Integrative Literature Review

Perspectives

Structural developmental psychology and health

promotion in the third age

Lars Bauger1,* and Rob Bongaardt2

1Department of Nursing and Health Sciences and 2Department of Health, Social and Welfare Studies,

Faculty of Health and Social Sciences, University College of Southeast Norway, Porsgrunn, Norway

*Corresponding author. E-mail: [email protected]

Summary

In response to the ever-increasing longevity in Western societies, old age has been divided into two

different periods, labelled the third and fourth age. Where the third age, with its onset at retirement,

mostly involves positive aspects of growing old, the fourth age involves functional decline and in-

creased morbidity. This article focuses on the entry to the third age and its potential for health promo-

tion initiatives. Well-being is an important factor to emphasize in such health promotion, and this arti-

cle views the lifestyle of third agers as essential for their well-being. The structural developmental

theory of Robert Kegan delineates how a person’s way of knowing develops throughout the life

course. This theory is an untapped and salient perspective for health promotion initiatives in the third

age. This article outlines Kegan’s approach as a tool for developing psychologically spacious health

promotion, and suggests future directions for research on the topic.

Key words: health promotion programs, quality of life, qualitative methods, older people

INTRODUCTION

Retiring from work is a major transition in life and in

many countries. It is the social marker of entering into

old age (Kloep and Hendry, 2006). The conception of

old age altered dramatically during the late 20th century

as people lived increasingly longer. As one consequence

of this, researchers now distinguish between the ‘third

age’ and ‘fourth age’ (Baltes, 1997; Baltes and Smith,

2003; Laslett, 1996). In gerontology the last stage of a

person’s life is often called the fourth age (Koss and

Ekerdt, 2016), which is a period characterized by func-

tional decline and an increased dependency. The third

age, with its onset in retirement, is seen as a period of

relatively good health with the potential of active social

engagement forming a solid base for healthy ageing

(Robinson, 2013). Even though the third age has a posi-

tive ring to it, it may come with some challenges that are

specific for this period of life. Retirement itself, whether

it comes voluntarily or, as may happen, involuntarily,

may be experienced as troubling (Daatland and Solem,

1995) and can have a negative effect on the well-being

of the retiree (Wang, 2007). Studies of retirement effects

on the person’s well-being have demonstrated that be-

tween 9-25% experience negative effects to their well-

being after retirement (Wang, 2007; Pinquart and

Schindler, 2007). In their recent review, Wang and Shi

(2014) highlighted different factors pre, during and post

VC The Author 2017. Published by Oxford University Press.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),

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Health Promotion International, 2018;33:686–694

doi: 10.1093/heapro/daw104

Advance Access Publication Date: 11 January 2017

Perspectives

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retirement that affected the well-being of the retiree.

The negative factors were ill health, involuntary retire-

ment, a concern with the maintenance of social status

and contacts, and strongly identifying with one’s work

role (Wang and Shi, 2014). Health promotion may help

retirees to find a suitable place in society and improve

well-being in spite of these negative factors. In addition,

health promotion will prolong this third age period and

as a consequence likely compress morbidity during the

fourth age period (Whitehead, 2011). Whitehead (2011)

also suggests that during the fourth age, persons may

draw on existential forces to overcome adversity, forces

that are built up during earlier stages of life, including

the third age. Health promotion is apt to endorse such

existential forces. In other words, health promotion dur-

ing the third age may postpone the onset of the fourth

age, make it shorter and more endurable once the person

faces adversity.

Health promotion typically targets large populations

and may be unable to address individual differences.

The third age population, however, is characterized by

an immense heterogeneity (George, 2011; Wang, 2007),

and many third agers have acquired a unique profes-

sional competence, a specific way of living, and a net-

work that intertwines two or three generations of family

and friends. Ideally, health promotion should be individ-

ually tailored to the needs of each third ager. However,

the group’s heterogeneity renders that unfeasible. In this

article we outline a feasible approach to shaping health

promotion, directed at the intermediate range between a

large population and the unique individual. We do so by

introducing the structural developmental theory to the

healthy ageing discourse and linking this to the policy

making and practice of healthy lifestyle promotion. The

specific purpose of this article, then, is to outline a struc-

tural developmental approach to the field of health pro-

motion that targets the well-being of third agers. Before

presenting the structure of the rest of this article, we will

first delineate some central concepts.

