health problem related to maternal and infant health- 2 page
Integrating Psychology and Public Health Challenges and Opportunities
L a u r a C. Leviton University o f Alabama, Birmingham
Psychology has made significant strides in developing ap- plications relevant to public health. However, improve- ments are still needed to integrate psychology into the public health infrastructure. The challenge .(or public health is to recognize psychology's special contributions to poli~T and "practice, especially to prevention o f disease and injuo'. The challenge.for psychology is to assure co- herent integration o f relevant theories, knowledge bases, and public health practice. Recommendations to address these challenges include (a) demonstrating how psychology incrementally improves public health service systems; (b) developing middle range and small theories o f public health problems and practice (Lipsey, 1993, Merton, 1968); (c) developing intervention models in partnership with nonpsychologists so that the effects can become wide- spread," and (d) ongoing scrutiny o f the intervention models to assure that theory has been operationalized well. Psy- chology's unique role in public health is to act as the stew- ard o f a correct application o f behavioral knowledge and theory.
I n the 1980s, health psychologists expanded their ac- tivities in public health as well as in medicine. In 1982 a special issue o f the American Psychologist e x a m i n e d
psychology's relationship with public health. T h e con- tributors n o t e d the points o f contact, some achievements o f psychology in application to public health, and the general scientific areas in which psychology and public health could be o f benefit to each other ( D e L e o n & Pallak, 1982). Among others, Singer and K r a n t z (1982) an d Jef- fery (1989) have distinguished public health from medical applications by e x a m i n i n g public health's focus on the health o f populations and on society as a whole. These researchers viewed a dual focus on individual-level be- havior and on populations as a desirable one that could foster psychology's intellectual growth into areas such as public policy and c o m m u n i t y - b a s e d intervention.
A comprehensive case for psychology's relevance to public health problems was m a d e by Winett, King, an d Altman (1989), who outlined the i m p o r t a n c e o f behavior in the most prevalent causes o f illness and death in de- veloped countries. T h e y also described the achievements o f behavioral theorists in addressing some m a j o r public health problems. By describing specific applications to a variety o f activities that f o r m a part o f public health prac- tice, Winett et al. demonstrated, psychology's potential.
T h e y cautioned, however, t h at m u c h o f this potential had yet to be achieved.
In the mid-1990s, psychology is achieving increased acceptance in some diverse areas o f public health policy and practice. Technology for smoking cessation and weight reduction are well established in patient care set- tings and c o m m u n i t y programs (Brownell, 1982; Burns, Cohen, Gritz, & Kottke, 1993; C O M M I T Research G r o u p , 1995a, 1995b). A variety o f public health issues have been explored by psychologists, and those issues have been regularly addressed in the pages o f the American Psychologist. T h e Association o f Schools o f Public Health requires that accredited programs include some exposure to behavioral science for all Masters o f Public Health stu- dents (Miller, Fowler, & Bridgers, 1982). Although the behavioral science r e q u i r e m e n t is i m p l e m e n t e d incon- sistently in public health graduate schools, academics in the other fields o f study have at least some appreciation for the utility o f psychology (Matthews & Avis, 1982).
Yet beyond a general application to health education and to certain interventions for lifestyle change, the public health infrastructure has n o t yet i n co rp o rat ed psychol- ogy's knowledge base. N o r has it recognized the variety o f opportunities t h at psychology offers for p r o m o t i n g health. T h e public health infrastructure is defined as the organizational base from which public health goals are addressed in American society. T h e reader should rec- ognize that the public health i n frast ru ct u re provides rou- tine services that may or m ay n o t be tested t h ro ugh re- search. Psychology has had a greater influence on research an d d e m o n s t r a t i o n a c t i v i t y - - t h e t e m p o r a r y , limited, and innovative strategies t o i m p ro v e health in p o p u l a t i o n s - - t h an on the p e r m a n e n t and ongoing services o f health d e p a r t m e n t s and other organizations t h at provide public health. As the i n frast ru ct u re learns to work m o r e effec-
Edilor~ note. This article was originally presented as part of a Distin- guished Contribution to Psychology in the Public Interest award address at the 102rid Annual Convention of the American Psychological Asso- ciation in Los Angeles. California, in August 1994.
Author's note. Discussions with many colleagues have informed this work: Thomas D. Cook, Ralph DiClemente, Paul Farnham, David Holtgrave, James Raczynski, Kim Reynolds, and William Shadish. Spe- cial thanks go to Mary Guinan and to the late Robin Gorsky for crys- talizing these thoughts.
Correspondence concerning this article should be addressed to Laura C. Leviton, Department of Health Behavior, 121 Mortimer Jordan Hall, University of Alabama at Birmingham, Birmingham, AL 35294-2010.
42 J a n u a r y 1996 • A m eri can Psychologist Copyright 1996 by the American Psychological Association. Inc. 0003-066X/96/$2.00
Vol. 51, No. 1, 42-51
tively with psychology (and vice versa), both fields will achieve more of the potential Winett et al. (1989) described.
