health psychology and public health: theoretical possibilities

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DOI: 10.1177/1359105304036099

2004 9: 13J Health PsycholSimon Murphy and Paul Bennett

Health Psychology and Public Health: Theoretical Possibilities

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13

Health Psychology andPublic Health:TheoreticalPossibilities

SIMON MURPHYUniversity of the West of England, UK

PAUL BENNETTUniversities of Wales, Swansea, UK

S I M O N M U R P H Y is a principal lecturer in healthpsychology at the University West of England, Bristol.Previously he held a senior research post in the healthservice in the area of public health and healthpromotion.

PAU L B E N N E T T is a professor of clinical and healthpsychology at the University of Wales, Swansea. Hewas recently research director of the Bristol ClinicalPsychology Doctoral Training Programme and haspreviously worked as both a practitioner and academicin both the health service and universitites of Cardiffand Bristol.

Journal of Health PsychologyCopyright © 2004 SAGE PublicationsLondon, Thousand Oaks and New Delhi,www.sagepublications.comDOI: 10.1177/1359105304036099Vol 9(1) 13–27

Abstract

Public health has eitherimplicitly or explicitly drawnupon a range of psychologicaltheories. This paper identifiesfour areas where theapplication of such theory couldbe developed, healthcommunication, environmentalinitiatives, the negotiation ofbehaviour and participation andempowerment.Recommendations are maderegarding content, sources andrecipient characteristics that canbe used to develop targetedhealth communicationcampaigns. Psychology also hasa role to play in informingstructural approaches toprevention. To facilitate this, aframework which focuses oncues, reinforcer and barriersand an understanding of howbehaviour is achieved throughnegotiation and interaction isoutlined. Finally we highlight arole for psychology inapproaches that focus onparticipation and empowermentin relation to health.

Keywords

health psychology, public healththeory

AC K N OW L E D G E M E N T S. Acknowledgement text.

C O M P E T I N G I N T E R E S T S: None declared.

A D D R E S S. Correspondence should be directed to:S I M O N M U R P H Y, Psychology, University of West England, Fishponds,Bristol, BS16 2JP. [email: [email protected]]


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Introduction

P U B L I C H E A LT H activities have traditionallyfocused on protecting and improving the healthof populations and communities. To date thecontribution of psychological theory to suchactivities has, in the main, focused oneducational processes concerned with reducinglifestyle risk factors by encouraging individualbehaviour change (Bennett & Murphy, 1997). Indoing so, a limited and sometimes partial rangeof psychological theories have been utilized,despite frameworks that stress the importanceof theory-driven and evidence-based inter-ventions (Bartholomew, Parcel, Kok, &Gottlieb, 2001; Green & Kreuter, 1999). Theemergence of a Public Health Psychology as anintegrative field of scientific inquiry has beennoted by Ewart (1991). The aim of this article isto highlight some of the implications for theoryand practice as such a field develops. In particu-lar, we argue for an improved understanding ofpublic health communication processes withinmass media campaigns. These should be basedon a consideration of message, source andrecipient variables and a recognition that publichealth campaigns take place within a socialsystem where messages are reinterpreted andexchanged. Psychological theory also has a partto play in operationalizing and achieving thepublic health agendas set out in such documentsas the Ottawa Charter. Here the aims, amongothers, are to create supportive environments,develop healthy public policy, increase personalresources and strengthen community action(WHO, 1986). Consequently we identify anincreased role for psychology in informingapproaches that focus on the interactionbetween the individual and their physical andsocial environments, in particular how behav-iour is negotiated within its social context.Finally, we suggest that health psychology, bydrawing on approaches to community publichealth, could contribute to strategies thatacknowledge and promote community partici-pation and empowerment. In this way, we argue,health psychology could move from a predomi-nately social regulationist model of preventionto one that is more radical structuralist in nature(Caplan, 1993).

Understanding healthcommunication

Perhaps the most obvious contribution ofpsychology to public health initiatives can befound within the design and implementation ofmass media campaigns. Despite this, manycampaigns have been criticized for being atheo-retical or for applying inappropriate or partialpsychological models (Bennett & Murphy,1997), while others appear to have limitedbehavioural effects. Wimbush, MacGregor andFraser (1998) for example, assessed the effect ofa mass media campaign in Scotland designed topromote walking. Although awareness of thecampaign was high (70%) it had no impact onbehaviour and of only 16 per cent who wereaware of a telephone help-line only 5 per centutilized it. In a similar vein Mudde and de Vries(1999) found limited behaviour changes associ-ated with a smoking cessation campaign in theNetherlands. Such limited outcomes have ledsome to argue that the expectations of whatmass media public health campaigns canachieve should be moderated. Winett et al.(1989) for example argues for a change of goal,from that of behaviour to knowledge, whileMcGuire (1985) has argued for outcome effec-tiveness to be examined within a five-stepresponse: attention, comprehension, yielding,retention, and then behaviour. Along with sucha reassessment, psychology has the potential toimprove outcome effects by providing a moresophisticated account of how media messagesare received and responded to. Here researchhas focused on an understanding of the relativeinfluence of message content, recipient charac-teristics and sources of information onoutcomes.

