The Emergence of Critical Health Psychology

Systematic review of frameworks used to conceptualise health pathways of individuals diagnosed with cardiovascular diseases

The treatment of cardiovascular disease (CVD) is managed inadequately globally. Theoretically informed frameworks have the potential to account for the multiple elements which constitute the CVD patient pathway, and capture their inter-relationships and processes of change. However, a review and critique of such frameworks is currently lacking. This systematic review aims to identify and critically assess frameworks of access to and utilisation of care which capture the pathways of patients diagnosed with one or more CVDs. The specific objectives are to (1) review how existing frameworks have been used and adapted to capture CVD patient pathways and (2) draw on elements of Strong Structuration Theory to critically appraise them, in terms of their ability to capture the dynamics of the patient journey and the factors that influence it. Five bibliographic databases were searched in January 2019. We included qualitative and quantitative studies containing frameworks used to capture the patient pathway of individuals with CVD, encompassing symptoms, diagnosis, treatment and long-term management. Data on patient behaviour and structural factors were interpreted according to elements of Strong Structuration Theory to assess frameworks on their ability to capture a holistic patient journey. The search yielded 15 articles. The majority were quantitative and all focused on management of CVDs, primarily hypertension. Commonly used frameworks included the common-sense self-regulation model, transtheoretical model and theory of planned behaviour. A critique drawing on elements of Strong Structuration Theory revealed these frameworks narrowly focused on patient attributes (patient beliefs/attitudes) and resulting patient action, but neglected external structures that interacted with these to produce particular outcomes, which results in an individualistic and linear view of the patient pathway. We suggest that a framework informed by Strong Structuration Theory is sufficiently flexible to examine the patient pathway, while avoiding a strict linear view facilitated by other frameworks.

Health psychology in Ghana: A review of the multidisciplinary origins of a young sub-field and its future prospects

This article presents a historical overview of psychology applied to health and health psychology in Ghana. A brief history of health, illness and healthcare in Ghana is introduced. Then, the history of psychology in Ghana is presented, with signposts of the major turns in the field in relation to psychology and other disciplines applied to health and the emergence of health psychology as a sub-field. Selected health psychology studies are reviewed to highlight ideological trends in the field. Finally, future prospects are considered in terms of how the sub-field can transition into an established critical field with unique contributions to make to global health psychology.

Health Psychology in African Settings

African settings provide an important context in which to examine the relationship between cultural beliefs and health. First, research in African settings helps illuminate the sociocultural grounding of health and illness: the idea that beliefs play a constitutive role in the experience of distress. Second, research in African settings helps to illuminate the cultural grounding of health sciences: the idea that theory and practice reflect particular constructions of reality. We examine these ideas in the context of three research examples: the prominent experience of personal enemies; epidemic outbreaks of genital-shrinking panic; and fears about sabotage of vaccines in immunization campaigns.

The social context of tuberculosis treatment in urban risk groups in the United Kingdom: a qualitative interview study

OBJECTIVES

There is scant qualitative research into the experiences of tuberculosis (TB) treatment in urban risk groups with complex health and social needs in the UK. This study aimed to describe the social context of adherence to treatment in marginalized groups attending a major TB centre in London.

METHODS

A qualitative cross-sectional study was performed using semi-structured interviews with patients receiving treatment for TB. Analytical frameworks aimed to reflect the role of broader social structures in shaping individual health actions.

RESULTS

There were 17 participants; the majority were homeless and had complex medical and social needs, including drug and alcohol use or immigration problems affecting entitlement to social welfare. Participants rarely actively chose not to take their medication, but described a number of social and institutional barriers to adherence and their need for practical support. Many struggled with the physical aspects of taking medication and the side effects. Participants receiving directly observed therapy (DOT) reported both positive and negative experiences, reflecting the type of DOT provider and culture of the organization.

CONCLUSIONS

There is a need for integrated care across drug, alcohol, HIV, and homeless services in order to address the complex clinical co-morbidities and social needs that impact on the patient's ability to sustain a course of treatment.

Improving the health of the public: What is the role of health psychologists?

Changes in human behaviour are at the heart of any response to the current epidemic of chronic disease. Health psychologists are in a unique position to address these major public health challenges, but need to focus efforts on maximising the scale of our impact. Training frontline health and social care practitioners of every type to deliver evidence-based behaviour change support to patients and clients is an approach with great potential in this regard.