Integration of Psychology and Public Health: Challenges Structural and Intellectual Challenges
The Institute of Medicine gave new insight and direction to the field of public health in its 1988 report The Future o f Public Health. The report described a public health infrastructure made up of diverse and fragmented com- ponents, including (a) law and regulation; (b) enforcement of the law by inspectors and the courts; (c) the rank and file of state and local health departments; (d) community agencies when they devote attention to the health of pop- ulations; (e) the medical care system to the degree that it focuses on prevention and the well-being of populations; and (f) grassroots organizations that focus on public health goals. The report described planned systems such as those for sanitation, as well as de facto systems, such as medical care practices in which prevention activities can occur. Public health policy aims at gaining the support of these and other constituencies for relevant programs, laws, and resource allocation. Public health practice, in contrast, involves implementation and quality assur- ance for organized public health activities (Institute of Medicine, 1988).
Psychology still has much to contribute to both pol- icy and practice. Winett et al. (1989) noted "surprisingly little integration" (p. xi) of the strengths of public health and health psychology. Their book contributed a frame- work for integrating the two fields. They noted several obstacles: the need for health psychologists to become familiar with the knowledge and skills of public health practice; the need to communicate effectively with public health policymakers and practitioners; the breadth of is- sues in public health; and a focus in public health on an empirical knowledge base as opposed to formal theory. Some of these represent challenges to psychology, includ- ing the need to translate behavioral effects into health consequences and to develop widespread, cost-effective interventions. Others are challenges to public health, in- cluding some traditions of the field that may impede integration.
Variation in Acceptance of Psychological Knowledge
Acceptance of the utility of psychology varies widely among public health practitioners (Matthews & Avis, 1982). Variation in its acceptance for policy becomes ob- vious to anyone reviewing the supporting documentation for the Year 2000 Objectives for the Nation (Public Health Service, 1990). References to psychological knowledge and technology are most plentiful in areas in which utility has been most thoroughly demonstrated; for example, in the areas of addiction and lifestyle changes to prevent chronic disease. Yet psychologists have applied their knowledge in highly diverse ways to public health prob-
lems. The way psychologists apply social cognitive theory to lifestyle change (Bandura, 1995) differs on many di- mensions from the way psychologists advise environmen- tal experts on risk perception and risk communication (Fischhoff, Bostrom, & Quadre, 1993; Slovic, Fischhoff, & Lichtenstein, 1987). Both of these applications differ dramatically from community psychologists' activities in planning for drug abuse prevention in partnership with affected communities (Linney & Wandersman, 1991). Several authors who work at the intersection of psychology and public health encourage diversity by pointing to the application of a variety of theories and technologies in their frameworks (e.g., Fishbein et al., 1992; Leviton, 1989b; Prochaska, DiClemente, & Norcross, 1992; Wi- nett et al., 1989).
The diversity of psychological approaches poses practical challenges to integration. Because policy and program responsibilities in public health are themselves fragmented, the diverse applications may not all come to decision makers' attention. Even if they did, outsiders to psychology do not readily perceive that the various ap- plications come from a single discipline. Public health practitioners look to an authoritative body, such as the Centers for Disease Control and Prevention, for guidance and standards of practice. They see no similar authority for guidance in applying psychological theory to health behaviors. Nevertheless, both policymakers and practi- tioners are increasingly aware that psychology is relevant to a wide variety of their tasks. Some policymakers and practitioners are simply puzzled about bow to apply the new tools. As the Director of the Centers for Disease Control and Prevention recently put it, "You have con- vinced me that behavioral science is important. Now, tell me how to use it."
Can we show public health how to use psychology? We, as psychologists, are still learning how to use it to address public health problems. In the long run, im- provements in integration may come through the creation of more general health behavior theories (e.g., Ewart, 1991). However, the public has pressing health needs in the short term. Iscoe (1982) pointed out that public health expects action research from psychology: the application of methods and theory to concrete public health prob- lems. Thus the aim of this article is to outline some in- crementalmless than perfect, but practical--applications of psychology to public health policy and programs. To achieve incremental improvement, a diversity of approaches is required. Some illustrations are now presented.
Challenges for Public Health, Opportunities for Psychology
Certain traditions in public health are being actively de- bated by practitioners. In actuality, these debates present opportunities to illustrate the value of psychology. They are particularly convincing because they address some of public health's most acute dilemmas.
January 1996 • American Psychologist 43
Focus on I n c r e m e n t a l I m p r o v e m e n t s
Public health has long recognized a mistaken expectation that prevention will somehow offer complete pro t ect i o n (Cares & H i n m a n , 1992). Rarely can prevention activity achieve a 100% reduction in risk o f d i s e a s e - - m o s t options represent incremental improvements only (Russell, 1985). Yet past successes lead public health professionals to as- pire to complete protection.
