ib iplma psychology pinal companion

IB DIPLOMAPsychology

OPTIONAL CompanionHealth Psychology

LAURA SWASH, SIRI BERMAN & Joseph Sparks

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IB diploma Psychology: health Psychology

ContentsDeterminants of Health Part 1A: Biopsychosocial Model of Health and Wellbeing 4 Part 1B: Dispositional Factors and Health Beliefs 12 Part 1C: Risk and Protective Factors 17

Health Problems Part 2A: Explanations of Health Problem[s] 24 Part 2B: Prevalence Rates of Health Problems [s] 33

Promoting Health Part 3A: Health Problems 44 Part 3B: Effectiveness of Health Promotion Programmes 49

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INTRODUCTION When your doctor asks you about your health, what’s the first thing you think about? Is it your body and how healthy your muscles, stamina, and weight feel? Is it your mind, and how emotionally stable and satisfied you feel? Or could it possibly be your behaviours, like your thoughts on whether you feel confident or nervous about the amount of exercise you do, the food you eat, or the substances you try? Health is comprised of all of these things and more, and what determines our health status is a unique recipe of factors for each person, starting with our genetic makeup, which is seasoned with a number of behavioural, social, cognitive, and cultural factors, all of which affect and are affected by the other ingredients as well! This is why the IB Diploma Psychology of Health option uses the biological, cognitive and sociocultural approaches to explain our health behaviours, problems and health promotion programmes.



PART 1: DETERMINANTS OF HEALTH In this section we will view health determinants through three different lenses: 1. the biopsychosocial lens 2. a dispositional and belief lens 3. a risk and protective lens

What’s important to remember is that these categories are not mutually exclusive in their descriptive and explanatory power. They all hold truth and are all different pieces in the puzzle of understanding how we can live longer, happier and healthier lives. As you read, try to make connections between the sub-sections, and see if you can find any common threads that tie each piece of the health puzzle together. WHAT YOU NEED TO KNOW Part 1A: Biopsychosocial model of health and well-being - Discuss how the biopsychosocial model

helps us to understand health and well-being.

Part 1B: Dispositional factors and health beliefs - How are the mind and body related when it comes to health?

Part 1C: Risk and protective factors - How is our health affected by risk factors and protective factors?

PART 1A: BIOPSYCHOSOCIAL MODEL OF HEALTH AND WELL-BEING Key Question: Discuss how the biopsychosocial model helps us to understand health and well-being. The biopsychosocial model of health (BPS model) posits that the state of our health is dependent on an interaction between physiological factors (genetics, neurotransmission, brain anatomy, etc.), psychological and behavioural factors (attributional styles, cognitive distortions, schemas, etc.), and social and environmental factors (poverty, isolation, family trauma, etc.). Supporters of the BPS model assert that a medical diagnosis that considers the interaction of biological, psychological, and social factors should lead to an improved diagnosis and better predictions about treatment and follow-up, and that interventions involving all three elements are greater than treatments grounded in any single-factor approach. In order to truly understand the nature of the interactions between these factors, and their effect on health and well-being, it is important to grasp that we must not merely explore each factor on its own, and then ‘combine’ all the knowledge at the end, but rather, we must understand how each factor affects and is affected by the others. In this respect, a true understanding of the BPS model is better represented by a Venn diagram than a pie chart (see picture below).



Psychiatrist George Engel proposed the Biopsychosocial model for understanding health in 1977 after deciding that the Biomedical approach to understanding health was too reductionist and detached from the patient. He put forth the idea that we cannot fully understand and treat health problems if we cannot understand at least some the patient’s subjective experience of their health problem, as well. This personal, subjective experience includes taking into account a patient’s perceptions, feelings, social relationships, daily interactions, and culture, as well as their relationship with their physician and the healthcare system. While many would agree that the BPS model is paving the way for the future of understanding health and well-being (and their negative counterparts of health problems and illness), there is still much progress to be made in bringing theory to application: the ideal to reality. Currently, the BPS model helps us understand health through a range of concepts grounded in the simple premise that our minds, bodies, and social contexts are in a constant cause and effect feedback loop.

