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The objective of this paper is to provide an overview of the biomedical, the biopsychosocial, and the social humanistic theories of health and to propose a framework for integrating the latter into health care. In summary, the definitions of health, illness and disease are essential to the practice of health care and play fundamental roles in how patients’ experiences of being ill are valued and assessed within health care systems. Principally, the biomedical perspective proceeds from pathoanatomical deficiencies defining disease and malfunction; the addition of psychosocial components forms a biopsychosocial perspective. In addition, the social humanistic perspective extends from a person’s will, their ability to act, and the possibility to fulfill wanted actions. Thus, health care that does not address the social humanistic perspective may lack the power to describe how these entities are related to the patient on a personal level; thus, the will of the patient is not always fully addressed. Importantly, by targeting the will of the patient and the patient’s ability to act, the proposed framework of integrating a social humanistic perspective into health care may further emphasize and strengthen the interrelatedness of medical perspectives. A framework for integrating a social humanistic perspective into health care is proposed and its potential impact on health care is discussed.

Aim: The objective of this study is to analyze the commitment to a more health-promoting health service and to illuminate important barriers for having a health-promoting role in daily practice, among Swedish health care professionals.

Material and method: Out of a total of 3751 health professionals who are working daytime in clinical practice in the province of Västerbotten, 1810 were invited to participate in a survey. The health professionals represented eight different occupational groups: counselors, dieticians, midwives, nurses, occupational therapists, physical therapists, psychologists, and physicians. A questionnaire that operationalized perceptions found in a previous qualitative study was mailed to residential addresses of the participants.

Results: The majority believed that health services play a major role in long-term health development in the population and saw a need for health orientation as a strategy to provide more effective health care. Willingness to work more in health promotion and disease prevention was reported significantly more often by women than men, and by primary health care personnel compared to hospital personnel. Among the professional groups, psychologists, occupational therapists, and physiotherapists most frequently reported willingness. The most common barriers to health promotion roles in daily practice were reported to be heavy workload, lack of guidelines, and unclear objectives.

Conclusions: This study found strong support for reorientation of health services in the incorporation of a greater health promotion. A number of professions that are not usually associated with health promotion practices are knowledgeable and wish to focus more on health promotion and disease prevention. Management has a major role in creating opportunities for these professionals to participate in health promotion practices. Men and physicians reported less positive attitudes to a more health-promoting health service and often possess high positions of power. Therefore, they may play an important role in the process of change toward more health promotion in health services.

The aim of this thesis was to investigate if the outcome of rehabilitation efforts is depending on what view health care has in relation to what need of care people have and if the outcome for different groups of patients with low-back complaints (specific versus non-specific complaints) is various successful. The outcome is measured in length of sick leave, number of spells and granted sickness and disability pensions.

This thesis combines a theoretical analysis of different theories of health with studies of two empirical materials. One material comprises a group of individuals with low-back complaints (specific versus non-specific complaints) from a nation-wide survey of Living Conditions conducted by Statistics Sweden in 1981. The other material comprises a sample of individuals on sick leave either due to low-back complaints or other kinds of complaints than low-back complaints. The outcome of these studies are measured as to what extent people with low-back complaints are granted a disability pension (Paper III) and which the characteristics are of those on sick leave due to low-back complaints compared to those with other kinds of complaints (Paper IV). The results from Paper III revealed a difference concerning socio-economic group and granted disability pension between those with specific, non-specific and frequent low-back complaints. Those with non-specific and frequent low-back complaints were to higher extent manual workers and disability pensioners. The results of Paper IV reveals also a socio-economic difference besides that those with low-back complaints had longer sick leave periods and more spells. 