J o h n Snow's victory against cholera is often cited as an example o f what public health can achieve (Lillienfeld & Lillienfeld, 1980). Snow was the physician who first demonstrated a practical relation between cholera an d unsanitary water supplies. By removing the p u m p handle from a well, he probably ended an epidemic in the Soho district o f London. The m o d e r n d i l e m m a was voiced by a m e m b e r o f the audience at a 1994 workshop sponsored by the National Institute on Occupational Safety and Health. " W e all want to be J o h n Snow. We expect to remove a p u m p handle and eradicate disease. Well, we haven't found a p u m p handle for these m o d e r n day p ro b - lems." T h e goal these days is not perfection, b u t the max- imization o f the achievable i n c r e m e n t in protection.
Recognizing new opportunities for i n c r e m e n t a l im- provements and demonstrating those improvements offers a major route toward integrating psychology into public health practice. Some i m p r o v e m e n t s have behavioral sci- ence applications as their centerpiece. For example, public campaigns for lifestyle changes would fall into this cate- gory. Other applications are m o r e modest and improve an existing service delivery system, program, or policy. In all cases, it is necessary not merely to show behavior change, but to show how such change improves the ef- fectiveness o f public health systems.
An example comes from a seminal policy analysis o f hypertension control c o n d u c t e d by Weinstein and Sta- son (1976). Figure l is a flow chart representing a public
health system in which people are screened for hyperten- sion, are detected as having high blood pressure, begin medical care for the condition, are treated or not treated, stay in t r e a t m e n t or not, and have their blood pressure controlled or not. (A later rendition would probably in- clude adherence to medication or n o t as an explicit stage in the process.) Each stage in the flow chart represents an activity and each step a transitional probability; po- tential participants are lost at each stage between initial blood pressure screening and the e n d p o i n t o f hyperten- sion control.
T h e probability o f getting to the next stage might be incrementally i m p ro v ed b y adding resources or interven- tions. T h r o u g h analysis o f these probabilities, Weinstein and Stason (1976) were able to d e m o n s t r a t e that addi- tional dollars could be used m o re effectively by improving the later stages (i.e., achieving control) rather t han the earlier stages (i.e., detecting additional hypertensives). N o t e that the crucial stages represent behavioral inter- ventions: keeping people u n d e r a physician's care and improving adherence to t reat m en t . Psychologists have long recognized these obstacles an d have contributed substantially to techniques that i m p ro v e adherence (Lev- enthal, Meyer, & G u t m a n n , 1980; Leventhal, Z i m m e r - man, & G u t m a n n , 1984). T h e purpose o f this article, however, is to provide a case in p o i n t in which psychology improves on the existing strategies. It is not the center- piece, but it is highly relevant to improving the transitional probabilities in a s y s t e m o f services.
T h e analysis o f transitional probabilities (and incre- mental successes) can be adapted to m a n y public health p ro b l em s an d services, ranging from i m m u n i z a t i o n to exercise (Russell, 1985) and from needle exchange pro- grams (Kaplan & Brandeau, 1994) to rat control (Leviton, 1983). Psychology has sometimes c o n t r i b u t e d to public health p r o g r a m development by identifying stages o f set-
F i g u r e 1 State-Stage Model of a Public Health System for Hypertension Control
I Not "~ 1 -P4 hypertenslveJ ~
T 1 --P2 Target Primary ~ Suspected [-=--~lSeconoaryl -~ Confirmed "
hypertenslon hypertens on population screening ] ] / I screening ] i be, " ~ 7 "l Controlled[
" \ not treated not coot,o.ed Note. From Hypertension: A Policy Perspective, by M.C. Weinstein and W.B. Stason. Copyright © ] 9 7 6 by the President and Fellows of Harvard College. Reprinted by permission of Harvard University Press.
44 J a n u a r y 1996 • A m eri can Psychologist
vice delivery (e.g., Leventhal, Zimmerman, & Gutmann, 1984) or by showing practitioners how clients can make the transition to the next stage (Prochaska, DiClemente, & Norcross, 1992).
State-stage modeling becomes an important tool for integrating psychology and public health. The models have appeal for public health policymakers, who find probabilities and estimates of risk reduction to be per- suasive. Practitioners also find the flow charts used in such models to b e helpful because they illustrate the components of service delivery and provide a basis for program improvement. The models are also helpful be- cause they fit with the public health tradition. Unlike practitioners in many other fields, public health staff are accustomed to outlining measurable objectives for service delivery. Flow charts illustrate how objectives build upon each other, and they can depict how improvements in outcomes can be achieved through tinkering with service delivery (Suchman, 1967).
Exhortation Is not Enough
Practitioners committed to health feel that people should listen to them. Yet the Institute of Medicine (1988) noted that the public does not seem to understand the need for public health measures. Perhaps it has seldom done so. An obituary of Chadwick, the great sanitarian of the Vic- torian age, stated, "had he killed in battle as many as he saved by sanitation he would have had equestrian statues by the dozen put up in his memory" (Gray, 1979, p. 278).
Public health's alliance with medicine may be partly responsible for the tendency to exhort. Leventhal, Zim- merman, and G u t m a n n (1984) contrasted medicine's fo- cus on prescribing behavior change with psychology's fo- cus on enabling the conditions for behavior change. How- ever, public health has a unique social mission that also drives its communication style. Public health evolved over centuries, as individual communities and then states agreed that their collective interest demanded quarantines, sanitation, and other measures (Rosen, 1958). Cole (1994) cited an informed public as one of the major justifications of the public health enterprise. The media has presented the Surgeon General as using "the bully pulpit" to en- courage healthful behavior.
