Health Psychology: An Introduction
Health Psychology in the Context of Biology, Society and Methodology
’Cell, organ, person, family each indicate a level of complex integrated organization about the existence of which a high degree of consensus holds. … In no way can the methods and rules appropriate for the study and understanding of the cell as cell be applied to the study of the person as person or the family as family.’
George Engel (1980)
In this chapter, we introduce health psychology as a field of inquiry. At the beginning, we introduce the concept of ’health’ from a historical perspective. We define health psychology and review theories of need-satisfaction and subjective well-being. We present a new Theory of Well-Being that includes the constructs of attachment, life satisfaction, subjective well-being, affect and consumption. Problems with measurement are examined. Finally, a framework we call the ’Health Onion’ is described.
What Do We Mean by ’Health’?
It seems logical — although few textbooks do it — to discuss what is meant by the term ’health’ in a book about health psychology. Otherwise, how do we understand the subject? It seems slightly bizarre that few textbooks ever consider it. We must never take the meaning of ’health’ for granted.
To unravel the origin of the word, we need a quick dip into etymology. The word ’health’ is derived from Old High German and Anglo-Saxon words meaning whole, hale and holy. The etymology of ’heal’ has been traced to a Proto-Indo-European root ’kailo-’ (meaning whole, uninjured or of good omen). In Old English this became ’hælan’ (to make whole, sound and well) and the Old English ’hal’ (health), the root of the adjectives ’whole’, ’hale’ and ’holy’, and the greeting ’Hail’. The word became ’heil’ in German (unhurt, unharmed), ’Heil’ (good luck or fortune), ’heilig’ (holy) and ’heilen’ (to heal). In Old Norse there was ’heill’ (health, prosperity, good luck). From the same roots, ’Hello’ in English, ’Hallo’ in German, or ’Hi’ are everyday greetings.
Ancient links exist between the concepts of ’health’, ’wholeness’, ’holiness’, ’hygiene’, ’cleanliness’, ’goodness’, ’godliness’, ’sanitary’, ’sanity’ and ’saintliness’, as in: ’Wash you, make you clean; put away the evil of your doings from before mine eyes; cease to do evil’ (Isaiah, 1:16, King James Bible) and: ’O you who believe! when you rise up to prayer, wash your faces and your hands’ (Quran). The concept of health as wholeness existed in ancient China and classical Greece where health was seen as a state of ’harmony’, ’balance’, ’order’ or ’equilibrium’ with nature. Related ideas are found in many healing systems today. On the other hand, there are traditional associations between concepts of ’disease’, ’disorder’, ’disintegration’, ’illness’, ’crankiness’ (or ’krankheit’ in German), ’uncleanness’, ’insanity’, ’chaos’ and ’evil’.
Galen (CE 129—200), the early Roman physician, followed the Hippocratic tradition with hygieia (health) or euexia (soundness) as a balance between the four bodily humours of black bile, yellow bile, phlegm and blood. Galen believed that the body’s ’constitution’, ’temperament’ or ’state’ could be put out of equilibrium by excessive heat, cold, dryness or wetness. Such imbalances might be caused by fatigue, insomnia, distress, anxiety, or by food residues resulting from eating the wrong quantity or quality of food. Human moods were viewed as a consequence of imbalances in one of the four bodily fluids. Imbalances of humour corresponded to particular temperaments (blood—sanguine, black bile—melancholic, yellow bile—choleric, and phlegm—phlegmatic). The theory was also related to the four elements: earth, fire, water and air (Table 1.1).
In the winter, when it is chilly and wet, people might worry about catching a cold, caused by a build-up of phlegm. In summer, when a person is hot and sweaty, they may worry about not drinking enough water or they could otherwise become ’tetchy’ or ’hot and bothered’ (bad tempered). It is remarkable that some common beliefs today are descendants of early Greek and Roman theories of medicine from 2,000-plus years ago. It is significant that the concept of balance/equilibrium and the idea that a basic bodily process exists to restore balance (homeostasis) are as much core issues in Science today as in Classical times.
Universal interest in health is fuelled by a continuous torrent of content in the media about health and medicine, especially concerning the ’dread’ diseases. In 1946 the World Health Organization (WHO) defined health as: ’the state of complete physical, social and spiritual well-being, not simply the absence of illness’. It is highly doubtful whether ’complete physical, social and spiritual well-being’ can ever be reached by anyone. Apart from this idealism, the WHO definition overlooks the psychological, cultural and economic aspects of health. Psychological processes, the main subject of this book, are a key factor in health and are embedded in a social context. For this reason, the term ’psychosocial’ is often used to describe human behaviour and experience as an influence on well-being. Social inequalities and poverty are also strongly associated with health outcomes and warrant explicit inclusion in any definition of health. With these thoughts in mind, we define health in the light of five key elements (Box 1.1).
Box 1.1 Definition of Health
Health is a state of well-being with satisfaction of physical, cultural, psychosocial, economic and spiritual needs, not simply the absence of illness.
Need Satisfaction, Happiness and Subjective Well-Being
To be useful, the above definition of health needs to be unpacked. Philosophers, psychologists, poets, songsters and others have had much to say about what makes a person feel well. A key concept is that of need satisfaction, immortalized in the 1965 Rolling Stones release ’(I Can’t Get No) Satisfaction’. In Maslow’s (1943) more academic hierarchy of needs (Figure 1.1), a person is healthy if all of their needs are satisfied, starting with the most basic needs for air, food, water, sex, sleep, homeostasis and excretion. Then as need satisfaction moves towards the top of the pyramid, the epitome of need satisfaction, a person becomes more and more ’satisfied’, and thus physically and mentally healthy to the point of ’self-actualization’.
