‘The people we work with literally love health psychology’

How did you first get into psychology?

I went to study medicine. I did not quite a year, and absolutely hated it. The only bit I liked was the 'psychology roadshows', the holistic thing. It was the early 90s, there was lots of stuff around the psychology of HIV, but also the psychology of long-term conditions and decision-making around health. It was brilliant. I realised I didn't want to be a doctor, so I went and begged the psychology department to let me in – at that time, the grades for medicine were lower than the grades for psychology.

So I transferred, did my three-year degree, and the health bit was just always fascinating to me. I did my undergraduate thesis on quality of life in women with terminal breast cancer, and then tried to get a PhD position with Suzanne Skevington down in Bath. The funding wasn't available, but she did say 'we've just started this new Masters programme, it's in health psychology'. The only way I could do that was by working full-time, so I got a job as an Assistant Psychologist working full-time, squeezed into four days so that I could do my Masters on one day, part-time.

Dedication! What came next?

The job that I had, which was in a memory clinic, funded my PhD, around quality of life and people with severe dementia. After that, I got chatting to Kavita Vedhara at the DHP conference in St Andrews, and she was looking for a postdoc. I got that job with her, and then had a very strange 10-year period in which I had many children! I was in and out of health psychology, and came back into full-time work in 2009. I worked in Liverpool for a year, and then got a lectureship over Manchester.

That's where I picked up again with Jo Hart. We had met as PhD students through the early career workshop of the European Health Psychology Society, run by Marie Johnstone and John Weinman. So many people met at that workshop. I've worked with Jo ever since. We got really interested in this crossover between health professional education and behavioural science.

Is that what attracted you to health psychology, coming from that medical background, the behavioural stuff?

When I was doing my postdoc, I was fascinated by the mind-body connection stuff, the psychobiology. But there were a lot of people who could do that better than I could… I just didn't have the right kind of brain. Kav's work is just so brilliant, and Mark Wetherell's – we were both postdocs for Kav, on the same project – and that probably wasn't where my strengths were. My strengths are really in application. I'm a bit broad, not very deep, in many ways! I'd love to be doing the sort of brilliant theoretical work that other people do, but they're probably doing it a lot better than I would.

You want to see the impact, the change.

Yes, and to understand the change from a psychological perspective as well. That's what I'm really interested in. Not necessarily the 'what' of health psychology, but the 'how'. With a lot of current health psychology we've distilled stuff down, we've reduced it into its constituent parts. I worry that we miss the magic. The behaviour change technique, I use it in my work all the time. But I sometimes wonder if we're thinking about what it is, rather than what it's in a bed of.

I'm a trustee of a public health charity, Medical Aid Films. What got me interested in working with them is that people who create films to change behaviour have heuristics about what has worked and what engages people. How do we specify those components using something like the behaviour change technique taxonomy? What is the glue that makes one film more salient or more impactful than another film? What is the difference between watching Schindler's List and reading a history book? I just think it's so interesting… how do those making the films know what they're doing in that way?

Have you come to conclusions about that?

No, it's an area where we could focus some energy. The reductionist work, about coding and understanding the active ingredients of interventions is really important. And then there is also important work that should be done around what things are holistically. For example, in doctor-patient communication. What makes an interaction meaningful? It's hard to break it down into constituent parts. I'm interested in those aspects and therefore in how we apply psychology to make change.

In my experience of the division and conferences, there is usually a clear line through two or three major models which have clearly been very influential, through to applied aspects. Health psychologists are always looking to make things better, and change.

Definitely. We need to reward all of that. We're also seeing the emergence of more participatory research. People are talking more about the patient-public involvement they do. I was talking to a delegate yesterday, a researcher with lived experience of the condition she's researching. One of the pre-conference workshops was about using creative methods more, such as photo elicitation.

'We're also seeing the emergence of more participatory research. People are talking more about the patient-public involvement they do.'

That's exciting, because it speaks more to embedding the research we're doing within a cycle of impact. It's about the participation, and it's also about social accountability. The days are numbered for applied research divorced from people they should be socially accountable to for that research. But we shouldn't put down research that is really fundamental, experimental, there's space for both.

Do you think the Division and the conferences manage that? Do you think they're representative of health psychology in the UK?