Public health professionals are earnestly seeking al- ternative ways to communicate about health problems. Some communication strategies derived from psychology address lifestyle issues and synthesize psychological theory and social marketing (e.g., LeFebvre & Flora, 1988; McAlister, 1991). Other psychological strategies are sur- prising, at least to public health professionals. For ex- ample, when engineers and toxicologists face citizens who are suspicious and angry over an environmental problem (Harris, 1984), they often come to value psychology's contributions to risk communication (National Research Council, 1989b). The same applies to state and local pub- lic health officials who are actively debating the need to work in partnership with communities (Centers for Dis- ease Control, 1985; National Association of County Health Officials, 1991). Community psychologists can
assist health officials as they establish a different type of engagement with communities from the top-down, au- thoritative statement (Tanabe, 1982).
Cost a n d Consequences o f M a n d a t e s
Reliance on mandated health and safety standards are a third public health tradition, one under review at the highest level of government (see, e.g., the National Per- formance Review, 1995, on "reinventing" the Occupa- tional Safety and Health Administration). Public health mandates were and are enforced as part of governments' police powers, as infectious persons and unsanitary con- ditions pose a clear and present danger to society (Cole, 1994; Risse, 1988; Rosen, 1958). Indeed, some European countries instituted "health police" during the 18th and 19th centuries (Rosen, 1958). Although some opposed the consequent limitations on individual liberty, the lim- itations were generally accepted as important to the com- munity's welfare (Beauchamp, 1985; Porter & Porter, 1988). However, public health professionals need to rec- ognize that sometimes mandates are not feasible, may cost too much, or may not be acceptable to address mod- ern public health problems. The trend is toward less reg- ulation and toward decreasing government resources for enforcement.
Psychology can improve the available strategies in at least three ways: (a) by identifying realistic alternatives to mandates, (b) by reducing the need for inspection and enforcement, and (c) by helping to craft more effective mandates. Some compelling illustrations come from oc- cupational health. In Minnesota, only one tenth of one percent of small businesses are inspected for health and safety in any given year--a situation typical of many states (Leviton & Sheehy, in press). Because small businesses employ the great majority of workers in the United States, this is a sobering figure. Therefore, practitioners are searching for lower cost alternatives, supplementing scarce inspection and enforcement resources and freeing re- sources to be used where they will have the greatest effect. Social marketing has been proposed to assist in one area, encouraging the adoption of low cost, protective tech- nology by small business. The costly and labor-intensive process of inspection and enforcement can then increas- ingly be shifted to the small percentage of businesses that pose the greatest threat of injury and illness (Leviton & Sheehy, in press).
Psychology can help to conserve limited inspection and enforcement resources in other ways. The Occupa- tional Safety and Health Administration is proposing the replacement of across-the-board inspection and enforce- ment with worker-management teams to identify and abate health and safety hazards (e.g., Gjessing, Schoen- born, & Cohen, 1994). Inspection and enforcement would then be reserved for those companies that fail to imple- ment such teams (National Performance Review, 1995). To increase the effectiveness of such decision-making teams, the knowledge base of group dynamics and group decision making is clearly relevant (Fiedler, 1967; Lippit, 1985). Voluntary efforts have been applied successfully
January 1996 • American Psychologist 45
in the past; for example, c o m m u n i t y psychologists would recognize these same strategies in the National Urban Rat Control Program. Engagement o f low income neigh- borhoods often led to voluntary cleanup, which reduced health departments' time and expense in taking people to court (Centers for Disease Control, 1977; Systems Re- search and Development Corporation, 1980).
Mandates are an i m p o r t a n t tool for lifestyle change: Psychology's contributions in this area have increased an awareness that health psychology is not health education (Winett, King, & Altman, 1989). However, psychologists also have an opportunity to help craft these mandates. Psychologists are uniquely able to speak to the likely con- sequences o f law and regulation affecting b e h a v i o r - - a prospective look at consequences is vital to the policy- maker. For a model discussion o f the behavioral conse- quences of policy, the reader should turn to an economist's analysis, not a psychologist's. K e n n e t h Warner's (1983) analysis of seat belt laws and m a n d a t e d airbags is a tour de force on likely consequences o f policy. Behavioral sci- entists do sometimes contribute i m p o r t a n t information to discussions o f policy consequences. For example, pro- posals for condom distribution to adolescents perturb cit- izens who worry that the programs may encourage sexual activity by teens. Evaluations indicate no basis for these fears (Holtgrave et al., 1995).
Summary of Public Health Challenges
I have presented some debates in public health policy and practice to which psychology can contribute. They are by no means comprehensive. However, they represent important dilemmas, and policymakers would be grateful for some solutions. Note that, in each example, appli- cations of psychology do not replace the existing strategies or programs; rather, they provide a complement to in- crementally improve those strategies. To realize the po- tential for such improvements, however, psychology faces some challenges o f its own.