Maslow’s hierarchy framework has been influential. It puts the concept of ’self-actualization’ at the top of the pyramid, a state in which the person feels they have achieved a so-called ’peak experience’ of meaningful and purposeful existence. Maslow’s needs hierarchy emphasizes the great importance of safety, love and belonging, and self-esteem. For every good principle in psychology, there are always exceptions, and human needs do not always fall into any fixed hierarchy. For example, an extreme sports enthusiast who is into mountain climbing may put ’esteem’ and ’self-actualization’ ahead of ’safety’. We read about it in the news the next morning. Few would disagree about the existence of the five levels of need within the pyramid. However, there are also key elements of human fulfilment that are not explicitly mentioned in Maslow’s hierarchy, for example, agency and autonomy — the freedom to choose — and the often-neglected spirituality — the subjective intuition that lacks any hard empirical proof that not all that is significant is of the physical world.
Figure 1.1 Maslow’s hierarchy of human needs
Homeostasis is a core concept within Physiology, a regulating property of the organism wherein the stability of the internal environment is actively maintained. The function of cells, tissues and organs are organized into negative feedback systems. Homeostasis operates at cellular, organismic and ecosystems levels. At organismic level, homeostasis regulates core body temperature and the levels of pH, sodium, potassium and calcium, glucose, water, carbon dioxide and oxygen in the body.
In Chapter 2 we present a Homeostasis Theory of Behaviour which has application across all areas of health psychology. If homeostasis breaks down, a person can suffer a variety of life-threatening conditions, including diabetes, obesity, starvation, chronic thirst and insomnia (Marks, 2015, 2016a, 2016b). Homeostasis is not actually a ’need’ as suggested by Maslow’s pyramid; it is the process that works towards the restoration of equilibrium, as we shall see in Chapter 2. A broad spectrum of evidence from many scientific fields suggests that homeostasis is an organizing principle of considerable generality, not simply at the level of physiological need, but throughout the psychological universe of regulation of thought, feeling and action (Marks, 2018).
Other scholars have also attempted to improve upon Maslow’s needs hierarchy with limited success. Doyal and Gough (1991: 4) argued that: ’“health” and “autonomy” are the most basic of human needs that are the same for everyone … all humans have a right to optimum need-satisfaction. … For this to occur … certain societal preconditions — political, economic and ecological — must be fulfilled.’ The satisfaction of three basic needs — physical health, autonomy of agency and critical autonomy — are necessary to achieve the avoidance of serious harm as a universal goal in all cultures. A related psychological theory, called ’Self-Determination Theory’, suggested three basic human needs: competence, relatedness and autonomy (Ryan and Deci, 2000), but Maslow’s hierarchy suggests a more nuanced and complex set of needs than just these three.
Throughout history, philosophers have discussed the nature of a good and happy life or what, in health care, is termed ’quality of life’ (QoL). For Aristotle, happiness was viewed as ’the meaning and the purpose of life, the whole aim and end of human existence’. For utilitarians such as Jeremy Bentham, happiness was pleasure without pain. To individuals suffering from cancer or other conditions with pain, unpleasant physical symptoms and treatment options, and an uncertain prognosis, QoL has special relevance.
QoL has been defined by WHO as (take a deep breath):
An individual’s perception of their position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. It is a broad ranging concept, affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment. (WHOQoL Group, 1995: 1404)
A sixth domain, concerning spirituality, religiousness and personal beliefs, was later added by the WHOQoL Group (1995). The Collins dictionary defines QoL more simply as: ’The general well-being of a person or society, defined in terms of health and happiness, rather than wealth.’ The QoL concept overlaps with that of subjective well-being (SWB), which has been defined by a leader in the field, Ed Diener (’Dr Happiness’), as: ’An umbrella term for different valuations that people make regarding their lives, the events happening to them, their bodies and minds, and the circumstances in which they live’ (Diener, 2006: 400). Another definition states: ’Subjective well-being is defined as “good mental states”, including all of the various evaluations, positive and negative, that people make of their lives and the affective reactions of people to their experiences’ (Durand, 2015). The latter definition includes life evaluation (i.e., reflective assessment of a person’s life, such as joy and pride), current affect (i.e., feelings or emotional states, such as pain, anger and worry), and eudaemonia (i.e., sense of meaning and purpose). The evidence linking SWB with health and longevity is strong and plentiful.
With a global population of more than seven billion unique individuals of diverse cultures, religions and social circumstances, one wonders whether QoL can ever be assessed using a single yardstick. A few courageous individuals and organizations have given it a try and, since the 1970s, many scales and measures have been constructed. A few examples are listed in Table 1.2.
By far, the most utilized scale to date has been the SF-36, which accounts for around 50% of all clinical studies (Marks, 2013). These ’happiness scales’ are diverse and consist of items about what makes a ’good life’. For example, Diener et al.’s (1985) brief Satisfaction with Life Scale (SWLS) uses a seven-point Likert scale with five items:
In most ways my life is close to my ideal.
The conditions of my life are excellent.
I am satisfied with my life.
So far I have gotten the important things I want in life.
If I could live my life over, I would change almost nothing.
Using the 1—7 scale below, testees indicate their agreement with each item by placing the appropriate number on the line preceding that item. They are asked to ’be open and honest’ in their responding.
7 Strongly agree
5 Slightly agree
4 Neither agree nor disagree
3 Slightly disagree
1 Strongly disagree
Luhmann et al. (2012) distinguished between ’cognitive’ and ’affective’ well-being. They carried out a meta-analysis to examine whether life events have different effects on cognitive and affective well-being and how the rate of adaptation varies across different life events. They integrated longitudinal data from 188 publications that had reported studies on 313 samples with 65,911 people to describe the reaction and adaptation to four family events (marriage, divorce, bereavement, childbirth) and four work events (unemployment, re-employment, retirement, relocation/migration). The findings showed that, for most events, the effects on cognitive well-being are stronger and more consistent across samples.
For the vast majority of people, SWB is relatively stable over the long term. Using longitudinal data, Headey and Wearing (1989) reported that when the level of SWB changed following a major event, it tended to return to its previous level over time. To account for this, the authors proposed that each person has an ’equilibrium level’ of SWB, and that ’personality’ restores equilibrium after change by making certain kinds of events more likely. Restoration of equilibrium is nothing to do with personality; it’s a fundamental stabilizing process across all living systems called ’homeostasis’.