'Complex' but coping: experience of symptoms of tuberculosis and health care seeking behaviours--a qualitative interview study of urban risk groups, London, UK

BACKGROUND

Tuberculosis awareness, grounded in social cognition models of health care seeking behaviour, relies on the ability of individuals to recognise symptoms, assess their risk and access health care (passive case finding). There is scant published research into the health actions of 'hard-to-reach' groups with tuberculosis, who represent approximately 17% of the London TB caseload. This study aimed to analyse patients' knowledge of tuberculosis, their experiences of symptoms and their health care seeking behaviours.

METHODS

Qualitative interviews were conducted with 17 participants, predominantly homeless and attending a major tuberculosis centre in London, UK. Most had complex medical and social needs including drug and alcohol use or immigration problems affecting entitlement to social welfare. Analytical frameworks aimed to reflect the role of broader social structures in shaping individual health actions.

RESULTS

Although participants demonstrated some knowledge of tuberculosis their awareness of personal risk was low. Symptoms commonly associated with tuberculosis were either not recognised or were attributed to other causes for which participants would not ordinarily seek health care. Many accessed health care by chance and, for some, for health concerns other than tuberculosis.

CONCLUSIONS

Health education, based on increasing awareness of symptoms, may play a limited role in tuberculosis care for populations with complex health and social needs. The findings support the intensification of outreach initiatives to identify groups at risk of tuberculosis and the development of structured care pathways which support people into prompt diagnosis and treatment.

Patient neglect in 21st century health-care institutions: a community health psychology perspective

Despite the technological and organisational advances of 21st century health-care systems, care scandals and burgeoning complaints from patients have raised concerns about patient neglect in hospitals. This article reviews the concept of patient neglect and the role of community health psychology in understanding its occurrence. Patient neglect has previously been conceptualised as a problem associated with hospital staff attitudes and behaviours, with regulation and training cited as solutions. Yet, a community health psychology perspective shows that the wider symbolic, material and relational aspects of care are crucial for understanding why patient neglect occurs and for outlining new solutions to augment existing interventions.

Reimagining community health psychology: maps, journeys and new terrains

This special issue celebrates and maps out the 'coming of age' of community health psychology, demonstrating its confident and productive expansion beyond its roots in the theory and practice of small-scale collective action in local settings. Articles demonstrate the field's engagement with the growing complexity of local and global inequalities, contemporary forms of collective social protest and developments in critical social science. These open up novel problem spaces for the application and extension of its theories and methods, deepening our understandings of power, identity, community, knowledge and social change - in the context of evolving understandings of the spatial, embodied, relational, collaborative and historical dimensions of health.

Turning health research into health promotion: a study of causality and 'critical insights' in a United Kingdom health campaign

This article examines how important decisions about health can alter between public health policy formulation and eventual marketing implementation. Specifically, the article traces the development and production of a major United Kingdom social marketing campaign named Change4Life, and examines how ideas about the causes of and solutions to the obesity epidemic are produced in differing ways throughout the health promotion process. This study examines a variety of United Kingdom health research, policy, marketing strategy and marketing messages between 2008 and 2011. This research demonstrates that claims about causality oscillate and alter throughout the research, policy and Change4Life marketing process. These oscillations are problematic, since the Department of Health described the original consumer research as 'critical'. Given both the importance of the health issues being addressed and the amount of funding dedicated to Change4Life, that 'critical' research was directly contradicted in the campaign requires urgent review. To conclude, the article discusses the utility of social marketing when considering causal claims in health promotion.

‘Don’t mention obesity’: Contradictions and tensions in the UK Change4Life health promotion campaign

The emphasis on body weight and the terms ‘fat’, ‘overweight’ and ‘obese’ are increasingly political in public health promotion. The UK government’s 2009—2011 social marketing campaign, Change4Life explicitly avoids the term ‘obesity’ and imagery that connotes it, despite the emphasis on obesity in the preceding research, policy and strategy. Using a critical health psychology perspective, this research explores the tensions arising from the omission of ‘obesity’ in the Change4Life campaign. We argue the justifications for omitting obesity are at times contrary to evidence that informed the campaign. Considerations are offered for the construction of future health promotion campaigns.

Let's get real (with a small 'r'): for a health psychology that prioritizes the concrete

Depending on which kind of philosophy of science we espouse, health psychology can be a relatively concrete or relatively abstract activity. Estacio, I suggest, prioritizes the concrete, by foregrounding real social phenomena. I argue that prioritizing the concrete has two particular benefits: it increases the social relevance of health psychology, and it increases the validity of our analyses, by ensuring that they are close to reality. To further the pursuit of the concrete, I suggest that critical health psychology is in particular need of exemplars of critical health psychology in action, rather than reflexive commentary on critical health psychology itself.

