2.1 Why do we need a social model?
In Engel’s seminal work, the biomedical model was defined as assuming ‘…disease to be fully accounted for by deviation from the norm of measurable biological (somatic) variables. It leaves no room within its framework for social, psychological, and behavioral dimensions of illness’ (1977, p. 196). But this model clearly needs to be expanded to encompass a broader, more holistic approach to treatment and care. Although holism considers ‘the complete woman’ by looking, for example, for social and emotional explanations for their disease and symptoms (Henderson, 2014), the social model of health takes a different perspective. The social model explains health and wellbeing through the social context. Rather than starting with a woman in a particular state of health or disease, the main focus is on how living conditions and social factors affect health and wellbeing.
Looking at Dahlgren and Whitehead’s diagram (Figure 2), you could think of holism as starting with ‘Age, sex and constitutional factors’ and working outwards. By contrast, the social model would focus first on general socioeconomic, cultural and environmental conditions before working its way through the layers to eventually consider a woman’s constitutional factors.
Women frequently have limited control over the many sociocultural factors that affect their health and wellbeing. Therefore, the social model of health lends itself to campaigns arguing for social justice and better working and living conditions. In addition, the biomedical model isn’t always able to account for how sociocultural factors can interact with the diagnosis it is – or isn’t – able to provide, or how this can impact on a woman’s sense of wellbeing.
For example, Yvonne John is an author who has documented the experiences of childless women. In the following activity you will hear her speak about her own experiences around childlessness.
Activity 2 Wellbeing beyond the reach of biomedicine
Listen to Yvonne John talking on BBC Woman’s Hour about her experiences of childlessness.
Transcript: Audio 1
SPEAKER 1: I had been trying for three years naturally with my husband, and within that time, we had infertility investigations. And at the end of that, my consult sat with me and told me I had unexplained infertility.
SPEAKER 2: How difficult was it for you to tell your story within your family?
SPEAKER 1: It was really hard. It was-- I think when you are in so much pain and so much grief, you don't understand it yourself, anyways. It's really hard to find the words to describe it. And what I found is then trying to tell my family, because I couldn't explain it for myself, it was really hard to tell them. And when I did try and tell them, they all wanted to fix it. No one wants to see you hurt and in pain. They just automatically wanted to give you all that you know. That you shouldn't feel that way, it's OK, just keep praying about it. It's God's will. You know, I had so many things that really were unhelpful. So it was just a really difficult time for me.
SPEAKER 2: And what about friends?
SPEAKER 1: Friends were the same. Again, no one wants to see you be hurt so they just want to comfort you and give you things like, you know, well, you've got a good job, have one of my children, it's all OK. And no one really allows you to be that sad about it.
SPEAKER 2: You used the word grieving. Why?
SPEAKER 1: Because it is a sadness. It's this place where you don't understand and no one understands why because you haven't lost anything, but we have lost the dream of being mothers. It's something we had-- a lot of women from childhood, we were brought up hearing, when you become a mum, you'll understand. I remember my parents telling me all the things that I did that I'll get back when I was going to be a mother.
So I always knew I was supposed to be a mum, and all of a sudden I was in this place where it wasn't going to happen. Wasn't going to happen, and I didn't know what that meant for me or my marriage, and I didn't know who I was anymore. Where did I belong?
SPEAKER 2: We heard women talking about this last week. Why is it a taboo subject, particularly among women of colour? I know you have two aunts who don't have children.
SPEAKER 1: That's right, yeah. What I found, and it's something I've experienced myself, but I talked to my black friends about it just to see what their experience were around motherhood and the whole notion of becoming a mum, and one of the things that was very common with all our experiences was the shame. So being first generation British, it was the pride that our parents had when they'd come to this country, the racism they went through, the things that they stood up for to afford us this privilege to be in England, to be educated in England, to have lives and good jobs, because they fought a lot for that.
So to come here and show any weakness, or shame, or negativity in any way wasn't an option. So it was always about hiding all of that and not talking about it. And also I found religion was another big thing. So it was all about pray and turning to God, and I also felt like if we did talk about it, it was like we didn't trust God because instead of talking to someone about it, we should be on our knees praying and believing and trusting in God. And in the absence of that, it almost means-- feels like you don't trust God or you don't believe in him. When actually, for me, that isn't true, but that was the experience I had from it.
SPEAKER 2: What kind of things, in the period that you've gone through, have you found helpful and comforting from other people?
SPEAKER 1: Was being allowed to be sad. Somebody saying to me, oh, my gosh, that sounds really difficult, was one of the best things I ever heard. And getting a hug, as well. It's being allowed to be sad and being accepted for being sad. You know, even things like when I can't go to my friend's birthday-- my goddaughter's birthday party because actually it's so painful to be amongst parents and young children. And for her to say, you know what? I really understand. It's OK, let's have time on our own and spend that together instead.
SPEAKER 2: And just one more question. Interestingly that childfree has been the sort of expected-- accepted expression for women who don't have children. You use childless. Why?
SPEAKER 1: Because childfree is by choice. So we use childless by circumstance to explain that, actually, it wasn't our choice not to have children.
Now answer the following questions.
- What role did biomedicine play when Yvonne and her husband were trying to conceive, and how was biomedicine unable to help her?
Yvonne received ‘infertility investigations’ that concluded she was unable to conceive. There was no particular cause found, which meant that there was no detectable ‘defect’ to treat medically.
- What challenges to Yvonne’s health and wellbeing did she face following the medical diagnosis? What was the impact of social and/or cultural expectations on her wellbeing?
Yvonne experienced many challenges, starting with the difficulties of talking to her family when she was experiencing shock and grief. She was grieving when there was no visible loss. She also talked a lot about how being diagnosed with unexplained infertility challenged the beliefs and cultural expectations of her and her family, and this further had an impact on her wellbeing, in particular:
- There was an expectation that there should be a way of fixing her infertility (perhaps referencing a biomedical approach).
- Yvonne experienced shame in not being able to live up to the expectation that she would one day become a mother. Being from an immigrant family increased the pressure of this expectation. Perhaps the pressure of having to be positive about the situation was the worst element.
- The diagnosis interfered with her sense of identity and belonging.
- She experienced religious challenges, particularly surrounding expectations of turning to God.
- What did help Yvonne?
Things that helped were simple human gestures, such as ‘being allowed to be sad’, receiving a hug and ‘being accepted for being sad’.
- Taking a social model perspective, what might you want to better understand in order to improve the health and wellbeing of Yvonne and other women in a similar situation?
If taking a social model perspective, you might want to understand why immigrant families feel the pressures they do. You might also want to look at the place of women in society regarding their reproductive roles and expectations.
The social model of health attempts to integrate social structures and women’s bodily existence in the world. It goes beyond the body to address the social, economic and environmental determinants of health. As you have learned, female reproductive health is one example where the social model offers a useful perspective. The biomedical model would consider reproductive health in relation to the body and reproductive roles, whereas the social model starts from the perspective of the social, cultural and economic, as well as equality issues. You will read more about the social model of health next.