Diener and Chan (2011) review evidence that having high SWB adds four to ten years to life. The evidence for an association between SWB and all-cause mortality is mounting. As always, there could be a mysterious third variable influencing both SWB and mortality (e.g., foetal nutrition, social support, lifestyle) and, if the relationship between SWB and mortality did prove to be causal, the possible mediating processes would be a matter for speculation and further research. For the time being, it seems safe to assume that happy people live longer.
Subjective Well-Being Homeostasis
The most basic property of SWB is that it is normally positive. On a rating scale from ’feeling very bad’ to ’feeling very good’, only a few people lie below the scale mid-point. General population data from over 60,000 people gathered over 13 years by the Australian Unity Wellbeing Index surveys (Cummins et al., 2013) found that only 4% of scores lie below 50 percentage points. Feeling good about yourself is the norm.
While it has been generally agreed that SWB consists of both affect and cognition, it is thought that SWB mainly comprises mood (Cummins, 2016). Russell (2003) coined the term ’Core Affect’ to describe a neurophysiological state experienced as a feeling, a deep form of affect or mood. Russell considered it analogous to felt body temperature in that it is always present, can be accessed when attended to, existing without words to describe it.
Robert A. Cummins introduced the idea that homeostasis is operating on SWB, as it does in biological systems of the body: ’It is proposed that life satisfaction is a variable under homeostatic control and with a homeostatic set-point ensuring that populations have, on average, a positive view of their lives’ (Cummins, 1998: 330). Cummins suggested the concept of ’Homeostatically Protected Mood’ (HPMood) as the most basic feeling state of SWB (Cummins, 2010). The concept of ’HPMood’ places the regulation of mood in the same framework as physiological homoeostasis, which controls body temperature, blood pressure, and a thousand and one other bodily systems (Cannon, 1932). Cummins’ describes HPMood as follows:
1. It is neurophysiologically generated consisting of the simplest, constant, non-reflective feeling, the tonic state of affect that provides the underlying activation energy, or motivation, for routine behavior.
2. It is not modifiable by conscious experience, yet it is a ubiquitous, background component of conscious experience. It is experienced as a general feeling of contentment, but also comprises aspects of related affects, including happy and alert.
3. When SWB is measured using either the Satisfaction with Life Scale (Diener et al., 1985) or the Personal Wellbeing Index (International Wellbeing Group, 2013), HPMood accounts for over 60% of the variance.
4. Under normal conditions of rest, the average level of HPMood for each person represents their ’set-point’, a genetically-determined, individual value. Within the general population, these set-points are normally distributed between 70% and 90% along the 0—100-point scale.
5. For each person’s set-point there is a ’set-point-range’, the limits within which homeostatic processes normally maintain HPMood for each individual.
6. HPMood ’perfuses all cognitive processes to some degree, but most strongly the rather abstract notions of self (e.g., I am a lucky person). Because of this, these self-referent perceptions are normally held at a level that approximates each set-point range’ (Cummins, 2010: 63).
7. Under resting conditions, SWB is a proxy for HPMood. However, SWB can vary outside the set-point-range for HPMood when a strong emotion is generated by momentary experience. ’When this occurs, homeostatic forces are activated, which attempt to return experienced affect to set-point-range. Thus, daily affective experience normally oscillates around its set-point’ (Cummins, 2016: 64).
One of the principal goals of health psychology is to understand the links between subjective well-being and health. The application of the concept of homeostasis from Physiology in the discipline of Psychology holds significant potential. A general homeostasis theory of well-being, physical health and life satisfaction is summarized in Box 1.2.
Evidence from several domains suggests that there is a causal link between life satisfaction, positive affect, moderate levels of consumption and well-being, as indicated in the theory. Attachment style has been shown to influence life satisfaction and a gamut of health-related behaviours, including alcohol abuse, drug abuse, smoking, insomnia, accidental injury, trauma, grief, chronic illness, and responses to natural disasters. The literature shows that a significant mediator of the association between life satisfaction and positive health outcomes is a moderate level of consumption. As that well-worn cliché states: ’Anything in moderation.’
Box 1.2 Homeostasis Theory of Well-Being
The Homeostasis Theory of Well-Being (HTWB) shows causal links between some significant determinants of physical and mental well-being (see Figure 1.2). In addition to emotion, and the role of income, restraint and consumption, the HTWB places emphasis on the developmentally important construct of attachment (Bowlby, 1969, 1973, 1980). The manner in which a baby attaches to its mother, father and/or other caregiver is assumed to create a template for life based on the infant’s need to maintain proximity to an anchor person who provides a ’secure base’ for exploring the environment. The availability and responsivity of the anchor person to attachment are internalized as mental models that are generalized to relationships throughout life until the individual’s death (Ainsworth et al., 1978). The different ways of attaching to anchor figures is termed ’attachment style’.
Of relevance to the GTWB is the basic construct SWB. The hedonic conception of SWB of Diener and Chan (2011) can be contrasted with the eudaimonic approach, which focuses on meaning and self-realization and defines well-being in terms of the degree to which a person is fully functioning (Ryan and Deci, 2001). Waterman (1993) has argued that eudaimonic well-being occurs when people are living in accordance with their ’daimon’, or authentic self. Eudaimonia is thought to occur when people’s life activities mesh with deeply held values and are fully engaged in authentic personal expression.
An important aspect of life satisfaction is the search for eudaimonic meaning. Empirical studies suggest that there exists a strong and stable relationship between meaning in life and subjective well-being (Zika and Chamberlain, 1992). People who believe that they have meaningful lives tend to be more optimistic and self-actualized (Compton et al., 1996), and experience more self-esteem (Steger et al., 2006) and positive affect (e.g., King et al., 2006), as well as less depression and anxiety (Steger et al., 2006) and less suicidal ideation (Harlow et al., 1986). The ’Salutogenic Theory’ of Antonovsky (1979) also emphasized the relationship between meaning and purpose in life, assessed by the Sense of Coherence scale and positive health outcomes (Eriksson and Lindström, 2006).