A Work in Progress Although the concept behind the BPS model intuitively makes sense, it’s difficult to truly understand, empirically research, and effectively apply than one may think. In its current manifestation, the BPS model suffers from a number of challenges that the well-intentioned field of Health Psychology has either neglected or been unable to prevent, including: Seemingly inevitable dichotomising between biological, psychological, and social factors by a species

that loves to categorise and distinguish (us!)

The model’s ambiguous status as an actual scientific model Difficulties with the complex tasks of linking and prioritising subsystems A limited understanding of the multivariate statistical approaches that are required to adequately

analyse BPS influences from vast quantities of data A limited understanding of ‘culture’, its heterogeneous relevance to specific health outcomes, and

how it can be accurately measured



A lack of feedback from researchers, who often do not know how their results and recommendations have fared in the real world, and cannot assess the generalizability of results or applicability of theories.

The key study below illustrates some of these challenges empirically.

Key Study: Suls and Rothman (2004) Aim: To assess the extent to which health psychologists embrace and examine the multiple systems (biological, psychological, sociocultural) that underpin the BPS model. Method: Researchers independently read and coded all of the studies published in Health Psychology journal over a 12-month period from November 2001 to September 2002, documenting the number of times the following four variables were being assessed in the studies: biological variables, psychological variables, social variables, and macro variables. Social variables focused on factors like self-reported social support and marital satisfaction, whereas the assessment of macro variables, such as ethnicity, income and age, were considered sufficient only if investigators measured at least age, gender, ethnicity, and either education or income. Results: Of the studies included, only 26% included measures from all four domains (i.e., biological, psychological, social, and macro) and an additional 38% included measures in three of the four domains. While psychological variables were measured in over 94% of the studies being assessed, biological, social and macro variables only showed up in around half of the studies. And looking more closely, their inclusion was limited, in terms of relevance to the actual aim of the research. For example, the majority of biological factors assessed typically referred to a disease used to determine the sample; the majority of social factors assessed measured people’s subjective judgments about relationships with friends and family, and the majority of macro variables assessed were simply used to describe the demographics of the sample. Upon reviewing the combinations, it was found that investigators mainly focused on the interactions between either psychological and social factors or psychological and biological factors. Conclusion: Overall, this meta-analysis shows us that researchers have acknowledged the BPS model enough to reference it in their research, but they have a way to go in terms of actually focusing their research on studying the links between the different subsystems, and balancing that focus on the entire range of variables associated with the BPS model. Research exploring interconnections between biological and social factors appeared to have been especially limited.

Evaluation of Suls and Rothman (2004) STRENGTHS: This meta-analysis paints a general picture of how the BPS model appears in a year's

worth of research. The information is objective and complete, covering a 12-month period, so there is little room for researcher bias.

LIMITATIONS: Because the words were coded without much context, we don’t have much depth of

understanding about how the variables associated with the BPS model were weighted or analysed. Terms were included even if they were mentioned once in the entire article, even if their inclusion was unimportant and not analysed, so the numbers that we see represent the presence of a word, and possibly little more, in terms of analysis or relevance to the aim or results of the study. The study was carried out between 2001 and 2002, so it is over 15 years old. It would not be surprising if the frequencies of BPS references and focus have increased, especially since new research has come out confirming the effects of our experiences and perceptions on our biological health.



Current Applications of The Biopsychosocial Model There are a number of fields within psychology and medicine that are now exploring the multidirectional interactions between social, biological, and psychological factors related to our health. Here we will explore three: sociosomatics, epigenetics, and neuroplasticity.