Appropriate message content

One particular approach to communication thathas proved particularly popular within publichealth media campaigns is the use of fearmessages. Early studies of the impact of fear-arousing communications focused on themanipulation of levels of fear. A classic study byJanis and Feshbach (1953) exemplifies this typeof research. It involved three conditions inwhich high school students sat through a 15-minute lecture and slide presentation on dental

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hygiene. Level of threat was manipulated byvarying the degree of personally threateningslides in each presentation. Immediately afterthe presentations, students in the high arousalgroup reported higher levels of motivation tocare for their teeth than the other groups. Oneweek later, however, they had retained lessinformation and their behaviour did not differfrom that of any other group.

An explanation of this effect may be found inProtection motivation theory (PMT) (Maddox& Rogers, 1983). It posits that individuals willrespond to information either in an adaptive ormaladaptive manner dependent on theirappraisal of threat and their own ability torespond to that threat. Threat appraisal is afunction of both perceived susceptibility toillness and its severity, while coping appraisal isa function of both outcome and self-efficacybeliefs. Consequently an individual is mostlikely to behave in an adaptive manner inresponse to a fear-arousing health message ifthey: believe they are susceptible to disease;believe that the disease will have severe conse-quences; perceive a link between protectivebehaviours and reduced risk; and considerthemselves capable of engaging in them.

Threat however, can be conveyed in anumber of different ways. For examplemessages can be framed in either positive(stressing positive outcomes associated withprevention) or negative terms (emphasizingnegative outcomes associated with failure toact). While some have argued that negativeframes are more memorable (Newhagen &Reeves, 1987) and have been found to be moreeffective than positive messages in influencingprevention (Meyerowitz & Chaiken, 1987),others have claimed that positive messagesenhance information processing. This is particu-larly the case when time is short and individualsare less motivated to receive a message (Isen,1987). The effectiveness of positive framing isillustrated by Detweiler, Bedell, Salovey, Proninand Rothman (1999). They examined therelative effectiveness of factual information thateither emphasized the positive outcomes ofusing or the negative consequences of not usingsunscreen. Pre and post measures of attitudesand intentions were collected and behaviourwas assessed via a redeemable voucher forsunscreen. Results showed that compared to

messages that emphasized the losses in not usingsunscreen, those that emphasized the gains wereassociated with significantly higher requests forsunscreen and greater intentions to reapplysunscreen at the beach and to use higher factorsunscreen.

The theory argues that most persuasivemessages are those that not only evoke a threatbut also emphasize the efficacy of response. Thisview is supported by Solomon and DeJong(1986) who found that video instruction basedon fear techniques was ineffective in changingbehaviour and concluded that fear needs to bebalanced with constructive information.Without such information fear can encourageresistance to the message (Franzkowiak, 1987),denial that it applies to the individual (Soames-Job, 1988) and encourage the targeted riskbehaviours. For example Louira (1988) foundfear messages increased drug usage and Malfetti(1985) that it was counter-productive to drinkdriving. This is because coping appraisal canresult in what health promoters may see asmaladaptive responses, such as denial or blunt-ing (information avoidance). For the individualconcerned such responses represent distinctcognitive coping styles which serve a protectivepurpose, representing an emotional coping planin the face of a health threat. Such styles ofcoping have also been conceptualized as repres-sion/sensitization (Byrne, 1961), with repressorsdealing with threatening information throughavoidance and sensitizers seeking out infor-mation about threat. Indeed a modest yetsignificant relationship has been observedbetween monitoring and health promotingbehaviours (van Zuuren & Dooper, 1999.Coping style and self-reported healthpromotion and disease detection behaviour.British Journal of Health Psychology, 4, 81–89).This effect of such coping behaviour is demon-strated by Keller and Block (1999) who foundthat when individuals’ prior intentions areincompatible with fear messages, that denial ofrelevance and shallow message processing wereeffective methods of reducing negativeemotional responses.

