What is Health and What is Health Psychology?
This article will introduce the area of health psychology. It will outline briefly the historical background to the field, consider the development of our understanding of health behaviors and introduce the major models which have been developed to aid our understanding of people’s health-related behavior. We will look at individual differences and how they impact on health behaviors. Finally. we will consider the methodologies used in health research and the particular ethical problems which accompany research in these areas.
What is Health Psychology?
How are you feeling today? As you read these words are your eyes sore? Does your backache? How’s the head? Do you find your concentration wandering (already? 9. It is extremely unlikely that anyone reading this book is entirely and absolutely healthy and free of symptoms. It would be difficult to know what that would mean; we all are ‘imperfect machines. The study of health psychology is concerned with the ways in which we, as individuals, behave and interact with others in sickness and in health.
Any activity of psychology which relates to aspects of health, illness, the health care system, or health policy may be considered to be within the field of health psychology. Health psychology deals with such questions as What are the physiological bases of emotion and how do they relate to health and illness? Can certain Behavior predispose to particular illnesses? What is stress? Can educational interventions prevent illness?
And many others. The beginnings of the formal interest of psychologists in these areas can be dated to the convening of a conference in the USA in 1978 and to the creation of a section devoted to health psychology in the American Psychological Association in 1979. The British Psychological Society (BPS) set up a Health Psychology Section only in 1986. This year (1997) the section should become a formally recognize division of the BPS and the profession of health psychologists may be established in the UK. Some time ago the World Health Organization put forward a definition of health which has been widely quoted.
Health is ‘a state of complete physical. Recently this definition has come under scrutiny and some criticism as representing an unrealistic goal, nevertheless it does emphasize the holistic nature of health involving body and spirit, physical and mental states. Matarazzo in 1980 offered a definition of health psychology which has become widely accepted: This definition emphasizes the diversity of issues encompassed by the emerging discipline. There is also variety in the approaches brought to those issues. Some health psychologists would see themselves primarily as clinicians.
Others as psychophy siologists, and others still as cognitive psychologists; some will practice health psychology in the health care settings, others will teach and research in academic institutions — what unifies them is their interest in the areas delineated by Matarazzo and their approaches to these issues. The recognition of health psychology as a clearly designated field is very recent, as we have seen: however, many of the ideas and basic concepts have been around psychology for a great deal longer. The relationship between mind and body and the effect of one upon the other has always been a controversial topic amongst philosophers, psychologists, and physiologists. Within psychology, the development of the study of psychosomatic disorders owes much to Freud.
Psychologists such as Dunbar (1943), Ruesch (1948) and Alexander (1950) attempted to relate distinct personality types to particular diseases with an implicit causation hypothesis. The work of this type has become more sophisticated in its approach and the article in the book on coronary heart disease and cancer is illustrative, and critical, of this orientation. This approach has been largely abandoned by health psychologists in favor of more Behavior or biological approaches that seek to employ interventions derived from behavioral medicine.
Another important aspect in the development of health psychology has been the changing patterns of illness and disease. If we were to compare 1898 with 1998 we would see that contagious and infectious diseases now contribute minimally to illness and death in the Western world, and other illnesses have become more frequent and are of a different nature. Major breakthroughs in science have reduced the prevalence of diseases such as smallpox, rubella, influenza, and polio in the Western world: more deaths are caused now by heart disease, cancer, and strokes. Recent studies and theories suggest that these diseases are, in part, a by-product of changes in lifestyles in the twentieth century.
Psychologists can be instrumental in investigating and influencing lifestyles and Behavior which are conducive or detrimental to good health. The article in this book on AIDS and coronary heart disease illustrates areas where such interventions are being attempted. Increasingly, then, the major causes of death are those in which so-called behavioral pathogens are the single most important factor.
Behavior pathogens are the personal habits and lifestyle Behavior, such as smoking and excessive drinking, which can influence the onset and course of the disease. It is not just the diseases of the ‘developed’ world which can be affected by behavior and attitude: combating malaria, schistosomiasis and other diseases endemic in different parts of the world can also be greatly helped by psychological input into campaigns to change behavior. As people the world over live longer, the long-term effects of what Matarazzo (1983) calls ‘a lifetime of behavioral mismanagement’ can begin to express themselves as diseases such as lung cancer, and heart and liver dysfunctions.