The structural developmental theory focuses on con-

secutive stages of mental structures in a person’s life.

Such a theory is perhaps best introduced by contrasting

it to phase theories of life course development that

emphasize normative phases of life, such as birth, child-

hood, education, young adulthood, marriage, parent-

hood, working life and retirement (e.g. Erikson, 1980).

Whereas the phase developmental theory focuses on the

content of age-dependent periods of life, structural de-

velopmental stage theory underscores how this content

is put into perspective by the person – i.e. the extent to

which one takes responsibility for the unfolding of

events, and, ultimately, how the story of one’s life is told

at any particular moment in time. The development of

these perspectives is referred to as the development or

growth of complexity of mind (Kegan, 1994).

The field of health promotion often refers to the life

style concept. However, definitions of the lifestyle con-

cept abound. We assume that lifestyle is made of the fab-

ric of a person’s attitudes, manners, behaviours and

practices, which are all woven into a Gestalt

(Cockerham, 2005; Elstad, 2000). In our view, a per-

son’s complexity of mind underpins his or her lifestyle.

We thereby emphasize coherence in what are often pre-

sented as separate lifestyle ‘factors’, such as smoking,

diet, exercise, etc. (cf. Veal, 1993). Furthermore, lifestyle

and well-being can be seen as reciprocally related – well-

being is embedded in lifestyle and takes shape through

it. Well-being is a heavily debated topic within health

psychology and we are not advocating for any of its

schools of thought. In this article, we take a broad per-

spective and focus on the subjective experience of the

phenomenon. Nevertheless, our use of well-being is in

line with how Huppert (2009 p.137) defines psychologi-

cal well-being, i.e. ‘the combination of feeling good and

functioning effectively’. Feeling good, then, is not just

concerned with happiness and contentment but addi-

tional emotions such as ‘interest, engagement, confi-

dence and affection’ (2009, p. 138), whereas functioning

effectively captures ‘the development of one’s potential,

having some control over one’s life, having a sense of

purpose (e.g. working towards valued goals), and

experiencing positive relationships’ (2009, p. 138).

The structure of this article is as follows. We first re-

view and present the key concepts of our article; the

third age, health promotion and lifestyle. Then we sum-

marize Kegan’s theory of structural development of the

mind. After that, we present the design of a study that

addresses the experience of well-being premised on com-

plexity of mind, and, finally, discuss the logical implica-

tions of a psychological developmental approach to

tailoring health promotion for third agers.

HEALTH PROMOTION AT THE ONSET OF THE THIRD AGE

A positive perspective on the third age is well captured

by the gerontology term ‘successful ageing’. The term

gained popularity during the last decades of the 20th

century (Baltes and Smith, 2003). It was introduced by

Rowe and Kahn (1987) who reacted to the tendency in

gerontology to distinguish only between older people

with disease or disability and those without such condi-

tions. They introduced successful ageing as a positive

concept in order to address high cognitive and physical

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functioning and an active engagement with life, in addi-

tion to a low probability of disease and disability. In the

newfound optimism in the field of gerontology, the per-

ception of ageing changed from a passive experience to a

process of active engagement and participation (Baltes

and Baltes, 1990).

This more optimistic perspective on ageing has influ-

enced political discourse (Villar, 2012), as witnessed by

the introduction of the term ‘active ageing’ by the World

Health Organization (2002). The WHO defines active

ageing as ‘the process of optimizing opportunities for

health, participation and security in order to enhance

quality of life as people age’ (2002, p. 6). The WHO pol-

icy is to promote active ageing as a way to address socie-

tal and economic challenges stemming from an ageing

population as well as individual challenges associated

with getting older (World Health Organization, 2002).

Here the focus is on adding ‘more life to years, not just

years to life’ (Vaillant, 2004, p. 561), which is a hallmark

of health promotion in the third age. Wilson and Palha

(2007) argue that health promotion during this transi-

tional period will not only assist in maintaining existing

health but could also improve health and well-being sim-

ply because this is a period when one has more time to at-

tend to health-related needs than when one was working.