Sociosomatics Expanding the scope of what has commonly been known as psychosomatics (the study of the effects of the mind on the body), American psychiatrist and Harvard University Professor Arthur Kleinman introduced the term sociosomatics in 1986, which explores the social aetiology of health problems. Simply put, Kleinman describes sociosomatics as ‘the study of the mind and body in context’. An excerpt from the key study below will illustrate how ‘bodily dynamics are often shaped through complex interactions among subjective experiences, cultural meanings, and situated contexts…’ (Hatala, 2012, p. 55)

Key Study: Svenberg et al. (2009) Aim: To capture the authentic meanings and messages behind the words of Somali refugees living in Sweden, when interviewed about their health. Method: Thirteen participants (5 women, 8 men) were recruited in a major Swedish city via purposive sampling by an intermediary who had contacts within the local Somali community. The intermediary (who was trusted by the Somali refugees) recruited people who were born in Somalia, but who had been living in Sweden for at least 10 years. Information about the aim and consent was shared with all participants before they committed to interviews. Narrative interviews took place in the participants’ homes, in a casual, conversational tone, at times in the presence of friends and family members. The intermediary acted as a translator for three of the interviews. Each interview lasted approximately 1.5 hours. The initial question asked was ‘could you tell us how you feel about your health?’ and the follow-up questions depended on the response. All interviews were recorded and transcribed verbatim. In the first phase of interpretation, the authors read and listened to each interview several times. In the subsequent approach, the text was re-read many times, with the intention of identifying specific narratives, expressions, or phrases that seemed to be particularly significant. Results: The major theme of all of the interviews was ‘a life in exile’, which was connected to many of their experiences and the meanings they gave to those experiences. Other major themes that arose were ‘longing for the homeland, pain- a companion in exile, prejudice and discrimination, family-comfort and trouble, religion and beliefs in Jinns.’ Here is an excerpt from the study that clearly illustrates an opportunity for sociosomatic analysis: Pain – a companion in exile The coping and acceptance process includes thoughts and memories of the situation in pre-war Somalia and the climate in the Horn of Africa. Bad health in Sweden is often perceived in contrast to the memories of the sun that makes one warm and perspire during hard physical work.

But didn’t you get any pain back in Somalia? Oh, no! Why? Because back home, you have to do hard physical work, nobody feels sick and you sweat a lot.



So here in Sweden then, you don’t work? What about all the kids you look after? Well yes, my mother comes home and cooks all the food. And the kitchen here is so different compared to in Somalia. There, you go out and collect wood, you light a fire, you are on the move all the time, you train. But here, all you do is to press a button and the food is cooked and the laundry is done. (Female, age 36) Before my husband died we went back to Somalia. There I felt completely healthy, I was never sick, I moved around all the time, it was warm and I perspired. I never touched any painkillers. (Woman, age 70) (p. 283) Conclusion: Somali refugees’ thoughts and beliefs about health were deeply connected to their social context of living away from Somalia, and this sometimes manifested in physical symptoms.

Evaluation of Svenberg et al. (2009) STRENGTHS: The qualitative nature of the data gathered provided a richness of detail about the

refugees’ experiences in Sweden that quantitative data would not have provided. Because the research design used narrative interviews which were carried out in the homes of the interviewees, the validity of the information shared should be higher than had it been in a more formal setting, such as a research facility.

LIMITATIONS: The sample of participants was small (13 participants), so generalizability even to other

Somali refugees in Sweden would need to be treated with caution. Although validity should be relatively high for these interviews, both interviewers were from the health-care sector, so the informants may have modified their answers in order to please the interviewers. In three interviews the intermediary acted as interpreter, which could have resulted in a less spontaneous response.

As we can see in the study above, sociosomatics is a fascinating and holistic lens through which we can view a person’s health experience that considers the multidirectional relationships between biological, psychological, and social factors. While research in sociosomatics is still somewhat vague in terms of identifying how social and psychological factors ‘get under the skin’ of psychological health and well-being, the next two fields of study apply the BPS model in a more specific manner.

Epigenetics (Psychosocial Genomics) Epigenetics is the study of how environmental factors can affect gene expression. In the health psychology world, it is also sometimes called psychosocial genomics. In our text on the Biological Approach, we looked at possible epigenetic explanations for increased risk for depression (pages 44-45, Devlin et al., 2010), and the study below will explore the same process, but with a focus on stress instead.