We will now look at Behavior which can be part of maintaining a healthy lifestyle and avoiding ill health. These are known as (protective) health Behavior. Harris and Guten (1979) conducted an exploratory study of 1250 residents in Greater Cleveland, USA. Residents were asked: What are the three most important things that you do to protect your health? Following this free recall, they were presented with statements on cards that described health behaviors and were asked to sort them into those that they did and those that they did not practice. Cluster analyses performed on these data produced categories to account for the various responses obtained by both methods. Categories of health-protective behaviors thus found were:
- • Environmental hazard avoidance – avoiding areas of pollution or crime
- • Harmful substance avoidance – not smoking or drinking alcohol
- • Health practices – sleeping enough, eating sensibly and so forth
- •Preventive health care – dental check-ups, smear tests
- • Safety practices – repairing things, keeping first aid kits and emergency telephone numbers handy.
Other studies carried out by Pill and Stott (1986) and Amir (1987) confirm these findings that people can identify behaviors that they carry out to protect health. Amir (1987) developed the General Preventive Health Behaviours (GPHB) Checklist. It consists of twenty-nine items that were selected to represent a range of behaviors thought to be relevant to a British population. Amir carried out the study on elderly (65-75 years) Scottish people and found the following items to be endorsed by more than 90 percent of respondents:
- • Avoid drinking and driving
- • Wear a seat-belt when in the car
- • Do all things in moderation
- • Get enough relaxation
- • Check the safety of electrical appliances
- • Avoid overworking
- • Fix broken equipment around the home
- • Eat sensibly
At the other end of the spectrum, only 10 percent reported taking dietary supplements or vitamins, and only 12 percent regularly got a dental check-up. It is likely that these percentages would look very different in different age groups (see the discussion topic at the end of this article). There is thus a common-sense notion that a relationship exists between good health and personal habits. Plato said, where temperance is, their health is speedily imparted’. Many groups have codified ‘good’ living habits into their religions and there is strong evidence of the outcome of healthy living and abstinence in such communities:
Mormons in Utah have a 30 percent lower incidence of most cancers than the general population of the USA, and Seventh-day Adventists have 25 percent fewer hospital admissions for malignancies (Matarazzo, 1983). Such statistics are powerful indicators that personal lifestyles do much to ensure healthy bodies. This idea was first studied systematically by a much-cited study carried out in Alameda County, California and reported initially by Belloc and Breslow (1972). They asked 6928 county residents which of the following seven health Behavior they practiced regularly:
• Having breakfast each day
• Having no more than one or two alcoholic drinks each day
• Taking regular exercise
• Sleeping seven to eight hours per night
• Not eating between meals
• Being no more than 10 percent overweight
They also measured the residents’ health status via a number of illness-related questions: for example, how many days they had taken off from work due to sickness in the previous twelve months. They were also interested in physical, mental and social health which they defined as the degree to which individuals were functioning members of their community’. Although criticisms have been made of this study, most notably the lack of independence between the questions, some strong and well-replicated relationships were demonstrated. A healthy habit is a health Behavior which is well established and often carried out semi-automatically: do you actually decide each morning and evening clean your teeth, or do you just do it?
Adults in the study who engaged in most of the health habits reported themselves to be healthier than those who engaged in few or none. A follow-up study nine-and-a-half years later showed that mortality rates were significantly lower for both men and women who practiced the seven healthy habits. Men who had all seven healthy habits had only 23 percent of the mortality rate of men who carried out none or fewer than three healthy habits (1980).
There were also clear links between physical, mental and social health. These findings reinforce the holistic notion of health proposed by the WHO as a composite of effective functioning, whether physically, mentally or socially. This original Californian cohort has been studied for twenty-five years. A survey in 1982, seventeen years after the study first began, considered those individuals who had been at least 60 years old at the time of the first survey. It was found that not smoking, taking physical activity, and regular breakfast eating were strong predictors of their mortality (Schoen born, 1993). The Alameda Study rein-forced the idea of ‘moderation in all things as the basis of good health. It also emphasized the role of social and mental aspects in achieving good physical health.
Although most of us are familiar with the need to engage in preventive health behavior, few of us actually do so. Berg (1976) has stressed that most people are aware of which health Behavior should be engaged in; however, they frequently do not do so, and furthermore, do engage in activities that they know to be harmful to their health. The dilemma or challenge then is how best to encourage, persuade or coerce people into adopting the healthy habits which it is believed are good for them. This enterprise carries values and expectations which will be examined in the final article.
The dilemma for health psychologists is to explain why some or many people do not do what they know is in their own best interests to do; and why some people are more amenable to the adoption of healthy habits than others. A consistent focus has been the role of knowledge in changing Behavior. People need to be informed of the risks to themselves that certain Behavior (or non-Behavior) can engender. Having been apprised of the risks they will then decide, so the argument goes, in a rational manner, to modify their behaviors in the direction of greater health promotion and protection.
