Stan Maes & Sandra N Boersma. Handbook of Health Psychology. Editor: Stephen Sutton, Andrew Baum, Marie Johnston. Sage Publications, 2008.
Introduction
As Goethe wrote: ‘Knowing is not enough, we must apply. Willing is not enough, we must do.’ However, applications imply a body of knowledge, composed of theories or models and/or intervention principles and techniques that can guide these applications. This implies that applications can be approached from both a theoretical and a practical perspective. While a theoretical perspective is more universal and can be a tool as well as an objective, it requires a vast body of research concerning an organized set of hypotheses. In health psychology, these kinds of research findings are frequently absent. There are many successful intervention programs that lack a theoretically sound and effective explanation. Therefore, a chapter on applications should work towards consequences for research and theory development, rather than present a descriptive list of practical successes. As a consequence, the first part of this chapter, which focuses on health promotion, describes research findings in different settings, followed by conclusions and recommendations for future research and theory building. The second part of this chapter considers psychological interventions in chronic illness. In this case a model of intervention (distinguishing aims, level and channel of intervention) is used as the structure for the description of specific examples of interventions. Likewise recommendations for future research and theory development are given at the end of this section. A general conclusion and discussion section completes the chapter.
Health Promotion Initiatives
This section provides examples of successful interventions aimed at promoting health behavior, changing risk factors for disease and/or reducing morbidity and mortality at a population level. We have tried to present the state of the art for health promotion in different settings, including media-based health promotion and community-based health promotion, as well as health promotion at school, at the worksite and in health care settings. At the end of this brief review, we have formulated suggestions for future health promotion programs.
Media-Based Health Promotion
Mass media are a very popular and effective mode of communication, which can influence or motivate people to change. However, they are often unsuccessful in producing long-term health behavior changes when utilized alone and without other supporting mechanisms (Tones & Tilford, 1994). Therefore, it is suggested that a combination of several different methodologies be used in order to achieve more enhanced results.
A study by Reid (1985), evaluating the effects of a mass media style campaign on smoking, illustrates its relative ineffectiveness at producing such behavioral change when used on its own. In 1984, the UK sponsored a national No Smoking Day for 2 weeks, in which there was wide newspaper coverage, and radio and television slots devoted to the stopping smoking campaign. As a consequence, public awareness was very high. An evaluation study among 4,000 smokers three months after the campaign revealed that about 11 per cent had tried to stop smoking, but only three out of these 4,000 were successful (following the study) at the time of study. While this is an older initiative, the results are still exemplary for the effectiveness of mass media campaigns.
As a consequence, rather than mass media being used in ‘splendid’ isolation, they should be designed to support initiatives from health organizations and community groups. More specifically, they can be used to prepare a large population for a health promotion intervention. Such interventions can consist of self-help materials or face-to-face contact. The following study may illustrate the importance of this comprehensive approach. During the late 1980s a televised smoking cessation intervention was broadcast for 20 days on the local Chicago ABC station. Smokers who were interested in quitting received a self-help manual. To prevent relapse within a few weeks without additional intervention, researchers from DePaul University conducted monthly follow-up support groups for a year and provided incentives to the participants. During the two-year follow-up the abstinence rate of this group was much higher (30 per cent) than the rate of the participants who received no group support (20 per cent) (Jason, 1998). Results from another initiative, the Florida ‘Truth’ campaign, a teenage led anti-tobacco intervention, support these findings. ‘Truth’ made use of print and broadcast ads, teenage action groups, school curricula, tobacco sales restrictions and a website. The campaign resulted in increased knowledge of tobacco possession laws in adolescents and in a significant decline in teenage smoking during the first two years of implementation. These results suggest that media that are designed to attract the attention of adolescents may have a significant impact in combination with other methods (Perry, 2000).
In addition, as media reach the masses, heterogeneity of the target population is an important concern. As a consequence, tailoring messages to the needs of different segments of the population may prove to be a more adequate strategy for intervention. Selecting a specific segment of the population may be the easiest way to reach this goal. From this perspective, there is an urgent need to evaluate the differential effectiveness of media-based health promotion campaigns. For example, the COMMIT Program, a campaign which was supported by the Canadian Ministry of Health, failed to show any effect on quitting in heavy smokers, but proved to be successful for moderate smokers (Institute of Medicine, 2002).
Finally, the use of computer technology for intervention development and delivery provides new perspectives on intervention, including the use of internet sites related to health promotion (an example is the Harvard Cancer Risk Index, which provides cancer prevention assessment and feedback: see http://www.yourcancerrisk.harvard.edu); websites set up to support specific intervention programs (as in the Florida ‘Truth’ campaign); computer-controlled telephone counseling (Friedman, 1998); and tailored interventions using computer-based ‘expert systems’ programs to match messages to the individuals’ information needs (Dijkstra, De Vries, Roijackers & Van Breukelen, 1998; Emmons, 2000). Moreover, a combination of these methods could provide a powerful intervention strategy for health promotion, but to our knowledge there is no published health promotion project that has made use of all these new assets.
Community Health Promotion
The increased awareness that the modification of risk factors and associated lifestyles could influence morbidity and mortality at a population level gave an impetus to community-based health promotion programs. In a first generation of programs there was a concentration on isolated risk factors, such as unhealthy diet, physical inactivity or lack of medication compliance, without documenting whether modification of the risk factor had beneficial effects on morbidity or mortality (Blackburn, 1972). A second generation of programs, which appeared in the 1970s, is characterized by the belief that several risk factors have to be tackled simultaneously in order to influence (cardiovascular) disease outcomes. Examples of these multifactorial trials are the OSLO Study and MRFIT. In both studies large male high-risk populations were selected on the basis of a screening for coronary risk factors (cholesterolemia, hypertension and cigarette smoking). In both cases health education and behavior modification strategies were offered to influence health behaviors that are related to these risk factors (such as smoking, unhealthy diet and lack of medication compliance). The evaluation of the OSLO Study showed impressive results with respect to cholesterol, smoking and consequent cardiovascular morbidity and mortality. The MRFIT Program, on the other hand, was successful in the modification of risk factors but failed to influence cardiovascular endpoints (Van Elderen & Kittel, 1993). Third-generation programs focused primarily on the population at large rather than on selected high-risk groups. However, they were still characterized by a (cardiovascular) disease prevention perspective. Key programs are the Finnish North Karelia Project and the Stanford Three Community and Five City Projects, and more recently the Pennsylvania County Health Improvement, the Pawtucket Heart Health and the Minnesota Heart Health Programs. These programs have been described extensively elsewhere (Taylor, 2001; Tones & Tilford, 1994), but the most important conclusion is that they have the potential to change risk factors and related health behaviors at a population level. With the exception of the North Karelia Project, however, which produced impressive results, the programs failed to show long-term effects on (cardiovascular) morbidity and mortality. Studies of community programs which were developed in relation to other targets, such as cancer prevention, show comparable results (Hancock et al., 1997). Hancock and colleagues (1997), who reviewed methods and outcomes of six community programs related to cardiovascular disease and seven related to cancer, come to the following conclusions. With regard to the method aspect, they state that while the advantages of community action are potentially high, published evaluation studies do not meet proposed criteria for rigorous evaluation. Although several programs do show effects in terms of behavior change, this cannot be attributed to specific interventions, due to a lack of process evaluation. Finally, due to political pressure, there is not enough investment in the development, pre-testing and evaluation of these programs. With respect to outcomes, they make several observations. First, there is a need for practitioners (and policy makers) to accept that the gains in public health will be small, and that it requires a lot of time before effects in endpoints may appear. Second, the population size must remain manageable (somewhere between 6,000 and 20,000 would be ideal). However, it should be noted that most studies were conducted within far larger communities. Third, interventions should focus not only on the most difficult behavioral targets (e.g., smoking cessation) but also on easier or more accepted targets (e.g., solar protection). Fourth, many studies offered very narrow interventions. More variability and flexibility in approach would be more appropriate. Finally, many programs relied on major external funding. Interventions that use existing community resources will not only increase financial viability, but also enhance community ownership of the problem. The authors suggest that the community should also be involved in the evaluation of the programs.
These last remarks may be vital for future community health promotion programs. Most programs are initiated and financed by external parties, such as for study purposes, and are therefore discontinued at a relatively early stage. O’Loughlin, Renaud, Richard, Sanchez-Gomez and Paradis (1998) investigated the factors related to the perceived sustainability of 189 heart health promotion interventions initiated by a public health department or research initiative and implemented in a variety of organizations in Canada. Overall about 44 per cent of these 189 interventions appeared to be very permanent. Independent correlates of perceived sustainability included: (1) the intervention used no paid staff, (2) the intervention was modified during implementation, (3) there was a good fit between the local provider and the intervention, and (4) there was the presence of a program champion. Consideration of these remarks could importantly increase the effects of community-based health promotion programs.