The Nature of Health Psychology
The importance of psychosocial processes in health and illness is an established part of health care. The evidence on the role of behaviour and emotion in morbidity and mortality has been steadily accumulating over the last century. By the end of the First World War, the British Army had dealt with 80,000 cases of shell shock, including those of poets Siegfried Sassoon and Wilfred Owen. Millions of men suffered psychological trauma as a result of their war experiences. Since that time, and the experiences of many other wars, much research has been conducted to investigate the possible role of trauma, stress and psychological characteristics on the onset, course and management of physical illnesses. Health psychology has grown rapidly, and psychologists are increasingly in demand in health care and medical settings. Psychologists have become essential members of multidisciplinary teams in rehabilitation, cardiology, paediatrics, oncology, anaesthesiology, family practice, dentistry, and other fields, including defence, intelligence, policing and justice.
Figure 1.2 General Theory of Well-Being (GTWB)
Source: Marks (2015)
Increasing interest is being directed towards disease prevention, especially with reference to sexual health, nutrition, smoking, alcohol, inactivity and stress. A current ideology is ’individualism’, in which individuals are viewed as ’agents’ who are responsible for their own health. From this neoliberalist viewpoint, a person who smokes 40 a day and develops lung cancer is held responsible for causing their own costly, disabling and terminal illness. Traditional health education has consisted of campaigns providing a mixture of exhortation, information and advice to persuade people to change their unhealthy habits. By telling people to ’Just say no’, policy makers have expected people to make the ’right’ choices and change unhealthy choices into healthy ones. There has been notable success in tobacco control, which provides a benchmark for what may be achieved through health education, and policy in other clinical areas, such as coronary artery disease, obesity, diabetes and metabolic syndrome.
Against the view that keeping ourselves healthy means making responsible choices, there is little convincing evidence, beyond the example of smoking, that people who change their lifestyle actually do live longer or have a greater quality of life than people who ’live and let live’ and make no real attempt to live healthily. Consider an example: a prospective study suggests that vegetarians live longer than meat eaters. But vegetarians may differ from the meat-eaters in many ways other than their choice of diet (e.g., religious beliefs, use of alcohol, social support). A statistical association between two variables, such as a vegetarian diet and longevity, can never prove causality or allow a prediction about any particular individual case. A vegetarian can still die of stomach cancer and becoming vegetarian does not necessarily lengthen the life of any specific individual. Epidemiology is a statistical science. It provides a statistical statement to which there will always be inconvenient exceptions, such as 90-year-old smokers.
The assumption that a person must ’live well to be well’ is prevalent today and can lead to victim blaming. If people get ill, it is seen as ’their own fault’ because they smoke, drink, eat poorly, fail to exercise or use screening services, do not jog or join a gym, and so on. Health policy is run through with blaming and shaming individuals for their own poor health. The ’smoking evil’ has been replaced by the ’obesity evil’. A person who smokes, eats fatty foods, drinks alcohol and watches TV many hours every day may be described as a ’couch potato’. A polemical GP, Michael Fitzpatrick (2001), compares disease with sin, and health with virtue. Medicine is portrayed as a quest against gluttony, laziness and lust. Diets are seen as moral choices, in which a ’balanced’ and healthy diet is a moral imperative.
Health campaigns are often based on the idea that by informing people they can make responsible choices. People are presumed to be free agents with self-determination. Yet human behaviour is influenced by so many factors in the social and economic environment, and especially by role models among family and friends or in the mass media. The herd instinct is as strong in humans as it is in bees, birds or sheep. Christakis and Fowler (2007) reported evidence that behaviour changes such as quitting smoking or putting on weight are associated with similar changes in networks of friends. Imitation is an important influence in human behaviour and one significant change approach, social cognitive theory, is based on this principle (Bandura, 1995).
The built environment, the sum total of objects placed in the natural world by human beings, is another influence. Included within this are the images and messages from advertisers in mass media, and the digital environment. A ’toxic environment’ has been engineered to draw people towards unhealthy products, habits and behaviours (Brownell, 1994). The obesogenic environment contains affordable but nasty, fatty, salty and sugary foods that readily cause weight gain and obesity on an industrial scale. Items for sale include foods such as ’hot dogs’ containing ’mechanically recovered meat’ and 0% real meat, and ’chicken nuggets’ with 0% chicken. The proliferation of such low-priced items in supermarkets and 24/7 stores offer low-income consumers an unhealthy selection of options.
Another ’poisoning’ of the environment begins early in life. Garbarino (1997) discussed the ’socially toxic environment’, in which ’Children’s social world has become poisonous, due to escalating violence, the potentially lethal consequences of sex, diminishing adult supervision, and growing child poverty’ (Garbarino, 1997: 12). The potential for toxicity is extended to all the major determinants of health and well-being.
In this book, arguments are presented on different sides of the ’freedom and choice’ debate. It is accepted that our present understanding of health behaviour is far from definitive. However, we also adopt a critical position towards the discipline. Health psychology is a relatively young discipline and there are many issues to be addressed. For the most part, health psychology has been formulated within an individualistic ideological formulation which is part of neoliberalist mass culture. The evidence presented in this book suggests that socio-cognitive approaches to behaviour change that target internalized processes in the form of hypothetical ’social cognitions’ are ineffectual and too small in scale (Marks, 1996, 2002a, 2002b). Apart from their theoretical shortcomings, mass dissemination of individualized therapeutic approaches through the health care system is unsustainable and unaffordable. The biomedical model remains the foundation stone of clinical health care.
Health psychologists work at different levels of the health care system: carrying out research; systematically reviewing research; designing, implementing and evaluating health interventions; training and teaching; doing consultancy; providing and improving health services; carrying out health promotion; designing policy to improve services; and advocating social justice for people and communities to act on their own terms. In this book we give examples of all these activities, and suggest opportunities to make further progress.
A community perspective on health work offers an alternative prospect for intervention. Community approaches are less popular within mainstream health psychology and have been the mainstay of community psychology. There could be valuable synergies between health and community psychology working outside the health care system. In working towards social justice and reducing inequalities, people’s rights to health and freedom from illness are, quite literally, a life and death matter; it is the responsibility of planners, policy makers and leaders of people wherever they may be to fight for a fairer, more equitable system of health care (Marks, 2004; Murray, 2014a).
