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Journal of Health Editorial: Health Copyright © 2004 SAGE Publications London, Thousand Oaks and New Delhi, www.sagepublications.com Psychology and Public DOI: 10.1177/1359105304036098 Health—Bridging the Vol 9(1) 5–12 Gap

JAN VINCK Limburg University Centre, Diepenbeek, Belgium

BRIAN OLDENBURG Queensland University of Technology, Brisbane, Australia

THOMAS VON LENGERKE GSF–National Center for Environment and Health, Neuherberg, Germany

Background third of the global loss of healthy life years. There is clearly no doubt that disease preven- THE MOST recently published World Health tion and have a very import- Report—World Health Report 2002: Reducing ant role to play in improving in the risks, promoting healthy life (WHO, 2002)—has years ahead. again identified the fundamental importance of In this context, health psychology has, by defi- health behaviours, and risk factors under behav- nition, much to offer, as is evident in ioural control, as causes of much of the world’s Matarazzo’s milestone explication: burden of disease. Indeed, the report states that Health psychology is the aggregate of the the 10 leading preventable risks to global health special educational, scientific, and include unsafe sex, , abusive alcohol professional contributions of the discipline of consumption, low fruit and vegetable intake, psychology to the promotion and mainten- physical inactivity, both underweight and over- ance of health, the prevention and treatment weight, high blood pressure, hypercholesterol- of illness, the identification of the etiologic aemia and iron deficiency (p. 91), each of which and diagnostic correlates of health, illness, has behavioural underpinnings. The key disease and related dysfunction. (1980, p. 815) and illness threats to global health to which these factors contribute include ischaemic heart This was amended by APA by adding ‘. . .and disease, cerebrovascular disease, lung cancer the analysis and improvement of the health care and chronic obstructive pulmonary disease, system and formation.’ (cf. AIDS and unipolar depressive disorders. The Matarazzo, 1982, p. 4), and subsequently report states that overall, these threats account adopted by most health psychology organiz- for an estimated 54 per cent of the 56 million ations and textbooks. deaths that occur world-wide each year, and a This definition has the stage for health

5 JOURNAL OF HEALTH PSYCHOLOGY 9(1) psychology to focus particularly on individual, by looking at health-related behaviours that personal and interpersonal processes contribut- were until recently neglected, such as political ing to individual health, drawing broadly from participation (von Lengerke, 2001; see also the social and behavioural sciences. In contrast, Rütten, von Lengerke, Abel, Kannas, has traditionally focused more on Lüschen, Rodríguez Díaz, Vinck, & van der those environmental, institutional and societal Zee, 2000). processes that enhance the health status of 2. At the level of application and interventions, populations, drawing upon a large range of health psychology’s sound base of know- scientific disciplines and using a range of ledge about health behaviours and other different methods (Last, 1995, p. 134). Notwith- steps in the multilevel causal chain to health standing this traditional difference between can be used to guide efforts at changing health psychology and public health, it is clear behaviour. For instance, the field has that over time health psychology is becoming contributed to numerous intervention more important as one of the key fields under- strategies in , with tech- pinning the practice of public health, as is niques for modifying behaviour, and enhanc- behavioural medicine (Oldenburg, 2002). ing and learning for health. More More specifically, health psychology makes recently, multilevel intervention models, an important contribution to the practice of including environmental and policy vari- public health at three different levels: ables, are being increasingly proposed and tested (e.g. Winett, Anderson, Whiteley, 1. At a theoretical and conceptual level, health Wojcik, Winett, Rovniak, Graves, & Galper, psychology’s contributions are quite diverse. 1999). These latter approaches have a lot to This discipline contributes to our understand- offer in order to further our understanding of ing of health and illness, among other things measures that have originated from other by proposing and studying quality of life as an public health disciplines, such as policy (e.g. important objective of efforts to improve tax policies) and environmental (e.g. healthy health (Kaplan, McCutchan, Navarro, cities) approaches to health promotion, Anderson, Atkinson, Chandler, Grant, & the which can thereby be used to develop and HNRC Group, 1994; O’Boyle, 1997), by implement more appropriate programmes. reinforcing a more positive view of health 3. Finally, health psychology can contribute to (Taylor, Kemeny, Reed, Bower, & Grue- the promotion of health and prevention of newald, 2000) and by examining possible disease by the development and application negative effects of health care (e.g. Lerman, of methodological and analytic standards that Trock, Rimer, Boyce, Jepson, & Engstrom, have been inherited from the associated 1991). It also expands our understanding of fields of statistics, general methodology and determinants of health and illness: it provides test theory, which can also be used to us with a strong and growing evidence base complement more traditional epidemiologi- for understanding the role of, among others, cal methods (Raphael & Bryant, 2002). For lifestyle, , social relations and, instance, multivariate analysis techniques more recently with the role of positive such as factor analysis are routinely , optimism and spirituality (Thore- employed in psychology; also, the relative sen, 1999). It assists, furthermore, with the contributions that can be made to our know- elaboration of models for understanding ledge by quantitative and qualitative behaviour and behavioural adaptations. In research methods, and how these yield pieces this respect social-cognitive models have of information that complement each other been very important and are gradually being (Murray & Chamberlain, 1999), is a relevant complemented by more socio-ecological case in point. Moreover, psychology’s rich models. Finally, it expands our knowledge of armamentarium of diagnostic instruments, health behaviour by exploring new aspects of tests and assessment tools may contribute to health-related behaviour, like the link many public health tasks such as health between health motives at an individual and surveillance. Finally, it can also contribute to at a social level (Kals & Montada, 2001), or the discussion about the nature of ‘evidence’

