By Professor Neville Owen MAPS
Director, Cancer Prevention Research Centre; Professor of Health Behaviour, School of Population Health, The University of Queensland
Avoiding physical exertion, watching sport on television, eating well, enjoying alcohol, smoking cigarettes and being outside in the sun are all part of the Australian way of life, to a greater or lesser extent, for most of us. There is now a solid body of evidence that these so-called ‘lifestyle’ behaviours are major, modifiable risk factors for type 2 diabetes and heart disease, and for breast and colon cancer.
National and state government health instrumentalities and key non-government organisations - including the Heart Foundation, Diabetes Australia and the Cancer Councils of Australia - clearly understand the importance of these behavioural risk factors. They identify behaviour change as the central challenge for their preventive strategies. Thus, the discipline and the profession of psychology have much to contribute to disease prevention and health promotion.
Australian health psychologists have made strong contributions to many of the successful preventive health programs that have been carried out in this country. Their contributions have been extremely helpful elements of the body of work that has been done to understand and influence the social, environmental, and public policy factors that act to determine these behaviours in whole populations. Health psychologists have been key members of the teams that have developed effective mass media campaigns, self-help resources, community programs, and environmental and policy initiatives to change these behaviours.
While much remains to be learned about precisely how behaviours act to influence health outcomes, there is now general agreement among public health researchers and health authorities that action is needed on many fronts: large scale, preventive initiatives to influence these behaviours in whole populations are now well-justified by the relevant scientific evidence. Over the past 20 years, we have seen an increasing number of large-scale disease prevention initiatives. These include graphic anti-smoking advertisements on television; mass-media promotions on physical activity; workplace and hospitality-industry bans on smoking; walking and bicycle paths being developed in local communities; and, many other initiatives.
The key questions for continuing to improve on these initiatives are: How may large numbers of people be influenced, in order to make the relevant behavioural changes? How can this be done in ways that are effective and affordable? How do we know if these preventive efforts are making a difference? Thus, the relevant approaches must be evidence-based. Psychological measurement methods and theories of health behaviour change have been impressively influential in shaping the knowledge base that is needed for evidence-based disease prevention and health promotion programs.
While psychology has much to contribute, the development, implementation and evaluation of these large-scale approaches to the prevention of ‘lifestyle’ diseases exceeds the capacities of any single discipline or profession. Consequently, health psychologists working in health promotion and disease prevention carry out their research and engage in practical initiatives as part of interdisciplinary teams.
In universities, health psychologists may be more likely to be found in schools of Population Health, Health Promotion, or Exercise Science, than in schools of Psychology.
In the real world, they work for government and non-government organisations concerned with preventing diabetes, heart disease and cancer. In those practical settings, they research, develop, and evaluate innovative health behaviour change programs and services. In the facilities where health psychologists do their behavioural research studies and where they pursue their practical efforts on important public health initiatives, we also find epidemiologists, nutritionists, exercise scientists, health educators, endocrinologists and other medical specialists, physical educators, and also experts from social marketing, policy analysis and a range of other professions.
Here, I describe a rather idiosyncratic selection of health psychology research, and its applications to public health policy and practice. My aim is to illustrate some of the ways in which health psychology has provided helpful conceptual and methodological guidance, and has helped to develop practical approaches to disease prevention and health promotion. The examples that I use are from my own work, and from a selection of my colleagues, dealing with physical activity and aspects of tobacco control. There is, of course, excellent work by many other Australian health psychologists, in many other areas of health promotion and disease prevention, to which I cannot do justice here.
These somewhat personal examples are intended to highlight how research by psychologists can influence the content and focus of health-behaviour programs; can improve how such programs are planned and delivered; how they may be systematically evaluated; and, how our efforts can also help to influence public-health policy.
Health psychology and behavioural epidemiology
How may we characterise these interdisciplinary domains in which health psychologists make their contributions to disease prevention and health promotion? The five main phases of the ‘behavioural epidemiology’ framework (Sallis & Owen, 1999), developed with my health psychologist colleague James Sallis from San Diego State University, can be helpful for this purpose.