Health Promotion at School
Schools can be considered as one of the most important settings for health promotion, since young people can be encouraged to adopt healthy lifestyles and avoid the uptake of unhealthy behaviors at an early moment in life. This is important for at least two reasons. The first is that the longer people have adopted an unhealthy lifestyle, the more difficult it is to change it. The second is that some lifestyles may already have irreversible health consequences relatively early in life. Among the many behaviors that have been the focus of school-based health programs, the following have received the most attention: behaviors related to unintentional injury; abuse of tobacco, alcohol and other substances; safe sex in relation both to pregnancy and to sexually transmitted diseases such as HIV; healthy nutrition; and physical exercise.
Health promotion in schools has a long history. During the first stage of school health promotion, the focus was primarily on hygiene, in an effort to prevent infectious diseases from proliferating. Moreover, health promotion was utilized to facilitate an overall healthy lifestyle and increase physical activity. During the second stage in the 1970s, health promotion programs aimed to prevent the development of risk factors, increase safety behaviors, and reduce behaviors related to substance abuse (especially smoking) and obesity. These preventive programs were usually directed at a single behavior problem and were mostly school and instruction based. In the 1980s a third generation of programs provided a shift towards health promotion programs that focused on lifestyle rather than on isolated behaviors.
These programs were accompanied by home-based and mass media approaches and based on psychological models. One of the earliest examples of a third-generation program is the Life Skills Training program, which took a competency enhancing approach to substance abuse prevention. It focused on the development of broad-based coping skills over a period of three years, namely from seventh through ninth grade. During the first year, 15 sessions were offered. Topics covered were: decision making, resisting advertising techniques, stress management, communication skills, social skills and assertiveness. Fifteen reinforcement sessions were offered during the eighth and ninth grades. The program, which was offered by good role models, became widely disseminated and proved to be effective in preventing substance abuse, including problem drinking, cigarette smoking and marihuana use. Assertiveness, self-esteem and negative attitudes towards unhealthy behaviors increased, while social anxiety, external locus of control and susceptibility to social pressure decreased (Botvin et al., 1992). This program showed that a more general intervention approach, focused on various addictive behaviors and based on psychological models, may bring forward broad effects. Many other programs have since profited from these findings.
The Know Your Body program is an example of a more recent skill-based program designed to promote healthy behaviors and prevent risk behaviors from preschool education through grade six (Resnicow, Cross & Wynder, 1993). The program focuses on a wide scope of health issues related to various forms of substance abuse, exercise, nutrition, hygiene, disease and injury prevention, growth and development, social relationships and environmental health. It also includes many extracurricular activities (e.g., walks and healthy food-tasting parties) and invites the participation of other peers, parents and community members. The program is very flexible as it can be adapted to the schools’ needs and resources and can also be integrated in a wide variety of subject areas. The effectiveness of the program was evaluated by means of a quasi-experimental research design and proved to have significant effects on a variety of outcome measures, including blood pressure, smoking and HDL cholesterol, which have been identified as the main risk factors for coronary heart disease. More recent programs such as the Seattle Social Development Project (Hawkins, Catalano, Kosterman, Abbott & Hill, 1999) also highlight the importance of the social environment and the social context in youth and adolescent health promotion initiatives. This multicomponent project consists of continuous interventions from first to sixth grade in 18 urban, public elementary schools. The intervention aimed to increase social bonds between children, family and the school and consisted of: (1) teacher training in classroom management, interactive teaching methods and cooperative learning; (2) social competence training for the children; and (3) parent training to increase skills for promoting school achievement and to prevent substance abuse. At age 18, adolescents who had been exposed to the intervention during the whole primary school period reported less involvement in violence, sexual intercourse and heavy drinking (but not in other forms of substance abuse), as well as a higher commitment to school and better academic achievement, than a comparable control group.
These results show the importance of complementary interventions, which focus on the social context and environment, for interventions directed at health behavior changes at an individual level. Data from the Tobacco Policy Options Program pointed in the same direction. This program aimed at reducing teenage access to tobacco from stores and vending machines by means of a community action team. It resulted in policy changes in the community related to tobacco access. This approach proved to bring about a significant reduction in teenage smoking over the three-year period of intervention (Forster et al., 1998).
As a consequence, the state of the art suggests that comprehensive programs that are based on psychological theory, are supported by out-of-school activities to create a bond with the family and the community, and are offered over a long period, are the most effective (Orlandi & Dalton, 1998).
Health Promotion at the Worksite
The promotion of wellbeing, health and safety at the worksite has a long history which can be characterized in a series of stages (Goldbeck, 1984). During the first stage, interventions focused on the quality of the product and physical aspects of safety. For example, a smoking ban was introduced in the food industry in order to prevent contamination of the products and in the petroleum industry in order to prevent fires and explosions, but not because smoking harms the individual. During the second stage, in the 1960s, there was growing attention to the wellbeing and health of managers. As a consequence, stress management and/or physical fitness programs were offered to this specific group. For the other employees at best only existing safety measures were expanded to promote individual safety. During the third stage in the 1970s, the concept of disease and accident prevention became central: the reduction of recognized risk factors (such as smoking, hypertension, high serum cholesterol or unsafe behaviors) was the focus of a range of interventions that consisted primarily of behavioral advice following screening procedures. During the fourth stage in the 1980s, total ‘wellness-health’ promotion programs were introduced. These programs recognized the interrelation between these two concepts, and were offered to all employees instead of specific subgroups. Furthermore, health promotion, instead of disease prevention, was the ultimate goal. Two frequently cited examples of such programs are the Johnson and Johnson Live For Life program and the Data Control’s Stay Well program. These American programs were designed to improve wellbeing and health by promoting individual behaviors (including, e.g., smoking cessation, weight control, physical exercise, stress management, improved diet and nutrition, reduced alcohol consumption and blood pressure control) and changes in the working environment to support these behaviors (e.g., smoking bans, provision of space and optimal conditions for physical exercise, changes in food and alcohol supplies) (Cataldo & Coates, 1986). The effects of these programs were evaluated by means of quasi-experimental designs. Following one year, the findings indicated more favourable changes in the experimental Johnson and Johnson sites, which were exposed to the Live For Life program, with respect to the percentage of employees above ideal weight, physical exercise, blood pressure, cigarette smoking, and self-reported sick days. At the two-year follow-up, the program had a significant positive impact on exercise, physical fitness, and cigarette smoking. A three-year evaluation period was used to assess the effects of the program on self-reported absenteeism. Results indicated that the impact of the program on absenteeism was restricted to lower-income employees. A health care cost analysis of the Live For Life program indicated that inpatient costs for the experimental groups rose at a significantly lower rate than in the control groups. Evaluation of the Stay Well program showed comparable results (Wilbur, Hartwell & Piserchia, 1986).
Nowadays, a fifth stage can be observed in worksite health promotion (WHP) programs, especially in Europe, Canada and Australia. Besides interventions focusing on lifestyle and health risk of employees, the fifth-stage WHP programs intervene on quality of work aspects, which may be the real cause of problems in the area of wellbeing, health and safety. In this view, the workplace is recognized both as an important target (Wilson, Holman & Hammock, 1996) and as a determinant of health (Harden, Peersman, Oliver, Mauthner & Oakley, 1999). The improvement of working conditions is assumed to enhance wellness and health. In several countries in Europe, legislative guidelines concerning health and wellness at the worksite have stimulated this development. To give an example, in Norway and Sweden the Work Environment Act emphasizes that work conditions must permit the employee to influence his or her working situation. The work must also be organized to allow the development of competence, social contacts, and the ability to make decisions. In the Netherlands the Dutch Labor Act defines similar healthy work conditions.
One of the first representatives of the fifth stage is the Brabantia Project, named after a Dutch household products manufacturer where the program was implemented and evaluated. The project was evaluated by means of a quasi-experimental pre-test/post-test control group design with repeated measures. Interventions directed at lifestyle and working condition changes were implemented in the experimental site. Two other comparable Brabantia sites formed the control group. The control group received no intervention, but also completed the pre-test and a series of post-tests administered one, two and three years after the pre-test. In addition absenteeism data were gathered during the whole period of intervention. During the first year of intervention, activities were mainly targeted at lifestyles, including physical exercise, healthy nutrition, alcohol and drug consumption, smoking behavior, stress and pain. Interventions directed at working conditions or quality of work were implemented during the second and third years because a longer period of preparation is required for these interventions (Maes, Verhoeven, Kittel & Scholten, 1998). On the basis of a wellness risk assessment, an autonomous group of workers was established for each production unit and given authority over the entire production process, from collection of raw materials to delivery of the product to the sales department. This implied additional tasks for the workers such as initiating work orders, arranging supply and transport of raw materials and finished products, calculating hours spent on tasks, and performing quality checks. In addition to this greater variety of tasks, rotation of tasks became possible. Interventions at the individual level directed at lifestyle changes, which were introduced during the first year of intervention, brought about a favorable change in health risk at the first post-test. However, the initial effect on health risk disappeared at the second post-test, which illustrates the need for continuous and more extensive intervention to produce long-lasting effects on health outcomes. Furthermore, the program had favorable effects on working conditions, including psychological demands, control and ergonomic conditions, as well as on absenteeism.