Our definition of health psychology is given in Box 1.3. In discussing this definition, we can say that the objective of health psychology is the promotion and maintenance of well-being in individuals, communities and populations.
Box 1.3 Definition of Health Psychology
Health psychology is an interdisciplinary field concerned with the application of psychological knowledge and techniques to health, illness and health care.
There has been an unfortunate medicalization of everyday experience. Human behaviour, thoughts and feelings are given medicalized terminology; for example, a love of shopping is termed as an ’addiction’, a person worrying about their debts is said to suffer from ’chronic anxiety’, a person who is grieving after the loss of a loved one is ’clinically depressed’, and so on. Over millennia, the health care system has been dominated by medical doctors practising in different specializations. With the exception of nursing, the traditional ’hand-maiden to medicine’, other health care professionals (HCPs), including health psychologists, are referred to as ’paramedical’.
Although there are diverse points of view, health psychologists generally hold a holistic perspective on individual well-being, that all aspects of human nature are interconnected. While the primary focus of health psychology is physical rather than mental health, the latter being the province of clinical psychology, it is acknowledged that mental and physical health are actually ’two sides of one coin’. When a person has a physical illness for a period of time, then it is not surprising if they also experience worry (= anxiety) and/or sadness (= depression). If serious enough, ’negative affect’ (sadness and/or worry) may become classified as ’mental illness’ (severe depression and/or anxiety), and be detrimental to subjective well-being and to aspects of physical health. Each side of the ’well-being coin’ is bound to the other. The distinction between ’health psychology’ and ’clinical psychology’ is an unfortunate historical accident that is difficult to explain to non-psychologists (or even to psychologists themselves). There is also significant overlap between health and clinical psychology and ’positive psychology’ as an integrative new field (Seligman and Csikszentmihalyi, 2000; Seligman et al., 2005), although not without critiques of exaggerated claims (Coyne and Tennen, 2010).
Rationale and Role for Health Psychology
There is a strong rationale and role for the discipline of health psychology. First, the behavioural basis for illness and mortality requires effective methods of behaviour change. Second, a holistic system of health care requires expert knowledge of the psychosocial needs of people.
In relation to point 1, all the leading causes of illness and death are behavioural. This means that many deaths are preventable if effective methods of changing behaviour and/or the environment can be found. The mortality rates for different conditions in younger and older people are shown in Table 1.3.
Box 1.4 Key Study: The Global Burden of Disease Study
An important epidemiological perspective comes from measures of ’disability’ or ’disablement’. The Global Burden of Disease (GBD) study projected mortality and disablement over 25 years. The trends from the GBD study suggest that disablement is determined mainly by ageing, the spread of HIV, the increase in tobacco-related mortality and disablement, psychiatric and neurological conditions, and the decline in mortality from communicable, maternal, perinatal and nutritional disorders (Murray and Lopez, 1997).
The GBD study was repeated in 2010 and figures were prepared by age, sex and region for changes that had occurred between 1990 and 2010. Global figures for life expectancy show increases for all age groups (Figure 1.3).
The GBD uses the disability-adjusted life year (DALY) as a quantitative indicator of the burden of disease. It reflects the total amount of healthy life lost that is attributed to all causes, whether from premature mortality or from some degree of disablement during a period of time. The DALY is the sum of years of life lost from premature mortality plus years of life with disablement, adjusted for the severity of disablement from all causes, both physical and mental (Murray and Lopez, 1997).
Figure 1.3 Percent change in total DALYs, 1990—2010
Source: Institute for Health Metrics and Evaluation (2014), www.healthdata.org/infographic/percent-change-total-dalys-1990-2010
The data in Table 1.4 indicate that nearly 30% of the total global burden of disease is attributable to five risk factors. The largest risk factor (underweight) is associated with poverty (see Chapters 4 and 5). The remaining four risk factors are discussed in Part 2 of this book (see Chapters 8—13).
There were changes in the total DALYs attributable to different causes between 1990 and 2010, as shown in Figure 1.3. Good progress is evident in DALYs for the lower respiratory tract and diarrhoea, but a huge increase of 354% occurred in DALYs for HIV patients. Moderate but significant increases in DALYs occurred for heart disease, stroke, low back pain, depression and diabetes.
The statistics on death and disablement indicate the significant involvement of behaviour and therefore provide a strong rationale for the discipline of health psychology in all three of its key elements: theory, research and practice. If the major risk factors are to be addressed, there is a pressing need for effective programmes of environmental and behavioural change. This requires a sea change in policy. The dominant ideology that makes individuals responsible for their own health may not be the most helpful approach. The environment is a hugely important factor. In our opinion, a psychological approach in the absence of environmental change is like whistling in the wind.
Source: Ezzati et al. (2002)
Health psychologists are at the ’sharp end’ of the quest to produce health behaviour change on an industrial scale. The fact that people are highly constrained by their environment and socio-economic circumstances militates against such change. In a sense, without adaptations of the environment, this effort is disabled. There are strong constraints on the ability of health care systems to influence health outcomes at a population level because of the significant social and economic determinants that structure the health of individuals and communities. The environment must change, and by that route there can be behaviour change on a societal scale. Attempting to change behaviour without first attending to the environment is akin to ’the tail wagging the dog’.
A second rationale for health psychology is growing recognition that a purely medical approach to health care is failing to meet the psychosocial needs of many patients. This has led to a search for an alternative perspective that values holistic care of patients and attempts to improve services through higher quality psychosocial care. In spite of their very high costs, health care systems are often perceived to be inefficient, ineffective and unfit for purpose. This is especially the case in the USA, where the largest per capita expenditure is producing some unimpressive outcomes.