Phase 1: Identify the relevant health-related behaviours
Given the large public health investment required for population-wide prevention programs, it is crucial that the relevant behaviours be identified clearly and explicitly. For example, cigarette smoking may appear to be a simple, unambiguous behaviour. However, when we consider variations in patterns of smoking in populations, we find that there are many adults who do not identify themselves as smokers, but who nevertheless regularly consume cigarettes. Occasional smoking, social smoking, or tobacco ‘chipping’ is common among many groups of young adults, that can be a stable pattern of behaviour or can lead to regular, higher rate, dependent smoking. Earlier population-based behavioural studies in South Australia with Melanie Wakefield and colleagues identified some relevant attributes of these groups (Owen, Kent, Wakefield & Roberts, 1995), and have helped to inform how public campaigns and policy initiatives can be pursued. More recent studies from our group in Brisbane, led by Liane McDermott, have focused on life-stage factors and social influences that can shape patterns of tobacco uptake among young adults (McDermott, Dobson & Owen, 2006).
Taking the case of physical activity as another example, it might seem self-evident that ‘exercising’ for fitness is the most relevant behaviour. However, the epidemiological evidence shows that, on a population-wide basis, the greatest preventive gains among adults will result from ‘activating the sedentary’. The goal is to increase the rates of regular, moderate-intensity physical activities, particularly walking, among the more than 50 per cent of Australian adults who are insufficiently active in their leisure time for health benefits (Cerin, Leslie, Bauman & Owen, 2005).
Recent Australian studies have also identified the public health importance of sedentary behaviours as entities distinct from a lack of physical activity (Salmon, Owen, Crawford, Bauman & Sallis, 2003). Using data from the national AusDiab survey, studies with David Dunstan, Jo Salmon and colleagues at the International Diabetes Institute in Melbourne have found abnormal blood glucose levels to be more prevalent among those who watch more than two hours of television a day, independent of their leisure time physical activity levels (Dunstan, Salmon, Owen, Armstrong, Zimmet, Welborn, Cameron, Dwyer, Jolley & Shaw, 2004).
Phase 2: Develop and apply measures of health behaviours in populations
It is crucial that we have solid evidence on the population prevalence, trends over time, and the variations within the population in relevant health behaviours. Health psychologists have made important contributions to the development of behavioural risk factor surveillance systems in Australia. This has included state and national surveys on tobacco, alcohol, and drug use, and physical activity.
For example, studies led by our epidemiologist colleague Adrian Bauman have provided the basis for local and international population surveillance systems on physical activity. We now have the standard ‘Active Australia’ survey methodology that is used for population surveys and for campaign evaluations (Bauman, Bellew, Owen & Vita, 2001). This measurement methodology identifies moderate- and vigorous-intensity behaviours, plus walking, using brief survey items. It has been built on an analysis of the epidemiological evidence on the most relevant behaviours (Bauman, Owen & Leslie, 2000), and on laboratory and field studies by our team of exercise physiologists, epidemiologists and health psychologists, who have examined the measurement properties of the population survey items used in the Active Australia method (Booth, Owen, Bauman & Gore, 1996).
There is also new evidence on the health-related energy expenditures that are associated with moderate-intensity household and garden tasks; these will be important behaviours to assess in future population studies as rates of sedentary time use and obesity continue to increase (Gunn, Brooks, Withers, Gore, Owen, Booth & Bauman, 2002).
Phase 3: Understand the modifiable determinants of health behaviours
If we understand the factors that make it more or less likely that people will engage in health-risk behaviours, then, in order to change the behaviours, we must change the relevant determinants. For example, a recent review led by our exercise scientist colleague Stewart Trost has identified new behavioural studies on the correlates of physical activity participation. These show that confidence about being physically active, plus social norms about physical activity, are both strongly associated with adults being active (Trost, Owen, Bauman, Sallis & Brown, 2002).
