to more effectively use health resources, and enable better health for all, we will need to continue to strengthen these approaches and use them to inform not just healthcare provision, but social and economic policy more broadly.

Notes

1. Shiell, A., and Jackson, H. (2018). 'How much does Australia spend on prevention and how would we know whether it is enough?' Health Promotion Journal of Australia, v.29; S1.

2. World Health Organisation. (1946). World Health Organisation Constitution. Retrieved September 2020 from: https://www.who.int/about/who-we-are/constitution.

3. Declaration of Alma Ata. (1978) https://www.who.int/publications/almaata_declaration_en.pdf

4. Ottawa Charter for Health Promotion. (1986) https://www.who.int/healthpromotion/conferences/previous/ottawa/en/

5. Engel, GL. (1979). The need for a new medical model: a challenge for biomedicine. Science, v.196; pp.129-136.

6. McLeroy, K.R., Bibeau, D., Steckler, A., and Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, v.15; pp 351-377.

7. Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and Design. Cambridge, Massachusetts: Harvard University Press.

8. Islam, M. (2019). 'Social Determinants of Health and Related Inequalities: Confusion and Implications.' Frontiers in Public Health 2019 7: 11. Published online 2019 Feb 8. doi: 10.3389/fpubh.2019.00011.

9. Whitehead M. and Dahlgren G. (1991) 'What can be done about inequalities in health?' Lancet, v.338(8774): pp: 1059-1063.

 

Can we help?

Lirata assists organisations to plan, develop and evaluate health initiatives which respond to individual and community health needs. We have a particular emphasis on supporting health promotion and illness prevention projects. We work in close collaboration with people using services and the service providers who support them.

For further information or assistance, please contact the Lirata team:

Phone: +61 (0)3 9457 2547
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
 

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External resources

The following resources provide further information about social health models, practice and current thinking: