Explanatory Model


Definition


An explanatory model reveals how people make sense of their illness and their experiences of it. Explanatory models are often used to explain how people view their illness in terms of how it happens, what causes it, how it affects them, and what will make them feel better. It is a method used in both clinical settings and qualitative research as a way to obtain individual explanations of a particular phenomenon. In the latter, explanatory models allow researchers to collect textual data.

Relevant Characteristics


Explanatory models are elicited through a series of specific open-ended questions. The first model was devised by Arthur Kleinman, and contains eight questions described below. Kleinman came up with these questions in an attempt to distinguish between disease and illness, and to bridge the gap between clinical knowledge and constructions of clinical reality.[1]

This method is a tool that could be used alone in qualitative research, or with other techniques such as life histories, key-informant interviews, participant-observations, focus groups or pile sorting, among others. In mental health studies, explanatory models can be used together with tools such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). Researchers have refined Kleinman’s model into a mixture of open-ended and direct questions that lets them quantify results.[2] These include the Explanatory Model Interview Catalogue (EMIC), Short Explanatory Interview Model (SEMI) and the Illness Perception Questionnaire (IPQ).[3] The pattern of questioning are similar in these later models, and the differences lie in how they are structured. SEMI and EMIC have built-in classification features that permit qualitative data to be synced with quantitative data, while IPQ questionnaires contain a fixed range of causes for participants to select.

EM_copy.jpg
Bhui and Bhugra, 2002


Clinically, explanatory models are not diagnostic tools. In medical and research settings, explanatory models provide clinicians and researchers with an idea of how patients experience and interpret their conditions. This method lets clinicians improve quality of care. It also helps health researchers understand their subjects, and this could help in the design of appropriate therapies or interventions, or explain why some people reject medication or refuse to comply with a prescribed therapy.

In his introduction to the model, Kleinman provided a case study where an explanatory model may be useful in a clinical setting. A 60-year-old Protestant grandmother who was hospitalized for heart problems exhibited ‘bizarre’ behavior during her recovery. She made herself vomit and wetted her bed frequently, but became angry when told to stop. When asked about her behavior, her explanation was revealing. As the wife and daughter of plumbers, the woman thought she had “water in her lungs” and that the only way to clear the “pipes” hooked to her lungs was to remove as much water as possible.[4] Her induced vomiting and urination were part of this process, and she could not understand why people were angry with her. After this explanation, clinicans provided her with an alternate description of human anatomy and diagrams. When she understood her doctors, she stopped her earlier behavior.

Method Made Easy


Explanatory models can be administered either as an interview or through a questionnaire. Kleinman’s model contains eight questions:
  • What do you think has caused your problems?
  • Why do you think it started when it did?
  • What do you think your sickness does to you?
  • How severe is your sickness? Will it have a long or short course?
  • What kind of treatment do you think you should receive?
  • What are the most important results you hope to receive from this treatment?
  • What are the chief problems your sickness has caused for you?
  • What do you fear most about your sickness?

Advantages


Explanatory models are able to “integrate clinical, epidemiological and social science frameworks” [5] by improving the depth of scientific understanding of disease and illness. The major advantage of this method is that it allows researchers and clinicians to draw illness experiences from their participants in a structured way. Results of these interviews can be used to complement or reinforce quantitative data, providing researchers with lived illness experiences that would otherwise be overshadowed by numbers and statistics. Textual data derived from explanatory model interviews can either stand on their own in research, or be used as a way to form hypotheses for further studies. They can also be paired with other qualitative techniques and complement quantitative findings to flesh out hypotheses. Explanatory models are flexible and applicable in many scenarios, such as studying violence in Iceland, HIV-related stigma among South Asians in Canada, or understanding hypertension and sick roles among Americans[6][7][8]

Limitations


Explanatory models can be limiting in several ways. In one study, researchers showed that the demographic background of an interviewer, such as ethnicity, may influence a respondent’s answers. When working in international or non English-speaking settings, researchers often have to deal with the translation of the questions and answers, and this could be a tedious and difficult process. Also, there needs to be more research on comparing illness explanatory frameworks to understand or reconcile how illness is perceived and experienced among different groups, an important factor when trying to understand treatment-seeking behavior.[9] Some critics also argue that the use of the approach in clinical settings assumes the primacy of the biomedical perspective, and that efforts to reconcile the doctor-patient models of an illness result in the alignment of the patient’s views with the doctor’s.[10] Also, the usefulness of explanatory models is limited if the interviewer is just focused on diagnosis or introducing treatment or solution.

Analysis


Findings or textual data from explanatory model interviews can be analyzed in various ways including content analysis. In two studies that used explanatory models as the main tool, researchers first organized their questions and then obtain data through group interviews and from participant-observation.[11][12] Then, the interviews are transcribed (some textual data may require translation).

In terms of content analysis, researchers could either use the questions to frame domains for data coding, or to derive themes from the collected data set. They can approach the analysis through grounded theory, i.e.: using the data to form their findings or to capture common themes; or they can predetermine some themes to see whether the narratives of the participants fall into those. The latter helps researchers reinforce or support an existing idea or hypothesis. Findings from either could be presented on their own, as a collection of narratives on what research participants think of a specific topic, or paired with other quantitative data such as epidemiological information.

In clinical settings, physicians can use this method to find out what their patients think about their ailments and how they are experiencing their illnesses. This information can help physicians understand their patients’ beliefs and behavior, to facilitate further discussion of an ailment, and perhaps to prescribe more appropriate treatments.

