A healthy contribution

The emergence of health psychology (HP) as a distinct disciplinary area can be traced back to an American Psychological Association (APA) task force that met in 1973 (your first author was a corresponding member) to examine ways in which psychologists could contribute to the maintenance of physical health, the management of people with physical health problems and healthcare delivery. This led to the development of the APA Division of Health Psychology and Joseph Matarazzo's 1980 presidential address on a 'new health psychology'. The term 'health psychology' was first used in print by Stone et al. (1979), and the first journal (Health Psychology) appeared in 1982, followed by Psychology & Health in 1987 and the British Journal of Health Psychology in 1996.

Looking back, there are many possible reasons for the emergence of HP:

- Epidemiological evidence of the importance of behavioural factors to health: such as the link between reduced smoking behaviour and rates of lung cancer (Doll et al., 2004), as well as the early results from the Alameda County Study (Housman & Dorman, 2005) underlining the potential for behaviour change as a method of enhancing health.

- Evidence for health service effectiveness and efficiency: which became necessary and led to the measurement of a wide range of outcomes, with many being in a psychological domain.

- Medical schools: that added behavioural sciences to the curriculum, often taught by psychologists. The publication of projects from medical students created a body of health psychology research.

- Communication skills training: began to develop for health professionals, originally with the aim of improving patient satisfaction and adherence.

- Primary care: became a focus for clinical psychology where the line between physical and mental health was more blurred and interventions based on psychological theory were applied.

- Behaviour modification and therapy: had demonstrated that theoretically based methods could change behaviours and be clinically effective (D.W. Johnston, 1991).

- Psychophysiology and psychoneuroimmunology (PNI) emerged: coming from an understanding of how psychological and physiological factors interact, particularly in the cardiovascular (Steptoe, 2007) and immune (Ader & Cohen, 1975) systems.

- Social psychologists: frequently used the health domain for testing theoretical propositions, such as the relations between beliefs, attitudes and behaviour (e.g. Fishbein & Azjen, 1975), resulting in a body of evidence and theory development in factors that can predict health behaviour.

- AIDS/HIV: was diagnosed in the early 1980s, leading to increasing interest in behaviour change and to the funding of behavioural research.

However, the immediate prompt to action in the UK was the British Psychological Society's reconsideration of the role of the Medical Section. In a letter to the BPS Bulletin (the precursor of The Psychologist) in August 1985, Marie Johnston and John Weinman argued there was a need for a Health Psychology Section. Following consultation with the BPS, the Section was inaugurated at the BPS London Conference in December 1986 with Marie Johnston as chair.

The first Section conference was in Sussex in 1987 and there has been an annual conference ever since. In 1993 the BPS Annual Conference invited a review of 'Current Trends in Health Psychology'. This paper (M. Johnston, 1994) proposed a definition of HP as 'the study of psychological and behavioural processes in health, illness and healthcare', to offer a simple definition and re-emphasise the scientific nature of HP. The paper reviewed six developments representing health (PNI; social cognition models), illness (disease vs. behaviour outcomes; effective interventions) and health care (preparation for surgery; screening for disease).

In 1993 the Health Psychology Section became a Special Group and in 1997 health psychology in the UK was given Divisional status, recognising the distinct training needs and professional practice of health psychologists in the areas of research, consultancy, teaching and training. This allowed members to obtain chartered status within the BPS, which regulated training and practice in HP until 2010 when the regulation of professional standards and qualifications was taken over by statutory registration with the Health Professions Council. 

Research

So what progress have we seen in the last 25 years? In terms of research, this can be gathered under various headings.

Theory and models
In 1987, the year after the start of the HP section, a paper for the BPS Bulletin by Marie Johnston and Theresa Marteau on 'the danger of neglecting psychological models' argued that health psychologists tended to frame questions and offer theory and methods within a medical framework. It argued that progress as a discipline would require more focus on psychological principles in framing research questions, using theory and designing methods of investigation. 

In the early 1990s, symposia at HP and European Health Psychology Society (EHPS) conferences focused on social cognition. There is now much agreement about core models, with theories such as the theory of planned behaviour (TPB) and the health action process approach (HAPA) explaining behaviour, the commonsense self-regulation model (CS-SRM) explaining the response to illness or health conditions, and the social cognitive theory (SCT), implementation intentions and control theory often used to assist behaviour change.

Methods
There have been substantial developments in research methods, specifically in measurement, design and statistics. Methods have become more transparent and replicable, for example in developing theory-based measures, and there is more reporting of early qualitative work and theories such as the TPB and SCT, which have clearly published methods of measuring key variables. There is also much agreement that useful evidence can be obtained by both quantitative and qualitative methods.

Measurement
Since the 1980s there has been less emphasis on measuring deficit or negative states such as anxiety, and increasing emphasis on measuring behaviour and theoretical constructs postulated to influence behaviour. The emergence of new psychometrically sound measures (M. Johnston et al., 1995) led to a greater consensus. However, there has been disappointing progress in establishing the validity of many measures. 

Behavioural and psychological measures are increasingly important as health outcomes. There is a growing emphasis on finding objective measures of behaviour, including routinely collected data, such as: the use of electronic monitoring to assess medication adherence; prescribing data to reflect the behaviour of clinicians: the use of exercise facilities to reflect exercising behaviours; and the use of accelerometers to assess activity levels. However, these methods have additional problems, including the difficulty in gaining a true match to the behaviour and measuring the full and appropriate range of behaviours (Hrisos et al., 2009).