It swings… it's easy for people to identify as a practitioner or a researcher / academic, and then to worry they're not in the right place… that there's not enough of their thing. We need to keep our ears open, make sure that the pendulum is as close to the middle as we can get it.

With our committee, we realised a couple of years ago that we weren't addressing diversity and inclusion, either in our discipline, or in the work that we're all conducting. We created two co-opted roles and asked those individuals to create a taskforce to make us think about those things. We're very much a work in progress on that.

It's about the whole process of health psychology, nationally. It's no longer good enough in any research to say, 'Our sample's like this, because they're hard to reach'. We need to be beyond that now. There are lots of researchers here at the conference who are working in a participatory way with people who have been marginalised… we need to identify and highlight more of that.

It's an interesting time for that, because a lot of the talks at this conference have talked about the impact of Covid – studies and interventions having to move online. The positive impact is being able to reach groups who were previously hard to reach in a health context. But there are also risks, in terms of the increasing digital divide.  

Absolutely. The whole of our health service needs to be doing better around that. It worries me, as someone who is a carer for older people… how do they manage today's Covid world, where they can't even ring and speak to their General Practitioner, it's an e-consult. My uncle's 87, he's just never going to do that. How many people are there like him? That's before you even start with people who are marginalised through poverty and so on.

In terms of Covid, do you think a lot of the things around that will prove to be a blip, albeit a major one?

I think they've changed for good. That's my gut feeling. If you look at the landscape of private medicine, delivering everything through digital is going to be massive. And the other thing is some elective surgeries – some people will just die before they get those surgeries, and what can help those people? It's going to be stuff around self-management and self-care. We know from research that physiotherapy, medication adherence, there's very poor adherence to those things. We need more research and health psychology practice, to support people who are now living with conditions that won't ever be treated in a medical sense.

How does your own research speak to that?

I'm interested in health professional thoughts, feelings, and behaviours, and how they are changed. We can apply that to how they're changed to promote self-management. We have done some work with the NHS around Making Every Contact Count. But the majority of my own work is around a person who's going along doing their job in the way that they've been taught – whatever the clinical field, it might be anaesthesia, antimicrobial resistance in prescribing, maternal health – and maybe they've done it for a long time.

Then here's a new thing – a pathway, guidelines, a care bundle, whatever – how do they change in order to be able to deliver that care in that new way? With Jo, we overlap a lot, but Jo considers how the educational route does that, and I'm thinking about the psychological drivers of current practice and changes in practice.

How is your input as a health psychologist received by medical professionals?

The people we work with literally love health psychology. It's because of the COM-B model. They love it. A long time ago, you'd have gone in and said 'Well, there's these 60 theories, and there's a couple of constructs that I'm interested in…' But now, if we're pitching to somebody – usually people who are trying to deliver health systems strengthening projects, across the UK and in low income countries – and we say, 'what are the reasons that you think people aren't changing?', we then scribe them into a piechart of COM. We say, 'OK, these are all Capability, these are Motivation'. And they completely get that. And then we say, 'COM-B is the centre of the behaviour change wheel, and this is what we can do'. It's amazing.

It seems so obvious, but in a way that probably all genius ideas do seem obvious.

Absolutely. So when we're working internationally, people may say 'but this is from the UK', or 'this is from all of that psychology which is WEIRD [Western, Educated, Industrialised, Rich, Democratic]. How do we know that it's applicable at all in Mozambique, or Tanzania, or wherever?' We say, 'that is a really good criticism, we need to see if it is or not'.

We need to work with you to see if that way we think about the determinants of change and behaviour, in a Global North sense, actually has anything to do with the majority world. And so I was interested in Eleanor Bull's talk yesterday, about some of the work that she's done in Gulu, Uganda, around antimicrobial resistance. I asked if she got a sense that there were things that they were talking about that didn't map on to the Theoretical Domains Framework, or the COM-B. Eleanor said that although the relative weighting of the different facets was different, there wasn't anything outside of our understanding. A couple of other people in the room said that was their experience too.

That's always been an interesting aspect of your work – that you take that international perspective, at a time when the last few years have taught us how we are globally. Health in other countries impacts health in our country.

There's something really levelling about it. I've got a colleague, who's a Dame Professor, a midwife and midwifery researcher. She's unbelievably inspirational. She realised about 15 years ago that if they were going to really improve midwifery services in sub-Saharan African countries, what they needed was midwifery research leaders. So she created a Capacity Building Network of midwifery research leaders in six different countries – Kenya, Malawi, Tanzania, Uganda, Zambia, and Zimbabwe.