In conclusion, in contrast to the American fourth-generation WHP programs, the Brabantia Project emphasized the organization and content of work rather than lifestyle. Therefore, it is not surprising that the project had the strongest and most enduring effects on perceived working conditions and absenteeism. The American fourth-generation programs focused more exclusively on a healthy lifestyle and health risk, and therefore tend to score better on health-related variables. It seems that the positive effects that these programs have on outcomes such as absenteeism are achieved through a different pathway. A combination of both approaches may produce superior and more sustainable effects.
Health Promotion in Health Care Settings
From a cost-effectiveness point of view, it is surprising how many existing health care services remain unused as a source of health promotion. In particular, primary health care physicians or nurses and basic health services could play an important role in health promotion. The INSURE/Life Cycle Preventive Health Services Study (Logsdon, Lazaro & Meier, 1989) was one of the first comprehensive trials which demonstrated the possible cost-effectiveness of this approach. The American study was set up in order to determine the possibility and cost of providing preventive health care through primary health care physicians. The intervention comprised a combination of regular medical check-ups and X-ray examinations with patient education and counseling for behavioral risk factors. The study used a controlled design and involved 5,000 patients, who were seen by 74 physicians from five group practices. Data from a three-year feasibility study revealed that costs were controllable and showed several interesting effects: 17 per cent of the patients who smoked quit smoking as a consequence of the INSURE intervention; 33 per cent of the previous sedentary patients reported to have increased exercise levels one year after their INSURE check-up; 43 per cent of the patients lost weight; 22 per cent of those initially not wearing seat belts reported they were now using them; 53 per cent of the women who did not do breast self-examinations before the intervention now did so; and 35 per cent of the chronic drinkers reported to have decreased their alcohol consumption. The yearly average cost of the INSURE examination was $73 per person and the average utilization by patients was 38 per cent.
However, not all trials were equally successful. Ashenden, Silagy and Weller (1997) published a systematic review on the promotion of lifestyle changes in primary care. This review examined how effective lifestyle advice offered by primary health care physicians influenced patients’ behavior related to smoking, alcohol consumption, diet and exercise. The review includes 23 trials for smoking, six for alcohol consumption, 10 for dietary behavior and six for exercise. Two hypotheses were examined: (1) that provision of advice is more effective than no advice; and (2) that intensive advice is more effective than brief advice. For smoking the first hypothesis was supported, but no significant difference was found between intensive and brief advice. Because of the small number of trials on the other three behaviors, only the results for the first hypothesis are reported here. It appears that advice can be effective for alcohol consumption, and that this benefit can be detected at a biochemical level. For dietary behavior, no conclusions could be drawn because of the wide variety of outcome measures used in the different studies. For exercise there is evidence that advice may have an effect on self-reported exercise levels. Notably, all changes were small. The authors conclude: ‘that at present there is insufficient evidence to warrant a mass population approach to health checks and lifestyle advice in a general practice setting’ (1997:173). However, even if the effects are small at a population level, the absolute number of people who would change their health behavior might be substantial if an INSURE-like program were to be offered throughout the Western world by all primary health care settings. Indeed, primary health care professionals see large parts of the population on a regular basis and are seen as credible agents of change. However, many of them seem to lack time and/or motivation to engage in health promotion initiatives (Bowler & Gooding, 1995). This is at least partly due to the fact that the main cost of preventive interventions is not covered by (national) health insurances, but also because the role of physicians and nurses as health agents, in the real sense of the word, will require a change in the mentality of the population, the health professionals, and policy makers.
Conclusion and Discussion
Health promotion initiatives in all these settings have proven to be successful in creating health behavior change and/or risk factor reduction and to have the potential to influence morbidity and mortality at a population level. In the beginning, the focus of initiatives was on disease prevention rather than on health promotion. The programs aimed at changing isolated behaviors (e.g., smoking, exercise or diet) that were narrowly linked with proven risk factors for a specific disease. As these programs did not prove to be very successful in influencing disease outcomes and mortality at a population level, a change in strategy followed during recent decades. This development can be described in terms of the following trends. First, program developers realized that unhealthy behaviors do not exist in isolation, but are linked to other behaviors, which constitute a lifestyle. As a consequence, interventions became more comprehensive, focusing for example on the prevention of substance abuse rather than on smoking (Botvin et al., 1992) or on an even wider variety of behavioral targets (including smoking, weight, physical exercise, use of alcohol, diet and nutrition, and stress), as for example in the Johnson and Johnson Live For Life program (Cataldo & Coates, 1986). Second, program providers were convinced that programs had to be continued over a long period of time in order to have substantial and lasting effects. For example, in contrast to earlier school-based health promotion programs, the Seattle Social Development Project (Hawkins et al., 1999) was offered throughout elementary school from the first to the sixth grade. Third, a related insight concerned the sustainability of programs, which was enhanced by collaboration with the community. A good example of this may be found in the community-capacity building approach of the Stanford Five City Project (Jackson, Altman, Howard-Pitney & Farquhar, 1989). Fourth, many earlier programs were conducted in a social vacuum, focusing on individual health behavior change. Recent successful health promotion programs involve the community to support and complement lifestyle changes. School-based health promotion programs which made use of community action, such as the Seattle Social Development Project (Hawkins et al., 1999) and the Tobacco Policy Options Program (Forster et al., 1998), are good examples of this trend. The Brabantia Project, which focused on changes in the work environment in order to improve quality of work life, next to lifestyle changes, is an example of this social ecological approach at the worksite (Maes et al., 1998). Fifth, there is a trend to combine levels and channels of intervention in order to maximize effects. For example, although media-based health promotion is mostly unsuccessful in bringing about health behavior change, Jason (1998) reports that a combination of a mass media approach with self-help material and support groups proved to substantially cut smoking rates in the target group. The Florida ‘Truth’ campaign, which made use of broadcasts, teenage action groups, school curricula, tobacco sales restrictions and a website, is another example of a wide scope program which effectively reduced teenage smoking (Perry, 2000).
There are however two other remarks to be made which can further improve future health promotion programs. The first concerns the extent to which these programs are based on sound psychological models for behavior change. While many agree that the use of appropriate theory should be part of the design and evaluation of health promotion initiatives (Green & Tones, 1999), this is not always the practice. On the one hand, there are initiatives which were also set up for research purposes. These initiatives frequently involve psychological expertise and are usually theory based. For example, Botvin and colleagues (1992) developed an effective program for the prevention of teenage substance abuse based on social learning theory. These programs tend however to be smaller and often have problems with sustaining the intervention over time and disseminating them widely in the population (Brunner et al., 1997). On the other hand, there are broader initiatives which involve simultaneous actions in several settings and address large parts of the (general, school, worksite or health care) population. Some of these initiatives have explicit theoretical roots, as for example the North Karelia Project and the Stanford Three Community and Five City Projects (Tones & Tilford, 1994), and are mostly ‘demonstration’ projects set up by university departments in cooperation with the community. However, policy makers and/or managers at broadcasting centers, schools, worksites or health care institutions usually participate in these larger initiatives. Psychologists are thus seldom at the helm of these initiatives. As a consequence, these programs make use of mass media, and educational or medical (including social epidemiological) expertise, but seldom reflect the psychological knowledge base concerning health behavior change. It should be noted, however, that psychologists have not been very active in cooperating with other experts in this respect (Jason, 1998) and that the diversity of psychological models that can be applied to health promotion constitutes another barrier. The health action model analysis of the psychosocial and environmental influences on health-related behavior is a good illustration of the diversity of psychological influences on health behavior (change) (Tones & Tilford, 1994). As many health psychologists tend to work only within one or a few paradigms, which are relevant for these influences, psychological knowledge is not very accessible for other professionals, who would like to address the full range of these influences. In other words, psychologists have not put enough effort into the translation and communication of their knowledge base to other professionals. The aforementioned Dutch worksite health promotion program, known as the Brabantia Project, was based on a set of principles for intervention, which can be the start of such a translation effort. The principles are derived from a variety of theoretical perspectives in psychology, including operant conditioning, associative learning, cognitive-behavioral theory, social cognition, social learning, and stage theories, and thus provide a sound basis for an effective and integrative approach to health behavior change (Lee & Owen, 1985; Maes, 1990). Table 11.1 gives a brief description of these principles. The interested reader is referred to Maes and Van Elderen (1998) which describes them in more detail. While these principles may seem elementary, they are frequently violated in existing health promotion initiatives.