Unfortunately health messages frequentlyemphasize vulnerability and severity whileneglecting efficacy. This is illustrated by a recentcontent analysis of breast self-examinationleaflets, which found that they contained an

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unbalanced proportion of threat to efficacyarguments (Kline & Mattson, 2000). Neglectingthe dimension of efficacy can result in only thoseleast at risk responding to fear messages. Indeedfear messages have been shown to motivatechange under conditions of low levels ofperceived vulnerability (Higbee, 1969), highself-esteem (Rosen, Terry, & Leventhal, 1982)and high self-efficacy (Maddox & Rogers, 1983;Strecher, Deveillis, Becker, & Rosenstock,1986). Nevertheless fear messages remainpopular among the general public and poli-ticians (Rhodes & Wolitski, 1990), perhapsbecause they conform to naive psychologicaltheories of human behaviour. Given the hetero-geneous nature of population beliefs and self-efficacy it could be argued that the use of fearwithin ‘mass’ media campaigns is inappropriateas it runs the risk of reinforcing risk behavioursand encouraging denial among some of its audi-ence. More effective may be approaches thattailor fear messages based on an understandingof the diversity of populations and their readi-ness to change.

Population diversity

The need to understand target audiencesbeliefs, competing information and perceivedbarriers to change before launching any massmedia campaign has been highlighted byMcGuire (1985). Support for this approach isprovided by Kreuter, Bull, Clark and Oswald(1999). They found that overweight adults whoreceived information booklets tailored to healthlocus of control beliefs had greater positivethoughts about the material and behaviouralchange intentions compared to those thatreceived untailored materials. While Leathar(1981) found the key factors, which influencedyoung men’s drinking in Glasgow, was not theamount drunk in units on any one occasion, butthe time spent and social costs of drinking.These factors, not the originally intended healthwarnings related to units drunk per week,became the focus of the campaign. Similarlyinitiatives that supplement informationcampaigns with environmental components,that address barriers to change, may prove to bemore successful. Boots and Midford (1999)report positive outcomes, especially for females,associated with a mass media campaign that

aimed to promote the use of designated driversto reduce drunk driving in Australia. Signifi-cantly television advertising was supplementedby a nightclub campaign that provided free softdrinks for drivers of two or more passengers.

Stage models of change have proved particu-larly popular as a way of understanding popu-lation diversity. The most famous of these wasproposed by Prochaska and DiClemente (1984)who identified five major stages of cognitiveprocessing and behaviour that individuals canpass through: precontemplation; contemplation;preparation; action; and maintenance orrelapse. In the precontemplation stage, changeis not being considered, whether through ignor-ance, denial or demoralization. In the contem-plation stage, the individual is consideringchange at some remote level but is not yetcommitted to change, and has not thoughtthrough how this may be achieved. Public healthinitiatives for individuals at these stages wouldtherefore aim to raise awareness, highlight riskand suggest effective changes. As the individualmoves to the preparation stage, they beginactively considering and planning change. As itsname implies, the action stage is when behav-ioural change actually occurs. For these indi-viduals it is important to address skilldevelopment and goal setting. When behav-ioural change is considered significantly estab-lished the individual is considered to be in themaintenance stage. However individuals whoreach the action stage may fail to maintain anychanges made, and relapse back to any one ofthe previous stages.

It has been argued that the popularity of suchstage models within public health is becausethey provide both order and direction forinitiatives (Laitakari, 1998). Indeed, researchutilizing stages of change has shown that indi-viduals classified within different stages demon-strate different needs (Dijkstra, de Vries,Roijackers, & van Breukelen, 1998). Jaffe,Lutter, Rex, Hawkes and Bucaccio (1999) in anexamination of incentives and barriers tophysical activity for working women found thatwhile precontemplators had few positive expec-tations regarding exercise, contemplators hadpositive expectations but reported a highernumber of perceived barriers. Evaluationsmeanwhile, have suggested that in certaincircumstances tailoring initiatives to stages can


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result in positive outcomes. One such exampleis provided by Peterson and Aldana (1999). Inan evaluation of a worksite programme, theyexamined the effectiveness of written messagestailored to individuals’ reported stage of changecompared to non-tailored messages for acomparison group. Six weeks after the materialwas received they reported greater movementfrom lower to higher stages among those whoreceived the stage-based materials.

The need to understand recipient diversityand the need for targeted rather than massinitiatives has also been highlighted in relationto PMT. Block and Keller (1998) examinedstudent responses to safe sex brochures thatmanipulated levels of vulnerability and severityin the message. Results suggested that people atdifferent stages of change were affected bydifferent aspects of PMT, with those at precon-templation motivated by vulnerabilitymessages, those at contemplation by severitymessages and those at the action stage byefficacy messages. If mass campaigns are toreach those most at risk, rather than supportingthose already engaged in preventive behaviour,it may be advantageous to re-orientate thetraditional focus on threat and coping appraisal.Keller (1999) found that while high fear appealsfollowed by avoidance recommendations waspersuasive for those already following therecommendations, those most at risk were moreresponsive when the recommendations werefollowed by a fear appeal, rather than the otherway round. They argue that those at riskperceived themselves as more susceptible,consequences as more severe, recommen-dations more efficacious and to have higher self-efficacy due to lower levels of messagediscounting. Similar differences in informationneeds have been found for smokers classified atdifferent stages of change (de Vries, Mudde,Willemsen, Dijkstra, & Peters, 1998).