The third age is a period where one is left more to one’s

own devices with few established social structures and so-

cially defined roles (Freund et al., 2009). People are often

more free to do what they want, but those who do not

know or have not planned for what to do with this new

freedom could easily become ‘passive and couch ridden’

(Solem, 2012, p. 88; our translation).

It is evident that retirement is seen as an important

period for health promotion efforts. However,

retirement-specific research on health promotion is still

in its early stages. Reviewing the research, Wilson and

Palha (2007) identified 20 studies on the topic. Their

content analysis of these studies revealed four major

themes in the research on health promotion at the onset

of the third age, i.e. retirement: (1) the considerable ef-

fect of retirement and the need to support positive retire-

ment, (2) the identification and overcoming of barriers

to health promotion at retirement, (3) the best methods

to promote and sustain healthy lifestyle changes among

retirees and (4) the short and long-term benefits of

health promotion at retirement (Wilson and Palha,

2007). Given the aim of the present article, we will elab-

orate on theme (3), which links successful ageing to the

promotion of healthy lifestyles.

We emphasized above that the Gestalt of a person’s

attitudes, manners, behaviours and practices can be seen

as his or her lifestyle. A lifestyle approach to health

promotion builds on the assumption that the individual

can amend this lifestyle (Elstad, 2000; Nutbeam, 1998).

Although studies show that adopting a healthy lifestyle

may be beneficial for healthy ageing, the literature re-

ports some difficulty in promoting a healthy lifestyle

through interventions (Zhang et al., 2013). The main fo-

cus has been restricted to financial planning (Osborne,

2011), whereas psychological or social changes that

might occur after retirement have received hardly any

attention (Kloep and Hendry, 2006). Health promotion

initiatives usually communicate messages about healthy

lifestyles to a large target population through health ed-

ucation booklets or pamphlets. Kreuter et al. (1999)

have criticized this way of promoting health for its ‘one-

size-fits-all’ approach, with little consideration of indi-

vidual needs and personal relevance. In response to this

criticism, there has been a growing interest in tailoring

interventions to different individual users and user

groups (Davis, 2008; Orji and Mandryk, 2014). We

share this interest and wish to contribute. Our contribu-

tion to the development of tailor-made methods to pro-

mote and sustain healthy lifestyle changes among

retirees is based on structural developmental theory,

which we describe in the following section.

STRUCTURAL DEVELOPMENTAL THEORY

Neo-Piagetian psychologist Robert Kegan developed a

structural developmental theory (1982, 1994) which

proposes that individuals interpret and make meaning of

their world in qualitatively different ways. These ways

of meaning-making develop throughout the life course

along an invariant path whereby more complex ways of

meaning-making build upon and transform earlier ways

of meaning-making. The ways of meaning-making are

termed structures or orders of mind. Kegan (1982) has

described three orders of mind that capture most of the

adult population. He refers to these orders as the social-

ized, the self-authoring, and the self-transforming mind

(Kegan, 1994). Each order captures what an individual

can take as an object – can see ‘in front of’ him or her –

and what an individual is subject to – is part of and

thereby lacks a perspective on.

Individuals who have developed a socialized order of

mind can think in abstract terms and have the capacity

to internalize the meaning systems of others, such as

family values, social values, professional culture, etc.

They have the ability to subordinate their own desires

and be guided by the norms and standards in the ideolo-

gies, institutions or people that are most important to

them (Fitzgerald and Berger, 2002). At this order of

mind, one easily sees beyond one’s own needs and can

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adopt a larger picture, in which one is part of a socially

defined reality. Even though one has the capacity to in-

ternalize others’ points of view, one is embedded in these

points of view and is essentially dependent on them.

That is to say, the individual’s experience of being a per-

son or ‘self’ is entangled with ‘the quality of . . . internal

experiences of others’ experiences of them’ (Lewis,

2011, location 692). This means that at this order of

mind one does not ‘have the capacity to stand apart

from the values, beliefs, expectations, or definitions of

one’s tribe, community, or culture and make indepen-

dent judgments about them’ (Kegan, 1998, p. 201).

Individuals who make meaning with a self-authoring

mind have distanced themselves from the sense of being

entangled in others’ feelings and ideas about themselves.

