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Psychology, public health and the enduring vitality of a discipline

Someone once said that history repeats itself; it has to because nobody listens the first three times around. The relationship between some of the social sciences and public health practice sometimes feels a bit like that to me.

Psychology as a part of public health practice is something which still elicits a range of opinions. There are those who feel it is an essential tool for any behavioural programmes, and the (relatively) recent field of Health Psychology is an example of what psychology can bring as an ally to public health practice. Others feel that psychology has a limited contribution to the science of public health because public health as a medical science has different epistemological foundations and approaches to those of psychology. (To be fair, even psychologists differ on whether psychology is art, science, social science or hybrid. But I’m not going to get into the philosophy of psychology here, much as I know that would thrill you.)

The nature of public health as a discipline and insights from others

This, though, raises the question once again of whether public health is art or science or both. There are those who strongly defend the scientific basis of public health, and that’s a good thing. Others highlight the political and tactical nature of public health when engaged in policymaking.  But my own view is that public health is more of a technology – a means of organising, integrating and using a range of different tools, methods, sciences and techniques to achieve outcomes.  Biology, environmental science, epidemiology, mathematical statistics, probability, organisational behaviour, law and political economy all have a role to play. And yes, social sciences besides political economy have a role too.  

In early Summer2013  the British Academy will launch a report on the contribution of social sciences to public health with a foreword by Michael Marmot, whose idea the report was. As one of the Editorial Group and co-author of the introduction my hope is this forthcoming publication will help public health and policymaker colleagues identify and make more use of the social sciences in the daily work of delivering public health.

This ability of public health to absorb insights, methods and techniques from different tools and perspectives is something we should see as a sign of strength and vitality: public health is in rude health, in some senses. 

This vitality applies whether it’s the stricter academic science of public health using and testing methodological innovations as we saw in the public health science conference in November 2012 (and coming again on 29 November 2013), or the recognition that public health leadership needs a range of insights and tools to enable leaders to do their jobs well.  It’s a sign of such rude health in our discipline that as a discipline we have people from a range of philosophical backgrounds, methodological persuasions and professions from communications to environmental health and so on. What we perhaps need to spend some more time doing is revisiting the philosophical and value core of who and what we are as people in the public health field(s). I suspect if we do we will reinforce what the history of public health tells us, it has always been a “both and”  field taking insights and tools from where it needed, and building on the core discipline of the actor. It has never really been an “either or” field – science or politics.

And this is perhaps the greatest lesson we can learn from history – both the history of ideas and the history of cultures : the most successful and enduring movements, states and ideas have taken insights from other cultures they encountered. Christianity absorbed hellenistic philosophy in the first five centuries as a dialogue partner to help it explain itself. Aristotle was introduced via Arab culture in the middle ages to mediaeval philosophy and theology. The Romans absorbed anything they thought would add to their vitality. So public health shouldn’t be worried – taking a lesson from history, public health is doing precisely what successful movements have done for centuries. 

This doesn’t mean everything for public health is rosy,  but it does mean that as a discipline faced with a new world and new home we have the intellectual horsepower to recognise we need new and different tools and we also have the heritage of doing that more or less successfully; which should stand us in good stead. That is a strong ground for hope for the future of public health, even if some of the organisations and bodies in public health have over the last two years seemed much less agile than we needed them to be.

Disposition counts

The key issue of our success will be whether we adopt a hermeneutic of suspicion (a perspective that nothing good comes from other disciplines; I exaggerate) or a hermeneutic of generosity ( we ask what is there in other disciplines which might help me, without losing my own best traditions and insights from my public health training.) I’d rather, personally, be generous than suspicious. And one of the things I know is that building public health requires building alliances. For me, working with business, social entrepreneurs, third sector and others to bring a range of insights to challenges has been essential to achieving the outcomes I need. That lesson was reinforced most recently when in Hertfordshire we participated in a succesful  trial of promoting routine physical activity in the workplace, via StepJockey

Revisiting the contribution of psychology: health psychology as an example

And this brings me to my first point about psychology – the nature of the public health challenges facing us is so heavily linked with behaviour, lifestyle and lifecourse accumulation of risk and morbidity that we need psychology as a set of tools to help us face what many regard as the major epidemiological challenge of the twenty first century. The psychology content of the public health training curriculum is no longer fit for purpose. We need to bring to public health practitioners and teams across the country the best of what psychology can offer. It’s being done elsewhere: psychology for nurses, psychology for ministers of religion, psychology for business leaders. If  they can do it, we in public health can.

Taking health psychology, the putative “public health psychology” movement has generated quite a literature, and below is just a very select sample which predates “nudge”. (And no, I’m not a fan of nudge. If you want to know why, read Martin Delaney’s blog here.) These examples alone create a significant agenda for us to work on.

  1. http://www.nsph.gr/Files/FileManager/Psihologia_ygeias/Notes/1h_imera/Editorial5-12.pdf
  2. http://www.thepsychologist.org.uk/archive/archive_home.cfm?volumeID=18&editionID=129&ArticleID=947
  3. http://www.ncbi.nlm.nih.gov/pubmed/14683568
  4. http://www.emeraldinsight.com/journals.htm?articleid=17053907
  5. http://onlinelibrary.wiley.com/doi/10.1348/135910700168955/abstract
  6. http://www.ncbi.nlm.nih.gov/pubmed/14683577
  7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1382037/
  8. http://www.apa.org/pubs/books/431644A.aspx
  9. http://courses.washington.edu/phequity/Glass%20and%20McAtee.pdf
  10. http://www.sagepub.com/upm-data/26636_Chapter1.pdf
  11. http://www.med.mcgill.ca/epidemiology/courses/655/chapter1.pdf

Health Psychology since its emergence some 50 or so years ago has pretty much become its own discipline. It needs to be a stronger part of the public health training curriculum, and needs to have a stronger showing in how public health organisations tackle the growing burden of issues like vulnerable older people, non-communicable disease and young people developing avoidable psychological and physical morbidity. That is an agenda in itself for public health. But we could do worse than dialogue much more closely with health psychologists and develop tools and insights.

