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Public Health is an Interdiscipline, and

about Wholes and Journal of Health Psychology Copyright © 2006 SAGE Publications Parts London, Thousand Oaks and New Delhi, www.sagepublications.com Vol 11(3) 395–399 Indeed, Critical Health DOI: 10.1177/1359105306063311 Psychology Needs to Join Forces Abstract Hepworth’s assessment of critical health psychology’s capacity to contribute to public health promotion (this issue) is THOMAS VON LENGERKE commented on and supplemented Hannover Medical School and GSF-Institute of Health by selected issues relevant to Economics and Health Care Management, Neuherberg, Hepworth’s timely call for Germany interdisciplinary research and action in this context. Drawing on eco-epidemiology, multilevel research strategies are suggested that comprehensively account for individual/psychological and population/sociological factors. It is delineated how health promotion policies may be backed by psychologically informed policy analysis. Regarding health, it is argued to keep scrutinizing ill-health and to resist simplistic notions of quality of life or wellness but also to enhance these by incorporating concepts from positive psychology. Finally, it is considered whether transdisciplinarity may be in aid of fully realizing the potentials of blending the merits of health psychology and public health.

Keywords

COMPETING INTERESTS: None declared. ■ critical health psychology ■ interdisciplinarity ADDRESS. Correspondence should be directed to: ■ public health THOMAS VON LENGERKE, PhD, Hannover Medical School, Medical Psychology Unit (OE 5430), Carl-Neuberg-Str. 1, 30625 Hannover, ■ public health psychology Germany. [email: [email protected]] ■ transdisciplinarity

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JOURNAL OF HEALTH PSYCHOLOGY 11(3)

PUBLIC health’s classic definition, which follows inequities, i.e. unwanted disparities in health Winslow (1920) and to me is still a valid one, is due to material or social deprivation, e.g. SES or that of the science and art of preventing ill- social capital. health, prolonging life and promoting health Simultaneously, I agree with Hepworth (this through organized societal efforts. As such, I am issue) when she (citing Adler, 2003) maintains positive that it is best pursued as an ‘interdisci- that CHP is not equal with social epidemiology, pline’, to which other disciplines essentially but continues to be psychology as well. I might contribute, above all epidemiology, medicine, add that otherwise the CHP definition cited psychology, sociology, political science, econ- earlier from Marks (2002) may almost read omics and health services research. Thus, I fully more like describing something such as political support Hepworth’s call (this issue) for critical health economy. So what are psychology’s health psychology (CHP) to join forces with traditional areas of expertise? Well, human these and other related fields through interdis- agency and behaviour and mental processes, ciplinary research and action. Having said this, I aren’t they? Thus, I support that we apply gladly take the opportunity to spotlight some ecological thinking on ‘our’ outcomes. Take, for conceptual and strategic issues that may be of example, body weight dissatisfaction: clearly a avail to the success of such interdisciplinary mental phenomenon and a risk factor for public efforts. To begin with, what is CHP about, public health problems such as mental disorders, health-wise? social-relational problems and health-compro- I find it helpful to draw on Rose’s (1985) mising behaviours. Recently, McLaren and seminal contribution to public health in this Gauvin (2002) reported that in Canadian context. Among other things, Rose differenti- women, for a given body mass, body weight ated causes of cases versus causes of incidence of dissatisfaction was more likely in affluent neigh- ill-health, showing that these need not be the bourhoods—astoundingly independent of indi- same. Schwartz and Diez-Roux have delineated vidual affluence, and despite higher rates of with impressive clarity that at the heart of this obesity in less affluent neighbourhoods. argument lies an understanding about wholes Evidently, standards of beauty work differently and parts which has it that ‘although populations in different socio-economic contexts; however, are comprised of individuals, the population has the authors also state that ‘research is needed to characteristics that are distinct from the mere identify what it is about the affluence of a neigh- summation of the characteristics of the indi- bourhood that translates into different preva- viduals in the population’ (2001, p. 436). Hence, lence values of body dissatisfaction’ (2002, the ‘characteristics of the population may be p. 198). Unless I am quite mistaken, psychologi- influenced by characteristics of the individuals cal social comparison theories will be of much but the characteristics and behaviours of the avail here! Also, imagine looking at this issue individuals are also shaped by the character- e.g. in India, with more poverty and an opposite istics of the population’ (2001, p. 436). Given social gradient in obesity. Finally, gender: in CHP is the ‘analysis of how power, economics German men, for example, a positive association and macro-social processes influence health, between individual SES and body weight health care, and social issues, and the study of dissatisfaction has been found (Mönnichs & von the implications for the theory and praxis of Lengerke, 2004). At any rate, all this shows me health work’ (Marks, 2002, p. 12), and grounded the worth of multilevel analysis in the border- in the ‘analysis of society and the values, land of health psychology (HP) and public assumptions and practices of psychologists, health (Vinck & von Lengerke, 2004) so as to health care professionals, and of all those whom avoid both psychologistic and sociologistic they aim to serve’ (Marks, 2002, p. 12), it is obvi- fallacies (Diez-Roux, 1998). ously very much about population- and system- However, clearly the above is mostly about level factors. Thus, I see a clear proximity to research, and even given perfect evidence for multilevel eco-epidemiology (Susser, 1998) and ecological public health approaches, they are generally eco-social perspectives (Krieger, unlikely to translate easily into policy. For 2001), primarily in social epidemiology. Substan- example, the MAREPS policymaker survey has tively, surely a key issue for CHP is health underlined that political will is the strongest