They now have the capacity to be in charge of their own

feelings and generate an internal personal meaning sys-

tem, theory or ideology. Thus, one is able to take as an

object the values, beliefs and expectations of others

(one’s ‘tribe’, local community, or culture) that one was

subject to earlier. Individuals making meaning with this

order of mind perceive others as independent entities,

with their own integrity, distinct from themselves.

Unlike individuals at the socialized order of mind who

may struggle heavily with conflicting internalized views,

the self-authoring mind tolerates such conflicts or re-

solves these by invoking a system of self-authored values

and knowledge. This system has typically developed

over a period of years, gradually integrating the experi-

ences and reflections of personal encounters with a wide

variety of other knowledge and value systems (Kegan,

1994). This system of ‘self’ requires strong boundaries,

which may prevent the person from recognizing the con-

structed nature of the system itself. When meeting this

construction of self, others may experience it as a some-

what distant way of being, an obstacle to gaining direct

contact. However, ‘[t]his greater psychological indepen-

dence does not mean that [the person is] any less com-

mitted to you and to . . . other close relationships’

(Lewis, 2011, location 1111).

Those individuals who make meaning according to

the self-transforming mind have gained a perspective of

their own identity construction, and are no longer

‘blind’ to their self-authored identity. At this order, the

construction of identity is object to them. This implies

that they are now hesitant to see personhood as coincid-

ing with ‘a single system or form’ (Kegan, 1994, p. 313),

but rather see their system of self as incomplete and in

continuous development. At this order, individuals view

the ‘other as part of oneself’ (Souvaine et al., 1990, p.

253) and they are characterized by their embeddedness

in a multisystem perspective (Rosen, 1991). These

individuals are less likely to view the world in dichoto-

mies, and ‘suspicious of their own tendency to feel

wholly identified with one side of any opposite and to

identify the other with the other side of that opposite’

(Kegan, 1994, pp. 311-312). Meaning-making with this

order of mind concerns the reflections on the process of

making meaning itself more than the outcomes of this

process. The individual reflects on his or her own need

for meaning while acknowledging that knowledge is al-

ways partial, and he or she thrives on ‘rending every

new veil that comes into awareness, because . . . closure

and fixed boundaries [are] restrictive’ (Cook-Greuter,

1999, p. 107).

In his book In over our heads: The mental demands

of modern life, Kegan (1994) asks whether people make

meaning in accordance with society’s demands. In other

words, he asks what order of mind is required to suc-

cessfully parent, partner, work, learn, heal, and collabo-

rate as modern society frames these life tasks. He shows

that society implicitly demands a self-authoring mind

for all these tasks. In a composite study sample of adults

(Kegan, 1994, p. 195), about half of the persons did not

construct their experiences as complexly as the self-

authoring mind.

What are the mental demands on ageing in our mod-

ern Western society? Does the ageing population meet

these demands? Currently, hardly any empirical research

exists that answers these questions. Newhouse (as refer-

enced in Kegan, 1998) suggests a number of tasks and

expectations typical of the third age: giving up a central

identity formed around work and a career, changing

from a highly structured to a less structured everyday

life, needing to create new friendships after the loss of a

ready-made social network, and remaining relatively in-

dependent of the care-taking resources of family or soci-

ety. Kegan infers from Newhouse’s list that it is ‘the self-

authoring mind that constitutes the implicit mental

threshold for successfully handling this curriculum, a

threshold many adults will not yet have reached in old

age, and not having done so, will be ‘at risk’ for poorer

outcomes thereby’ (1998, p. 209; italics in original).

Therefore, he argues that it may be ‘an absolutely crucial

educational or mental health goal serving as a protective

factor against decline and depression in old age’ (Kegan,

1998, p. 212) to develop a self-authoring mind since it is

with this order of mind that one can meet the demands

of ageing. Moreover, if it is true that more people

make meaning with a self-authoring mind, then the so-

cial institutions relevant to the third age are challenged

to provide the space for the personal paths and demands

that are so typical for individuals with this order of

mind.

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It is against the backdrop of Kegan’s theory and its

possible implications for the third age that we now turn

to outlining the research we envision. In the following

section, we juxtapose the promotion of healthy lifestyles

during the third age with Kegan’s psychological develop-

ment theory.