To take but one example, intervention mapping has become a powerful tool to help keep behavioural intervention programmes consistent with the evidence and theory, so they are well implemented. I know from my own experience how useful the insights of intervention mapping can be, especially in large scale behaviour change programmes.

More than just good friends: an agenda for psychology and public health

But there is a much wider set of issues on which psychology can help public health professionals, and this brings me back to what I mentioned above as our ability in public health to absorb and adapt insights. Looking across public health, there are a range of fieldsor sub-disciplines. Commissioning public health, for example, or environmental health as well as health protection and health improvement. Psychology too has a a range of sub-disciplines, and has a regular habit of throwing up new sub-disciplines whenever a body of scientific knowledge emerges to support them.  This is exciting but can be confusing for non-psychologists. But it shows that psychology and public health are both adaptive and thriving.

Rather than go through every single sub-discipline in psychology, I am going to selectively choose just a few to illustrate some benefits of using psychological insights.  Yes, this list is biased, but we have to start somewhere. In any case, benefits from clinical psychology, neuropsychology and so on should not be that unclear to many of us.

  1. Health Psychology – the benefits of this field for prevention and management of non-communicable disease, achieving and sustaining behaviour change, making every contact count in a meaningful way, and the thorny issue of good self-management in secondary prevention are salient and need to be explored further.
  2. Occupational Psychology -this could inform recruitment, selection, training and job design for the public health workforce. Designing jobs with the competencies people need for local government and community interfaces, and then designing the training for those roles.
  3. Organisational Psychology – can help us in understanding organisations and how to influence them. Recent work on strategic leadership in business could be applied to strategic leadership in the public sector to help us embed public health across local government functions especially.
  4. Developmental Psychology – the growth of lifecourse methods and aproaches in epidemiology and public health is significant.  Lifecourse approaches to chronic diseases theoretically and evidentially show promise. The use of lifecourse approaches for maternal and child health, and in children with complex disabilities, are two areas of particular challenge.  Combining these insights with approaches from developmental psychology such as behavioural development, cognitive development, socialisation, the influence of peers and others on behaviour and factors likely to mitigate for healthier lifestyle or good emotional resilience could have applications ranging from child obesity to child mental health and resilience, as well as inform issues like risk-taking and bullying.
  5. Positive Psychology –  Some folk would call this an application of psychology or a perspective rather than a sub-discipline but positive psychology is a fast growing perspective and is the study and promotion of optimum human functioning and happiness. This very new sub-discipline can make significant contributions to public mental health and resilience, design and planning of the public realm for better human functioning and even design of emotional resilience programmes for schools. There are even applications across workforce design such as strengths psychology.
  6. Community Psychology – another relative newcomer where there is a debate about whether it’s a mindset or a sub-discipline. Community psychology focuses on communities as the unit of intervention with the aim of reducing inequalities and improving well-being. There could be a lot of benefit here in some joint consideration of community interventions and technologies for two fields (public health and psychology) which have often wanted to intervene with communities but whose methodological and evidential comfort zone is too often the individual as intervention focus.

Ok, this is ambitious, and some of you undoubtedly think I am flying a kite. But we have to start somewhere, and speaking from my own experience I have found the various sub-disciplines of psychology a rich source of insight for public health practice. If we at least map out where there are links, we can identify some priorities to take forward.

What’s not going in the British Academy report: an opportunity

What isn’t going to be in the forthcoming British Academy report is an enormous amount of psychology, partly because the report is trying to take an overview of where social sciences can help (and showcase some of the less obvious), and partly because psychology could take up the whole report. But equally – as I hope I have shown – the report doesn’t need to. There is more than enough out there already for us to build on. We have the opportunity to have conversations and develop some tools and joint areas for work between psychologists and public health. We should just get on and do it.

Next steps in the conversation

It would be great to see a series of masterclasses organised around areas of psychology and public health interface.  Perhaps some brief guides on applications of psychology to public health practice could follow. We have in the UK some of the leading academics and practitioners who can do this.

What would also be useful would be for us to have an eirenic discussion within public health and with dialogue partners about the epistemological and hermeneutic issues the challenges to public health practice bring about, and to look at what this means for us and how we bring in social scientific and psychological insights to help us with those challenges. The two public health science conferences are an attempt to show and disseminate the strength and innovation in research and science.  Perhaps we need something similar on social science and public health interfaces.  One way as suggested above is to have some psychology and public health masterclasses for public health professionals.

While we’re at it we could look once again at how we train our workforce for the challenges they will face. As we await the much vaunted launch of the workforce strategy, holding its principles and insights up to the mirror of occupational psychology could help us develop a public health workforce which is resilient, adaptable, able to integrate insights to deliver change and can renew itself: a bit like the intellectual corpus of public health itself.  That can only be a good thing, surely.

Jim McManus is a Chartered Psychologist, Chartered Scientist and Associate Fellow of the British Psychological Society.

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