Key Study: Perroud et al. (2014) Aim: To test the effect of in utero maternal stress, as measured by PTSD severity, on behavioural outcomes, and to investigate genetic correlates (especially the NR3C1 gene) in the offspring. Method: Participants were 25 widows of Tutsi ethnicity exposed to traumatic experiences in the context of the Rwanda genocide and who were in their second and third trimesters of pregnancy during the genocide period; their 25 offspring born after that period; and 25 women from the same ethnicity who were living abroad at the time of the genocide, and therefore not exposed to the traumatic experience and their 25 offspring born during the same period.



The PTSD 17-item checklist (PCL-17) was used to assess the severity of PTSD. The questionnaire was administered by a trained psychologist. The Beck Depression Inventory (BDI-13), a self-report questionnaire, was used to assess the severity of depression. And blood samples were taken from all women and sent to a Geneva hospital, where DNA, plasma, and protein information was extracted. Results: Mothers exposed to the genocide had significantly higher PTSD and depression severity than mothers not exposed to the genocide. There was a significant correlation between NR3C1 activation status in the mothers and activation status in the children. Analyses showed that being exposed as a foetus to environmental stress is associated with specific activations of the glucocorticoid receptor gene NR3C1. Exposed mothers, as well as their children, had lower cortisol levels than non-exposed mothers and their children, respectively. Conclusion: This type of activation of the NR3C1 gene is associated with changes in the HPA (hypothalamic–pituitary–adrenocortical) axis, which is where the nervous system and the endocrine system interconnect. These changes are associated with blunted cortisol levels. Abnormal HPA axis activity may play a central role in the physiology of PTSD and depression, and the mechanisms underlying these dysfunctions could explain the inheritance of these disorders, from the mother to her offspring.

Evaluation of Perroud et al. (2014) STRENGTHS: The results of this study support prior research on the topic. The sample was matched

with an appropriate control group. This study is one of the first to demonstrate the transgenerational effect of extreme stress on genetic expression.

LIMITATIONS: Results should be considered with caution due to the small sample size. Although the

results are significant, it is still unclear to the researchers exactly how to interpret these findings. For example, what is really transmitted by the mother? In the words of the research team, ‘Is it firstly the environment that the mother with PTSD is creating for her child, her way of living, of dealing with the stress, being too protective of her child and not letting him/her naturally undergo voluntary separation resulting in less secure attachments and poor emotion regulation? Or does maternal PTSD confer a risk of PTSD on the offspring firstly through epigenetic modifications and biological alteration of the HPA axis and only secondarily leads to the development of PTSD?’ (p. 343). This question is significant, as it acknowledges that we are still often unable to truly separate sociocultural and biological explanations from each other with certainty. Also, this study is focused on the implications of PTSD resulting from the experience of genocide, so whether or not the findings apply to other, and arguably lessor stressors, is still unclear.

As we can see above, the relationship between experiences, genes, and the entire HPA axis is a complicated one. The good news, however, is that the effect of experience on genetic expression should be a consistent function; just as negative experiences can affect our genes, so too can positive experiences. According to Garland and Howard (2009), it is ‘conceivable that psychosocial interventions, the tools of social work practice (like talk therapy or even yoga), may produce alterations in gene expression, leading, in some cases, to measurable neurobiological changes’ (p. 6).

Neuroplasticity We know from the Biological Approach chapter that neuroplasticity is the process by which neurons in the brain can develop new synaptic connections in response to experience and learning throughout one’s lifespan. We put neuroplasticity third in this section on current applications of the BPS model because it incorporates aspects of both sociosomatics and epigenetics. While both epigenetics and neuroplasticity can fall under the umbrella concept of sociosomatics, neuroplasticity is thought to ‘play out’ via the