What does these results indicate? Are non-specific and frequent low-back complaints not successfully treated within the health care system? Is this due to how these matters have been identified? Are these individuals truly disabled due to their low-back complaints, if so how are they assessed and treated? I believe that the notions of health and disease as well as the social context in which people act influence the outcome of rehabilitation. If people judge their health as bad (here due to low-back troubles) and in need of health care and the health care system do not recognise their need when not identified as diseased a problem arises. These individuals claim that their ability to work is hampered due to the low-back complaint and the society has an obligation and needs a legitimate solution for those individuals that cannot support themselves due to ill health. This obligation makes a demand on the health care system.

If non-specific complaints are assessed as non-medical problems, from a biomedical point of view, health care lacks measures to take care of these people if they ought to be taken care of within the health care system at all. But this outcome (a disability pension) may also indicate that people suffer from a “true” illness although not defined by objective findings. If that is the state one may ask if there is a lack of sufficient diagnostic procedures and measures as well. A rehabilitation approach stemming from a humanistic social perspective might lead to a more favourable outcome for people with low-back complaints, whether or not these complaints have been identified in a biomedical sense, as this perspective take into account both the goals, the resources and the social context of that individual. 

This thesis has paid attention to the matter that conceptual notions, which seldom are considered within clinical praxis, are of vital importance for the outcome of rehabilitation. Health care falls short especially when it comes to non-specific and frequent low-back complaints and this may be due to the biomedical model being used too strictly within a domain where other models, here exemplified as Pörn’s Theory of Health, might result in a more favourable rehabilitation outcome for the individual.

Low back pain (LBP) has become a serious economic problem and a multifactorial problem to be solved within medicine. Investigations have demonstrated that the problem may best be solved outside medicine or, if within, in cooperation with behavioural scientists and with involved elements outside medicine such as the National Health Insurance System. How is LBP defined? Do all people involved in the rehabilitation of LBP define it in the same way? Are there any alternative ways to define it? In this paper, I will present a humanistic-social perspective of how LBP can be denned. This perspective or theory of health takes into account these outside factors as well as a person's ability to act in relation to the social context within which that person is living. In order to provide more effective treatment, in the sense of giving people the support they need to get better, other methods of treating LBP must be developed. This humanistic-social perspective indicates that a person's goals and actual circumstances at the time of rehabilitation should be the base for the planned activity. From this perspective, the objective findings should only be the base for the choice of technical method, not the base for the overall rehabilitation strategy.

The aim of this study was to investigate in what way people on sick leave due to low-back troubles distinguish as a group from other individuals on sick leave. The population in this study consisted of all individuals 20-64 years of age, who in 1991 belonged to a local health insurance office in northern Sweden. All individuals, born on day 5, 15 and 25, who had been on sick leave due to low-back (LB) complaints (low-back group) and a random sample of individuals, who had been on sick leave due to other kinds of complaints (reference group) constituted the study sample. Information was collected from their sickness records and from a questionnaire sent to each individual comprising questions about education, working environment, perceived health, social support, leisure time activities and smoking habits. There were no differences found regarding the sex of the individuals, leisure time activities or social support between the two studied groups. In the multivariate logistic regression analysis the result revealed that the LB group had longer sick leave periods, more spells and was to greater extent blue-collar workers.

This may indicate differences in the working situation between the groups, which in turn may aggravate LB problems leading to longer sick leave or more spells. 

The purpose of this study was to investigate the distribution of selfreported low-back (LB) complaints in the social structure, and to investigate how the variables - physical work load, physical ability, Activities of Daily Living (ADL), mental job strain, social support, health and smoking - were associated with the different LB complaints. The Survey of Living Conditions carried out by Statistics Sweden 1980-81 has been used as the basis of the investigation. The LB complaints were dichotomised into specific and non-specific LB complaints according to an assumed grade of measurability. The non-specific LB complaints showed a social gradient which specific complaints did not despite the association with some of the variables. People, with a non-specific LB complaint, were besides that associated with a higher risk to become a sickness and disability pensioner than people with a specific LB complaint. This may indicate that either strategies used within the health care system in general are more suitable for specific complaints perhaps due to their higher grade of measurability or that people with a non-specific complaint suffers from an incapacitating illness that cannot be cured.