Appropriate sources ofinformation

The ability to communicate with those with littlemotivation to receive a message may beenhanced by a consideration of who delivers amessage. The Elaboration Likelihood Model(Petty & Cacioppo, 1986) suggests the influenceof media output is the result of an interaction

between message factors and the cognitive stateof the recipient, namely their pre-existingbeliefs and attitudes. Individuals are more likelyto ‘centrally process’ messages if they are ‘moti-vated to receive an argument’, because it iscongruent with their pre-existing beliefs, haspersonal relevance to them or they have theintellectual capacity to understand the message.Such processing involves evaluation of argu-ments, assessment of conclusions and their inte-gration within existing belief structures.Consequently any resulting attitude change islikely to be enduring and predictive of behav-iour. In contrast, ‘peripheral processing’ is likelyto occur when individuals are unmotivated toreceive an argument, have low issue involve-ment or incongruent beliefs. Such processinginvolves a response to the credibility and attrac-tiveness of the source, but is likely to be tran-sient and not predictive of behaviour. Indeedthe attractiveness of the source has been shownto be most important to those with low compre-hension of message content (Ratneshwar &Chaiken, 1991). As such this theory againstresses the need to understand existing beliefs,as do ‘static’ models of attitudes and relatedfactors such as the theory of planned behaviour(e.g. Ajzen & Madden, 1986), and tailormessages accordingly, but also suggests thatthose who are unmotivated may be influencedby the careful selection of who delivers themessage or the type of emotional appeal chosen.For example Scollay, Doucett, Perry andWinterbottom (1992) reported that a messagesource known to be HIV positive or have AIDSresulted in greater increases in knowledge, lessrisky attitudes and safer behavioural intentionsthan a neutral source.

Communication within asocial system

Our understanding of the influence of healthcommunication is largely based on studiesconducted in the laboratory or within closedsystems such as the classroom and clinic. Masspublic health communication however takesplace within a social system and it is importantto recognize that much of the informationreceived from the mass media is disseminatedthrough interpersonal communication and themodelling of behaviour via social networks


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(Reardon & Rogers, 1988). As such informa-tional influences can be varied and interact; forexample individuals may be exposed toconflicting information on vulnerability fromfriends and television. Kraft and Rise (1988)argue that interpersonal communication is thekey to attitude change and information uptakeand Flay (1986) that it increases the likelihoodthat it will influence behaviour. This issupported by Pinford (1999) who reports on anintervention study that sought to reduce diar-rhoea in rural north-eastern Thailand bypromoting hand washing via a variety of mediasuch as posters, stickers, leaflets, comics andbadges. Examination of reduced fingertipcontamination was found for those reporting asecondary source of information, namelyschoolchildren.

Diffusion of innovation theory was proposedby Rogers (1983) as a way of explaining thespread of new ideas and behaviours withinsociety and recognizes that public healthmessages are interpreted and exchanged viasocial networks. Rogers focuses on three mainareas to explain how innovations are successfullydiffused. They are the characteristics of the inno-vation, the classification of individuals withincommunities and interpersonal communication.The first of these provides guidance for howinitiatives are presented, as successful inno-vations typically involve minimal costs orcommitment, are simple to understand or imple-ment, result in observable benefits and areperceived to be part of an existing social norm.If these conditions are met the entry and legit-imization of an innovation typically follows an S-shaped curve, with what are termed ‘earlyinnovators’ accepting the innovation. They areusually from high socio-economic groups whoseek information and so can be reached by massmedia campaigns. Their adoption brings theinnovation to the attention of a minority of ‘earlyadopters’, opinion leaders within the communitywho are more typical, have good communicationnetworks and status. They bring the innovationto the attention of those in their community viainterpersonal communication channels andmodelled behaviour. If the innovation isperceived to possess benefits, which outweigh itscosts, the next group, the ‘early majority’ decideto adopt it. These in turn influence the ‘latemajority’, who have lower social status, gain

information from those around them and beginto conform to the emerging social norm. Thereis a final slowing of the diffusion process as aminority with more traditional views, termed‘laggards’, resist acceptance but are influencedby compliance to the majority.

Viewing communities as heterogeneoussuggests public health should progress throughstages with different communication channelsand messages for each group. Rogers suggests aprocess where change agencies develop inno-vations and change agents communicate infor-mation about and promote the innovation torecipients of the innovation. Havelock (1974)argues that rapid diffusion is more likely tooccur if the decision is imposed from above bysuch a change agency, rather than from belowand collectively. However, it can be seen thatchange can occur without such top–downprocesses in the area of media advocacy and therise of health coalition groups such as the anti-smoking group ASH and the Terrence HigginsTrust in relation to HIV. Utilizing diffusiontheory also provides a framework whereby thecongruence between public health programmesand the micro and macro environments canbe assessed (Roberts-Gray & Scheirer, 1988).