process of epigenetics. With an understanding of epigenetics, we are able to better understand neuroplasticity. According to Nobel Laureate Eric Kandel (1998), ‘Genes and their protein products are important determinants of the pattern of interconnections between neurons in the brain and the details of their functioning…Alterations in gene expression induced by learning give rise to changes in patterns of neuronal connections…Stated simply, the regulation of gene expression by social factors makes all bodily functions, including all functions of the brain, susceptible to social influences. These social influences will be biologically incorporated in the altered expressions of specific genes in specific nerve cells of specific regions of the brain’ (pp. 460-461). In other words, the development of our neural connections is affected by epigenetic processes. In the Biological Approach chapter on neuroplasticity, the research of Luby et al. (2013) explored the effect of poverty on children’s brain development, as well as the mediating roles played by caregiving and stressful events on that process. This research concluded that poverty was associated with less white and grey brain matter and with smaller hippocampus and amygdala volumes. However, whether the caregiver was supportive or hostile mediated the effects of poverty on both hippocampi, while stressful life events mediated the relationship between poverty and left hippocampal volume. Taking a closer look at the role of stress in this study, we see that poverty is often associated with high levels of stressful and traumatic life events, and that their measurement of poverty, the ‘income-to-needs ratio’, is often used as a proxy for ‘cumulative development stress’ (p. 1136). This could mean that when we are looking at the effects of poverty on brain development and connections, we are really looking at the effects of cumulative development stress on brain development. Below is a study that further details the correlation between prenatal risk factors, postnatal care, and neuroplasticity in the hippocampus.

Key Study: Buss et al. (2007) Aim: To determine if the hippocampal volume is affected by both prenatal risk factors and postnatal family care. Method: Subjects were recruited for this correlational study by online advertisements at local Universities. The final sample included 44 subjects, all born at term (>37 weeks), who were split into four groups. Twenty-one subjects were born small for gestational age (SGA- within the 10th weight percentile) and assigned to the prenatal risk group, and 23 subjects were born at an appropriate weight for gestational age (AGA- between the 40th and 70th percentile), constituting the reference group. The prenatal risk groups were then further split into postnatal risk groups, characterized by the subjects’ scores on the PBI, a questionnaire that retrospectively measures the self-reported quality of parental care and bonding during the first 16 years of life. Within the SGA group, 11 subjects reported high maternal care (six men and five women) and 10 subjects reported low maternal care (five men and five women). Among the subjects born AGA, 11 reported high maternal care (five men and six women) and 12 subjects reported low maternal care (five men and seven women). Hippocampal volume was measured using MRI. Birth weight, postnatal care, and hippocampal volume were assessed for correlations among all of the groups. Results: In the low maternal care group, there was a positive correlation between birth weight and hippocampal volume in females only. In the high maternal care group, there was no correlation between birth weight and hippocampal volume for males or females.



Conclusion: Overall, this study found that the quality of postnatal maternal care mediates the effects of birth weight on hippocampal volume (but not total grey matter volume) in females only. This supports the hypothesis that the hippocampus is a key area of the brain that is affected by environmental stressors, which can lead to a range of biological and psychological outcomes.

Evaluation of Buss et al. (2007) STRENGTHS: To the researchers’ knowledge, this was the first study to show an association between

birth weight and hippocampal volume in a healthy population without confounding perinatal medical complications. The results are supported by many rodent studies looking at the effect of postnatal care on prenatal risk.

LIMITATIONS: There are many causes of low birth weight, so the researchers could not control for the variables associated with those. Although the PBI measure has shown to be a reliable measure of parental care and bonding, it is still limited by its self-report nature and is subject to current contextual biases. The sample of 44 was small, and limited to one region of the United States; therefore, generalizing the results to other populations is difficult.