DEVELOPING HEALTH PROMOTION FOR THIRD AGERS

Structural developmental theory has informed classroom

practice in educational psychology, where developmen-

tally conscious teachers are teaching in ways that en-

courage students to make meaning in an increasingly

complex way, while also meeting students at their stage

of development (Helsing et al., 2004). In the context of

business coaching and counselling, Berger (2012) refers

to this practice as keeping conversations ‘psychologi-

cally spacious’. Inspired by such thinking, we envision

health promotion initiatives to be psychologically spa-

cious and tailored to a person’s order of mind. Neither

our aim nor our interest is in highlighting or facilitating

the development towards one specific order of mind

(e.g. self-authoring). Our contribution is rather to raise

awareness of the qualitatively different ways of making

meaning in the world, and, where possible, outline how

health promotion can be formulated in developmentally

spacious ways, to enable more people to be reached and

feel included.

In order to do so, we require a knowledge base that

links a person’s lifestyle to his or her stage of structural

development. Our research will hopefully help to estab-

lish this knowledge base. The rationale for our research

is that much information can be gained from the experi-

ences of individuals who report that they have recently

transitioned successfully into the third age. In other

words, our preferred starting point is narratives concern-

ing a successful lifestyle during retirement, i.e. one that

leads to an experience of well-being. True to this

experience-oriented bottom-up approach, we employ no

specific definition of well-being. The next logical step in

our rationale is to relate these situation-specific experi-

ences to a person’s order of mind. Kegan’s measure of

order of mind indicates in general terms how a person

structures his or her life in terms of responsibility alloca-

tion and perspective taking, that is, how a person under-

stands him- or herself to play a role in his or her own

life. The assumption is that persons with different orders

of mind structure retirement-specific experiences in dif-

ferent ways, because lifestyle and the ensuing experience

of well-being are dependent upon order of mind.

More concretely, our research will unfold as follows.

We will recruit participants recently retired from work-

ing life and reporting having done so satisfactorily ac-

cording to their own expectations and standards. To

assess the participants’ orders of mind, we will conduct

subject-object interviews (SOI) (Lahey et al., 1988/

2011) with all our participants. During the SOI, ten

emotionally laden probes (e.g. ‘Can you tell me of a re-

cent experience of being quite angry about something?’)

are presented to a participant, and he or she is asked to

write down recent experiences brought to mind by the

probes. The participant then selects some of the experi-

ences to elaborate on. During the interview, the inter-

viewer listens sympathetically and confirms the content

of the participant’s experience, while also probing for

the structuring of the experience. The combination of

the emotionally laden probes and the why-questions in-

vites the participants to describe their experiences at the

borderline between what is and is not explicitly reflected

upon. An analysis of transcripts from the interview al-

lows the researcher to score where participants are on

their developmental journey according to Kegan’s devel-

opmental theory (1982, 1994). This score indicates

whether the participants are currently at one order of

mind or in transition between two orders of mind,

where four sub-stages can be distinguished. The inter-

rater reliability for the SOI ranges between 0.82 to 1.00

for agreement within one discrimination unit (Kegan,

1994; Lahey et al., 1988/2011). We have completed

training in subject-object interviewing, are experienced

and reliable scorers, and we will establish and report on

our inter-rater reliability within this study. If a partici-

pant scores at a transitional order of mind, we will allo-

cate him or her according to the dominant order. We are

interested to include all adult orders of mind in this

study, preferably three participants within each order.

However, we are aware of the difficulty of recruiting

persons who make meaning at the self-transforming

mind as they are few and far between (Kegan, 1994).

Knowing this, and given the resources necessary to con-

duct and analyse such SOIs, it is unlikely that we will be

able to recruit enough participants at the self-

transforming mind. It is likely that we can include at

least three persons at the socialized mind and three at

the self-authoring mind, as these are the two orders

where most of the adult population makes meaning

(Kegan, 1994).