The formal testing of diffusion of innovationtheory has proved difficult. The diffusionprocess can be spread over a long period oftime, requiring longitudinal studies and detailedprocess research. The costs involved in conduct-ing such research have meant that the majorityof studies have depended on respondent recallof environmental and behavioural changeswithin cross-sectional designs with little objec-tive verification of self-reports (Macdonald,1992). A recent review of 1210 published healthpromotion articles conducted by Oldenburg,Sallis, French and Owen (1999) found that only1 per cent could be categorized as diffusionresearch, leading the authors to call for anincrease in systematic empirical studies in thisarea. Accordingly, while diffusion of innovationtheory has high face validity, its empirical statushas yet to be fully understood.

Addressing environmentalinfluences on health behaviours

Psychology not only has a part to play inimproving our understanding of communication


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processes, it can also contribute to assessmentsof environmental and structural influences onhealth behaviours. The health belief model(HBM) (Rosenstock, 1974) provides a strongframework for public health initiatives by focus-ing on five clear dimensions. These are:perceived susceptibility (subjective perceptionsof risk in relation to the health threat);perceived severity (evaluations of the conse-quences of the threat); perceived benefits(assessments of the efficacy of preventiveactions); barriers (assessment of difficulties andnegative consequences of preventive behav-iour); and cues to action (triggers for thedecision-making process). More recently healthmotivation, that is an individual’s readiness tobe concerned about their health, was added tothe model (e.g. Becker, Haefner, & Maiman,1977). Drawing on this model public healthinitiatives need to identify a link between anindividual’s risk behaviour and disease, to high-light the severity of the disease and to make itrelatively easy to engage in behaviour likely tolead to a reduction in risk for that disease.

Numerous researchers have identified thedifficulties in influencing risk perception,arguing that while individuals may acknowledgea general social risk, they downplay personalrisk (Larwood, 1978; Perloff & Fetzer, 1986;Snyder, 1978; Weinstein, 1989). Failing toacknowledge the effect of risk perceptions andcoping cognitions can result in initiatives reach-ing those least in need. A study by Hannon,Carey, Tannahill, Kelly, Gilmour, Tannahill andMcEwen (1998) found that only certain groupsresponded positively to a workplace screeningprogramme. An examination of the effect ofrespondent characteristics showed that reduc-tions in risk behaviours were found in those withlower levels of perceived risk for CHD (coron-ary heart disease) and higher perceived healthstatus. Those with greater perceived risk andlower perceived health were more likely to seethe health check as threatening. It could beargued, however, that the model’s greatestcontribution to public health is its emphasis onbarrier reduction and the development of cuesto healthy behaviours and increasing barriersand the reduction of cues to unhealthy behav-iours. The health belief model is not the onlysocial cognition model to do so, of course. Withits emphasis on the importance of real and

perceived barriers to engaging in particularbehaviours, the theory of planned behaviour(Ajzen & Madden, 1986) also highlights theneed to address environmental issues in anyintervention.

The empirical value of reducing environ-mental barriers to healthy behaviours is demon-strated by Damron, Langenberg, Anliker,Ballesteros, Feldman and Havas (1999) whoreport lack of transportation and child care ascommon reasons for non-attendance at a nutri-tional education programme increasing fruitand vegetable consumption among women.Large-scale disease prevention programmesthat have focused on whole communities, suchas the North Karelia Project (Puska, Nissinen,Tuomilehto, Salonen, Koskela, McAlister,Kottke, Maccoby, & Fraquhar, 1985) and Heart-beat Wales (Nutbeam, Smith, Murphy, &Catford, 1993), have emphasized the reductionof such environmental barriers to behaviours.This approach has resulted in the developmentof healthy eating choices in restaurants and foodretailers and the provision of exercise facilitiesin communities. Evaluation of communityprogrammes has proved difficult not leastbecause of problems in maintaining non-inter-vention reference communities and the fact thatenvironmental manipulations are traditionallysupplemented by mass media campaigns andskills training, making it difficult to isolate theeffect of barrier reduction (Nutbeam et al.,1993). Such difficulties have led to a paucity ofevaluations of environmental initiatives (Sallis,Bauman, & Pratt, 1998). However, initiativesconducted in more controllable environments,such as schools and the workplace, suggest thatincreasing the availability and the promotion ofhealth food choices can improve healthy eating(Glanz, Lankenau, Foerster, Temple, Mullis, &Scmid, 1995) and that increasing exercise facili-ties and providing time off for exercise canincrease levels of exercise (Linegar, Chesson, &Nice, 1991).