Kelley (1979) examined the role of media in improving public health. He pointed out that the use of safety belts in cars greatly reduces the probability of death and injury following crashes. However, the availability of seat-belts in cars does not guarantee their use. A study conducted in the USA in 1968 recorded only 6.3 percent of car drivers wearing seat-belts in a city area Kelley attempted to design and execute a definitive test of mass media effectiveness in increasing seat-belt use.
He was able to utilize cable television such that he could have a number of households which would receive advertisements concerning seat-belt use, and another, an equivalent number of households which would not He used six different advertisements, produced professionally, and shown at specific times designed to target specific audiences. The advertisements were shown regularly over a period of nine months. He estimated that the average television viewer in the experimental group saw one or another of the messages two or three times a week over the test period.
Observers positioned at designated sites within the area under study recorded seat-belt use and the car license plate which enabled a trace to be made to indicate which of the two cable television companies was available to that person’s house. Kelley’s conclusion was depressing: ‘The results were clear-cut The campaign had no effect whatsoever on seat belt use.’ There were no significant differences between drivers from households that had received the messages and drivers from the control households.
Nor did the drivers from the test group change their seat-belt wearing at all across the test period. Kelley argues very forcefully from this study that mass media campaigns are ineffective and an inefficient means of changing health Behavior. So what else is required, other than knowledge, to persuade people to look after their health? We will now examine suggestions for other factors that could influence health behavior.
Models of Health Behavior
Early studies of protective health-focused upon demographic variables such as age, race and socioeconomic class as determinants of the adoption and practice of health Behavior & This research resulted in descriptions of population groups that did or did not engage in healthy behaviors. These findings were some-times contradictory and often did not serve any great purpose – one cannot change one’s age, sex or race and there is only limited opportunity to change occupation or alter income.
Consequently, research has shifted to structural variables such as the cost or complexity of the behavior, with a view to improving the adoption and practice of preventive health behavior. There are several theories or models which have evolved in this context. All the models share a common framework in that they exemplify a biopsychosocial approach to health. Such an approach recognizes the biological and genetic bases of many illnesses, acknowledges the role of psychological elements such as beliefs, behaviors, and cognition in the development of all illnesses, and recognizes that the social, economic and cultural setting will have a great impact on health.
This approach, first developed by Engel (1977), underpins much of health psychology and will be apparent throughout this book. We will now consider in detail some of the more important models and note their shared characteristics.
The Health Belief Model
This is probably the ‘oldest’ and best known of the models of health behavior. It is the one against which more recent models have been developed. This model was specified initially by Rosenstock (1966) and was modified by Becker and Maiman (1975). It attempts to explain both health behavior and compliance. It should be useful in predicting both health Behavior before illness, such as screening for cancer, and compliance with medical regimens once ill.
Thus, both sick role behavior and preventive behaviors should be capable of being predicted. The model proposes that a person’s likelihood of engaging in health-related behaviors is a function of several dimensions. An outline of the model is presented in Figure 1.1. It proposes that for a person to take preventive action against disease, that person must:
• Feel personally susceptible to the disease
• Feel that the disease would have at least moderately serious consequences
• Feel that preventive behavior would be beneficial either by preventing the disease or by lessening its severity
• That barriers, such as pain, embarrassment or expense should not outweigh the perceived benefits of the proposed health action in order for the preventive health behavior to occur,
• That cues to action may trigger consideration of the proposed health action.
Protection Motivation Theory
Rogers (1984) examined health behaviors from the point of view of motivational factors; thus it built on HBM by incorporating motivational elements into its basic structure. The protection motivation model suggests that motivation to protect oneself from a health threat is based on four beliefs:
• That the threat is severe
• That one is vulnerable to the threat
• That one can perform the behavior required to protect against the threat
• That the response made will be effective
Early research emphasized fear as a motivational factor but Rogers now suggests instead that attempts need to be directed at all four of the elements described above to achieve effective change. It is not clear which of the four elements is more important than the others, nor how to develop a campaign that can adequately address all elements simultaneously.
Leventhal’s Self-Regulatory Model
A rather different approach is that of Leventhal and co-workers who have developed a model of illness behavior and cognitions. This could be characterized as a problem-solving model since it conceptualizes the individual as an active problem solver whose behavior reflects an attempt to close a perceived gap between current status and a goal, or an ideal state.
Behavior depends on the individual’s cognitive representations of his or her current health status and the goal state. plans for changing the current state, and techniques or rules for assessing progress. Leventhal’s self-regulatory model of illness defines three stages that regulate behavior. These stages are:
- • Interpretation of the health threat — this concerns the cognitive representation of the threat, which includes dimensions such as symptom perceptions, and social messages such as potential causes or possible consequences.