Health behaviour theories, particularly social cognitive theory and related models, help us to apply this knowledge from the relevant research on the determinants of behaviour (Sallis & Owen, 1999). For example, using social cognitive theory constructs, studies have found that self-efficacy (confidence) can be enhanced by providing a program that is made up of a series of small steps that lead to gradual success in becoming habitually more physically active (Marcus, Owen, Forsyth, Cavill & Fridinger, 1998). In Australian mass media campaigns on physical activity, particularly those that have targeted middle-aged and older adults, social cognitive theory has been used to guide how carefully selected, moderately overweight older adults may be used in social modelling interventions via television advertisements and in other campaign materials (Owen, Bauman, Booth, Oldenburg & Magnus, 1995).
To comprehensively examine the determinants of health behaviour, broader conceptual models are needed that will help to take into account the multiple levels of influence on health behaviours, and identify how relevant theoretical constructs such as self-efficacy or social support operate in the context of other relevant determinants of behaviour (Sallis & Owen, 2002). Ecological models of health behaviour are helpful for this purpose. These models identify a range of domains of influence on health behaviours: in the beliefs, knowledge, attitudes, and skills of individuals; in the proximal social environment; in social norms; in organisational and community social structures; and, in relevant attributes of physical environments (Owen, Humpel, Leslie, Bauman & Sallis, 2004). The determinants of health-related behaviour choices operate at all of these levels, and different factors will act in different ways to influence particular behaviours.
Phase 4: Develop and evaluate population health interventions
When we have clearly identified behavioural targets, have good population data on, for example, the social groups who are more likely to smoke or to be physically inactive, and we have an understanding of the determinants of the relevant behaviours, then evidence-based public health interventions can be developed. Such interventions ideally should be able to be made available to large numbers of people at an affordable cost. Mass media campaigns have, in societies like our own, a key role to play in informing people about behavioural health risks, in setting an agenda to change, in influencing social norms, and in drawing attention to the availability of the relevant programs and services.
Mass-reach tobacco control strategies in Australia have made use of innovative combinations of telephone, print, and internet media to deliver health behaviour change programs. These include, for example, the QuitLine, which uses telephone counselling and print materials with behavioural advice for smokers who are trying to quit (Borland, Balmford, Segan, Livingston & Owen, 2003). In Australia, we have high quality smoking cessation materials based on health behaviour theories that are distributed on an as needed basis through health professionals, by mail, or are used as adjuncts to telephone delivered advice. There is also the Quit Coach website (www.thequitcoach.org.au), which generates a unique program for each individual smoker through its internal logic. It is based on a conceptual model of behaviour change developed by health psychologist Ron Borland, to guide the automated delivery of detailed and highly personalised online advice.
For physical activity, printed self-help materials and website programs, based on psychological studies of the determinants of motivational readiness, have been tested in large-scale controlled trials (Marshall, Leslie, Bauman, Marcus & Owen, 2003). Such programs that are being developed and tested for public health implementation in Australia are strongly evidence-based. This is due in large part to the efforts of health psychologists, who together with experts from other disciplines have built a solid knowledge base using the relevant health behaviour theories, and have tested interventions in large-scale controlled trials and in practical evaluation studies.
Phase 5: Inform and shape public-health policy
It is crucial that broader use be made of the knowledge gained through defining behaviours, through behaviour risk factor monitoring, through understanding the determinants of behaviours, and through what we have learned from developing and evaluating public health interventions. Health psychologists in Australia have had a strong influence on the public health agenda in several key areas relating to chronic disease prevention.
Health psychology researchers and practitioners have taken on demanding and time consuming service roles in order to translate evidence-based approaches to health behaviour change into public health policy and practice. Individuals and groups of health psychologists can be identified as highly influential in several key areas, particularly so in the field of tobacco control. One such health psychologist is David Hill, AM, Executive Director of the of the Anti-Cancer Council of Victoria and President of the International Union Against Cancer (UICC), who has made wide ranging contributions to tobacco control research, has chaired national tobacco control initiatives, and has made extensive international contributions to tobacco control research and advocacy. His scientific and policy contributions have been recognised by national and international bodies, including the Australian Psychological Society, through the Ian Matthew Campbell Award.