More common are approaches that increasethe barriers to unhealthy behaviours. It could beargued that social policy approaches to publichealth are implicitly based on assumptionscommon to the health belief model, in that legis-lation and taxation can act as effective barriersto unhealthy behaviours and facilitators ofhealthy behaviours. Economic measures related


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to public health have been largely confined totaxation on tobacco and alcohol. The price ofalcohol impacts on levels of consumption (UKCentral Statistics Office, 1980), particularly forwines and spirits: beer consumption may be lesssensitive to price (Godfrey, 1990). It has beenargued that these effects may hold not just for‘sensible’ drinkers, but also those who are mani-festing alcohol-related problems (Sales, Duffy,Plant, & Peck, 1989). Increases in tobacco taxa-tion may also be the most effective measure inreducing consumption rates, with an estimatedreduction in consumption of 4 per cent for every10 per cent price rise (Brownson, Koffman,Novotny, Hughes, & Eriksen, 1995). Indeed,Keeler, Hu, Barnett, Manning and Hai-Yen(1996), while comparing the relative effective-ness of taxation and media campaigns ontobacco consumption in California, estimatedthat a 25 per cent tax increase resulted in areduction in sales of 819 million cigarette packscompared to 232 million packs due to mediainfluences. The use of taxation seems to be aparticularly effective deterrent among theyoung, who are three times more likely to beaffected by price rises than older adults (Lewis,Coates, & Grossman, 1981). These findingshowever must now be interpreted against anincreasing trade in bootleg alcohol and tobacco.Legislating the availability of unhealthyproducts and behaviours has also proved prob-lematic. In theory laws which prevent youngpeople’s access to such things as tobacco repre-sent a significant barrier, but as Brownson et al.(1995) have highlighted enforcing such lawswithout a licensing scheme such as that appliedto alcohol has been difficult. Prohibitionapproaches to the availability of alcohol andother drugs meanwhile have proved contro-versial and politically sensitive, with many ques-tioning their effectiveness. While prohibitionmay be seen as a necessary barrier by someothers have called for more modest barriers toavailability. Godfrey (1990) for example hassuggested restricting outlets for drugs such asalcohol thereby increasing transaction costs andreducing cues.

Cues to action can prompt existing behaviour,but can also trigger any intended behaviourchange. Such cues can occur in the socialenvironment (for example a family memberfalling ill or the onset of physical symptoms) and

within the physical environment. Examples ofthe latter include product labelling such ashealth warnings on cigarettes and nutritionalinformation on food, although evidencesuggests that they reinforce existing behaviourrather than prompting the consideration ofbehaviour change. For example Levy, Patterson,Kristal and Li (2000) found that consumers didnot necessarily understand dietary fat infor-mation on food labels and that label compre-hension was not associated with fat intake.Similarly Glanz et al. (1995) found the publicrarely understood nutritional information onfood packaging especially among those with lowincomes. While health warnings on cigaretteshave been found to be ineffective in changingexisting smokers’ behaviour, they may serve toprevent smoking initiation (Richards, Fisher, &Conner, 1989). Developing the prominence ofsuch cues however may increase effectiveness.Borland (1997) evaluated the effect of the intro-duction of larger and clearer health warnings oncigarette packets in Australia by comparing self-reports in two matched cross-sectional samples,surveyed six months apart. Sixty-six per cent ofsmokers reported noticing the warningscompared with 37 per cent at baseline, with 14per cent refraining from smoking as a resultcompared to 7 per cent at baseline.

Cues to action can not only act as prompts forhealthy behaviours, they can also act asreminders to behave in unhealthy ways. Conse-quently it has been argued that public healthshould strive to limit and legislate against suchthings as tobacco and alcohol advertising andthe depiction of unhealthy behaviours in themedia. Support for restrictions on advertisingcan be found in longitudinal studies that haveexamined attitudes to advertising and smokingbehaviour. Chapman and Fitzgerald (1982)found a preference of the most heavily adver-tised brands among under-age smokers, whileAitken, Eadie, Hastings and Haywood (1991)found that positive attitudes to tobacco advert-ing were associated with intention to smokeamong 11 to 14 year-olds, a relationship whichincreased in strength over time. It could beargued that media depictions of unhealthybehaviours can influence perceptions of appro-priate social norms via modelled behaviour andcue prompts to behaviour. MacFadyen, Amos,Hastings and Parkes (2002) in an examination of


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UK students’ perceptions of smoking imagery inmagazines, found them to be potentially morepowerful influences than direct advertisingimagery. Depictions of smoking were perceivedto be attractive, reassuring and sociable and assuch to reinforce smokers’ identities. SimilarlyPechmann and Shih (1999) examined the effectof smoking scenes in movies on non-smokingschoolchildren compared to the same sceneswith the smoking behaviour edited out. Resultsshowed that the smoking scenes enhancedpupils’ perceptions of smoking status and inten-tion to smoke. Calls for reforms in the way thatsuch things as alcohol consumption areportrayed in the media is supported by Smith,Roberts and Pendelton (1988) who found 80 percent of popular programmes making verbal orvisual references to alcohol and its depiction asan acceptable personal coping strategy.