The biomedical model has been criticized since the 1970s (Illich, 1976). While medical experts want to give modern medicine the credit for the decline of disease in the twentieth century, critics have suggested that health improvements are due mainly to better hygiene, education and reduced poverty (McKeown, 1979). In addition, there has been a growing awareness of psychological and social influences in health and illness which has been formulated as the biopsychosocial model (BPSM) (Engel, 1977). Following in the footsteps of Weiss and von Bertalanffy, Engel observed that nature is a ’hierarchically arranged continuum with its more complex, larger units superordinate on the less complex smaller units’ (Engel, 1980: 536). He represented the hierarchy either as a vertical stack or as a nest of squares, with the simplest at the centre and the most complex on the outside (Figure 1.4). At the very beginning of this chapter, we print a quotation from Engel (1980), part of which states: ’In no way can the methods and rules appropriate for the study and understanding of the cell as cell be applied to the study of the person as person or the family as family.’ Our review of the core construct of homeostasis in the next chapter will prove this part of Engel’s statement to be 100% false. Homeostasis is a unifying principle across the continuum of natural systems from the molecule at one end to the biosphere at the other.
Figure 1.4 Continuum of nature from the simplest unit to the most complex
Adapted from Engel (1980)
The vertical stack was sub-divided into two stacks, the first starting with subatomic particles and ending with the individual person, the second starting with the person and finishing with the biosphere. The first is an organismic hierarchy, the second a social hierarchy. The constructs of a biological/organismic and a social universe are both integral to the study of health psychology. There has been a lot of discussion in health psychology about the adoption of the BPSM. However, the evidence of this adoption in medical education is meagre. A majority of US physicians reported not receiving effective training regarding the role of the BPSM, and thus have feelings of low self-efficacy in addressing and managing biopsychosocial issues (Moser and Stagnaro-Green, 2009). In a review of twenty-first-century utility of the BPSM in US medical schools, Jaini and Lee (2015) found a growing trend in research on the BPSM in medical education since the 1970s. However, only five medical schools featured utility of the BPS model in their curricula. The explicit use of the BPSM in US medical schools remains limited, and the situation is not very different elsewhere. Some reference to the BPSM occurs in the nursing research literature on patient-centred care, but the specific influence of the BPSM on nursing is not significant (e.g., Mead and Bower, 2002; Kitson et al., 2013). The paradigm shift that Engel proposed for health care is yet to happen.
One crucial tool in the development of the BPSM and of health psychology as a discipline is the need for measurement of psychological variables.
In the natural sciences, attributes of the physical world, such as space, time, temperature, velocity and acceleration, are all measured quantitatively. Psychologists, concerned with behaviour and experience, are unable to measure many of the most interesting psychological attributes in the same objective manner and have struggled to justify the discipline as a science.
Psychology’s early years as an infant science were spent developing psychophysics and ability testing. Despite some apparent successes in these two areas, the measurement problem in psychology had not been satisfactorily resolved. In the 1950s the influential Handbook of Experimental Psychology was published by a professor at Harvard, Stanley Smith Stevens (1951). Stevens proposed a solution, or so he hoped, to the measurement problem by invoking the principle of operationism. Since that time, psychologists have assumed that measurement is simply what Stevens said it was: the assignment of numbers to attributes according to rules. Unfortunately, Stevens’ solution is purely illusory.
It is apparent that numbers can be readily allocated to attributes using a non-random rule (the operational definition of measurement) that would generate ’measurements’ that are not quantitatively meaningful. For example, numerals can be allocated to colours: red = 1, blue = 2, green = 3, etc. The rule used to allocate the numbers is clearly not random, and the allocation therefore counts as measurement, according to Stevens. However, it would be patent nonsense to assert that ’green is 3 × red’ or that ’blue is 2 × red’, or that ’green − blue = red’. Intervals and ratios cannot be inferred from a simple ordering of scores along a scale. Yet this is how psychological measurement is usually carried out. Despite its obvious flaws, Stevens’ approach circumvented the requirement for quantitative measurement that only quantitative attributes can be measured (Michell, 1999). This is because psychological constructs, such as the quality of life, are nothing at all like physical variables that are quantitative in nature. However, psychologists have routinely treated psychological constructs as if they are quantitative in nature and as amenable to measurement as physical characteristics. For more than 60 years, psychology has been living in a make-believe world where making rules for applying numbers to attributes has been treated as if it were proper measurement. This fundamental issue cuts off at its very roots the claim that psychology is a quantitative science on a par with the natural sciences.
However, this would be a very short textbook if we were to give up at this point! We must soldier on as if we have solid ground to walk upon rather than boggy sand.
Measurement can be defined as the estimation of the magnitude of a quantitative attribute relative to a unit (Michell, 2003). Before quantification can happen, it is first necessary to obtain evidence that the relevant attribute is quantitative in structure. This has rarely, if ever, been carried out in psychology. Unfortunately, it is arguably the case that the definition of measurement within psychology since Stevens’ (1951) operationism is incorrect and psychologists’ claims about being able to measure psychological attributes can be questioned (Michell, 1999, 2002). Contrary to common beliefs within the discipline, psychological attributes may not actually be quantitative at all, and hence not amenable to coherent numerical measurement and statistical analyses that make unwarranted assumptions about the numbers collected as data.
The situation is akin to the ’Emperor has no clothes’ story. Psychometricians are forced to pretend/make the inference that the ordering of scores is a reflection of an underlying quantity and therefore that psychological attributes are measurable on interval scales. Otherwise there would be no basis for quantitative measurement in psychology. Michell (2012: 255) argued that: ’the most plausible hypothesis is that the kinds of attributes psychometricians aspire to measure are merely ordinal attributes with impure differences of degree, a feature logically incompatible with quantitative structure. If so, psychometrics is built upon a myth.’ This view is supported by Sijtsma (2012), who argued that the real measurement problem in psychology is the absence of well-developed theories about psychological attributes and a lack of any evidence to support the assumption that psychological attributes are continuous and quantitative in nature. This fundamental measurement problem exists as much within health psychology as it does within psychology as a whole.