A second remark concerns methodological shortcomings. The effectiveness of interventions should be judged in terms of the achievement of prior stated goals. In providing such evidence, evaluation studies frequently suffer from the typical errors known as type I error, type II error, and type III error. Green and Tones (1999) give a good description of the relevance of these methodological requirements for the evaluation of health promotion programs. Type I error occurs when inadequate use of control groups is made in randomized controlled trials. However, for many health promotion initiatives, it is not feasible or even advisable to randomly allocate individuals to experimental and control groups. A more realistic perspective may be to randomize institutions (such as schools, worksites or health care centres), but in some cases, as for example in the case of community health promotion programs, it may very difficult to find adequate control groups. In addition, the intervention may be hard to control in the cases where the initiative comes from the community itself and contamination of the control group is also likely to occur. Type II error occurs when the research design fails to tap the actual changes that are caused by the intervention. While this can be due to lack of measurement sensitivity there are many other sources that can cause this error. A common problem of many intervention programs is that they are too ambitious in the sense that they set change goals that are hard to achieve, for example changes in morbidity and mortality. These epidemiological changes mostly require a very long time frame, which is preceded by a change in risk factors and health behaviors, which are in turn preceded by determinants of health behavior change like changes in knowledge, context and efficacy beliefs or skills. There are many authors who plead for the formulation of realistic and achievable goals (Hancock et al., 1997). Another problem is that many programs aim for general rather than relative effectiveness. For example, a Canadian antismoking campaign, the COMMIT Program, proved to be effective for moderate smokers, but not for heavy smokers (Institute of Medicine, 2002). Finally, another common shortcoming that will cause type II error is that the sample size is too small to demonstrate statistically significant differences (Hancock et al., 1997). Type III error refers to rejection of program effectiveness on the basis of inadequate program design or delivery. To prevent this type of error it is necessary to document and monitor program delivery and implementation. However, this type of information, usually referred to as process evaluation, is seldom available in evaluation studies.
Table 11.1 Principles of health promotian
| Principle | Description of the principle | |
| 1 | Behavior change occurs in stages | Behavior change is a dynamic process, characterized by at least three stages: the decision to change, the initial active change and the maintenance and generalization of the new behavior. Different interventions are required for each stage |
| 2 | Appropriateness and convenience of settings | Behavioral change programs should be easily accessible, be available to all and free. Environmental changes are thus necessary to support programs |
| 3 | Setting realistic goals and shaping the process of change | Small changes are more likely to be effective in producing initial change. The goal of intervention should thus be close to peoples’ current behavior and carry them stepwise to other levels |
| 4 | Intrinsic value | People are more likely to persist in activities they find enjoyable and interesting. Programs should be attractive and integrate activities that counteract possible reductions in wellbeing, which accompany the change |
| 5 | Soundness and specificity of information | Health messages need to be specific and inform people concerning how, when and where to act |
| 6 | Variety | Offering many alternative ways to achieve behavior change is more successful |
| 7 | Multiple levels | Behavior change should be supported by changes in people’s immediate and distant environment, including regulation and legislation |
| 8 | Use of social networks | Existing social networks in various settings have an important impact on individuals’ lifestyles. Individual behavioral change should thus be complemented by social changes and community action |
| 9 | Choice and personal goals | If people make the decision to change themselves, they are more likely to persist in it. Interventions should thus start from personal goals or carefully plan a goal adoption process |
| 10 | Independence | Dependence on any particular place or person reduces the individual’s capacity to continue the target behavior if the situation alters. People should thus be involved in program development, delivery and dissemination |
| 11 | Sustainability of interventions | Maintenance of behavioral change requires continuous intervention. Interventions should thus not occur as single or temporal events, but should be continuous |
Psychological Interventions in Chronic Illness
While health promotion initiatives traditionally have a large population focus, psychological interventions in chronic illness focus on smaller, more specific patient groups. Many of the principles that were described at the end of the previous section can also guide the development of psychological interventions for patients with chronic diseases. Nevertheless, most of the existing interventions are more individual or clinical in nature, relying on principles derived from stress management, (cognitive) behavior therapy, rational-emotive therapy, and other clinical intervention paradigms. As a consequence, the theoretical base for many of these interventions is more derivative. In an attempt to structure the variety of interventions offered to patients with chronic diseases, Maes (1993; see also Maes & Van Elderen, 1998) developed a model that makes a distinction between intervention aims, levels and channels. As such three different dimensions are discerned along which an intervention can be located, namely: (1) intervention aims (restoring or increasing quality of life versus promotion of self-management); (2) intervention level (the patient, a group of patients or the larger physical and social environment of the patient); and (3) intervention channel (direct face-to-face contact between a psychologist and a patient, or indirect interventions through for example trained health professionals). The following sections are based on these three dimensions. All psychological interventions in chronic disease are in principle directed at quality of life, self-management or both, and the intervention aims dimension is considered in terms of these two forms.
Intervention Aims: Quality of Life Interventions
Interventions that focus primarily on quality of life aim at increasing the physical, psychological or social wellbeing of the patient and his or her immediate environment. These interventions are designed to stimulate a process of adaptation to or acceptance of the disease. More specifically, these interventions are aimed at reducing stress, pain, or problems related to the performance of daily activities (including work, leisure and household activities, as well as activities related to social roles within the family). These include physical training programs, stress management programs, and interventions that provide social support.
Various physical training programs are offered to different groups of patients, including patients with coronary heart disease (CHD) and chronic respiratory diseases. These programs seem to have effects on quality of life and wellbeing (as, e.g., a reduction of anxiety and depression) as long as patients engage in physical training (Maes, 1992; Van den Broek, 1995). Physical exercise, however, can also have important effects on disease-related outcomes. For example, meta-analyses have indicated beneficial effects on morbidity and mortality of physical exercise for patients suffering from CHD (Maes, 1992), and show that exercise reduces glycosylated hemoglobin (HbA1c) and the risk of complications in diabetic patients (Boule, Haddad, Kenny, Wells & Sigall, 2001).
Stress management programs include intervention techniques such as cognitive restructuring and relaxation, as well as coping skills training and social support interventions. As will be illustrated in this section, more elaborate stress management programs not only improve quality of life but can also affect disease progression and even mortality in patients with cancer, CHD and HIV. An example of a group intervention targeted at enhancing the management of stress is ‘the hook’. This technique helps post-myocardial infarction patients to gain control of their emotional reactivity to daily stressors (Powell, 1996). It was part of the Recurrent Coronary Prevention Project, a 4.5-year clinical trial aimed at altering type A behavior, that had impressive beneficial effects on the recurrence of myocardial infarction (Friedmann et al., 1984). This cognitive exercise was especially designed to promote a shift in basic beliefs and attitudes and is a good example of cognitive restructuring. The strategy consists of a group discussion around three questions. A simple and straightforward metaphor, that is a hook, was used to allow participants to recognize a stressor as such and to change their cognitions instantly instead of changing the stressor. More specifically, when starting the group session, participants were asked to describe an incident in which they became angered, irritated or impatient. At the first question (‘What is behavior modification?’), the general idea of cognitive change was introduced. Participants worked interactively with the therapist to come up with answers and examples. The second question (‘What is impatience/irritation?’) sensitized participants to the type of stressors, small and unexpected, that are likely to promote the quick response of anger or impatience/irritation. At this point, the metaphor of ‘the hook’ was introduced to describe these responses. At the third question (‘What can we do about it?’), the alternative cognition of labeling a stressor as a hook instead of an unfair situation was used, thus neutralizing its arousal effect. Patients in the trial reported that of all the strategies they were being offered, ‘the hook’ helped them most in reducing their irritabilities and anger.
Besides cognitive restructuring, some forms of relaxation are often used alone or in combination with other techniques in order to enhance the management of stress and subsequently improve quality of life. Nowadays, there is a wide span of relaxation techniques that can be used either individually or in group programs (Dixhoorn, 1998). Examples are progressive muscle relaxation training, guided imagery, meditation, biofeedback, and breathing techniques such as yoga. Relaxation is widely recognized as an effective intervention strategy for hypertension (Johnston, 1992). An example of a successful intervention program of which this form of stress management is an important ingredient (next to diet, physical exercise and group support) is the Ornish Program for reversing coronary heart disease. This program proved to bring about lifestyle changes in patients with coronary heart disease, paralleled by a reversal of coronary atherosclerosis within one year. Even more regression was noted after four years, resulting in a significant improvement in blood flow to the heart and thus in a reduction in angina complaints, comparable to that achieved after coronary artery bypass grafting or coronary angioplasty The stress management component is based on hatha yoga and includes stretching, progressive relaxation, breathing techniques, meditation and visualization. Patients practice a combination of these techniques at least 1 hour a day on the basis of an audiocassette with a pre-recorded program (Billings, 2000).