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VON LENGERKE: PUBLIC HEALTH IS AN INTERDISCIPLINE determinant of effective health promotion policy sum, while I agree with Hepworth (this issue) implementation, while research utilization was that health psychologists are not specialist public associated with policy impact only in the case of health policy experts, I think that they can poor political will (von Lengerke et al., 2004a). contribute much to the analysis of policy While this does speak for sound research especi- processes and implementation. ally given adverse political agendas, the call for Methodologically, I fully agree with Marks action Hepworth (this issue) recaps is timely. that ‘using qualitative or quantitative methods Plus, while arguably not all health psychologists does not make one a particular kind of psychol- have to be political activists (Sykes, 2003), HP ogist, nor does a particular kind of psychologist from its very beginning promised to contribute necessarily use qualitative or quantitative to ‘the analysis and improvement of the health methods’ (2002, p. 10). Far from it, I suggest to care system and health policy formation’ totally disentangle the dimensions of ‘main- (Matarazzo, 1982, p. 4; it may be of anecdotic stream-critical’ and ‘quantitative-qualitative’. interest that this was not part of Matarazzo’s The latter methods have pros and cons in differ- original HP definition in 1980, but included in ent situations, and I concur with Hepworth (this 1982, based on an interim poll in which a ‘small issue) that multi-method designs are needed to majority’ of those APA’s HP division members capitalize on both their pros (by the way: market voting endorsed the amendment). Well, there is research successfully sells such multi-method another option to get involved in the larger mixes; ask their customers why they buy them). political picture, based on the definition of poli- However, two things seem vital to me when the cies as ‘laws, regulations, formal and informal issue is public health. First, as noted HP has to rules, and understandings that are adopted on a give more credit to multilevel methodologies collective basis to guide individual and collective (Hepworth, 2004; von Lengerke, 2001). Second, behaviour’ (Mosher & Jernigan, 1989, p. 249, at the end of the day we need population-based emphases added). That is, I suggest for HP to data; thus, I agree with Wardle (2000) in her call engage in psycho-political analysis of which poli- to synergize methodological strengths of cies are best pursued via which politics (decision- epidemiology and (health) psychology. making processes, enforcement of goals and One but last: a remark on health. Using a interests, power politics) in which polities (insti- chronic disease example, Hepworth (this issue) tutions in which politics take place, ways in which maintains that ‘the distinction between health procedures are regulated, normative structures). and illness is made impossible as well as un- A cogent example is Leek’s (1991) mental repre- desirable’, and that ‘understanding and explain- sentational approach to health policy analysis. ing the psychological aspects of health becomes Also, citizens’ political participation and politi- inseparable from aspects of illness’ (p. 333). cally relevant behaviours suggest themselves Apart from the fact that I do not quite grasp maybe even more easily to psychological analy- why this should be a corollary of CHP’s foun- sis (Campbell & Jovchelovitch, 2000). For dation rendering potential criticism to be ‘over- example, empowerment can be viewed as inclusive redundant’, my response is ‘yes, but’. contextualized self-efficacy or as collective effi- ‘Yes’ because I feel HP and public health should cacy (starting to be discussed in public health not focus on concepts of quality of life or well- terms: Bandura, 1998). Also, policies may relate ness: health is also the absence of illness. ‘But’: to behaviours via perception: e.g. the MAREPS to me models of ill-health/health, especially in population survey revealed that social climate in times of chronic disease, should allow for any terms of positive population-level appraisal of person at any time to be healthy and ill simul- national health policy is positively associated taneously, i.e. not just more or less ill or healthy. with physical activity and political participation Here, I feel HP would miss an opportunity if it (von Lengerke et al., 2004b). Besides, individual would not enhance overly simplistic concepts of health protection can be co-motivated by the quality of life and wellness by relating to positive willingness to protect public health, thus reflect- psychology (e.g. Keyes & Haidt, 2003). After all, ing social responsibility (Kals & Montada, 2001). this strand of psychology not only highlights Notably, Hepworth (this issue) raises this topic, human strengths and values such as ethics, too, in terms of corporate social responsibility. In kindness, trust, responsibility, participation and

