such as social interaction and behaviour. The notion of health is seen as being socially constructed, which is central to the social model of health and this idea is discussed in more detail later in the chapter.
The social model operates from the view that a wide variety of factors need to be taken into account when conceptualizing health – factors such as the environment, influences on lifestyle choices, access to health-care services, employment status and gendered identities, for example. The social model recognizes individual differences in health experience as being socially produced. In addition, it seeks to provide explanations for why differences exist. Crucially the social model of health also takes into account lay perspectives about health, which are discussed in more detail later in this chapter.
The social model of health is not without its critiques. It has been criticized for being so broad a model as to render it almost unusable. Kelly and Charlton (1995) argue that the social model cannot necessarily be viewed as superior to the medical model, despite criticisms of it. For example, they point out that while health promotion is premised on a social model of health in terms of the way that health is conceived (holistically), the discipline still relies heavily on expert knowledge that can be traced back to scientific origins. Therefore, science (and the medical model of health per se) has its part to play in understanding about the nature of health. The social model has also been criticized on the basis that the breadth of understanding it takes into account may lead to practices in health promotion and public health that have different priorities and therefore can only be implemented on a small scale. Earle (2007a: 54) therefore suggests that, rather than being able to pin down the ways that the social model of health may be used to, for example, improve or promote health, the ‘rhetoric’ of the social model of health has been used in the following ways:
– as a set of underlying values (philosophical approach to health)
– as a set of guiding principles to orientate health work in a specific way
– as a set of practice objectives
In summary, the medical model views health as derived from biology, so ill-health is caused by biological factors that can be identified, diagnosed (as compared with a scientifically defined ‘norm’) and treated by expert medical knowledge. In contrast, the social model of health views it as socially constructed and influenced, so ill-health is caused by social factors, knowledge about ill-health is not confined to medical expertise and a more holistic, less reductionist view of health is subscribed to. Table 1.1 highlights the key differences between these two models.
The importance of social factors and the social model of health is demonstrated in Dahlgren and Whitehead’s (1991) rainbow of determinants (see part III, especially chapter 13).
Table 1.1 The medical model of health compared with the social model of health
| Medical model | Social model |
|---|---|
| Narrow or simplistic understanding of health. | Broad or complex understanding of health. |
| Medically biased definitions focusing on the absence of disease or disability. | More holistic definitions of health taking a wider range of factors into account such as mental and social dimensions of health. |
| Doesn’t take into account the wider influences on health (outside the physical body). | Takes into account wider influences on health such as the environment and the impact of inequalities. |
| Influenced by scientific and expert knowledge. | Takes into account lay knowledge and understandings. |
Salutogenesis
For the most part, in Western cultures at least, when we talk about health we are actually talking about negative health experience or ‘ill-health’ rather than more positive aspects of health. This has its roots in the medical model of health. Salutogenesis turns this idea around. Salutogenesis is concerned with what creates health and ‘what factors support health’ (Svalastog et al., 2017: 432). Antonovsky was the instigator of this idea and he has challenged the ‘pathogenic’ nature of the medical model including its fixation on the elimination of disease constituting ‘health’. Antonovsky (1996) argues that the focus should be on ‘symptoms of wellness’ rather than causes of disease and at-risk groups and that, given that we are ‘organisms’ we should accept that we will, at time, have things ‘wrong’ with us. The suggestion is, therefore, that ‘none of us can be categorized as being either healthy or diseased, (instead) we are all located somewhere along a continuum’ (Sidell, 2010: 27).
The holistic model
The contrasting medical and social models are not the only way to conceptualize health. Another way of looking at health is by taking a ‘holistic’ view, which takes a more integrated approach (Chronin de Chavez et al., 2005). Essentially holistic health is ‘an expression of wholeness’ (Svalastog et al., 2017: 431). This takes into account the interaction of biological, psychological and social factors (Earle, 2007a) and also views the person as a ‘whole’ rather than a sum of their ‘parts’. Holistic notions of health may be seen as taking into account mind, body and spirit (see Patterson, 1997 – in Earle, 2007a). The difference between the social model and a holistic approach to health is that the holistic approach tends to focus on the individual rather than social structures that influence the individual (Chronin de Chavez et al., 2005 and Earle, 2007a). A holistic approach underpins many complementary (or so called ‘alternative’) approaches to health. While a strength of a holistic approach is that it takes spiritual health into consideration, one of the criticisms of holistic approaches to health is that, similarly to the medical model, it is more individualistic and does not take wider social factors into account.
The biopsychosocial model
The biopsychosocial model of health is very closely aligned to holistic views about health but is nevertheless distinguished from it in the wider literature. Engel (1977, cited in Marks et al., 2015 and Sarafino and Smith, 2016) developed the biopyschosocial model of health and illness – an expansion of the (bio)medical model that combines social, psychological and biological aspects of health and accounts for the interaction between these. Biological factors include factors like genetics and our physiological condition and systems. Psychological factors include taking into account how we behave, how and what we think and how we feel. Social factors include consideration of the fact that we are social beings who interact with others within groups, communities and societies. This is a model of health that has influenced research, theory and practice in health psychology but arguably has not had as much impact in other disciplinary areas in relation to health.
Different perspectives
Different perspectives offer different contributions to our understanding of health. In the first instance let’s consider philosophical perspectives about health. Seedhouse (2001) argues that it is important to consider philosophy when trying to answer the question ‘what is health?’, since philosophy should be employed where competing and conflicting ideas about phenomena exist – health is a very good example of this. Another perspective is offered by psychology. Stephens (2008: 19) argues that psychology views health as ‘a matter for individual minds’. Mainstream approaches to health in psychology