Coping is an important moderator of stress in patients with chronic disease (Maes, Leventhal & De Ridder, 1996). Therefore coping skills training may also help patients to adjust to the stresses of illness and treatment. For example, anticipation of hospitalization for surgery and adjustment to limitations afterwards may be difficult, especially for children. In an attempt to reduce the distress that could lead to short-term and long-term behavioral and emotional problems, Zastowny, Kirschenbaum and Meng (1986) developed a coping skills training targeted at the child-parent dyad. The intervention was based on the stress inoculation theory (Meichenbaum, 1975). One week prior to hospitalization, both parents and children were shown a videotape in which a frog puppet described his rather positive experiences during hospitalization. Next, they were given a tour of the different units of the hospital. While the children were given an opportunity to play, the intervention focused specifically on the parents. First they were presented with videotaped lectures on the experience of stress and the use of coping skills on a conceptual level. They were explicitly told that deep breathing and physical relaxation could help reduce one aspect of the stress experience. The other aspects of stress could be reduced by going through the four phases of coping, namely: (1) preparing for a stressor; (2) confronting and handling a stressor; (3) coping with feelings at critical moments; and (4) reinforcing oneself for successful coping. Parents were invited to act as ‘coping coaches’, assisting their children by demonstrating procedures that would help them to reduce their own distress and by working together through a preparatory booklet for high-stress points during the upcoming hospitalization. Finally a videotape was shown to illustrate the desired kind of interaction, and parents were given a handout summarizing their responsibilities as coping coaches. Compared to a group of child-parent dyads who received only information about the positive and stress-reducing effects of spending extra time with their child in the week prior to hospitalization, the coping skills training group showed a reduction of children’s self-reported fearfulness and parents’ reported distress. Furthermore, there were fewer maladaptive behaviors observed during hospitalization, as well as less problematic behaviours in both the pre-admission week and the second post-discharge week.
Another group of interventions aimed at improving quality of life can be characterized as social support interventions. Social support has the potential to buffer stress (Cohen & Wills, 1985). Interventions that aim to increase social support may have important effects on patients’ psychological adjustment or quality of life. There is a plethora of literature demonstrating the beneficial effects of patient support or discussion groups for various groups of chronic patients, including rheumatoid arthritis patients, cancer patients, myocardial infarction patients, and epilepsy patients, among others (Taylor, 2001). However, it seems that not all forms of social sharing with other patients are equally beneficial. For example, patients who were paired up with either a post-operative or a non-surgical patient were shown to experience significantly less anxiety than when they shared a room with another pre-operative patient (Kulik, Moore & Mahler, 1993). Therefore, even more practical and low-cost interventions, such as roommate assignment on the ward, can lead to a reduction of patients’ pre-operative anxiety levels by increasing the opportunity for social support.
Some studies show that there is a beneficial effect not only on adjustment but also on recovery and mortality. The study by Spiegel, Bloom, Kraemer and Gottheil (1989) is a well-known example. In this study, which focused on group discussion, metastatic breast cancer patients were randomly assigned to a control group and an intervention group. Weekly group meetings were held during 1 year. These meetings focused on problems that the patients experienced and on ways to improve their social relationships. At the end of the intervention, the patients who received the intervention reported better adjustment than the control group patients. A 10-year follow-up proved that the intervention also increased survival rates. Results of another study (Fawzy et al., 1993) pointed in the same direction. In this study melanoma patients were randomly assigned to a control group and an intervention group that received six weekly 90-minute sessions. The intervention was more comprehensive than the one offered in the Spiegel study. Apart from group discussion, informational support was also provided (education, stress management and coping skills). The intervention proved to reduce psychological distress and to alter immune function at six months, and to increase survival at a six-year follow-up.
Helgeson and Cohen (1996) conducted a literature review on social support and adjustment to cancer. They came to the conclusion that correlational studies suggest that emotional support has the strongest association with better adjustment. However, the effectiveness of peer discussion groups is less convincing, since educational groups providing informational support appear to be at least as effective as peer discussion. In a recent study, researchers from Pittsburgh (Helgeson, Cohen, Schulz & Yasko, 2001) offered psycho-educational intervention, a social support intervention, or a combination of both interventions to three groups of early stage breast cancer patients. A fourth nonintervention group functioned as a control group. Patients who had received the psycho-educational or the combined intervention reported less distress and higher levels of adjustment than those who received the social support intervention or belonged to the control group. Ongoing research (Baum & Andersen, 2001; Helgeson et al., 2001) suggests that these interventions not only have the potential to improve psychological adjustment but also can alter the immune status and disease course.
Effective interventions for enhancing the management of stress in chronic patients seem thus to entail a combination of different strategies or components. The already described interventions by Ornish (Billings, 2000) and Helgeson and colleagues (2001) illustrate this point. Another illustration of a comprehensive intervention, targeted at restoring quality of life using a combination of different strategies, is a program designed to reduce anxiety and depression in HIV-seropositive gay men after their first diagnosis (Lutgendorf, Antoni, Schneiderman, Iroson & Fletcher, 1995). Based on those psychological factors that are likely both to facilitate or mediate quality of life in infected individuals and to be accessible to intervention, a 10-week cognitive-behavioral stress management (CBSM) group program was primarily targeted towards enhancing a sense of control, relaxation, effective coping strategies and adequate social support resources. During these 10 weeks, participants met twice a week, and attended one session in which CBSM strategies were taught and one weekly relaxation training. First, the participants were introduced to a cognitively based model of distress and were subsequently taught how to identify their personal and frequently used distortions and how to refute and replace them with more functional appraisals of their HIV status. Second, maladaptive coping strategies like denial and substance use were identified and more direct methods of coping to alleviate distress were introduced, as well as assertiveness training. Finally, the use of social support was emphasized through interaction with the group, and the identification of possible sources of social support and potential problems with social support systems. In the weekly sessions devoted to relaxation training, participants learned progressive muscle relaxation and were requested to practice relaxation at least twice daily at home. Compared to a control group including HIV-seropositive gay men, the men who participated in the program showed no increase in anxiety and depression after receiving the first diagnosis of their infection and reported no decrease in either levels of social support or adaptive coping strategies, in addition to an increase in immunological functioning. Interestingly, the amount of denial used as a coping strategy at the end of the intervention, as well as greater frequency of home practice of relaxation during the 10-week program, predicted better immune functioning one year later. A slightly modified version of the program was also offered to a group of patients with early HIV infection but who were still asymptomatic. Comparable results to the first study were reported. Furthermore, the use of active coping, planning and acceptance of the disease increased and these results were paralleled by immune status changes.
These results show that a psychological intervention with different components aimed at maintaining sufficient levels of life quality, despite challenging circumstances (the onset of a debilitating disease and a shortened but uncertain lifespan with a possible social stigma attached to it), apparently had an impact on psychological wellbeing as well as on the physiological status of the patients.
Thus far, we have focused on interventions that target increases in quality of life. We will now devote attention to interventions that target self-management.
Intervention Aims: Self-Management Interventions
Some intervention programs have a clear focus on self-management in chronic patients. Living with a chronic disease is a difficult task, which frequently requires important lifestyle changes and adherence to medical advice, aimed at stabilizing or slowing down the progression of the disease or reducing undesirable physical consequences and complications. Influencing the progression of the disease or preventing ‘things from getting worse’ is defined in the literature as secondary prevention. Preventing undesirable consequences and complications, for example accidents in epileptic patients or gangrene in diabetic patients, is seen as tertiary prevention. From a disease management point of view, required behavioral changes may vary from disease to disease, but include changes such as: (1) taking medication or keeping appointments with health care workers for various forms of diagnosis and treatment; (2) changing unhealthy behaviors like smoking and excessive fat, salt, sugar or alcohol intake; (3) adopting healthy habits like physical exercise, taking regular meals, maintaining normal body weight, taking enough sleep, rest or relaxation; and (4) engaging in a variety of self-management behaviors like monitoring blood sugar, taking sanitary measures at home and at work, avoiding working with machines, driving a car or swimming alone, and maintaining regular exercise for arthritic hands and fingers.
Research has repeatedly demonstrated that about half of chronic patients do not adequately follow medical advice. Interventions to assist patients to follow prescriptions for medications can range from instructional pamphlets, workbooks, pill containers and telephone reminders, to counseling and family therapy. Evidence suggests that written information and counseling are effective for short-term treatments. Effective interventions for long-term medication treatment appear to be complex and include various combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy and other forms of additional supervision or attention. Granted, these techniques do influence the extent to which patients adhere to medical advice with respect to medication, but the improvements are often not substantial (Haynes, McKibbon & Kanai, 1996). Many health care workers seem to be unfamiliar with the reasons for non-adherence. Research has shown that adherenceto medical advice is not related to personal characteristics such as age, gender, race, religion, educational level, income or personality characteristics. Noncompliance is also not dependent on objective disease characteristics, such as the severity of the disease or the nature and severity of symp toms. Instead, whether people follow medical advice or not is related to the nature and form of advice and social support, illness perceptions, comprehension of the advice and the treatment plan, and characteristics of the provider-patient relationship (Brannon & Feist, 1997).
