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Theoretical thinking in any scientific discipline consists of four broad types that vary according to their level of generality: paradigms, frameworks, theories and models. Paradigms explicitly state assumptions, laws and methods in a complete system of thinking about a field of inquiry (Kuhn, 1970). Frameworks have some of the characteristics of paradigms, but are smaller-scale and much looser, although they are a way of organizing information about a field. Figure 1.5 shows a framework about the main influences on the health of individual human beings that we find quite helpful. It has been adapted from the work of Dahlgren and Whitehead (1991) and we call this the ‘Health Onion’.

Figure 1.5 The ‘Health Onion’: a framework for health psychology

Source: Dahlgren and Whitehead (1991)

The ‘Health Onion’ has a multi-layered structure of ‘rings’, with the individual person at its core, surrounded by four layers of influence,‘systems’ or ‘rings’

Core: age, sex and hereditary factors (Part 1 of this book).

Level 1: individual lifestyle (Part 2 of this book).

Level 2: social and community influences (Part 1 of this book).

Level 3: living and working conditions, and health care services (Parts 3 and 4 of this book).

Level 4: general socio-economic, cultural and environmental conditions (Part 1 of this book).

The Health Onion is a systems framework with seven characteristics:

1 It is holistic – all aspects of human nature are interconnected.

2 It is concerned with all health determinants, not simply with events during the treatment of illness.

3 The individual is at the core with health determinants acting through the community, living and working conditions, and the socio-economic, cultural and physical environment.

4 It places each layer in the context of its neighbours, including possible structural constraints upon change.

5 It has an interdisciplinary flavour that goes beyond a medical or quasi-medical approach.

6 It makes no claim that any one level is more important than others.

7 It acknowledges the complex nature of health determinants.

Different theories and models are needed for each setting and context. However, there is also a need for a general paradigm for individual health within which specific theories and models can be nested. Such a paradigm should attempt to represent in an explicit, detailed and meaningful way the constraints upon and links between individual well-being, the surrounding community and the health care system (Marks, 1996). No such general paradigm exists. We are waiting for a Hippocrates, Darwin or Einstein.

BOX 1.6 Filtering of evidence in evidence-based practice

Some methodological purists believe we have a paradigm for all of health care in the form of evidence-based medicine or evidence-based practice (EBP). In EBP, randomized controlled trials are used to produce conclusions about the effectiveness of different methods and treatments. In theory, the approach sounds wonderful. In practice, it is far from perfect. Evidence on effectiveness in EBP is assumed to have an objective, inviolable status that reflects ‘reality’. It is given an iconic status. In some undefined ways, this evidence about ‘reality’ not only aids decision-making, but also determines it. In truth, evidence is never absolutely certain. It rests on subjective elements consisting of negotiable, value-laden and contextually dependent beliefs that are given the status of ‘facts’ when all they really are items of information. Until the Magellan–Elcano circumnavigation of 1519–22 the Earth was assumed by everybody to be completely flat. The flat-Earth was a belief masquerading as fact. Flat-earthers still exist, but their numbers are dwindling.

The nature of evidence, and the methods by which evidence is gained, are contentious issues in the history of science. In health care, evidence (= new knowledge) for a technique or treatment is not an accident, but the product of a series of ‘gates’ or ‘filters’ that must be passed before the technique is deemed to be useful.

Consider the sequence of processes through which evidence must pass if it is to be considered admissible in EBP. The filtering is so selective that, typically, systematic reviewers will be able to find only a dozen or fewer primary studies that fulfil the inclusion criteria from a field of several thousand. It’s not unlike making a pot of filter coffee – the stronger the filtering, the less fresh and flavourful the coffee or using a tea-bag to make a cup of tea.There are no guarantees the end product will be fit for purpose. The final product is almost certainly inferior to the genuine article. The filtering process in EBP consists of seven levels: current knowledge, theory and paradigms taught in universities and schools; funding priorities of government, industry and charities; hypotheses considered important by the funders; methodology approved by funders; journal publication; systematic reviews; translated into EBP.

To be judged ‘sound’, evidence must pass through these seven filters, which are biased towards the preservation of existing practices, knowledge and myths. In confirming the ‘sound’ status of the techniques that have passed through the filters, the ‘unsoundness’ of the unfiltered techniques occurs by default. Undeniably, evidence filtering is systematic and biased towards the status quo. Evidence is considered ‘sound’ or ‘unsound’ according to established criteria.

However, EBP is contentious on a number of grounds. First, it is wasteful that so much evidence is ‘thrown away’. Many unfiltered techniques are quite possibly as effective as techniques that have been filtered. Second, the filtering process gives a high weighting to techniques that conform to beliefs and values of the knowledge establishment. For example, pharmacotherapy will be established ahead of psychological therapies (pharmaceutical industry sponsorship at filters 1–4), quantitative techniques will be preferred to qualitative techniques (filters 5–6), and patient treatment care will be about outputs and outcomes, rather than feeling they have been cared for as human beings (filters 7). Third, innovation may have difficulty breaking through.

In this book, we review the results of many studies using the approach of EBP, but many studies that have not been based on EBP are also reviewed. Many such studies have been in settings where EBP would be unethical, impractical or impossible. We also include qualitative studies because the findings illuminate the lived experience of health and illness.

Source: Marks (2005, 2009)

Future Research

1 Psychology requires a solution to the measurement problem (if there is one): there is no evidence that psychological attributes are continuous quantitative variables of the kind studied in the natural and physical sciences.

2 Trans-cultural studies of health, illness and health care are needed to facilitate communication and understanding of systems of healing among different cultural, ethnic and religious groups.

3 Evidence needs to be gathered to confirm that lifestyle changes cause positive changes to life expectancy and quality of life.

4 The limits of evidence-based practice require innovative evaluation methods of interventions.

Summary

1 Health is a state of well-being with physical, cultural, psychosocial, economic and spiritual attributes, not simply the absence of illness.

2 The fundamental sociality of individual behaviour demands a social orientation to health psychology, which must be studied in the context of society and culture.

3 To be healthy in body and mind a person’s needs to interconnect and to act autonomously as an agent must both be satisfied as well as his/her biological needs.

4 Subjective well-being is normally positive for the majority of individuals. It fluctuates around a set-point inside a range and is regulated by homeostasis.

5 Behavioural and environmental changes need to be given equal priority in interventions.

6 Health psychology has grown rapidly, with increasing evidence that much illness and mortality is caused by behaviour, and there is a growing awareness of the psychosocial aspects of health and illness.

7 The ‘Health Onion’ is a useful framework for the investigation of health and illness. The core of the onion is an individual’s current health status, including age, sex, genetic and epigenetic factors. Four layers of analysis surrounding this core are: (1) individual lifestyle, (2) social and community influences, (3) living and working conditions, and (4) general socio-economic, cultural and environmental conditions.

8 Concepts about health and disease are embedded in culturally diverse ways, with significant differences in experience and behaviour between cultures and places.

9 The organization of knowledge in health psychology is structured within frameworks, theories and models. It is helpful to notice the difference between these three types of structure and to treat them differently.

10 The nature of evidence and the methods by which evidence is gained are contentious issues in science. In health care, new knowledge about a theory, technique or intervention is the product of a series of evidence ‘gates’ or ‘filters’ that must be passed before it is deemed to be useful.