Explanatory models and HIV
Culture, meaning and perceptions:
explanatory models and the delivery of HIV care
Please cite this page thus: Hodgson, I. (2000) - Culture, meaning and perceptions: explanatory models and the delivery of HIV care. Abstract MoPeD2772, XIIIth International AIDS Conference, Durban, South Africa, July 14th-19th.
Issues: Explanatory models of illness
have been considered in a large number of culture-focused studies, in general
health, and with reference to HIV. Located in both the developed and developing
world, these studies traditionally focus on the experience of clients, and
demonstrate the role of culture in shaping a persons' construction of the
meaning of illness and disease. In the case of HIV, insights into a person's
perceptions of risk have been especially valuable.
1. Centrality of culture
Culture dominates our lives; it forms the framework within which we understand and make sense of the world. It is variously defined, but the most useful states that culture is the acquired knowledge people use to interpret experience and generate behaviour (Spradley, 1980). A broader definition is: 'a set of guidelines…which individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or Gods, and to the natural environment' (Helman, 1994, p 2).
2. Explanatory models
Cultures, in making sense of illness, have clusters of explanatory models, the lenses through which cultures perceive and understand illness. First developed by Arthur Kleinman (1980), the term refers to interpretive notions about an episode of sickness and treatment that are employed by all those engaged in the clinical process. Importantly, both carers and patients utilise explanatory models extensively.
In particular, explanatory models address 5 aspects of illness:
· the cause of the condition
According to Kleinman, non-professional explanatory models tend to be idiosyncratic, changeable, and heavily influenced by cultural and personal factors. In a discussion of explanatory models, Helman suggests that medical explanatory models are 'based on single, causal chains of scientific logic' (1994, p111).
3. Explanatory models and HIV/AIDS
HIV and AIDS are complex and frightening phenomena, and explanatory models provide a toolkit to bestow some degree of meaning. This absorption of new phenomena into existing models is significant, and many studies have demonstrated this process of integration (e.g. Mogensen, 1997; Bechtel and Apakupakul, 1999).
Explanatory models, in this case adopted by health care workers in the West, are equally subject to 'rules of thumb' that appear at odds with scientific orthodoxy. Within the context of sophisticated health care systems, the role of cultural narratives, in the form of myths, are powerful engines in the shaping of explanatory models, and even a cursory literature review of the perceptions of HIV held by health care workers reveals that extant narratives are providing the basis for some of the more prevailing institutionalised representations informing explanatory models. These can be classified into:
4. A suggested framework
Health care interventions must be culturally adroit in order to have any chance of success (Dowsett, 1999), and this paper proposes a model that allows a critique of explanatory models according to two criteria: proximity to a context promoting physical safety (i.e. protection from infection); and proximity to a context promoting cultural safety (respect for the person). The structure is derived in part from the grid-group model developed by Douglas (1996/1970). See model below in fig. 1.
4.1 - The framework
Axis 1: this represents the degree of proximity to accepted notions of physical safety, based on what is known about HIV and modes of transmission.
Axis 2: this represents the degree of proximity to cultural safety - recognising and respecting the unique cultural identity of individuals (Kolaschek, 1998). This pertains to sensitivity to a person's social and cultural context, and is inversely related to the dominance of the institutionalised, Western explanatory models identified in section 3 above.
4.2 - The quadrants
Quadrant 1 : Pure biomedical position
Here, physical safety is maximised; scientific knowledge and information regarding safe behaviour is clear. The power of biomedicine is dominant, for knowledge of the physical body is extensive, and Foucault's 'medical gaze' is a reality. For Foucault, knowledge [in this case of the body] is power, and the transition of the person-as-individual to person-as-disease is an example of scientific objectivity meeting the 'naked individual' (Foucault, 1973). Tolerance of individual behaviour is likely to be low, because of an inability to 'listen' to alternative narratives - cultural safety is therefore at a minimum.
Quadrant 2: The 'popular' position
Here, physical safety is compromised - the accuracy of information regarding protective behaviour is poor, with flawed information regarding the virus being disseminated, often as an exaggerated fear of contagion. In addition cultural safety is also jeopardised - this is the position taken by the 'popular' (tabloid) press, where groups at risk of HIV are ostracised, and narratives conform to the prevailing cultural norms of blame and panic. The power of the Western institution remains, though the value of quadrant 1 (physical safety) is lost.
Quadrant 3: The 'individual/relativist' position
Here, physical safety remains compromised, though the threat to cultural safety is diminished, with the move away from institutionalised representations. Explanatory models in this quadrant are likely to be promulgated by people within social groups who may be at a higher risk of being infected with HIV, but choose to be selective about their risk of infection. Nemeroff (1995) suggests that certain people perceive HIV as socially discriminating - they know the risk factors, but consider that it does not apply to them.
Quadrant 4: The competent position
In this quadrant, both physical safety and cultural safety are maximised. Safe behaviour, and a consideration culture leads to cultural adroitness in health care interventions, coupled with a sure knowledge of maximising protection from infection. This is clearly the recommended location of the enlightened health care worker, who is sensitive to alternative understandings of sexuality generally, and HIV in particular.
Akinsanya, J. & Rouse, P. (1992). Who will
care?: A survey of the knowledge and attitudes of hospital nurses to people with
HIV and AIDS. Journal of Advanced Nursing 17(3): 400-401.
Webmaster: Ian Hodgson
Page updated February 15, 2001