Feature

More than a matter of belief

Psychological explanations of health beliefs and health behaviours may help us to understand the world—but can they help us to change it? Philip Banyard thinks not

Health promotion draws on psychology research to try to understand why people make the health choices they do, and to try to develop programmes to make general improvements in our health. The growth in health promotion has been mirrored by a growth in health psychology. The field of health psychology only dates back to the early 1980s but many research psychologists are now redefining themselves as health psychologists, and publishing in the rapidly growing library of health psychology journals.

Psychology can make some positive contributions to our understanding of health, but it also introduces some dangers. The example of early psychological work on health promotion, described below, shows the strengths of the approach. The more contemporary focus of health psychology is on individual behaviour and individual choice. The three major areas of personality types, stress and models of behaviour changehave each generated a vast amount of research that has passed into the health field, but which has obscured nearly as much as it has clarified.

When psychologists approach health issues they bring with them the results of research going back over 100 years. That research has been trying, with some limited success, to describe and define human behaviour and experience. Psychologists are able to offer a wide range of methods for studying people, and also a range of research findings directly relevant to health.

For example, John Watson, one of the most influential early psychologists, carried out research for the US army on the effectiveness of its anti-venereal disease programmes in the first world war. Along with his associate Karl Lashley, he investigated the impact of two films about VD which were produced in the form of stories and had graphic images of the devastating medical and social effects of having sex with prostitutes and developing VD.

The psychologists surveyed and interviewed over 1,000 people who saw the films, and found that 70 per cent had a good knowledge of the points made in the films. But sadly they found no evidence that the films had had any effect on behaviour either to avoid sex with prostitutes or to take health precautions. Their work illustrated that the link between what we think and what we do is quite weak. Messages aimed at changing behaviour will only have a limited effect. Watson and Lashley also made a number of observations about how to make health messages more effective, including the suggestion that fear-provoking messages do not always have the desired effect.

It is interesting to note that a review of media campaigns on HIV/AIDS concluded that they did not take on board the lessons first observed by Watson and Lashley.¹ Psychological evidence is used selectively, and some of the best lessons are ignored. More recently, psychological evidence has been selected to give weight to explanations of health and illness that concentrate on the individual.

In the field of personality, psychologists have looked at personality types and behaviour patterns that can be used to categorise people. This approach brought us the Type A behaviour patternwhich gives a simple description of the type of behaviour that makes an individual more prone to a heart attack. The Type A behaviour pattern has stimulated a vast amount of research. Some of this research has supported the connection between behaviour and coronary heart disease, and some of it has not.

The lasting appeal of the Type A behaviour pattern is its simplicity and plausibility. Categorising people on the basis of simple and easily observable behaviours is very appealing for people who want simple explanations and media sound-bites. The failure of the Type A behaviour pattern to stand the test of subsequent research has not dented its popularity.

Typologies such as this concentrate on individuals rather than their situation. Heart disease is seen as the result of self-destructive behaviour and therefore the responsibility of the patient. Although it is clear that we can improve our health through careful living, many of the risk factors for heart disease are beyond the control of ordinary people.

The area that receives most research interest in health psychology is stress. The academic interest for psychologists is that stress has physiological responses to social or environmental variables, and these responses are affected by the sense we make of them. It is the perfect topic for a discipline that attempts to combine physiological, psychological and social explanations. As well as the academic interest there is, of course, a commercial interest: stress research centres, stress reduction programmes and stress audits attract a lot of money.

Psychologists have studied stress in every imaginable location and devised a range of techniques for measuring stress and trying to reduce it. For example, systematic desensitisation is a technique that has provided relief for many people, and stress inoculation is another technique that has a range of uses. The downside of the psychological approach is that by concentrating on the individual experience of stress we can ignore environmental and social causes. If someone experiences stress at work a psychologist might suggest a stress reduction programme, but it could be that the demands of the job are inappropriate, or the management is vindictive. We can respond to stress by adapting to it or by mobilising for change. Psychologists concentrate on the former.

Sick building syndrome is an example of the selective approach to stress. The Health and Safety Executive notes that staff in some buildings are particularly prone to minor illness.² There is some evidence for the role of environmental features such as poor air conditioning, low humidity and a high level of dust in the air in the promotion of ill health. But there is also evidence that the same effects can be caused by social and management issues such as status.

The Health and Safety Executive’s report notes that some workers are more at risk than others. These include low paid, low status workers doing sedentary, repetitive jobs, clerical staff, public sector workers, people with allergies, and women rather than men. This list supports the idea that the effects of the sick building are made worse by other factors such as status, personal control and management style. So far, no one has suggested that illness at work could be due to ‘sick management syndrome’, although this might be a reasonable explanation of the evidence. Simple labels can be helpful in first instance, but they can come to obscure the complexities of a problem and focus attention on inappropriate solutions.

In the area of health promotion, psychology currently offers models of behavioural change such as the health belief model. This is one of many attempts to describe how people make the choices they do.³ It focuses on two judgements that an individual makes: what is the threat of illness or injury; and what are the costs and benefits of a change in behaviour.

If we look at over-eating and obesity, for example, the health belief model concentrates on the individual’s judgement of the health risks of obesity, and the advantages and disadvantages of changing their eating habits. The main focus of this model is on personal choice, and it gives less attention to other factors such as media influences and income.

Media influences, however, can have a dramatic affect on our eating choices. A study of advertisements in the US found that the average American child watched 10,000 commercials for food every year. Of these commercials, 51 per cent were for cereals, and 33 per cent were for sweets and biscuits. Less than 5 per cent of the adverts were for products without sugar and there were no adverts at all for vegetables. As part of the same study, 75 per cent of mothers said they were influenced in their food choices by the requests of their children. So a major issue in our choice of food is the commercial pressure applied to children through advertisements. It would be possible to make significant progress towards the targets in The Health of the Nation if the government took action to regulate commercials aimed at children. It is unlikely to do this.

In the three areas mentioned above, psychology can make a positive contribution to our understanding of health and illness. But danger lies in the prominence it gives to individual explanations of health to the exclusion of all others. Psychology is inevitably drawn to the individual and the choices he or she makes. As a result it develops a range of approaches for personal change that can give people direct help in their health problems.

But what if the source of stress is outside an individual’s personal control, or what if a damaging lifestyle is the most appropriate way to deal with particular social circumstances? The most damaging lifestyles for our health are those associated with low incomes. Throughout the Western world, the most consistent predictor of illness and early death is income. People who are unemployed, homeless, or on low incomes have higher rates of all the major causes of premature death.⁴ This evidence does not fit easily into psychological explanations of health.