Fast forward 10-15 years, and she now is the lead of an NIHR global health unit on neonatal death and stillbirth. The programmes within that are led by those research midwives, working beyond Africa and into Asian countries, driven by these powerful and brilliant research midwives. I feel we need to replicate that in health psychology.

What's stopping us?

At the moment, health psychology is not really seen as a discipline in most other countries, actually. In the Global South, particularly. So, in South Africa, for example, a brilliant colleague who's the national delegate for the European Health Psychology Society for South Africa is trying to gain traction for recognition of health psychology. If you're a psychologist, you have to train as clinical or counselling, so there'll be a clinical psychologist who does health psychology. In other countries, if we're seeking people who do our kind of research, they tend to be public health specialists.

'At the moment, health psychology is not really seen as a discipline in most other countries.'

So I feel we're reaching out, and it can be uncomfortable for us, because what we want is someone on the other side of the partnership who's the same as us. On multidisciplinary teams, there will always be a doctor from the UK, and a doctor from, say, Uganda, but there isn't a health psychologist from Uganda.

The health psychology seems to be pushed in with the Western models and theories. People are doing really good health psychology work, but there's huge inequality in our ability to access funding. Huge systemic racism around publishing. If I'm one of the authors on the paper, and one of the authors is from a lower income country, quite often I'll get a peer review that says, 'this manuscript needs checking by a native English speaker'. I've never had that, for a paper about work done in the UK.

I think it's just immediate. And I have to defend why it's in that country. No one ever says to me, 'but why Manchester?' Although our Welsh colleagues said yesterday, that same thing happens to them. 'Well, this is only Wales. It's not applicable to the rest of the UK.' How can that happen? There's loads of stuff we need to do better, I think.

The Division has been part of your career for a long time, right?

No, I'm a Johnny Come Lately! There's a big group of people around my age who came up through PsyPAG and BPS stuff, but I was off sunning myself in European countries with the European Health Psychology Society. I'd heard rumours that the DHP was quite cliquey, but that not been my experience. I'm a definite outsider, and I've been made to feel very welcome. I've done a couple of jobs on the committee, and now Chair. Honestly, I cannot tell you how functional it is as a group.

I feel so incredibly fortunate, like we're in that sweet spot where everybody is able to pull together, but is also very honest. Jo and I always say this for anyone who volunteers with us with our Change Exchange work… you do as much as you can. Too many voluntary jobs, people run themselves ragged. That's not sustainable. And it's also exclusionary, because someone who's like got a complicated life is going to think they haven't got the mental or physical space for it. Come along, pass the baton, and then someone else comes and does as much as they can.

And get something out of it for yourself. There's nothing wrong with wanting to go into these positions to benefit personally, even just in terms of the network opportunities.

Absolutely. And we just need more people to do more stuff. It's always a worry that you won't get people to take up the positions, but we've got a full complement and it's growing massively in Wales at the moment. The representation of the devolved nations on the committee has always been a bit lopsided.

The committee seem to be from England, and then the Welsh rep, the Scottish rep, Northern Ireland…. We've tried to approach people from the devolved nations to stand for different roles. We're lucky enough to have two people from Wales on the committee. That gives you a bit of power, doesn't it. Like me and Jo, always in a pair!

What's the Division's main emphasis for the next year?

Carrying on with the career stuff. I'm guiding the Health Education England pilot through, because if we can get that to work well, that is the first big evidence we've got for national funding across the reaches of England. We've taken a lot of advice from Scotland on that, because they've been doing that very well for quite a long time, their sponsor and Hannah Dale and so on.

And then a big focus on stopping being exclusionary, in terms of people coming to be with us as a group, and in terms of the content that we are showcasing. There are actually lots of people doing work with marginalised groups that is often participatory, and often very impactful. We want to be shining a light on that sort of work.

Then for me as a Chair, it's working with the Chair Elect Aimee Aubeeluck to think about succession. Through Jo and then Angel Chater and myself, we've been trying not to do anything that is short-termist. You need more than two years to make a change. So we have kept the same aims and objectives since Jo began. It's up to the Chair Elect where their emphasis lies, but I'll be working with Amy about keeping the momentum behind what we're doing.