In other words, faulty communication by health professionals is one of the most important sources of non-adherence. Unfortunately, faulty communication seems to be the rule rather than the exception. In a study by Phillips (1996) about half of the 320 obstetrics and gynecological patients that were questioned reported that they were dissatisfied with the care they had received. Complaints regarded lack of sensitivity to the patients’ conditions, evasion of direct questions, use of medical jargon and lack of information provision. This lack of attention for the patient may however not be a deliberate attitude, but can be attributed to a high workload (care requires time) or a lack of skills training. Remarkably, Williams et al. (1997) reported that only 16 per cent of a sample of young medical doctors affirmed being taught assessment of psychosocial factors. Doctors were also shown to have a different (problem solving) perspective from the patient. A study by Berry, Michas and Gillie (1997) presented 16 categories of information to both doctors and patients, and asked them to rank these from one (not at all important) to five (vital). A rank-order correlation between the doctors’ and the patients’ rankings showed no correlation (rho = 0.02). While this difference can be explained by the fact that patients and doctors have indeed different perspectives, medical curricula should pay more attention to training in information provision and doctor-patient communication in order to enhance self-management in patients.
It should be noted, however, that it is the patient and not the health professional that is ultimately responsible for adequate management of his or her chronic disease. From this perspective, terms like ‘compliance’ or ‘adherence’ are concepts of the past, since they suggest that patients must follow medical advice. Today, the self-management of a chronic disease is a more defendable intervention target. Many types of self-management techniques have been applied in interventions with chronic patients, including self-monitoring, goal-setting, behavioral contracting, shaping the process of change, self-reinforcement, stimulus control, covert control and cognitive restructuring, behavioral assignments and modeling, or observational learning (Bennett, 2000; Taylor, 2001). Self-management programs for chronic patients make use of a combination of these and other techniques such as rational-emotive therapy or training. At present, there are self-management programs for a variety of chronic conditions such as hypertension, coronary heart disease, asthma, diabetes, rheumatic diseases and renal failure. In a meta-analytic review of asthma patient education, Bauman (1993) came to the conclusion that self-management programs produce stronger effects on psychological outcomes, compliance and self-management skills than traditional health education programs, which are characterized by provision of information only. Other meta-analyses of arthritis, cardiac and diabetes education programs came to comparable conclusions (Brown, 1992; Dusseldorp, van Elderen, Maes, Meulman & Kraaij, 1999; Hirano, Laurant & Lorig, 1994; Mullen, Mains & Velez, 1992). This illustrates the need for behavioral expertise in the development and implementation of programs for patients with chronic disease, which goes beyond a traditional instructional approach.
An example of a multicomponent self-management programme is the Arthritis Self-Management Program (ASMP) (Lorig & Holman, 1993). Designed as a community-based program for mild to moderately severe patients, the ASMP is aimed at improving health behaviors and health status by increasing participants’ perceptions of arthritis self-efficacy and the use of cognitive-behavioral techniques. The program consisted of six weekly sessions of about two hours, was guided by a manual, and was delivered by pairs of lay leaders, most of whom had arthritis themselves. During the sessions, which were largely interactive, short informational lectures were given, along with group discussion, problem solving, role-plays and mastery experiences. Furthermore, participants were asked to set personal and realistic goals for every forthcoming week in a written contract and report back at the group on their achievements. The receipt of feedback thus enabled participants to monitor their progress, an important element of self-management. In comparison to a group of patients on a waiting list for the program, participants showed improvements in arthritis self-efficacy and health behaviors, and were significantly less depressed and exhibited a more positive mood. One year later, similar effects were reported, together with a decrease in pain and increased visits to the primary care physician.
While this section differentiates between quality of life and self-management interventions, it should be noted that most interventions in chronic patients are psycho-educational or a combination of both. The reason for this is probably that both intervention strategies have the potential to produce beneficial effects on comparable outcomes, but by different means, and that a combination of these pathways is thought to produce a stronger effect. For example, the large majority of the 37 studies that were included in a meta-analysis of intervention programs for patients with coronary heart disease (and showed important effects of these programs on health behavior change, risk factor reduction and mortality) offered combined interventions (Dusseldorp et al., 1999). Likewise psycho-educational interventions seem to have more effects on adjustment of cancer patients than emotional support groups (Helgeson & Cohen, 1996).
Intervention Level: The Individual Patient, the Group and the Larger Environment
Psychologists are mostly educated within an intervention paradigm that supports the idea that effective interventions are rather intensive, direct forms of intervention targeted at the psychological problems of individual patients. While this approach is certainly valuable in some cases, the disadvantage is that it implies doing a lot for a very small group of patients. More indirect forms of intervention at a group and environmental level are clearly called for, if health psychologists are to make a significant contribution to the care of chronic patients at a population level. In other words, clinical health psychologists must ‘go for the numbers’ rather than for the most intensive or personally satisfying form of intervention. In line with this reasoning, there is a trend towards development of programs for groups of patients and their partners. Most of these interventions are based on cognitive behavior or social learning theory and make use of many of the above mentioned self-management techniques. Such programs exist in several Western countries for patients suffering from diabetes, rheumatic diseases, cancer, chronic respiratory diseases and coronary heart disease (Bauman, 1993; Helgeson & Cohen, 1996; Institute of Medicine, 2002; Lorig & Holman, 1993; Van Elderen, Maes, Seegers, Kragten & Relik-van Wely, 1994).
One such group intervention program is the Dutch ‘heart and health program, which has been developed for patients with coronary heart disease (Van Elderen et al., 1994). The program is offered to groups of about eight patients and their partners during cardiac rehabilitation and consists of eight weekly 2-hour sessions and two follow-up sessions. Each session is devoted to a particular topic, selected on the basis of an assessment of the specific needs of the patient. During each session, patients’ questions related to the topic are answered. During the second part of the session patients and partners try, under the supervision of a psychologist, to identify and change irrational beliefs or thoughts, which can obstruct important rehabilitation goals. Apart from positive effects on patient satisfaction, the programme has been shown to have beneficial effects on smoking cessation, changes in diet and use of medical resources (Van Elderen et al., 1994).
Psychologists frequently underestimate the relevance of interventions on an environmental level. Such interventions are sometimes described as social engineering, because they are aimed at modifying the home, work or leisure environment of the patient so as to facilitate normal functioning of the patient in everyday life. Psychological expertise at this level is of special importance for some patients, such as those with rheumatic diseases, not only because the screening of these patients’ environments requires some psychological expertise, but also because acceptance of environmental changes by patients and their relatives may require psychological guidance (Moos, 1988).
Interventions at the broader environmental level also imply community-level interventions. For example, Daniel and colleagues (1999) evaluated a community intervention based on social learning theory, directed at diabetes control. The intervention that was offered to an experimental community included television, radio, and press coverage of program activities, which in turn included physical exercise classes, health events, cooking demonstrations, information provision and diabetes support groups. In comparison to two control communities, the intervention proved to have a beneficial effect on systolic blood pressure, but not on glycated hemoglobin (HbA1c). A combination of face-to-face and community interventions may produce more important and sustainable effects.
What is argued for is thus a combination of various levels of intervention, including individual or group-based interventions, alongside social engineering and community-based interventions. To our knowledge there is no single program that addresses all these levels of intervention, although this would almost certainly enhance program effectiveness.
Intervention Channel: Direct versus Indirect Interventions
Let us now look at the third dimension, namely the intervention channel. Direct face-to-face contact with a patient can be between a patient and a psychologist or between a patient and another health professional. From a psychologist’s point of view this latter form of communication is indirect. Other forms of indirect interventions involve the use of volunteers and of printed or audiovisual self-help materials or computer-based communications.
As stated in the previous section, many psychologists prefer direct psychological interventions, which they deliver themselves, rather than indirect interventions. However, such a preference is not defendable from a cost-effectiveness point of view because intensive face-to-face interventions are not the best type of interventions for all patients. Some patients may require less intensive intervention than others. Furthermore, intensive interventions do not necessarily produce superior effects. For example, Lewin, Robertson, Cay, Irving and Campbell (1992) demonstrated that cardiac patients could profit from a manual (The Heart Manual) given to them upon discharge from the hospital by a trained nurse. Together they assess what a good starting level for daily physical exercise would be (a level that even on a ‘bad’ day the patient would still be able to perform, e.g., walk to the mailbox two blocks away) for the six-week self-help intervention. This program is based on the principles of goal-setting and pacing (‘do what you plan, not what you feel like’), cognitive restructuring and relaxation training in order to foster a renewed sense of control, self-efficacy and realism or slight optimism about the future. The manual addresses common misconceptions and stress reactions related to the coronary incident, introduces stress management techniques, and suggests appropriate levels of activity and physical exercise for various stages of recovery. Guided by the structure of the manual, patients are encouraged to do the physical exercises every day both morning and evening, to note down their progress with respect to the physical exercises every evening in a fixed schedule, and to read and fill out quizzes about (mis)perceptions of their disease. They are also encouraged to practice relaxation training by listening to an audiocassette tape at least once a day. Every other week the nurse phones them at home and discusses their progress, motivating them to continue with the program. In the Lewin et al. (1992) study, half of a group of 190 coronary heart disease patients received the manual, while the other half (the control group) did not. Both groups received similar medical and psychosocial care. The experimental group reported less anxiety and depression than the control group, even 1 year after discharge. In addition, patients in the experimental group made significantly fewer visits to their general practitioner and were less frequently readmitted to the hospital than patients in the control group.