Physiological and psychophysiological measures continue to be important but tend to be restricted in use to groups specialising in their use. 

Research designs and statistical methods
There has been a shift from the much criticised, cross-sectional study of the relationship between two self-report measures to more prospective studies with objective assessments and the development and evaluation of theory-based interventions. Prospective designs offer some progress in assessing causal questions as the hypothesised cause precedes the outcome, but clearly experimental designs are necessary to test causality, and these continue to be rare. Process evaluations are increasingly used to assess whether an intervention has changed the targeted theoretical construct with resulting effects on the outcome variable. 

Intervention

Health psychologists are increasingly involved in developing interventions to change behaviour with a view to improving health outcomes, and this competency has been added to the professional training in HP. Interventions derive from two main traditions: persuasive messages based on social psychology, and cognitive behavioural methods more related to clinical psychology. While many successful interventions have been published in HP and medical journals, evidence synthesis has made it clearer than ever that we need shared transparent methods for describing interventions in order to have a cumulative body of evidence that can be applied in practice (e.g. M. Johnston & Vogele, 1993; Michie et al., 2009). The work done by Abraham and Michie (2008) and colleagues in developing reliable methods of describing behaviour change techniques using a taxonomy approach is a significant advance, but indicates the amount of work to be done. The future evidence base for interventions will depend on the publication of studies that have both clear trial methods and descriptions that allow reliable replication. 

Consultancy and committees

In offering consultancy, health psychologists bring their theory and methods to address identified problems, and this has been clearest in consultancy to government. Work for the Public Health Directorate of the Westminster government by Susan Michie, Charles Abraham and Nicky Rumsey focused on behaviour change to reduce behavioural risk factors for disease, such as smoking, low physical activity, alcohol use and 'unhealthy' diet. Amongst other things, they completed major reviews (Abraham & Michie, 2008; Michie et al, 2009) that contributed to the Wanless Report (2004; see tinyurl.com/6l2kzfs), and the Choosing Health public health White Paper (2004). Michie and Rumsey led the writing of the NHS Health Trainer Manual (2007) and the development and evaluation of the England-wide NHS Health Trainer Service. In Scotland, Diane Dixon and Marie Johnston were contracted to focus on the competencies needed by staff to deliver behaviour change programmes, and the work resulted in the Health Behaviour Change Competency Framework (2010; see tinyurl.com/628slol). Health psychologists are also often asked to respond to NICE and government consultations both directly and through the DHP Specialist Knowledge List as part of DHP Publicity and Liaison. Health psychologists also serve on research and health committees including MRC, NIHR, NICE, Scottish Government Chief Scientist Committee.

Teaching and training

Health psychology is taught in undergraduate psychology courses, in postgraduate master's and doctoral courses and in training other health professions. To become a full member of the Division of Health Psychology and apply for chartered status a student needs a BPS-approved psychology degree, MSc in health psychology (Stage 1) and two years supervised practice thereafter (Stage 2). To practise health psychology, they also need to be registered with the HPC.
Most university psychology departments were slow to recognise HP as a distinct area, and even now it is still relatively uncommon for it to be taught as a mandatory part of the undergraduate psychology degree. Nevertheless, there are now good textbooks, including several UK texts in more than one edition (e.g. Morrison & Bennett, 2006; Ogden, 2007). 

In contrast to the patchy role of HP in the undergraduate curriculum, the UK has seen the strong development of postgraduate training, particularly in the form of master's (Stage 1) programmes. From the first master's courses in HP in 1988 (London, City and Surrey) rapid expansion has resulted in well over 20 accredited courses, plus a few doctoral-level professional HP courses. In 2007 the Scottish Government (NES) supported the first funded Stage 2 trainee places in HP, and to date there have been 10 'Health Psychologists in Training' on this programme. However, it is not yet clear how the training and professional roles for health psychologists will be funded in future.
The numbers of postgraduates undertaking PhDs in HP has risen very impressively over the past 25 years, and many of these also completed Stage 1 and 2 HP training, thus qualifying as BPS-accredited health psychologists. 

On the basis of teaching and research, a number of university departments have developed strong HP research groups that have been influential in establishing the international recognition of UK HP research.

Conclusions

We have been mightily impressed by what has been achieved in HP from small beginnings. HP research has developed a large body of evidence with increasing sophistication of theory and methods used. Intervention development and evaluation is now on a more secure footing and looks promising for the future. We are increasingly called on as consultants or collaborators on programmes and projects where behaviour may influence health, illness or health care. Thus there continues to be a need for well-trained health psychologists and for other health professionals to have health psychology inputs.
The challenges lie in ensuring that professional commitments do not undermine our contributions to high-quality research, in enabling professional health psychologists to gain the posts that allow HP to make optimal inputs to health and health care and in continuing to integrate our work with that of other psychological as well as biomedical disciplines. We are confident that the current strength of health psychology can meet these challenges. This issue illustrates this, by asking top figures in the field to choose a significant contribution to the field and the health of the nation.

Marie Johnston is Professor of Health Psychology at the University of Aberdeen

John Weinman is Head of Health Psychology Section at the Institute of Psychiatry

Angel Chater is at the University of Bedfordshire

References

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