Understanding socialinteractions

The expectancy-value theories that have beenoutlined, and others such as the health actionprocess (Schwarzer, 1992) present useful frame-works for public health initiatives. Underlyingthem, however, is an assumption that behaviouris an outcome of formal decision making. Thismay not always be the case, as much of ourbehaviour appears to be habitual and relatively‘thoughtless’ (Hunt & Martin, 1988). This mayparticularly be the case for individuals in lowersocial positions. Findings from Lindbladh andLyttkens (2002) show such individuals are moreinclined to rely on health-related habits and toperceive habits as something good compared totheir higher social counterparts, leading theauthors to suggest that rational actor modelsmay be more useful with respect to those inhigher income groups. When rationality doesinfluence decision making, it is not alwaysgoverned by a desire to preserve health, anassumption of many of the theories so fardiscussed. For example Ingham and van Zessen(1997) found 36 per cent of their sample ofyoung people reporting consideration of therisks associated with unsafe sex only after theevent. While Jacobson (1981) found workingclass smokers making rational choices to smokeas a way of coping with stress and adversematerial circumstances.

Such issues highlight the need to examinehow habitual behaviours are maintained andnegotiated within people’s social environmentsand to understand how meaning is achieved. Insuch interactions, participants bring their ownunderstandings and expectations of appropriatebehaviours. Behaviour is then shaped by themutual responses of the participants. This isperhaps most obvious when examining the influ-ence of parenting styles as a form of interactionand their influence on health-related behavioursin children (Wickrama, Conger, Wallace, &Elder, 1999). Existing patterns of behaviour aretherefore open to modification and changedependent upon the individuals involved andthe circumstances they find themselves in. Byadopting such an approach, Health Psychologyacknowledges the influence of social structuresas well as individual cognitions and skills onbehaviour. As Winett states:

Psychologists have traditionally focused oncognition and behaviour as the figure, withenvironment often the distant amorphousground (or context). A reversal of figure andground is not suggested; rather, cognitionsand behaviour and the environment mustreceive equal and specific attention. (Winett,1995, p. 348)

These issues are perhaps most apparent inrelation to gender differences in health-relatedbehaviour. Issues of gender identity have beenshown to influence the negotiation of behaviourthrough differential power relationshipsbetween males and females. Buysee and Van-Oost (1997) for example, found that, althoughyoung adult women demonstrated moreconcern regarding safe sex and tried harder toimplement safe behaviour than their male coun-terparts, they faced greater difficulties in behav-ioural negotiations as a result of gender-powerrelations. While men could implement safe sexpractices either without negotiation or byraising the issue at the moment of intercourse,women often had to start negotiating longbefore the actual encounter in order to be assuccessful. Numerous studies have alsoidentified the importance of gender in thenegotiation of family behaviour. Backett (1990)for example, found gender differences in inter-actional and situational constraints on oppor-tunities to engage in preventive behaviours.


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Men were more likely than women to undertakepreventive actions such as exercise. Thesedifferences frequently did not correspond withdesired levels of exercise. Rather, they reflectedwomen’s negotiated role within their family, andtheir affording higher priority to other familycommitments than their own participation inregular exercise. Similarly, Young (1999) foundthat for women, health-related behaviours werefrequently a result of negotiation with otherfamily members based on time–spaceconstraints, rather than the result of individualdecision making. Such findings are alsosupported by Kerr and Charles (1983). Theyfound that although a majority of women werethe main provider of food within the household,they exerted little control over the choice offoodstuffs. Instead, they frequently find them-selves in the role of food negotiator, balancingcompeting family demands and conflict.

The importance of understanding social inter-action is illustrated by Plumridge and Chetwynd(1998), in an examination of how young inject-ing drug users accounted for sharing injectingequipment. Results suggested that while indi-viduals saw themselves as morally responsiblethey nevertheless shared equipment with otherswho were seen to be in need, desperate andpowerless. The responsibility for sharing wasseen to lie with the borrower, leading theauthors to suggest the need to encourage acommunity that takes equal responsibility forprotective norms. One of the few public healthinitiatives to be informed by an understandingof such factors is reported by Johnson andNicklas (1995). Their ‘Heart Smart Family’ wastargeted at families with children identified as athigh risk for CHD. It involved a 12–16 weekprogramme, which focused on increasing aware-ness of health issues, skill development andproblem-solving skills. Following the pro-gramme, parents evidenced lowered blood pres-sures, increased exercise levels and decreasedintake of total fat, saturated fat and sodium. Aclinically significant reduction in children’sblood pressure was also observed.