Critical Thinking What role does culture play in the BPS model? We can see in the research explored in this section that a true understanding of the biopsychosocial model is more than just a sum of its parts. As we piece together all the factors that affect our health and well-being, culture, viewed through a critical lens, also becomes more complicated than we thought. While social and environmental factors like socioeconomic status, social support, and relationship status have a somewhat predictable role in this model, culture can take on more meanings than one might initially assume. Often, cross-cultural studies are based on differences in nationality, religion, or language, but is that really the most accurate way to conceive of someone’s cultural experience? Arthur Kleinman, whom we referenced earlier for his work in sociosomatics, suggests that we conceptualize culture as ‘what’s at stake’ for someone in a specific situation (Hatala, 2012). This means that, instead of determining someone’s culture by their nationality, perhaps it is more accurate to determine their culture by how their life experiences and internalizations of those experiences have shaped the way they view, experience, and react to the world around them. This complicates trying to study the specific role of culture in the BPS model, because it may not be as simple as factoring someone’s nationality, religion, or language into an equation. How do we operationalize such a nuanced and personal variable? In the Theory of Knowledge course, this is where an acknowledgement of the differences between Personal and Shared Knowledge helps us understand the problem, even if we still have a way to go in terms of solving it!

POSSIBLE EXAM QUESTIONS FOR PART 1A: BIOPSYCHOSOCIAL MODEL OF HEALTH AND WELL-BEING Evaluate the biopsychosocial model of health and well-being. With the command term ‘evaluate’ you need to discuss the strengths and limitations of the model, and when you evaluate the research, make it relevant to your evaluation of the model. Be sure to include an overall appraisal or judgment after taking into account all points.



PART 3A: HEALTH PROMOTION Key Question: Discuss theories or models related to health promotion. As you can imagine, just about any theory that tries to explain or predict human behaviour can be applied to understanding health promotion. Clearly, if it helps us understand why people do something, it can help us understand the behaviours and decisions we make related to things like exercise, diet, stress, sexual health, and even seatbelt use. Three possible labels under which we can categorise theories/models related to health promotion are: Individual and cognitive Interpersonal and social Community and policy Below we will see how many of the theories we are already familiar with can fall under these labels, starting with the Theory of Planned Behaviour (Ajzen, 1985).

Individual and Cognitive Theory of Health Promotion As we read in the Health Determinants section of this chapter (and in the Cognitive Approach chapter), the Theory of Planned Behaviour (TPB) is one of the most well-known theories related to explaining and predicting health behaviours focusing on the constructs of attitude, subjective norms, and perceived control. Ideally, in applying this theory to health promotion strategies, we should be designing interventions that target these constructs, which should lead to changes in intentions and behaviours. While it is interesting to spotlight research focusing on one specific application of this theory to one specific health behaviour, it makes more sense to examine the theory through a meta-analytic lens if we are going discuss it as a health promotion theory. A study to recall here would be the McEachan et al. (2011) meta-analysis from the Health Determinants section, which found that there are a number of different factors that affect the Theory of Planned Behaviour’s power of prediction. The theory is able to predict some health behaviours (physical activity and dietary) better than others (safe sex, self-detection of health problems, and abstinence), and the effectiveness of the theory in predicting behaviour varies by the age of people carrying out the behaviours, the type of study reporting (objective vs. self-report), and length of follow-up. As such, if one is planning to apply this theory to a real-world health promotion issue, it is important to find comparable supporting research in terms of population, health behaviour, and measurement of variables, before designing an intervention based solely on the constructs identified in the theory.

Interpersonal and Social Theory of Health Promotion Another theory that helps us understand and plan for health promotion is Albert Bandura’s Social Cognitive Theory (1986), which we learned about in the Sociocultural Approach chapter. Bandura is a huge proponent of using his Social Cognitive Theory in understanding health promotion (Bandura, 2004).


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According to him, ‘There are many psychosocial models of health behaviour. They are founded on the common meta-theory that psychosocial factors are heavy contributors to human health. For the most part, the models include overlapping determinants but under different names’ (p.145). As an example, the table below shows how the constructs of the Theory of Reasoned Action and the Theory of Planned Behaviour can fall under the umbrella of the same constructs (which Bandura calls ‘determinants’) of Social Cognitive Theory, even though they have different names. He asserts that since the TPB’s constructs of ‘attitude’ and ‘norms’ are measured by perceived outcomes and perceived social pressures, respectively, they both fall under his SCT determinant of ‘outcome expectations’. He equates the TPB’s ‘perceived control’ with his ‘self-efficacy’, and the TPB’s ‘intentions’ with his ‘goals’.