Some Challenges for Psychology Public health policymakers will evaluate new behavioral interventions by the same criteria as existing strategies and programs. They want the following:
1. practically significant changes in health, or in the conditions conducive to health;
2. justification for every dollar spent. Scarce funds must be allocated rationally in an era of declining public resources; and
3. widespread interventions, so that change can be seen in entire populations.
Can Psychology Achieve Practically Signiflcant Prevention Effects?
Even when public health practitioners acknowledge that behavioral intervention is required, they may express skepticism about effectiveness. For example, Mary Guinan, Assistant Director for Evaluation at the Centers for Disease Control's Office of HIV/AIDS, believes much
o f the public health establishment is " i n vaccination m o d e , " waiting for what they regard as a more powerful way to prevent AIDS. Therefore, almost every study o f AIDS prevention begins with a reminder that behavioral interventions are the only available m e t h o d to prevent infection (e.g., G u i n a n & Leviton, 1995). Public health experts in other problem areas have expressed skepticism as well (e.g., Baker, O'Neill, Ginsberg, & G u o h u a , 1992), and it has been reinforced by the recent pessimistic results of the Minnesota Heart Health Study (Luepker et al., 1994) and the C O M M I T trial for smoking cessation (COMMIT Research Group, 1995a, 1995b).
Behavioral intervention can indeed be practically significant when effect sizes are compared with those o f medical interventions generally regarded as effective (Lipsey & Wilson, 1993). However, evaluations o f medical interventions c o m m o n l y translate effect sizes into their practical implications for health or for public health sys- tems, whereas behavioral interventions do so less fre- quently. The tools to do so are readily available and should be used (Centers for Disease Control and Prevention, 1994; Kaplan, 1990; Kaplan & Brandeau, 1994; Pettiti, 1994; Weinstein & Stason, 1976).
Behavioral interventions sometimes appear at a dis- advantage because their effects take time to become ex- pressed in health terms (e.g., Oster, Colditz, & Kelly, 1984). Also, the so-called " h a r d o u t c o m e s " o f illness and death may be difficult to obtain for logistic reasons. For example, no study o f HIV prevention has been able to demonstrate a decrease in new HIV cases, because the prevalence data are usually not available and the incidence of new cases is too low to develop meaningful comparisons (Leviton & Valdiserri, 1990; National Research Council, 1989a). Some health effects o f behavioral interventions take substantial time a n d large numbers o f participants before they are seen. To ask behavioral interventions to produce measurable health outcomes under less t h a n ad- equate circumstances is the equivalent o f asking a clinical drug trial to assess effectiveness without sufficient time or power.
As a substitute for direct assessment o f practically significant health effects, it is sometimes defensible to project or model the likely effects on health from the ob- tained behavior results. This is feasible when the clinical trials demonstrating those health effects have been con- ducted or when a sensitivity analysis o f likely effects can provide satisfactory information about upper and lower bounds on estimates of health outcomes. Such projections have been made for HIV infection and prevention (Kap- lan, 1990; Kaplan & Brandeau, 1994), for health and economic effects o f smoking and quitting (Oster, Colditz, & Kelly, 1984), and for hypertension control (Weinstein & Stason, 1976). As I shall demonstrate, this ability to model health effects also has implications for cost- effectiveness and cost-benefit analysis.
Can Psychology Help to Achieve Cost-Effective Interventions? Increasingly, public health agencies are assessing cost, cost-effectiveness, and cost-benefit in order to justify
46 J a n u a r y 1996 • American Psychologist
public expenditures on prevention (Russell, 1985). With the recent publication of a handbook on prevention ef- fectiveness, the Centers for Disease Control and Preven- tion aspires to bring these analyses to the evaluation of every prevention activity (Centers for Disease Control and Prevention, 1994). In particular, this publication focuses on the incremental cost-effectiveness of adding resources or components, a critical issue for some behavioral in- terventions.
Prevention itself does not always save m o n e y - - n o r should it (Russell, 1985). We still need to know the cost. Also, for some prevention programs, convincing "break even" analyses are available. According to such analyses, behavioral interventions can fare reasonably well. For ex- ample, most employers will at least break even from worksite hypertension control programs, seat belt cam- paigns, and some smoking cessation programs (Leviton, 1989a). Holtgrave, Valdiserri, Gerber, and Hinman (1993) used break even analyses to demonstrate that if even one HIV infection were prevented by a behavioral campaign, the savings to society would justify the expense of many programs.
Policymakers in public health sometimes view be- havioral intervention as prohibitively labor intensive, be- cause they equate it with one-on-one counseling by highly trained and expensive staff. However, it can be instituted through less expensive means. In fact, adding behavioral components to medically oriented programs often in- creases "reach," and thus increases the marginal cost- effectiveness of the medical intervention. For example, a program for former chemical workers exposed to a blad- der carcinogen used media and community-support strategies to make recruitment and patient education less labor-intensive than it would otherwise have been (Lev- iton, Chen, Marsh, & Talbott, 1993).