Recently, communication with patients also includes computer-based interaction. Balas, Jaffrey and Kuperman (1997) reported on the effects of 80 clinical trials that made use of electronic communication with patients, including computerized communication and various forms of computer-based telephone contact (e.g., for counseling, follow-up and reminders). About two-thirds of these studies reported beneficial effects regarding a variety of outcomes related to preventive care, cardiac rehabilitation, diabetes care and management of osteoarthritis.
An example of an intervention program that was delivered indirectly by trained volunteers is targeted at improving the quality of life of elderly cancer patients with symptoms of anxiety and/or depression while undergoing chemotherapy (Mantovani et al., 1996). Prior to the delivery of the interventions, these volunteers had received both 40 hours of formal training and 40 hours of supervision in how to provide practical, informational and emotional support to elderly cancer patients. The distressed elderly cancer patients as well as their partners received support for six hours a week, divided into two or three sessions, while still in hospital as well as at home, for the entire period of their cancer treatment. During these sessions, the primary aim was to transmit positive feelings to patients and to assist them emotionally, especially during significant episodes of their medical treatment. Information on the disease and its treatment was also given and patients were assisted in practical matters and invited to participate in recreational activities that could help them to take their minds off worries about their disease. At the same time, patients received psychopharmacological treatment that was progressively reduced or completely withdrawn when symptoms of anxiety and/or depression significantly subsided. The intervention was administered by volunteers and proved to be more effective in improving pain control, functional status, psychological distress and quality of life in general than psychopharmacological treatment alone. Furthermore, social support delivered by volunteers combined with structured psychotherapy proved to be equally effective as the social support alone in terms of the outcome measures mentioned above. Therefore, from a cost/benefit perspective, an inexpensive approach of training volunteers may be preferred with respect to these specific groups of patients. However, it is good to keep in mind that the effectiveness of this intervention in alleviating distress is probably dependent on thorough instruction and close supervision of volunteers.
These results indicate that indirect interventions can have impressive effects. Another advantage is that other health professionals, including medical doctors, nurses, physiotherapists and dieticians, are also in a better position to deliver psychological interventions (Swerrison & Foreman, 1991). For example, while there is little doubt that psychosocial care should be offered as a component of cardiac rehabilitation, the results of a European survey showed important differences in the degree of involvement of psychologists in cardiac rehabilitation in different European countries (Maes, 1992). In the Netherlands and Italy, psychologists are key members of most cardiac rehabilitation teams, but their involvement in cardiac rehabilitation is negligible in Sweden, Finland, Denmark, the United Kingdom and Switzerland. This does not necessarily mean that psychosocial care is not offered to cardiac patients in these countries, but rather that other health professionals (e.g., nurses in the UK) play a more central role in its delivery (Maes, 1992). As a consequence, health psychologists need to learn how to assist and empower others in the delivery of psychological interventions in order to enhance patients’ quality of life and self-management behaviors. Such indirect intervention may involve training of health personnel in psychological intervention and communication skills, and psychological consultation with other health professionals. There are many examples of effective interventions designed by psychologists but delivered by others, including the Weight Watchers movement. Weight Watchers, originally designed by the American psychologist Stunkard, proved to be an extremely effective weight reduction program offered at a community level by lay persons. Another example can be found in health education and counseling programmes offered to myocardial infarction patients during and after hospitalization. Many of these programmes have been designed by psychologists, although they are typically and effectively delivered by nurses and/or social workers (Van Elderen, Maes & Van den Broek, 1994). In many other contexts, as in the case of terminally ill patients, regular health personnel will be responsible for standard care, while psychologists may play a more distant advisory role.
In short, indirect interventions may vary from developing materials, computer-based programs or self-help courses for patients, through teaching psychological principles and methods to other health professionals, to designing intervention programs and providing advice and training in face-to-face situations to both professionals and lay persons. Some critics of indirect interventions have argued that they imply ‘giving psychology away’. As psychologists, we should instead be proud to have so much to give.
Conclusion and Discussion
At the end of this section, the reader may be convinced that psychological interventions have the potential to reduce stress and to increase quality of life in chronic patients via various forms of stress management interventions, including cognitive restructuring, relaxation, coping skills training and social support interventions. On the other hand, there are many intervention programs that are successful in enhancing self-management knowledge and skills in a variety of chronic patient groups, including patients with CHD, cancer, chronic respiratory diseases, arthritis and diabetes. Furthermore, there is evidence that combined interventions can have endocrinological and immunological effects, which can slow down the disease process and thus have the potential to influence morbidity and mortality, especially in the area of CHD, certain types of cancer and HIV. A surprising trend is that the pathways of change become more visible. For example, a meta-analysis of 37 controlled studies on psychological interventions in patients with coronary heart disease showed that these interventions achieved significant reductions in risk factors and related health behavior, as well as in recurrence of MI and in mortality. Studies that had the most effect on blood pressure, smoking and exercise also had the strongest beneficial effects on MI recurrence and mortality. This suggests that a reduction of risk factors and related health behavior can lead to more distant outcomes (Dusseldorp et al., 1999). The studies by Ornish (Billings, 2000) further proved that a reduction of risk-factor-related health behaviors results in a reversal of coronary atherosclerosis. Studies conducted at Miami showed that cognitive-behavioral stress management techniques offered to HIV-seropositive men result not only in enhanced mood but also in a lower production of excretion of stress hormones and testosterone and a ‘better’ immune function (Baum, 2000). This suggests that interventions that significantly reduce distress in HIV-infected men also have endocrinological and immunological effects. Finally, interventions with breast cancer and melanoma patients have shown effects on the immune system and enhanced survival, even if the results of some studies should be interpreted with care (Baum, 2000). While there is still a long way to go, the biological plausibility of the link between psychological (behavioral and mood) effects and morbidity and mortality is increasing.
Another conclusion concerns the fact that psychological interventions do not address the full scope at which they can be delivered. They are frequently limited to individual and small-group interventions delivered by psychologists. As argued above, this approach should be complemented by community-level interventions and social engineering, and psychologists should be more inclined to train others (including health professionals and volunteers) in the delivery of psychological interventions and to develop self-help materials and computer-based forms of patient education and communication. As Roberts, Towell and Golding (2001) state, psychology should avoid an excessive preoccupation with individualism and build more valid ecological models of human health. The same authors also correctly point at the fact that ‘psychologists should be concentrating less on providing justification for their professional role in health care settings and more on working with client groups so that they empower themselves’ (2001: 256). Their remark is valid not only for client or patient groups but also for the empowerment and training of other health professionals. Health psychology and medical psychology seem to have become different worlds, but if clinical health psychologists are not prepared to play a major role in the development, training and advice of health professionals, they may seriously endanger the future of their own discipline.
We would like to conclude with two additional remarks. The first concerns the theoretical knowledge base for psychological interventions with chronic patients; the second concerns methodological remarks on evaluation studies of interventions. While the theoretical knowledge base for health psychology is growing, many interventions in patients with chronic diseases do not rely on this knowledge. Among the many examples, research on quality of life in various patient groups is mostly atheoretical, as is research on various forms of rehabilitation, as for example cardiac rehabilitation. Yet, these areas rank among the most researched areas in health psychology, and are frequently cited as successful areas of intervention. The consequence of this is that it is very difficult to understand why some interventions are effective and under which conditions. The lack of a sound knowledge base has many other disadvantages: as not only interventions but also most measuring instruments (e.g., for quality of life) do not reflect well-defined concepts and/or relations in a theoretical framework, it is very difficult to judge whether there is a congruence between the intervention and the way the outcomes are measured, which seriously endangers the validity of the results. In other words, not only interventions but also measures should be based on sound theory. However, current models of health behavior (change), such as the health belief model, social cognitive theory, the theories of reasoned action and planned behavior, protection motivation theory and the transtheoretical model of change (Norman, Abraham & Conner, 2000), may be too narrow or only partially adequate for the design of interventions in chronic patients. This is because they focus on isolated behaviors, and on the adoption (or initiation) of a new behavior rather than on behavioral maintenance (Rothman, 2000). Moreover, they reduce the influence of the (social) environment on cognitive representations. Likewise, a limitation of the traditional stress-coping models (Lazarus & Folkman, 1984) concerns the underlying assumption that individuals cope in a reactive way with stressful, disease-related or health-related events. By focusing on the way the appraisal of the stressor shapes coping behavior, these models tend to overlook the effects of the individual’s life goals on the meaning, the representation of the disease and the selection of coping procedures (Maes et al., 1996). Effective applications may thus need new theoretical frameworks, including behavioral maintenance and self-regulation theory. Furthermore, they should include models that put more emphasis on the influence of the (social) environment on behavior (Brownlee, Leventhal & Leventhal, 2000; Carver & Scheier, 2000; Maes & Gebhardt, 2000; Roberts et al., 2001; Rothman, 2000).
