Introduction to The Two Agendas:

Dr Tiny Masupe, MBChB, MPH MSc

 Plenary Objectives

 Describe the nature of biomedical (‘disease’) and

psychosocial (‘illness’) agendas and how they may
differ from each other.
 Describe some of the problems that can arise from
failure to recognise this duality of agendas.
 Describe how the patient’s agenda may be explored
in the consultation process.
 Describe how biomedical and psychosocial
components may be interrelated.
What is health?
 What are some of the
perspectives on disease or ill
health – e.g. causation or
otherwise?
Perspectives to Ill health or Disease

• Disharmony, violation of taboos, ancestors warnings,

malevolent sorcery [witchcraft] – African, Papua New
Guinea

• Lack of balance of basic body elements: heat, cold, strong

emotions –Chinese, ancient Greek – need for equilibrium

• Biomedical - led to more individualistic approach, cause

and responsibility with individual rather than family or
community
Medical models of disease causation

 Germ theory –single cause theory

 All diseases were presumed to be caused by germs and by germs alone -- one
species of germ per disease. When infection with, for instance, the cholera germ
occurred, then the disease cholera should surely follow.
 The classic epidemiologic triad of host, agent, and environment
 Provided a better model for understanding the complex realities of disease
causation.
 carry over from germ theory
 The classic model, however, appropriate for the understanding of infectious
diseases.
 The CONCEPT of an AGENT as cause of disease still central
 The variety of relevant factors in the host and the multitude of environmental
influences acknowledged
 Chronic diseases challenge the AGENT focus..
Medical models –chain of causation

 Multi-causality model
 better expressed the complex reality of multiple causes of disease
 epidemiologists began thinking in terms of chains of causation.
 A causal event, then at the antecedents of that event, then at the
antecedents of the antecedent, and so on.
 What if model
 For instance, we note that a pregnant woman developed an illness
known as toxoplasmosis after becoming infected with toxoplasma Gondii
from a cat
 The chain of causation is thus: Infected cat -> contaminated urine ->
contaminated litter —> infected cut -»toxoplasmosis in host.
Sherwin’s Diet heart hypothesis

Myocardial
Diet saturated High blood Atherosclerosis
infarct (heart
fats cholesterol lipids (CAD)
attack)
 Diet heart hypothesis

 "diet-heart hypothesis" (DHH) as described by Sherwin (1978).

 a diet high in saturated fat and cholesterol leads to high blood lipids
 which lead to atherosclerosis (coronary artery disease)
 which leads to coronary heart disease and the clinical event of a myocardial
infarct (heart attack).
 Some important elements left out
 The link between diet and elevated blood lipids is also influenced by genetic
factors and emotional stress.
 The link between high blood lipids and atherosclerosis is also promoted by
other factors
 genetic factors
 aging, hypertension, smoking, stress, and low blood levels of the protective
high-density-lipoprotein cholesterol (HDL).
 DHH limitations

Genetic factors
Stress
High BP
Smoking

High cholesterol Heart Aging

& lipids
attack
Approaches to disease management

 Holistic
• Homeopathic, faith healing etc more appealing since approaches
“whole person’’ - no scientific evidence yet of clinical
effectiveness other than placebo
• Acupuncture – some evidence of effectiveness in chronic pain

 Functional
• Priority given to being able to work, to function, to be a useful
member of society [attributed to a capitalist ideology of value]
• Need for a healthy workforce – generated many social reforms in
Europe end 19th / early 20th century – parallel with approach to
treatment for AIDS
 Defining the two agendas

Biomedical Psychosocial
 Disease  Illness
 Pathological explanations  Unvoiced agenda items from
 Germ theory patients:
 Doctors failed to elicit 54% of  Worries about possible
patients’ reasons for diagnosis and prognosis
consulting  What the future holds
 Possible side effects
 Information relating to the
 ... and 45% of their worries social context
Relationship between biomedical
and psychosocial agenda
Health
behavior

Bio-psychosocial model
CNS
Psychological
processes Endocrine
responses

Health

Social and
Body
physical
systems
environment
 Bio-psychosocial model

 Why consider this model

 Explains influences on health
 WHO definition of health
 State of complete physical, mental and social wellbeing and
not merely the absence of infirmity
 Social factors
 Environmental factors
 Psychological factors
 Individual factors
 Provides a comprehensive framework for understanding
health
Exploring the patient’s agenda

 The consultation
 Building rapport with patient
 Identifying reasons for consultation
 Exploring patents’ problem
 Providing structure to consultation
 Building rapport

 Non verbal communication

 Eye contact
 Posture
 Gestures
 Vocal cues

 Demonstrate confidence

 Non judgmental attitude

Identifying reasons for consultation

 Identify problems that patient wishes to address

 Listen attentively
 Confirm, list, screen for other problems
 Negotiate the agenda
 Exploring patients’ problem

 Opening question
 Encourage patient to tell own story
 Listen attentively
 Pick up on non-verbal cues
 Clarify patient’s statements
 Periodic summaries
 Patient concerns, expectations, effects of the illness
 Encourage patient to express feelings
Misunderstanding of the 2 agendas:

 May lead to misunderstandings about “what the patient

wants” or expects

 Poor outcomes –
 non-adherence
 unwanted prescriptions
 Health provider trotting
 Loss of confidence in modern medicine
 Alternative medicine
 Self help remedies
 Traditional healers
 Biomedical and psychosocial
perspectives

• In one UK study average consultation times were 8 mins; giving pts

with psychosocial problems 1 minute longer was sufficient to
improve quality of care.
• There is need to increase the time spent, ensuring quality – hence
learning consultation skills
• Most ill health never comes to health professionals, dealt with
through self-care, pharmacies, home remedies
• Illness often left to run its course [lay understanding of natural
history]
• Consider “illness behaviour” “sick role” – the way symptoms are
acted on by a person who associates them with organic malfunction
 Summary

• WHO definition of health

• Identifies need for addressing two agendas
• perspectives on disease or ill health
• Models describing disease causation
• Biomedical agenda
• Psychosocial agenda
• Interrelation between the two
• Addressing the two agendas
• The consultation
• Consequences of failure to address the two
 Questions and comments

 Thank you
 References

 Broadbent A. (2009) Studies in History and

Philosophy of Biological and Biomedical Sciences 40:
302–311
 Kurtz, S, Silverman J, Draper J. (2008). Teaching and
learning communication skills in medicine. Radcliffe
publishing. oxford