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JOURNAL OF HEALTH PSYCHOLOGY 11(3) solidarity, but also positive institutions. More References generally, I agree with Hepworth (this issue) that CHP should take on the paradoxical chal- Adler, N. E. (2003). Looking upstream and down- lenge of bridging the gap between mainstream stream from the middle of the river: A commentary and critical work—intradisciplinary, so-to-speak on Prilleltensky and Prilleltensky. Journal of Health (remember Julian Rappaport: ‘In praise of Psychology, 8(2), 211–213. Bandura, A. (1998). Health promotion from the paradox’[!]). perspective of social cognitive theory. Psychology Finally, maybe even interdisciplinarity will not and Health, 13(4), 623–649. suffice to make a difference in promoting public Bolam, B., & Chamberlain, K. (2003). Professionaliza- health, but applied sciences may want to develop tion and reflexivity in critical health psychology a transdisciplinary stance (Rosenfield, 1992). practice. Journal of Health Psychology, 8(2), This would mean developing processes by which 215–221. experts from different fields not ‘only’ work Campbell, C., & Jovchelovitch, S. (2000). Health, together, but do so through genuinely shared community, and development: Towards a social conceptual frameworks that draw together disci- psychology of participation. Journal of Community pline-specific theories, concepts and methods to and Applied Social Psychology, 10(4), 255–270. Diez-Roux, A. V. (1998). Bringing context back into address a common problem, e.g. preventing ill- epidemiology: Variables and fallacies in multilevel health and promoting health on different levels analysis. American Journal of Public Health, 88(2), of human organization, or more specific topics. 216–222. Besides, I use the term ‘experts’ intentionally: Hepworth, J. (2004). Public health psychology: A while like Hepworth (this issue) I am aware of conceptual and practical framework. Journal of concerns about professionalization (Bolam & Health Psychology, 9(1), 41–54. Chamberlain, 2003), I decidedly support it— Kals, E., & Montada, L. (2001). Health behavior: An given the pros remain self-critical and -reflexive, interlocking personal and social task. Journal of and fundamentally allow for lay epistemology. Health Psychology, 6(2), 131–148. Admittedly, despite the notion of transdiscipli- Keyes, C. L. M., & Haidt, J. (Eds.). (2003). Flourishing: Positive psychology and the life well-lived. Washing- narity I myself am trying to contribute to the sub- ton, DC: APA. discipline of public health psychology (PHP; von Krieger, N. (2001). Theories for social epidemiology in Lengerke, 2001) originally advocated by Tanabe the 21st century: An ecosocial perspective. Inter- (1982). Of course, PHP is also a buzzword to national Journal of Epidemiology, 30(4), 668–677. provoke thinking out of the box, for instance the Leek, K. M. (1991). A mental representation approach box of adding yet another diminutive improve- to health policy analysis. In J. A. Skelton & ment to yet another social cognition model of R. T. Croyle (Eds.), Mental representation in health health behaviour, and then having to deal with and illness (pp. 163–192). New York: Springer. how best to compare and get the best out of these Marks, D. F. (2002). Editorial essay: Freedom, models. While I do not contest this may be very responsibility and power: Contrasting approaches to health psychology. Journal of Health Psychology, interesting, and has provided laudable inputs to 7(1), 5–19. health education, I query if it is cost-effective Marks, D. F. (2004). Rights to health and freedom from when the issue is public health. Thus, I think of illness: A life and death matter. In M. Murray (Ed.), PHP as the science and art of what people indi- Critical health psychology (pp. 61–83). London: vidually and collectively do and experience, and Palgrave. are (potentially) able to do and experience, to be Matarazzo, J. D. (1980). Behavioral health and healthy and not unnecessarily ill—as individuals behavior medicine: Frontiers for a new health and as societies. To me, what CHP adds is three- psychology. American Psychologist, 35(9), 807–817. fold: global perspectives (Marks, 2004), a focus Matarazzo, J. D. (1982). Behavioral health’s challenge on power politics and ethical premises of justice. to academic, scientific, and professional psychology. American Psychologist, 37(1), 1–14. All told, I endorse Hepworth’s call (this issue) for McLaren, L., & Gauvin, L. (2002). Neighbourhood CHP to avoid ‘a piecemeal approach to the level versus individual level correlates of women’s discovery of longstanding concepts and practices body dissatisfaction: Toward a multilevel under- in public health, health promotion or social standing of the role of affluence. Journal of epidemiology’ (pp. 339–340), and enter a prag- Epidemiology and Community Health, 56(3), matic phase both in research and action. 193–199.

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