Participation andempowerment

The most obvious advantage in the develop-ment of a Public Health Psychology is the

opportunity it offers to improve our under-standing and the efficacy of traditional publichealth communication campaigns. Perhapsmore importantly, it offers the opportunity forHealth Psychologists to draw on theories and tocontribute to initiatives that acknowledge aninteraction between individuals and their socialand physical contexts. In this way, communi-cation is viewed as taking place within a socialsystem, environmental influences are seen toeither inhibit or facilitate behaviours and anincreased emphasis is placed on understandinghow behaviours are negotiated. Significantly itoffers the opportunity for Health Psychology toreflect on the range of theories it has tradition-ally drawn upon.

It must be stated that our discussion hasfocused predominately on the historical role ofpsychology in understanding the influences onhealth risk and protective behaviour. Psychol-ogy however, has an important role in guidingand suggesting potential outcomes for initiativesthat adopt a more holistic approach to health(Reppucci, Woolard, & Fried, 1999). As suchHealth Psychology could usefully draw on thelong-standing tradition in public health ofcommunity involvement. As the World HealthOrganization has stated ‘To reach a state ofcomplete physical, mental and social well-being,an individual or group must be able to identifyand to realise aspirations, to satisfy needs, andto change or cope with the environment’(WHO, 1986: 1). Here such concepts as intra-and inter-group processes, participation,empowerment, self-esteem, self-efficacy thathave been traditionally viewed as processmeasures become important outcomes.

This type of approach, which places theemphasis on personal growth, development andempowerment, shares many of the assumptionsof the psychological perspective of humanism(e.g. Maslow, 1970; Rogers, 1967). Mostrelevant is its emphasis on human growth anddevelopment and its assumption that individualsare motivated by a desire to develop and self-actualize, a tendency towards fulfillment of allcapabilities. Although having a significant influ-ence on therapeutic techniques, humanism haslargely been neglected within the design andevaluation of public health initiative. Taylor(1990), however, identified two possibleapproaches using this perspective. The first, a


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humanistic approach, takes a client-centredapproach, and involves the individual determin-ing their health needs and developing theresources and skills to meet them. The second,a more radical humanist approach again focusedon client-centred participatory learning, butalso recognizes that such learning occurs withina social context of relationships. According tothis model, public health should encourage thedevelopment of social, organizational and econ-omic networks to support individual change.This, he argued, should lead to the developmentof community groups and collective and indi-vidual empowerment.

This is not to say that approaches tocommunity empowerment are without theircritics. Kar, Pascual and Chickering (1999) havehighlighted the scarcity of well-designed evalu-ations of such initiatives and a lack of publishedstudies of unsuccessful initiatives. Guldan(1996) goes further and identifies a number ofsignificant obstacles to successful empowermentand participation in industrialized societies.These include: the power of vested interestsranged against participatory approaches; thelack of long-term financial commitments to suchapproaches; the difficulties in co-ordinating andmaintaining participation; difficulties in definingwhat constitutes a community; and the adoptionof top–down rather than bottom–up models ofdevelopment. Nevertheless, she argues thatsuch obstacles can be overcome over time. Thisis supported by Lomas (1998) who has arguedthat public health should have the long-termgoal of improving social capital and social co-hesion, a shift from individual risk factors tosocial resources. This obviously mirrors workundertaken within community psychology andcommunity development initiatives where:

A community identifies its needs or objec-tives, orders (or ranks) these needs or objec-tives, develops the confidence and will towork at these needs or objectives, finds theresources (internal and/or external) to dealwith these needs and objectives (and) takesaction. (Ross & Lappin, 1967: 6)

Beeker, Guenther-Grey and Raj (1998) arguethat adopting such an approach rather thanreplacing traditional models of behaviourchange, widens the lens to include, not only theindividual, but their social and structural

context. In this way, the emergence of a PublicHealth Psychology may signal an increasingrecognition by Psychologists of radical struc-turalist, rather than social regulationist expla-nations of health (Caplan, 1993). The latterperspective accepts that existing structuressupport and regulate society and that changescan be effected within them, for example byinfluencing cognitions and skills. More radicalperspectives have warned that such an approachcan lead to a culture of victim blaming (Craw-ford, 1977) and argue that ill-health is a productof unequal power and access to resources insociety. The focus here for example would be toraise public awareness of issues and supportcommunity and political activism to effect struc-tural changes. Recognizing this social andpolitical dimension may represent the greatestpotential contribution for psychology in thearea of public health.

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health psychology and public health: theoretical possibilities

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