6 VINCK ET AL.: EDITORIAL in health promotion and public health (Oldenburg, 2001; see also Bandura, 1998). (McQueen, 2001). Second, a strong evidence base was built that confirms the contribution of psychosocial Following a symposium which examined various factors, such as a ‘sense of control’, social aspects of the relationship between health support networks, personal resilience, family psychology and public health, held as part of the environment and chronic stress, to a wide range Scientific Programme of the 2001 European of health and social problems. Third, since Health Psychology Society Conference in St primary prevention and health promotion Andrews, Scotland, we set out to bring together almost always involve behaviour change, behav- colleagues that share an interest in promoting ioural theories and behavioural interventions, the collaboration between health psychology whether directed at the individual or societal and public health. This Special Issue of the level, have been elaborated. Some of the Journal of Health Psychology is the result of this theories which have been used most frequently ongoing interaction, and we hope it will stimu- in the field of prevention include, besides SCT, late further interest in, and dialogue on, the the Health Model, the Theories of relationships between these two fields. Reasoned Action and Planned Behaviour, But first, we should examine what has been Protection Motivation Theory, Health Locus of achieved so far. Control-Theory and stage theories such as the of Change (see Conner Health psychology and public & Norman, 1996; Glanz, Rimer, & Lewis, 2002). health—what has been As noted by Winett, King and Altman: achieved so far? The health psychology field brings with it a rigorous scientific method for understanding The emergence and broadening of the fields of human , a tradition of delineating the health psychology, behavioural health and individual contexts of health and disease, and behavioural medicine from the late 1970s a burgeoning armamentarium of techniques through to the 1990s has helped to develop and and approaches for modifying behavior and strengthen the psychological underpinnings of enhancing motivation and learning. (1989, disease prevention and health promotion with a pp. 27–28) specific focus on key health behaviours like smoking, sedentary lifestyle and dietary behav- A number of large primary prevention trials iours. This followed the steady increase in targeting health risk factors for cardiovascular evidence emanating from the large prospective disease have been based on concepts and prin- epidemiological studies related to heart disease, ciples derived from such theories. The Stanford cancer and other conditions, in the years follow- Three Community Study (Farquhar & Maccoby, ing the Second World War. Collectively, the 1977) demonstrated the feasibility and effec- results from these studies have enhanced our tiveness of mass media-based educational understanding of the interplay of biological, campaigns and achieved significant reductions psychological, behavioural, social and environ- in cholesterol and fat intake. The Minnesota mental factors associated with the development Heart Health Project (Mittelmark, Luepker, & and pathogenesis of many different diseases and Jacobs, 1986), the Pawtucket Heart Health conditions. Program (Lefebvre, Lasater, Carleton, & Peter- In this process a number of things have been son, 1987) and the Stanford Five-City Project achieved. In the first place the social and behav- (Farquhar, Fortmann, Flora, Taylor, Haskell, ioural sciences, including health psychology, Williams, Maccoby, & Wood, 1990) used inter- have helped to generate many of the theories ventions aimed at raising public awareness of and models—e.g. risk factors for coronary heart disease (choles- (SCT)—that have provided an important link terol, obesity, cigarette smoking), and changing between understanding the modifiable determi- risk behaviours through education of health nants of disease and health, and development, professionals and environmental change implementation and evaluation strategies for programmes such as grocery store and restau- disease prevention and health promotion rant food labelling.