For physical activity, Australian health psychologists - working in collaboration with epidemiologists, exercise physiologists, and physical educators - have been part of initiatives that have helped to consolidate the evidence base for new physical activity programs and policies. The ‘Getting Australia Active’ document for the National Public Health Partnership (www.nphp.gov.au) is a guide for Australian health promotion practitioners and planners, in developing and delivering evidence-based physical activity programs (Bauman, Bellew, Vita, Brown & Owen, 2002). The challenges for dissemination and diffusion of such evidence-based programs in public health are considerable. Successful dissemination and diffusion requires the practical application of behaviour change principles in organisational and advocacy contexts, as well as in the community and health care settings where programs are delivered (Owen, Glanz, Sallis & Kelder, 2006).
Studies by health psychologist Nancy Humpel at the University of Wollongong, together with the compelling evidence from Billie Giles-Corti’s group in Western Australia (Giles-Corti, Timperio, Bull & Pikora, 2005), have shown how built environment attributes of communities are associated with walking. This evidence is now having a significant influence on the advocacy strategies of non-government bodies. These evidence-based physical activity advocacy efforts aim to shape public policy to positively influence transport infrastructure, urban design, and the provision of local community amenities for physical activity.
Australian health psychology has a healthy future
In Australia, we have made some excellent progress through public policy and environmental initiatives in reducing population smoking prevalence. Cigarette advertising is now banned, exposure to tobacco smoke in workplaces, hospitality venues and other public places is now uncommon, and cigarette packs now have graphic warning labels. The needs of individual smokers are not ignored: high-quality information and advice via telephone, the internet, and other modalities is available to smokers trying to quit. For physical activity, we still have some way to go as this is a relatively new area of public health research and action, but the knowledge base in Australia for future large-scale physical activity initiatives is well established.
In all of the major tobacco control and physical activity initiatives in Australia, there have been strong and positive influences from the discipline of psychology, and from the practical efforts and resourcefulness of many Australian health psychologists.
While much progress has been made, health psychologists still have many exciting and important opportunities to contribute to reducing the burden of premature death, disability and the impaired quality of life that result from largely preventable chronic diseases. The prevention of these ‘lifestyle diseases’ requires persistent, systematic and specific approaches that are designed to change the relevant behaviours in whole populations. These can be addressed in a disciplined and practically effective fashion, using the conceptual, methodological, and professional tools of our discipline. Psychology has much to contribute, particularly if those contributions are pursued in collaboration with colleagues from other public health disciplines and professions - colleagues who can inform, stimulate and guide us in making the very best use of our relevant knowledge and skills.
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Bauman, A., Bellew, B., Vita, P., Brown, W., & Owen, N. (2002). Getting Australia active: Best practice for the promotion of physical activity. Melbourne: National Public Health Partnership.
Booth, M., Owen, N., Bauman, A., & Gore, C.J.(1996). Retest reliability of self-reported leisure-time physical activity measures for population surveys. International Journal of Epidemiology, 25, 153-159.
Cerin, E., Leslie, E., Bauman, A., & Owen, N. (2005). Levels of physical activity for colon cancer prevention compared to generic public health recommendations: Population prevalence and socio-demographic correlates. Cancer Epidemiology, Biomarkers and Prevention, 14, 1000-1002.
Dunstan, D., Salmon, J., Owen, N., Armstrong, T., Zimmet, P., Welborn, T., Cameron, A., Dwyer ,T., Jolley, D., & Shaw, J. (2004). Physical activity and television viewing in relation to risk of 'undiagnosed' abnormal glucose metabolism in adults. Diabetes Care, 27, 2603-2609.
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