Can Psychology Promote Widespread Effects? The issue of "reach," or penetration to affect entire pop- ulations, has been discussed in health psychology for some time now. It can be achieved in a variety of ways, including social marketing (Lefebvre & Flora, 1988); marshalling of community support through a variety of channels (McAlister, 1991); working with medical professionals (Burns, Cohen, Gritz, & Kottke, 1993) or schools (Glynn, 1989); and work with the public health rank and file (Kamb, Dillon, & Fishbein, 1995). In line with the criteria for good health promotion practices set forth by the American Public Health Association (1987), all these strategies involve working within existing organizational structures.
To achieve widespread effects, work within existing structures, and maintain cost-effectiveness, however, it is often necessary to disseminate psychological principles to nonpsychologists. Permanent improvements require that these models be employed not only in research and demonstrations, but in the infrastructure. This can occur in several ways; there are excellent examples of each, but also causes for concern. First, public health practitioners may adopt models that were developed by psychologists,
as in the case of smoking cessation (e.g., COMMIT Re- search Group, 1995a, 1995b). However, implementation may be faulty in some cases, an issue that is important to evaluators (e.g., Stone, McGraw, Osganian, & Elder, 1994). Disseminating existing models is troublesome be- cause innovations are often "reinvented" by those who adopt them (Rogers, 1983). An important issue then be- comes whether practitioners have adapted a model to the situation or if they have actually transformed it into something else. Judging the appropriateness of modifi- cations requires more than simply measuring adherence to a protocol. Departures from a protocol may be forced by the situation, but might still be consistent with the underlying theoretical model (Cook, Leviton, & Shad- ish, 1985). But who judges the appropriateness o f mod- ifications? Who should determine whether a modifi- cation is still a meaningful exemplar of a theory-driven model?
Public health practitioners might also apply psycho- logical theory independently, as is the case when health educators apply the Health Belief Model as a framework for encouraging breast self-examination (Rosenstock, Strecher, & Becker, 1994). However, this raises other con- cerns. Rogers (1983) described how some adopters of an innovation can use it uncritically. In the same way, health practitioners have sometimes adopted a theoretical framework and used it injudiciously when a careful anal- ysis would call for consideration of an alternative frame- work. But who determines the appropriateness of the framework?
For both adoption of models and independent use of theoretical frameworks, there is yet another concern. Innovations are easier to modify when their components are loosely "bundled," that is to say, when adopters can pick and choose among components rather than being compelled to adopt the entire model or package (Rogers, 1983). Behavioral intervention models for public health are for the most part loosely bundled innovations; yet evaluators are highly concerned about maintaining effec- tiveness in the face of a piecemeal, uncritical adoption of components (Cook, Leviton, & Shadish, 1985). The same applies to piecemeal adoption of theoretical concepts without sufficient regard for their logical consistency in a greater whole--the discomforts over both technical ec- clecticism and theoretical integrationism (e.g., Bandura, 1995; Leventhal, Zimmerman, & Gutmann, 1984). These are problems psychologists see within their own ranks, let alone among public health practitioners. Who will de- termine whether program components or theoretical concepts have been integrated logically and consistently?
Summary of Psychology's Challenges Psychology faces three challenges to gaining recognition for its applications to public health problems: (a) trans- lating behavioral effects into health implications, (b) demonstrating cost-effectiveness, and (c) gaining wide- spread effects by working with the public health infra- structure. Some of the tensions for psychology are made evident, especially in work with the infrastructure, in
January 1996 • American Psychologist 47
which the danger o f "giving psychology away" is that the knowledge may be used inappropriately. I now t u r n to some ways to address those tensions.
R e c o m m e n d a t i o n s
Compromises to Achieve Integration
Psychology faces a dilemma: Public health d e m a n d s big effect sizes and action research from psychologists. In- tegration o f diverse behavior change techniques, theories, or knowledge bases could incrementally improve health outcomes. Yet integration makes theorists uneasy. It is too easy to integrate techniques or theories uncritically (Bandura, 1995; Leventhal, Meyer, & G u t m a n n , 1980). How can psychologists do so?
Over the longer t e r m a comprehensive t h e o r y o f health behavior m a y resolve the issue; over the short t e r m several legitimate compromises can achieve integration. One c o m p r o m i s e was a consensus outlined by Fishbein et al. (1992). These researchers stated that eight variables or theoretical concepts are the p r i m a r y d e t e r m i n a n t s o f any given behavior. T h r o u g h interview, observation, and content analysis, the variables can be made operational in a given situation. According to this view, integration is achieved only in context by developing interventions that focus on the variables most likely to achieve change.