Box 1.5 Measuring a Psychological Attribute — What the Majority of Textbooks Don’t tell you and About which You are not Supposed to Ask
A typical study requires participants to complete a set of ratings on questionnaire scales that are designed to measure a psychological attribute. The essential issue is whether the total score obtained from the numbers (ratings) provided by an individual is in any way a measure of an attribute along a quantitative scale, like the readings from a tape measure, which reflect the quantity of distance. Distance has an absolute zero and different objects can be placed at equal distances from each other or in fixed ratios. Now let’s consider the example of Diener’s Satisfaction with Life Scale (SWLS) (Table 1.2). The total scores on the SWLS are obtained by summing the seven-point ratings of each of five items. Thus, a maximum score is 35 and the minimum score is 5. The scoring scheme is given here:
31—35 Extremely satisfied
21—25 Slightly satisfied
15—19 Slightly dissatisfied
5—9 Extremely dissatisfied
Is there any basis for assuming the total scores on the SWLS are measures of a quantitative attribute ’Life Satisfaction’ such that there is an absolute zero (as there would be in any ratio scale) and a person with a score of 20 has exactly double the life satisfaction of a person who has a score of 10 and/or that two people with scores of 30 and 25 have a life satisfaction that is the same ’distance’ apart (5 points) as in the case of two people with scores of 20 and 15? If the 5-point differences were shown to be the same, then the SWLS would be an interval scale. However, neither of the hypotheses is plausible. We can only infer a person’s life satisfaction from their answers to items on the SWLS. This is because we have no independent definition of life satisfaction, and no evidence that life satisfaction is a quantitative attribute, apart from the SWLS scores themselves. This measurement problem cuts through the entire discipline of psychology. We infer or, in truth, are forced to act on the unproven assumption that a person’s score on the SWLS is a measure of her/his life satisfaction on a continuously quantitative interval scale.
The total scores on the SWLS really only allow respondents to be placed along an ordinal scale, yet it is common practice to treat the scores as if they were interval scale data that can be added together, subtracted, averaged and compared between groups using standard deviations and variance scores in statistical analyses.
[Nobody promised you a rose garden! We said at the outset that we would adopt a critical stance, and the measurement problem we have described here, which, for obvious reasons, is not normally talked about, is a good start. The situation is not completely hopeless, however, so please do read on.]
Fortunately, for a practical domain like health psychology, it is possible to ’get by’ without a solution to the measurement problem. This is because one of the main goals of health psychologists is to design interventions that are effective solutions to health problems. Normally we can find ways to objectively compare different interventions to see what works and what doesn’t work. The associations between interventions and outcomes can be observed and measured in quantitative terms. Additionally, a patient seeking treatment for an unpleasant condition can express their thoughts, feelings and motives using plain words by answering questions or items on a questionnaire. In the vast majority of cases, either psychological measures are assumed, for the sake of convenience, to lie along an interval scale or the data are purely categorical.
Health psychologists are concerned with patient—practitioner interactions, public health promotion, or working in communities where actions are carried out, all with observable inputs and outputs. Outcomes in these various scenarios are all objectively observable and measurable, even if the measurements themselves are not shown to have an underlying quantitative attribute. In addition, it is the experiences of the actors that are important, and these are amenable to qualitative methods where the presumption of quantitative attributes and the associated measurement problem do not apply.
A Cultural Perspective
There are wide variations in health beliefs between cultures and significant individual and group differences within each culture. Folk beliefs, knowledge and practices among individuals from different communities and social groups rub shoulders with each other and with those of health care professionals in a Tower of Babel. These diverse beliefs meld with practices and lifestyles in accord with people’s worldviews and values.
Theories in health psychology provide accounts of how psychosocial processes affect individual health experience. In reviewing such theories (e.g., see Chapter 8), it must be acknowledged that they are principally products of the US and British Commonwealth, together with inputs from Continental Europe and Scandinavia. Many of health psychology’s theories are adaptations of US/European cognitive and social psychology from the last 50 years. The resurgence of research in laboratory environments used structured psychometric instruments, questionnaires and performance tests that were designed to reveal the mechanisms underlying human behaviour. These methods lacked ecological validity, or, in other words, the findings could not be generalized to the world outside the laboratory. Critics have suggested that the laboratory experiment and the questionnaire are both subject to significant biases.
Cross-cultural psychology emphasizes cultural diversity and casts a sceptical eye over the ethnocentrism of contemporary psychology. It considers national or large-group samples as the unit of analysis rather than individuals. We discuss the role of culture in health in more depth in Chapter 6.
A Framework for Health Psychology
Theoretical thinking in health psychology consists of three broad types that vary according to their level of generality: frameworks, theories and models. Frameworks have some of the characteristics of paradigms (Kuhn, 1970) as they refer to a complete system of thinking about a field of inquiry. Paradigms explicitly state assumptions, laws and methods. Frameworks are much looser than paradigms but they are a way of organizing information about a field. Figure 1.5 shows a framework about the main influences on the health of individual human beings. It has been adapted from the work of Dahlgren and Whitehead (1991) and we call this the ’Health Onion’.
Figure 1.5 The ’Health Onion’: a framework for health psychology
Source: Dahlgren and Whitehead (1991)
The ’Health Onion’ has a multi-layered structure with the individual at its core, surrounded by four layers of influence or systems:
Core: age, sex and hereditary factors (Part 1 of this book).
Level 1: individual lifestyle (Part 2 of this book).
Level 2: social and community influences (Part 1 of this book).
Level 3: living and working conditions, and health care services (Parts 3 and 4 of this book).
Level 4: general socio-economic, cultural and environmental conditions (Part 1 of this book).
The Health Onion is a systems framework, it has seven characteristics:
It is holistic — all aspects of human nature are interconnected.
It is concerned with all health determinants, not simply with events during the treatment of illness.
The individual is at the core with health determinants acting through the community, living and working conditions, and the socio-economic, cultural and physical environment.
It places each layer in the context of its neighbours, including possible structural constraints upon change.
It has an interdisciplinary flavour that goes beyond a medical or quasi-medical approach.
It makes no claim that any one level is more important than others.
It acknowledges the complex nature of health determinants.