Method in Context


When Kleinman first conceived of his eight-question model in the 1970s, the United States was going through a health care crisis. Medical care was often inaccessible; the cost of care was escalating while the quality of care was poor.[13] These events are paradoxical to the advance of medical technology, he notes. As a psychiatrist and a medical anthropologist, Kleinman observed a gap between medical research and approaches to more practical solutions, and a mismatch between the physicians’ understanding of disease and the patients’ experiences of illness. To bridge this gap and to help clinicians break out of their medicocentric views, Kleinman proposed his eight-question model as a way to understand how patients view their conditions and their expectations or concepts of a cure. Such data could be used to train physicians in improving quality of care by allowing them a more systematic understanding of social or cultural constructions of illness.

Kleinman[14] wrote: “Eliciting the patient’s (explanatory) model gives the physician knowledge of the beliefs the patient holds about his illness, the personal and social meaning he attaches to his disorder, his expectations about what will happen to him and what the doctor will do, and his own therapeutic goals. Comparison of patient model with the doctor’s model enables the clinician to identify major discrepancies that may cause problems for clinical management. Such comparisons also help the clinician know which aspects of his explanatory model need clearer exposition to patients (and families), and what sort of patient education is most appropriate. And they clarify conflicts not related to different levels of knowledge but different values and interests. Part of the clinical process involves negotiations between these explanatory models, once they have been made explicit.” (p. 256)

Since then, the concept of the explanatory model has been used in a variety research in both the medical and public health fields. Researchers in the 1990s have also refined Kleinman’s model into questionnaires that allows for clearer analysis, such as the Explanatory Interview Catalogue, which Weiss and colleagues[15] devised to student leprosy and mental health in India. Other uses include understanding HIV-related stigma, causes of youth violence, and perceptions of mental illness and diseases such as Type 2 diabetes.

Online Resources


Anthropology Archive has an alternate description of explanatory models and how they relate to illness beliefs. It also has an anecdotal story on how a consultant/translator helped elicit an explanatory model from patients in Mexico.

Further Reading


Blumhagen, D. (1980). Hyper-tension: A folk illness with a medical name. Culture, Medicine, and Psychiatry 4:197-227

Kleinman, A. (1976). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.

Weiss, M.G., Doongaji, D.R., Siddhartha, S., Wypic, D., Pathare, S., Bhatawdekar, M., Bhave, A., Sheth, A., and Fernandes, R. (1992). The Explanatory Model Interview Catalogue (EMIC): Contribution to Cross-cultural research methods from a study of leprosy and mental health. British Journal of Psychiatry 160:819-930.

References


  1. ^ Kleinman, A. (1976). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.
  2. ^ Weiss, M.G., Doongaji, D.R., Siddhartha, S., Wypic, D., Pathare, S., Bhatawdekar, M., Bhave, A., Sheth, A., and Fernandes, R. (1992). The Explanatory Model Interview Catalogue (EMIC): Contribution to Cross-cultural research methods from a study of leprosy and mental health. British Journal of Psychiatry 160:819-930.
  3. ^ Bhui, K., and Bhugra, D. (2002). Explanatory models for mental distress: implications for clinical practice and research. The British Journal of Psychiatry 181: 6-7.
  4. ^ Kleinman, A. (1976). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.
  5. ^ Weiss, M.G., Doongaji, D.R., Siddhartha, S., Wypic, D., Pathare, S., Bhatawdekar, M., Bhave, A., Sheth, A., and Fernandes, R. (1992). The Explanatory Model Interview Catalogue (EMIC): Contribution to Cross-cultural research methods from a study of leprosy and mental health. British Journal of Psychiatry 160:819-930.
  6. ^ Biering, P. (2007). Adapting the concept of explanatory models of illness to the study of youth violence. Journal of Interpersonal Violence 22(7):791-811.
  7. ^ Blumhagen, D. (1980). Hyper-tension: A folk illness with a medical name. Culture, Medicine, and Psychiatry 4:197-227
  8. ^ Vlassoff, C, and Ali, F. (2011). HIV-related stigma among South Asians in Toronto. Ethnicity Health 16(1): 25-42.
  9. ^ Lynch, E., and Medin, D. (2006). Explanatory models of illness: A study within-culture
    variation. Cognitive Psychology 53(4): 285.
  10. ^ Scheper-Hughes, Nancy. (1990) Three Propositions for a Critically Applied Medical Anthropology. Social Science Medicine 30:189-197.
  11. ^ Biering, P. (2007). Adapting the concept of explanatory models of illness to the study of youth violence. Journal of Interpersonal Violence 22(7):791-811.
  12. ^ May, K. and Rew, L. (2010). Mexican American youths' and mothers' explanatory models of diabetes prevention. Journal for Specialists in Pediatric Nursing 15(1):6-15.
  13. ^ Kleinman, A. (1976). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.
  14. ^ Kleinman, A. (1976). Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251-258.
  15. ^ Weiss, M.G., Doongaji, D.R., Siddhartha, S., Wypic, D., Pathare, S., Bhatawdekar, M., Bhave, A., Sheth, A., and Fernandes, R. (1992). The Explanatory Model Interview Catalogue (EMIC): Contribution to Cross-cultural research methods from a study of leprosy and mental health. British Journal of Psychiatry 160:819-930.