Human exploitation is not a joke--so don't laugh!

In a previous article, I called for an open discussion and debate on health psychology perspectives on social and political issues relevant to health, in particular the issue concerning racism and the media (Estacio, 2009). In this article, I raise three topics for discussion which the controversial BBC 'Harry and Paul' sketch (un)intentionally exposed to the public domain: (1) racist humour, the media and health; (2) human rights abuses against domestic workers; and (3) third world poverty and labour migration. Its implications on health psychology theory, research and practice are also explored.

'Your freedom ends where my nose begins': health psychology's potential towards critical empowerment, media advocacy and social action

There is no question that health psychology needs to be more involved with matters concerning health inequalities and the social injustices associated with media racism, and racism in general. It is recognized that our discipline has the potential to develop and carry out research that can make valuable contributions to address such issues. Reflecting and discussing these matters were useful in this respect, however, the recommendations raised here need to be put into practice for real progress to be made. Engaging with society itself is also crucial.

A Pragmatist Approach to the Problem of Knowledge in Health Psychology

The multiplicity of forms of health-related knowledge, including biomedical knowledge, lay knowledge and critical constructionist knowledge, raises challenges for health researchers. On one hand, there is a demand for a pluralist acceptance of the variety of health-related knowledge. On the other, the need to improve health calls for action, and thus for choices between opposing forms of knowledge. The present article proposes a pragmatist approach to this epistemological problem. According to pragmatism, knowledge is a tool for action and as such it should be evaluated according to whether it serves our desired interests. We identify implications for research methodology and the choice of research goals.

Harry, Paul and the Filipino Maid: Racial and Sexual Abuse in Local Contexts

Estacio argues for critical health psychology to take action to address three issues raised (unintentionally) in the `Harry and Paul' sketch broadcast on British television. It is suggested that, although attempting humour, the sketch offensively reflected and reproduced patterns of social injustice that are far from funny. We argue here that micro-level analysis of the interactional elements of the sketch provides an understanding of how in everyday contexts Filipino workers are constructed in socially unjust terms and of how abuse can be justified. Such an understanding can allow critical health psychology to make a distinctive contribution to these topics.

Editorial: media exploitation, racism and health

The BBC comedy show ;Harry and Paul' sparked media controversy in the UK and around the world for inciting stereotyped racial discrimination, vulgarity and violation of human rights when it portrayed a Filipino domestic worker as a sex toy in Episode 4 of the series. This incident raises the issue concerning the media's role in framing social issues and how it affects the wider determinants of health. There is a need for health psychology as an academic discipline to engage more in these issues. The Journal of Health Psychology provides a unique platform for discussion and debate of perspectives on racism, the media and health.

The quest for meaningful theory in health psychology

Theories generate questions, which in turn generate findings, which in turn generate articles. Theories in health psychology have successfully generated research activity but with inconclusive results. Avenues for more fruitful exploration are described. One of these suggests that health psychology will alter its focus from the study of what is (description) to the study of what might be (explanation), from what individuals do and say (behaviour) to what that behaviour means (contextuality), from ;social cognitions' (box ticks) to personal subjectivities (mental experience), from the status quo (demographics) to social injustice (structures of power and inequality).

Homelessness and health: challenges for health psychology

Homelessness can be seen as a challenge for health psychology in research and practice on several levels: analysing the risks of becoming homeless; the living conditions of being homeless and their impact on health risks and problems; homeless youth as a specific phenomenon; health problems in the context of homelessness; service utilization and barriers and effects of interventions in the context of homelessness. With these levels, a framework is outlined for the contributions to this Special Issue. In the end, homelessness is discussed as an issue for prevention in three respects for a comprehensive approach in health psychology.

Critical health psychology: Julie Hepworth

Behaviour oriented health promotion has often relied on over-simplistic and over-deterministic models in which action emanates from individuals, not the social or economic structures they inhabit. Mainstream health psychology models are allied with official health ideology and policy, stressing self-control, self-regulation and responsible (low-cost) health citizenship. Discussion of psycho-political validity and of the use of a wider community of meanings and theories is welcome and moves beyond narrow disciplinary concerns by developing epistemological self-critique. Reflection and critique of psychology and its uses in public health is needed for theoretical and morally reasons and points to inseparability of psychology and politics.