A second, related c o m p r o m i s e is to incorporat e di- verse elements o f the knowledge base within a coherent, logical chain o f public health objectives, as illustrated b y the series of objectives or state-stages seen in the Weinstein and Stason (1976) framework o f Figure 1. E x a m i n i n g the framework, it should be obvious that although a t h e o r y o f adherence to medication is relevant to m a n y o f the stages, it will have its p r i m a r y impact on interventions made specifically to improve treatment. Applications o f other theories might assist at the earlier stages. As long as these theories do not conflict with the chosen adherence theory (either logically or in actual implementation), why should they not be i n c o r p o r a t e d to improve increm en t al effectiveness? Evaluation researchers often elicit these types o f integrated theories when they test "small theo- ries" o f programs (Lipsey, 1993; Rossi & Freeman, 1993). Small theories can specify key intervening variables needed to obtain outcomes, or can incorporate causal diagrams or state-stage analyses such as the Weinstein and Stason (1976) framework.
A third c o m p r o m i s e is to develop with public health practitioners what sociologists call theories o f the middle range (Merton, 1968). Middle range theories are not the grand and all encompassing theories o f behavior; rather, they can explain the health behavior o f particular pop- ulations at risk. Relevant applications can flow from these middle range theories. Middle range theories can assist psychologists in the need to draw on disparate theoretical perspectives, an issue o f great concern in the clinical lit- erature that is beginning to be addressed in health psy- chology. For example, a middle range theory o f adolescent risk for H I V and its prevention can draw u p o n social cognitive theory, but can legitimately c o m b i n e it with
theories o f adolescence (Brown, DiClemente, & Reynolds, 1991; Kelly, Murphy, Sikkema, & Kalichman, 1993). If African American adolescents are the population targeted for prevention, then it would be the height o f folly not to incorporate theories o f culturally specific health practices. All o f these are the subject o f middle range theory. T h e a p p r o a c h still confers the advantages o f a theory, because it is sufficiently general to be applied and tested in m a n y situations: a m o n g gangs, runaway youth, or rural y o u t h to n a m e a few.
T h e integration o f theories at the middle range is possible in health psychology because, unlike the behav- ioral and psychoanalytic therapists, health behavior psy- chologists generally agree o n epistemology, or "ways o f knowing" (Franks, 1984; Messer & Winokur, 1984). Fur- t h e r m o r e , integration can be accomplished at the level o f concepts in particular public health problems, an argu- m e n t with some merit in clinical work as well (Wachtel, 1984). Finally, integration is possible because we are dis- cussing different systems to be explained or explored (Schacht, 1984). It should be n o m o r e unusual to discuss a t h e o r y o f adolescent behavior in the context o f a health behavior t h e o r y t h an it is to discuss psychopharmacology in the context o f behavior therapy.
Development of Consensus About Appropriate Application
Although scientific a d v a n c e m e n t requires diversity and debates, some consensus about public health applications would be desirable. Competing theories do not imply that the applications must be incompatible. Achieving at least some consensus may help health psychology to develop the " b o d y o f a u t h o r i t y " that public health practitioners look for and that skeptics do n o t see. Psychologists are the ones who need to judge adaptations o f a theory-driven model. Psychologists ideally judge the appropriateness o f a theoretical framework and d e t e r m i n e whether concepts have been integrated logically and consistently. This is the most i m p o r t a n t area in which psychologists differ- entiate themselves fro m health educators. Psychologists are the stewards o f health behavior theory; by developing some consensus on applications, they can b e c o m e better stewards.
Integration as an Intellectual Partnership
To assure the c o h e r e n t integration o f psychology into public health practice, neither the dissemination o f intact models n o r independent application o f t h eo ry by prac- titioners is entirely satisfactory. Instead, there is evidence that psychologists and public health practitioners work best in partnership. Each possesses essential knowledge for the process.
Iscoe (1982) n o t ed that public health practitioners can seem u n c o m f o r t a b l e or awkward in applying psy- chology. In m y experience, it is a skills issue. Often we simply describe the concepts o f a t h e o r y to practitioners, assuming this is enough for t h e m to achieve the required flexibility in application. Public health professionals can and d o master the concepts. However, training an d prep-
48 J a n u a r y 1996 • A m eri can Psychologist
a r a t i o n in p s y c h o l o g y b e c o m e i m p o r t a n t i n d e c i d i n g h o w f a r a b e h a v i o r c h a n g e p r o g r a m c a n b e a d a p t e d a s well a s w h a t c o n s t i t u t e s a d e p a r t u r e f r o m a m o d e l o r f r o m c o - h e r e n t t h e o r y . R e s e a r c h p s y c h o l o g i s t s s p e n d t h e i r g r a d u a t e c a r e e r s a n d s u b s e q u e n t lives d e b a t i n g p s y c h o l o g i c a l t h e - ory, c r i t i q u i n g t h e l o g i c a l r e l a t i o n s h i p s a m o n g t h e o r e t i c a l c o n c e p t s , a p p r a i s i n g t h e q u a l i t y o f m a n i p u l a t i o n a n d t h e w a y c o n c e p t s a r e o p e r a t i o n a l i z e d , a n d t e s t i n g h y p o t h e s e s d e r i v e d f r o m t h e o r i e s . T h e s e s k i l l s a r e a l s o r e q u i r e d for a g o o d a p p l i c a t i o n o f t h e o r i e s t o p r a c t i c a l p r o b l e m s : A n a p p l i c a t i o n is j u d g e d g o o d o r b a d d e p e n d i n g i n p a r t on t h e w a y t h e i n t e r v e n t i o n ( i n d e p e n d e n t v a r i a b l e ) a n d o u t - c o m e s ( d e p e n d e n t v a r i a b l e s ) a r e o p e r a t i o n a l i z e d .