Different theories and models are needed for each setting and context. However, there is also a need for a general paradigm for individual health within which specific theories and models can be nested. Such a paradigm should attempt to represent in an explicit, detailed and meaningful way the constraints upon and links between individual well-being, the surrounding community and the health care system (Marks, 1996). No such general paradigm exists. We are waiting for a Hippocrates, Darwin or Einstein.
Box 1.6 Filtering of Evidence in Evidence-Based Practice
Some believe we have a paradigm for all of health care in the form of evidence-based medicine or evidence-based practice (EBP). In EBP, randomized controlled trials are used to produce conclusions about the effectiveness of different methods and treatments. In theory, the approach sounds wonderful. In practice, it is far from perfect. Evidence on effectiveness in EBP is assumed to have an objective, inviolable status that reflects ’reality’. It is given an iconic status. In some undefined ways, this evidence about ’reality’ not only aids decision-making, but also determines it. In truth, evidence is never absolutely certain. It rests on subjective elements consisting of negotiable, value-laden and contextually dependent beliefs that are given the status of ’facts’ when all they really are is items of information. Until the Magellan-Elcano circumnavigation of 1519—22 the Earth was assumed by everybody to be completely flat. The flat-Earth was a belief masquerading as fact. Across many cultures, epidemics of cholera, chlamydia or the Black Death were assumed to be caused by a miasma, a form of ’bad air’ emanating from rotting organic matter. The miasma theory was only slowly given up after disconfirming evidence was obtained, such as John Snow’s demonstration of the crucial role of water in the spread of cholera after removing the handle of the Broad Street pump in Soho. Thus, bad theories are only replaced by better theories as a consequence of disconfirming evidence.
The nature of evidence, and the methods by which evidence is gained, are contentious issues in the history of science. In health care, evidence (= new knowledge) for a technique or treatment is not an accident, but the product of a series of ’gates’ or ’filters’ that must be passed before the technique is deemed to be useful.
Consider the sequence of processes through which evidence must pass if it is to be considered admissible in EBP. The filtering is so selective that, typically, systematic reviewers will be able to find only a dozen or fewer primary studies that fulfil the inclusion criteria from a field of several thousand. Oakley (2001) described a systematic review of peer health promotion for young people that found 5,124 citations, of which exactly 12 (0.234%) were judged to have carried out ’sound’ outcome evaluations. She compared this search process to ’finding needles in haystacks’ (Oakley, 2001: 22—4). Another analogy is making a pot of filter coffee — the stronger the filtering, the less fresh and flavourful the coffee. EBP is somewhat similar: there are no guarantees the end-product will be fit for purpose. The filtering process involved in EBP consists of seven levels: current knowledge, theory and paradigms taught in universities and schools; funding priorities of government, industry and charities; hypotheses considered important by the funders; methodology approved by funders; journal publication; systematic reviews; translated into EBP.
To be judged ’sound’, evidence must pass through these seven filters, which are biased towards the preservation of existing practices, knowledge and myths. In confirming the ’sound’ status of the techniques that have passed through the filters, the ’unsoundness’ of the unfiltered techniques occurs by default. Undeniably, evidence filtering is systematic and biased towards the status quo. Evidence is considered ’sound’ or ’unsound’ according to established criteria.
However, EBP is contentious on a number of grounds. First, it is wasteful that so much evidence is ’thrown away’. Many unfiltered techniques are quite possibly as effective as techniques that have been filtered. Second, the filtering process gives a high weighting to techniques that conform to beliefs and values of the knowledge establishment. For example, pharmacotherapy will be established ahead of psychological therapies (pharmaceutical industry sponsorship at filters 1—4), quantitative techniques will be preferred to qualitative techniques (filters 5—6), and patient treatment care will be about outputs and outcomes, rather than feeling they have been cared for as human beings (filters 7). Third, innovation may have difficulty breaking through.
In this book, we review the results of many studies using the approach of EBP. Studies that have not been based on EBP are also reviewed. Many such studies have been in settings where EBP would be unethical, impractical or impossible. We also include qualitative studies because the findings illuminate the lived experience of health and illness.
Source: Marks (2005, 2009)
1. Psychology requires a solution to the measurement problem (if there is one): there is no evidence that psychological attributes are continuous quantitative variables of the kind studied in the natural and physical sciences.
2. Trans-cultural studies of health, illness and health care are needed to facilitate communication and understanding of systems of healing among different cultural, ethnic and religious groups.
3. Evidence needs to be gathered to confirm that lifestyle changes cause positive changes to life expectancy and quality of life.
4. The limits of evidence-based practice require innovative evaluation methods of interventions.
1. Health is a state of well-being with physical, cultural, psychosocial, economic and spiritual attributes, not simply the absence of illness.
2. The fundamental sociality of individual behaviour demands a social orientation to health psychology, which must be studied in the context of society and culture.
3. To be healthy in body and mind a person’s needs to interconnect and to act autonomously as an agent must both be satisfied as well as his/her biological needs.
4. Subjective well-being is normally positive for the majority of individuals. It fluctuates around a set-point inside a range and is regulated by homeostasis.
5. Behavioural and environmental changes need to be given equal priority in interventions.
6. Health psychology has grown rapidly, with increasing evidence that much illness and mortality are caused by behaviour, and there is a growing awareness of the psychosocial aspects of health and illness.
7. The ’Health Onion’ is a useful framework for the investigation of health and illness. The core of the onion is an individual’s current health status, including the particular factors of age, sex and hereditary. Four layers of analysis surrounding this core are: (1) individual lifestyle, (2) social and community influences, (3) living and working conditions, and (4) general socio-economic, cultural and environmental conditions.
8. Concepts about health and disease are embedded in culturally diverse ways, with significant differences in experience and behaviour between cultures and places.
9. The organization of knowledge in health psychology is structured within frameworks, theories and models. It is helpful to notice the difference between these three types of structure and to treat them differently.
10. The nature of evidence and the methods by which evidence is gained are contentious issues in science. In health care, new knowledge about a theory, technique or intervention is the product of a series of evidence ’gates’ or ’filters’ that must be passed before it is deemed to be useful.