7 JOURNAL OF HEALTH PSYCHOLOGY 9(1) The North Karelia Project in Finland (Puska, approach is less problematic for ‘clinical’ health Tuomilehto, Nissinen, & Vartianen, 1995) was psychology, where a large proportion of work is initiated in response to research demonstrating done with individual clients. The problem with that Finland had one of the highest rates of an individualistic approach becomes evident, heart disease in the world in the 1940s. The however, when it comes to prevention and prevention strategies were broad, diverse and health promotion. In prevention, risk groups are multilevel, including tobacco taxation and sometimes very large portions of the popu- related restrictions, televised instruction in skills lation, as is the case with obesity, physical inac- for non-smoking and vegetable growing and tivity or smoking. This population perspective is extensive organization and networking to build even more prominent in health promotion: here an education and advocacy organization. After the population is the target as well as the active 10 years, results indicated significant reductions force of health promoting efforts, like, for in smoking, blood pressure and cholesterol, and example, in the Healthy Cities-movement. a 24 per cent reduction in coronary heart disease 2. Health have to learn to use a mortality among middle-aged males. Between broader range of interventions, drawing on 1972 and 1992, cardiovascular disease mortality determinants of behaviour at multiple levels. declined in Finland by 55 per cent among men and 68 per cent among women, which was In health psychology there was, until recently, a primarily attributed to dietary change. strong tendency to rely primarily on health Of course these are only a few of the most education interventions based on social-cogni- well-known examples of how health psychology tive models, with much less attention for other has already made a substantial contribution to very relevant factors, e.g. environmental factors public health efforts. However important and (Chesney, 1993; Orbell, Norman, Ogden, rich this tradition, we believe that this still does Abraham, Bennett, Conner, & Sheeran, 1994; not realize the full potential of health psychol- Vinck & Chesney, 1996; Winett et al., 1989). In ogy’s contribution to disease prevention and recent years, there has been an increasing health promotion. number of efforts reported which have aimed to incorporate a broader range of social-environ- Health psychology and public mental strategies (Burgoyne & Jason, 1991; health—how can we proceed? Chesney, 1993; King, Stokols, Talen, Brassing- ton, & Killingsworth, 2002; Stokols, Allen, & We feel that some characteristics of mainstream Bellingham, 1996; Winett, 1995; Winett, King, & health psychology hinder both its actual and Altman, 1989, 1991). potential contributions to public health efforts It has indeed become very clear that behav- because health psychology has traditionally iour cannot be understood when it is isolated restricted its scope to an individually or group- from the context in which it is enacted; in other focused approach and to a restricted range of words, there is a need for a more ecological intervention strategies; furthermore, health approach to behaviour (Sallis & Owen, 2002). psychologists have tended to feel uneasy with This implies that important determinants of some important aspects of a behaviour are situated at an environmental and approach. We propose the following directions societal level and that lasting changes in the for the future of health psychology: behaviour of the population will not occur unless these environmental and societal deter- 1. Health psychology should expand its scope minants (e.g. road infrastructure, legislation in to include a much stronger population relation to smoking, pricing of alcohol and perspective. healthy food) are changed (see Hill & Peters, Over the last decade, several authors have 1998, for a similar argument regarding obesity). drawn attention to the fact that the main scope The tendency to fall back on traditional inter- of health psychology has been restricted largely vention strategies may be partly related to the to the individual and small group levels, and that relative shortage of descriptions in the this is unfortunate (Chesney, 1993; Ewart, 1991; professional literature of intervention tech- Marks, 1996; Winett, 1985). This individual niques from an ecological and motivational