THEORIES

PSYCHOSOCIAL DETERMINANTS OF HEALTH BEHAVIOUR

SELF-EFFICACY

OUTCOME EXPECTATIONS GOALS CHALLENGES Physical Social Self-

Evaluative Short Term

Long Term

Personal & Situational

Health System

SOCIAL COGNITIVE THEORY

THEORY OF REASONED ACTION

THEORY OF PLANNED BEHAVIOUR

However, because of the number of overlapping constructs or ‘determinants’ associated with different health promotion theories and models, it’s hard to truly separate them for comparison. For example, Bandura identified self-efficacy as the most important explanatory and predictive determinant in health promotion success. Does this mean that the Theory of Planned Behaviour is equally effective in health promotion if we simply focus on ‘perceived behavioural control’? What makes it difficult to truly measure the different theories against each other is that real-world health promotion interventions often incorporate parts of different theories, sometimes without even identifying them in the write-up. As a result, we can identify familiar concepts in successful or unsuccessful interventions, but we cannot necessarily attribute them to one theory, or one magic recipe of prioritised parts. This is demonstrated in the key study below.

Key Study: Prestwich et al. (2014) Aim: To assess the extent to which studies have reported using theory to develop interventions and to investigate whether differential theory use was associated with intervention effectiveness. Method: Researchers performed a meta-analysis with datasets from two previous meta-analyses: a review of the association between behaviour change techniques (BCTs) and physical activity and diet, and a review investigating BCTs in obese adults with, or at risk of, obesity-related co-morbidities. The behaviour change techniques being measured and compared were the Social Cognitive Theory and the Transtheoretical Model. The review included 140 separate studies published between 1990 and 2008, with a total number of 61,649 participants. Each study was coded for: a) the extent to which each BCT reported by the authors was linked to a theory-relevant construct; b) the extent to which the constructs within the underlying theory were specifically targeted by the BCTs; c) an ‘overall theory score’ that was generated based on all of the coded items that relate to using theory

to develop the intervention.



Results: Out of 190 interventions, 107 (56%) reported a theory base. Of these, 51 (47.7%) were reported to be based on a single theory, 8 (7.5%) reported using theory to recruit study participants and 42 (39.3%) reported using theory to tailor BCTs to recipients. Of these same 107 interventions, 11 (10.3%) reported explicit links between all BCTs within the intervention and the targeted theoretical constructs. 52 (48.6%) tests of interventions reported measuring theoretical constructs post intervention and 45 (42%) measured constructs both pre- and post-intervention. However, only 4 (3.7%) tests of interventions reported statistically significant mediated effects. A similarly small number (3 = 2.8%) reported suggestions for theoretical refinement on the basis of their findings. Interventions based on Social Cognitive Theory or the Transtheoretical Model were similarly effective but no more effective than interventions not reporting a theory base. Conclusion: These studies suggest that theory was not often used extensively in the development of health interventions and that the relationships between type of theory used and the extent of theory use and effectiveness were generally weak. Fewer than half of the interventions were based on a single theory. The findings also suggest that attempts to use the theories more extensively are unlikely to increase intervention effectiveness.

Evaluation of Prestwich et al. (2014) STRENGTHS: This meta-analytic review attempts to clarify how theories like the Social Cognitive

Theory are used in health promotion, and how they relate to intervention effectiveness. The chosen coding system differentiated between a number of variables related to the inclusion of theory and the extent to which theory is ‘utilised’ in a study. It went above and beyond ‘is theory being referenced/used in this study?’ and this helps us understand the role of theory in research more accurately. The included studies were all coded for bias, and in general, the comparisons were typically judged to be free from selective reporting and free from other problems that could put them at high risk of bias.