P u b l i c h e a l t h p r a c t i t i o n e r s s p e n d t h e i r p r o f e s s i o n a l lives d e v e l o p i n g a d i f f e r e n t b u t e q u a l l y i m p o r t a n t set o f skills. A s I s c o e ( 1 9 8 2 ) g e n t l y r e m i n d e d us, o t h e r s h a v e b e e n t h e r e b e f o r e u s i n d e v e l o p i n g b e h a v i o r c h a n g e i n - t e r v e n t i o n s . It t a k e s a g r e a t d e a l o f s k i l l t o c o n v i n c e p a - t i e n t s w i t h a s e x u a l l y t r a n s m i t t e d d i s e a s e t o n a m e t h e i r p a r t n e r s . I m p o r t a n t i n s i g h t s i n t o h u m a n n a t u r e b e l o n g t o t h e p u b l i c h e a l t h n u r s e s w h o c l i m b t e n e m e n t s t a i r s t o m a k e s u r e p e o p l e t a k e t u b e r c u l o s i s m e d i c a t i o n s o r t o c h e c k o n a n e w m o t h e r a n d b a b y . T h e y s h o u l d b e h o n o r e d for t h e i r s e r v i c e .
I n fact, t h e r e f l e c t i v e p u b l i c h e a l t h p r a c t i t i o n e r h a s d e v e l o p e d a c o n s i d e r a b l e k n o w l e d g e b a s e a b o u t p o p u l a - t i o n s a t r i s k for a d i s e a s e . T h i s k n o w l e d g e is e s s e n t i a l t o c r a f t s e n s i b l e i n t e r v e n t i o n s , a p r o c e s s t h a t is b e s t c a r r i e d o u t in c o n v e r s a t i o n . P s y c h o l o g i s t s d o n o t d e n i g r a t e p r a c - t i t i o n e r k n o w l e d g e b y c a l l i n g it e m p i r i c a l r a t h e r t h a n t h e - o r y d r i v e n ( S i n g e r & K r a n t z , 1982; W i n e t t , K i n g , & A l t - m a n , 1989). P r a c t i t i o n e r s c a n a r t i c u l a t e t h e i r i m p l i c i t t h e o r i e s a b o u t s e r v i c e delivery, t h e o r i e s t h a t p s y c h o l o g i s t s m a y n o t h a v e c o n s i d e r e d . S c h o l a r s o f h e a l t h b e h a v i o r h a v e g a i n e d i m p o r t a n t i n s i g h t s b y e l i c i t i n g s u c h t h e o r i e s (e.g., L e v e n t h a l , Z i m m e r m a n , & G u t t m a n , 1984).
Summary and Conclusion S e v e r a l c o m p r o m i s e s a r e p r o p o s e d t o i n t e g r a t e t h e o r y , k n o w l e d g e , a n d d i s p a r a t e i n t e r v e n t i o n s . S u c h i n t e g r a t i o n c a n i n c r e m e n t a l l y i m p r o v e p u b l i c h e a l t h s y s t e m s . I n t e - g r a t i o n c o u l d a l s o h e l p p s y c h o l o g y t o d e v e l o p a b o d y o f a u t h o r i t y w i t h w h i c h t o i n f l u e n c e d e c i s i o n s a b o u t p u b l i c h e a l t h . F i n a l l y , a p a r t n e r s h i p w i t h p u b l i c h e a l t h is p r o - p o s e d in w h i c h p s y c h o l o g i s t s g u i d e t h e c o r r e c t a p p l i c a t i o n o f o u r k n o w l e d g e b a s e t o p u b l i c h e a l t h p r o b l e m s .
I n t e g r a t i o n , c o n s e n s u s , a n d p a r t n e r s h i p c a n n o t b e u n d e r t a k e n lightly. To a c h i e v e b o t h t h e p u b l i c h e a l t h g o a l s a n d p s y c h o l o g y ' s s c i e n t i f i c goals, t h e m o d e l s t h a t i n t e g r a t e k n o w l e d g e b a s e s n e e d e v e n m o r e d e b a t e a n d d i s c u s s i o n t h a n t h e y r e c e i v e a t p r e s e n t . I m p l e m e n t a t i o n o f t h e m o d - els n e e d s s c r u t i n y b y p s y c h o l o g i s t s t o a s s u r e c o r r e c t o p - e r a t i o n a l i z a t i o n . F i n a l l y , p s y c h o l o g i s t s t h e m s e l v e s n e e d t o p r o v i d e m o r e c o n c r e t e g u i d a n c e t o p u b l i c h e a l t h p r a c - t i t i o n e r s o n t h e use o f t h e k n o w l e d g e b a s e f o r a c t i o n r e s e a r c h .
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