8 VINCK ET AL.: EDITORIAL perspective, making them less well known. So Overview of Special Issue when time pressure is high—which is virtually always the case—practitioners easily fall back This Special Issue begins with a number of more on, and restrict themselves, to the well-known general manuscripts. Murphy and Bennett health education theories and interventions. present the state of the art in health promotion, Regardless, many of the principles of behaviour and review areas of public health in which modification at an individual level can also be psychological theory is applied and could be translated to interventions at a population level developed. Kaplan and colleagues take a critical (e.g. Burgoyne & Jason, 1991; Winett et al., look at the traditional biomedical contribution 1999). to public health, whereas Hepworth reflects on how the educational and professional basis of 3. Health psychologists should turn to new health psychology should be further consoli- target populations and adapt to working in dated in terms of a public health psychology. complex systems. A second group of articles relates to health— Working with environmental and community and social—psychology’s contributions to public variables implies that health promotion health promotion. While Pinheiro and Spink professionals largely stop working directly with explore ’s input to integral the ultimate target population, and instead work health care in the promotion of what they term with systems and with those having control over ‘collective health’, Uutela and colleagues the environmental determinants of the target demonstrate how health psychology can population’s behaviour (e.g. politicians, the contribute to large-scale health promotion food industry, local communities—see Heller, programmes, taking as their example one of the 1990; Nathan, Rotem, & Ritchie, 2002; Runyan, very first of such undertakings, the North 1985). This type of public health practice is often Karelia project. Subsequently, Kok and quite different from the professional practice colleagues present ‘Intervention Mapping’ as a and experience of health psychologists protocol for the use of theories in the develop- (Simpson, Oldenburg, Owen, Harris, Dobbins, ment of theory- and evidence-based health Wilson, Vita, Salmon, & Saunders, 2000). More promotion programmes. research is required on how to work most effec- A third group of articles expands the perspec- tively with such economic and policy systems tive of the Special Issue by examining public (Bryant, 2002; DeLeon, Frank, & Wedding, health issues with specific relevance to middle- 1995; Lorion, Iscoe, DeLeon, & VandenBos, income economies and giving special attention 1996; Rütten, Lüschen, von Lengerke, Abel, to the role of socio-economic and cultural Kannas, Rodríguez Díaz, Vinck, & van der Zee, aspects. On one hand, from former socialist and 2000). now transforming Central-Eastern Europe, Of course, working at these ‘higher’ levels is both Kopp and colleagues and Piko examine the complex and health psychologists often feel situation in Hungary, focusing on psychological uneasy managing this complexity with the avail- processes that mediate between relative socio- able resources and feel unable to keep enough economic deprivation and morbidity (Kopp et control over what is going on to get scientific al.), and community orientations and health results. Here we need further work on how to behaviours (Piko). On the other hand, from the think systematically about these matters (e.g. point of view of a rapidly developing South- Boyce, 2002; Hancock, 2001; Sallis, Owen, & American economy, Sato and colleagues discuss Fotheringham, 2000). ways in which psychology has contributed to Remedies for the problems we have briefly public health services concerned with workers’ discussed are situated at different levels, and health in the State of São Paulo, Brazil. there can also be major differences both within Finally, one more group of contributions and between countries. For example, there can expands health psychology’s traditional perspec- be profound differences in training and tive by exploring different aspects of the education, professional organization and the relationship between health policy and health ways in which research is funded and behaviours. Sykes and colleagues identify conducted. specific discourses in the 1996–2000 EU Health