LIMITATIONS: Only Social Cognitive Theory and the Transtheoretical Model had enough data to

analyse, so other theories/models, like the Theory of Planned Behaviour, were not included. Although researchers differentiated between many variables associated with theory use, they were still not able to reflect every element associated with using a theory. Researchers were only able to investigate theory use as reported in published studies, which is likely to underestimate actual practice.

Community and Policy Model of Health Promotion The term ecology refers to the study of relationships between organisms and their environments. Humans and our respective environments are included in this concept, and we can use it to further understand health behaviours and health promotion. According to Sallis et al. (2008), ‘The core concept of an ecological model is that behaviour has multiple levels of influences, often including intrapersonal (biological, psychological), interpersonal (social, cultural), organisational, community, physical environmental, and policy’ (p. 466). If this sounds familiar it should because it encompasses the biopsychosocial model of health and well-being that we explored in the Determinants of Health section of this chapter. To understand the biopsychosocial model within the framework of an ecological model, we should look at the four core principles of ecological models of health behaviour, as proposed by Sallis et al. 1. There are multiple influences on specific health behaviours, including factors at the intrapersonal,

interpersonal, organisational, community, and public policy levels.

2. Influences on behaviours interact across these different levels.


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3. Ecological models should be behaviour-specific, identifying the most relevant potential influences at each level.

4. Multi-level interventions should be most effective in changing behaviour. The interesting thing about these core principles is that they reiterate what we have already seen throughout this chapter, and, more specifically, in our study of the biopsychosocial model. 1. Our exploration of the biopsychosocial model explains that one of the best approaches to

understanding health is to take into account factors at every level, as mentioned in principle 1.

2. Some examples of the multi-directional health relationships associated with the biopsychosocial model are sociosomatics, epigenetics, and neuroplasticity, and these examples all illustrate principle 2.

3. As demonstrated in the results of the McEachan et al. (2011) and Pressman and Cohen (2005) meta-

analyses, our understanding of health and associated influences needs to be behaviour and person-specific, which relates to principle 3.

4. As such, the more levels of understanding and intervention that we can incorporate into health

promotion, the more effective it will be, as stated in principle 4.

Below is a simplified version of Sallis et al.’s image from their 2006 article, ‘An Ecological Approach to Creating Active Living Communities.’ It depicts the multiple layers of influence on an individual who is making decisions about their life and their health. The use of the ecological model requires analysing and aggregating data from a range of fields, including public health, behavioural science, transportation and city planning, policy studies and economics, and the leisure sciences.



Critical Thinking Clearly, we should consider all the factors, from biological to political, that affect our health behaviour. Why don’t we always use ecological models to understand and promote health? With the application of ecological models to health promotion, we see broader perspectives and multi-layered understandings of health behaviours; however, it’s not as simple as ‘bigger is better’ (or ‘broader is better’) when trying to find the best lens through which we should view and understand health. While the principles of an ecological model make sense intuitively, they are actually very hard to prove empirically, and in peeling back the many layers of what affects our health decisions, we can also lose some of the focus and academic rigor that comes with a single, targeted study that explores the effects of one variable on one behavior. The more variables we consider, the harder it is to understand cause and effect relationships, as well as nuanced interactions between layers.

POSSIBLE EXAM QUESTIONS FOR PART 3A: HEALTH PROMOTION Contrast two models or theories of health promotion. ‘Contrast’ requires that you give an account of the differences between two items or situations, referring to both throughout. This means that you will need to focus on what is different between the two models/theories, as opposed to what they have in common. Consider the main purpose of each model/theory, and the major concepts it uses to explain or predict health outcomes, and then identify the places where the two models/theories diverge. Discuss one theory or model of health promotion. ‘Discuss’ requires a considered and balanced review that includes a range of arguments, factors or hypotheses. There is obviously not 100% agreement on any one model or theory of health promotion as being the best, so your job is to share a little about what a diverse range of researchers and/or critics would say about the theory/model of your choice. What makes this theory/model strong? What is it missing? In what health scenarios might it work best? Does it share concepts with other models/theories? Be sure to back up all opinions with evidence.

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