The second remark concerns methodological shortcomings of existing evaluation studies. While a lot of the intervention studies with chronic patients are randomized controlled studies, many of the control groups differ from non-treatment control groups. Most control group patients receive standard care, and it should be noted that standard care has improved substantially over time. For example, in Dutch cardiac rehabilitation settings, it became increasingly difficult to come up with a psychological intervention that would prove to be superior to standard care, since many of these interventions became part of standard care. As a consequence, evaluation studies should offer an adequate description not only of the intervention but also of the so-called standard care, since this can differ substantially from situation to situation, let alone from country to country. The objectives of many evaluative studies are often not well defined or represent a narrow focus on possible outcomes (many studies do not even assess risk factors or physiological outcomes, let alone morbidity and mortality outcomes). In addition, studies should also assess relative effectiveness rather than general effectiveness of a program, and the sample size should be large enough to demonstrate significant effects on risk factors, morbidity and mortality. Finally, process evaluation, which documents and monitors program delivery, should deserve more attention in the future. This would provide information on crucial questions, such as whether the psychologists, health professionals or volunteers who delivered the program were adequately trained and motivated to guarantee that the program was delivered as intended.
In the next part, we formulate some overall conclusions and suggestions for further research.
General Conclusion and Discussion
In conclusion, there can be little doubt that health psychology interventions can have important contributions to the area of health promotion, disease prevention and adaptation to and management of chronic disease. Psychology provides a useful knowledge base for various health promotion settings, including the community, media-based health promotion, schools, the worksite and health care settings, which proved to be successful in health behavior change, risk factor reduction and/or a reduction in morbidity, mortality and the use of health care resources. However, it seems that only initiatives that combine or link interventions in different settings have the potential to influence all these outcomes. Likewise, there is a lot of evidence demonstrating the effectiveness of quality of life (stress management and social support interventions) and self-management interventions in various chronic disease groups, including for example patients suffering from CHD, HIV, cancer, rheumatoid arthritis and diabetes. Beneficial effects range, depending on the chronic disease, from stress reduction and psychological adaptation to the chronic condition through pain reduction, treatment adherence, and adequate use of medical resources, to risk factor reduction, endocrinological and immunological effects, biological regression or deceleration of the disease process, and a reduction in morbidity and mortality. Also here, a combination of interventions is mostly required to produce (some of) these outcomes, and little is known about the effective components of these ‘cocktail’ psycho-educational interventions.
A related statement concerns whether many of the existing interventions are applications in the real sense of the word. Applications require, as mentioned in the introduction, a vast body of knowledge to apply, or in other words also a sound theoretical base. Most existing initiatives or programs are not based on such knowledge. It has been argued above that this is mainly because health psychologists are not always at the helm of these initiatives and fail to communicate their knowledge base to others. In addition, we stated that existing models for health behavior (change) (e.g., described by Norman et al., 2000) may also be too narrow for these applications, because they focus on isolated behaviors, concentrate on initiation of the change rather than on maintenance, and reduce the impact of the environment to cognitive representations.
Many methodological remarks have been made in this chapter concerning evaluation of health promotion initiatives and intervention studies with chronic patients. However, one stands out, referring to the fact that many existing evaluation studies seem to search for answers to the wrong question, ‘Is this intervention effective or not?’ Such a question reflects the quest for the Holy Grail. It implies that there is an effective intervention for all patients under all circumstances or conditions at all times. The question should rather be: ‘For which subgroup of individuals is this intervention effective (in comparison to other interventions and a nonintervention), under what conditions, and in which respect?’
The conclusions of both parts of this chapter point at the necessity to develop intervention programs, based on a sound knowledge base, which are offered to large parts of the (healthy or diseased) population for an extended period of time. This requires (1) that decision makers in this area are informed about health psychology knowledge and competencies and (2) that health psychologists are prepared to embark on these initiatives in cooperation with many other professionals. There is an apparent lack of dissemination of health psychology knowledge. As far as we know there are no accessible shortlists of advice or successes that can be sent to these decision makers. The International Academy of Education (a world-wide scientific organization to promote application of educational research findings) tackles this problem for the area of education by publishing small booklets. The booklets, which are widely disseminated all over the world and can be downloaded from the web (http://www.ibe.unesco.org/publications) thanks to the contribution of the International Bureau of Education, contain about 20 pages with principles, related research findings and advice for applications on topics such as ‘teaching’, ‘tutoring’, ‘preventing behavior problems’, ‘preventing HIV/AIDS in schools’, ‘motivation to learn’ and many others. A comparable initiative for health psychology in cooperation with the World Health Organization would help to put health psychology on the decisional map in many countries. Unfortunately, many health psychologists are usually not keen enough to participate in these disseminating initiatives. They frequently prefer to concentrate on the development and/or evaluation of small-scale ‘feasible’ projects, which mostly focus on single targets. While this may be defendable from a research point of view, in the end these projects should lead to cost-effective initiatives, which can be implemented in our communities.
A related concern regards the fact that the bulk of the existing health promotion research has been conducted in a social vacuum with limited attention to sociopolitical or regulatory factors. With the exception of social support, the influence of the social context is underrepresented in most health behavior or stress-coping models. Reviews consistently stress the importance of partnership with the community in order to address the social factors in health behaviors, which imply for example collaboration with community groups, social service agencies and health care providers. These forms of collaboration also imply that interventions are based on needs assessment in the community, rather than on experts’ opinion or preference (Emmons, 2000). In other words, interventions must be needed. However, for many intervention projects, it is unclear how they relate to the major problems within our health care systems and communities, and as a consequence they run the risk of not being adopted by the community and/or of lacking the funding they might deserve.
This community perspective also implies that more attention should be devoted to subgroups that are traditionally disadvantaged by our health care systems. These include people with a low social economic status (as low income is a predictor of poor health), women (as morbidity is higher in women than in men), the elderly (since they represent a growing part of the population in Western countries with increasing morbidity), and ethnic minority groups (with whom communication through our health care systems frequently fails because of cultural and social barriers) (Taylor, 2001).
Another major concern is that people at risk seem to become an increasing problem group in our health care systems. While health psychology concentrated traditionally on health promotion in healthy populations or interventions in diseased groups, the growth of medical technology and education led to increased identification of groups at risk for developing health problems. Traditionally some health risks attracted the attention of health psychologists, such as for example hypertensives or obese people. Recently, the development of gene technology led to the discovery and communication of new risks, such as those for developing breast cancer, blood diseases, neurological diseases and immune diseases. It is clear that health psychologists can play an important role in the development of screening procedures for such risks, including those in communication or interventions that help people to live with these risks.
This brings us to remarks regarding the interface between psychology and medicine. There is mounting evidence for the biological base of (health) behavior and the biophysio-logical consequences of a variety of behaviors and psychological conditions, including stress. From this perspective, it is difficult to understand why many psychological interventions in the area of health promotion, disease prevention or treatment of chronic disease have relatively isolated positions within medical care.
Collaborative interventions between psychologists and other health professionals (Taylor, 2001) are required, which will increase not only the relevance of the interventions, but also their implementation in standard health care. To promote communication between various health professions, health psychologists should have a sound biological knowledge base concerning this area of cooperation, and should have opportunities in their education where they learn to communicate with medical professionals. Topics such as screening for risk factors, quality of life, stress, pain management, management of chronic diseases, doctor-patient communication and the use of medical resources are areas where medical and psychological research are frequently conducted from very different perspectives and require closer cooperation. While psychologists frequently point at the medical profession as the main culprit for this lack of cooperation, it may be rather their lack of assertiveness and lack of communication with other health care professionals that are the real causes for this isolated position. There is indeed impressive evidence showing that psychological interventions delivered by non-psychologists can have substantial effects on a variety of health and disease outcomes. The use of new communication technology opens an important new avenue in this respect. On the other hand, efforts must also be directed at the improvement of psychology courses for a variety of health professionals, including for example medical doctors and nurses, since they seem to lack psychological knowledge and skills regarding health promotion, disease prevention and self-management of chronic disease.