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Promotion Programme, and their possible influ- Boyce, W. F. (2002). Influence of health promotion ences on how people think, feel and act, as well bureaucracy on community participation: A as on health promotion practices. Becker and Canadian . Health Promotion Inter- colleagues provide evidence that individual meat national, 17, 61–68. consumption on one hand and socio-political Bryant, T. (2002). Role of knowledge in public health and health promotion policy change. Health commitments regarding general meat produc- Promotion International, 17, 89–98. tion on the other share a common motivational Burgoyne, N. S., & Jason, L. A. (1991). Incorporating basis. Last, von Lengerke and colleagues, in a the ecological paradigm into behavior preventive multilevel analysis across six European coun- interventions. In P. R. Martin (Ed.), Handbook of tries, report positive associations of health behavior therapy and psychological science: An inte- behaviours with health policy both grative approach (pp. 457–472). New York: on individual and aggregate levels, suggesting Pergamon Press. that positive policy appraisals operate as a social Chesney, M. (1993). Health psychology in the 21st climate factor that may foster health behaviours. century: Acquired Immunodeficiency Syndrome as As a final point, it is important to remind the a harbinger of things to come. Health Psychology, 12, 259–268. reader of some of the relationships between Conner, M., & Norman, P. (Eds.). (1996). Predicting health psychology and public health that, for health behaviour: Research and practice with social reasons of time and space, are not taken up in cognition models. Buckingham: Open University this Special Issue. First, the protection of the Press. environment as a strategy of health promotion is DeLeon, P. H., Frank, R. G., & Wedding, D. (1995). not addressed. Second, no article specifically Health psychology and public policy: The political addresses health issues in low-income economies process. Health Psychology, 14, 493–499. (i.e. in so-called ‘underdeveloped countries’), Ewart, C. K. (1991). Social action theory for a public which points to the need of intensifying co-oper- health psychology. American , 46, ations of scholars from across the globe; also, 931–946. Farquhar, J. W., Fortmann, S. P., Flora, J. A., Taylor, and relating to the world-wide perspective as C. B., Haskell, W. L., Williams, P. T., Maccoby, N., well, globalization remains—like for virtually all & Wood, P. D. (1990). Effects of community-wide (at least social) sciences—a challenge to health education on cardiovascular risk factors: The psychology and public health not dealt with in Stanford Five-City Project. JAMA, 264, 359–365. this issue. Third, empirical assessment of the Farquhar, J. W., & Maccoby, N. (1977). Community specific virtues of public participation in health education for cardiovascular health. Lancet, 1, promotion planning, implementation and evalu- 192–195. ation represents a task that will expectantly call Glanz, K., Rimer, B. K., & Lewis, F. M. (Eds.). (2002). for substantial efforts. Fourth, the relative Health behavior and health education: Theory, unavailability of practical descriptions of behav- research, and practice, 3rd edn. New York: Wiley. Hancock, T. (2001). People, partnerships and human iour modification techniques at an ecological progress: Building community capital. Health level remains to be dealt with. Last, ethical ques- Promotion International, 16, 275–280. tions related to prevention and health promotion Heller, K. (1990). Social and community intervention. are only peripherally dealt with in this Special Annual Review of Psychology, 41, 141–168. Issue. Hill, J. O., & Peters, J. C. (1998). Environmental Notwithstanding these limitations, we hope contributions to the obesity . Science, 280, that this Special Issue will find the interest of 1371–1374. many involved in health research and Kals, E., & Montada, L. (2001). Health behavior: An promotion, and ultimately make an important interlocking personal and social task. Journal of contribution to bridging the gap between health Health Psychology, 6, 131–148. Kaplan, R. M., McCutchan, J. A., Navarro, A. M., psychology and public health. Anderson, J. P., Atkinson, J. H., Chandler, J., Grant, I., & the HNRC Group. (1994). Quality adjusted References survival analysis: A neglected application of the quality of well-being scale. Psychology and Health, Bandura, A. (1998). Health promotion from the 9, 131–141. perspective of social cognitive theory. Psychology King, A. C., Stokols, D., Talen, E., Brassington, G. S., and Health, 13, 623–649. & Killingsworth, R. (2002). Theoretical approaches

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