We will conduct an in-depth phenomenological inter-

view with each of the participants. This form of the

open qualitative interview will allow us to reveal the

phenomenon of well-being as it emerges in the partici-

pants’ descriptions of their experiences of the

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phenomenon (Giorgi, 2009). We have found that three

such interviews suffice to make valid inferences about

the participants’ experiences with the phenomenon un-

der investigation. That is mainly because a descriptive

phenomenological analysis makes use of all data mate-

rial and is not guided by themes that are established be-

forehand. We will analyse the descriptions separately for

each of the orders of mind, resulting in so-called general

meaning structures. Such a general meaning structure re-

veals the shared meaning across many variations of how

participants experience the phenomenon in their daily

life (Giorgi, 2009). In a final analysis, we will compare

and discuss differences and similarities in the general

meaning structure of the phenomenon between the or-

ders of mind. The results of this will feed into the next

stage of the project.

SHAPING STRUCTURAL DEVELOPMENTAL HEALTH PROMOTION

We referred earlier to a quote that a hallmark of health

promotion is the aim to bring ‘more life to years, not

just years to life’ (Vaillant, 2004, p. 561). One way to

bring more life to years is to facilitate experiences of

well-being through the promotion of a lifestyle pervaded

by such experiences. We will endeavour to make our re-

search results accessible to retirees as well as to the

policy-makers and welfare and health promotion profes-

sionals who are engaged in their well-being. What do we

expect to be able to tell them? What does our research

underscore or explicate? In the following, we present a

preliminary sketch along three lines of the contribution

value of the rationale presented above.

First, both forms of interview will most likely pro-

vide information about the shift from working life to re-

tirement. The phenomenological interview aims to

capture the general meaning structure of well-being dur-

ing early retirement. The SOI explores how the individ-

ual structures some of his or her recent experiences with

change, success, feeling torn, etc. A change of lifestyle

that comes with a major shift (such as retiring) appears

in the light of a structural developmental approach as ei-

ther solving a technical problem or overcoming an adap-

tive challenge (Heifetz and Linsky, 2002). The latter

implies a change in order of mind, whereas the former

means that the person maintains the same order of mind

while incorporating new activities in his or her daily life.

For instance, the third age could be lived so that time is

increasingly spent on previously well-established activi-

ties, or it could incorporate new activities that facilitate

or emerge with the structural development of mind. An

awareness of the differences between these changes

assists the retiree, welfare professional and policy-maker

alike in choosing or recommending one activity in fa-

vour of another.

Second, both types of interview will provide informa-

tion about how well-being takes shape in different orders

of mind. Following Labouvie-Vief et al. (1989), Noam,

Young, and Jilnina (2006) have argued that people at var-

ious levels of mental complexity may experience and un-

derstand their well-being in qualitatively different ways.

Bauer (2011) researched the content of the growth stories

told by persons with late stages of mental growth (with

what he refers to as ‘postconventional selves’). He found

that, on average, later stages of development do not nec-

essarily make a person more happy as measured by estab-

lished quantitative measures of well-being (Diener et al.,

1985), which is consistent with Kegan’s theoretical as-

sumptions. One finding, however, stands out, namely

that the individuals with the highest score of mental com-

plexity had indeed higher levels of well-being on average

when compared to the other stages (Bauer et al., 2011).

However, Bauer et al. (2011) findings are preliminary,

given the relatively small number of participants who

scored in the highest stage. Mental complexity, Bauer and

colleagues confirm, taps into different aspects of well-

being, but their research is inconclusive as to how the

first-person experience of well-being relates to mental

growth, especially concerning individuals who have not

reached the very late stages of development, i.e. the ma-

jority of the population.

Kegan (1982, pp. 267-268) has looked into what can

be called psychological ‘ill-being’ and its relation to

mental complexity. He analysed patient journals at a

psychiatric hospital and inferred three different kinds of

depression, characterized by three types of loss, respec-

tively: a loss of one’s own needs or the increasing costs

of trying to satisfy these needs, a loss of an interpersonal

relationship leading to loneliness or even a loss of parts

of oneself, and loss of control over meeting one’s own

standards. Upon first measuring mental complexity and

then relating it to these three types of depression, a

strong association between type of depression and men-

tal complexity was observed.

We aim to follow up on the interest of Noam et al.

(2006) and Bauer et al. in the link between mental com-

plexity and well-being, and use a research design in-

spired by Kegan’s study of depression. Here we will first

divide our participants up into groups according to their

SOI score, and then interview them to discover how they

experience well-being.

Third, the combination of both interviews will pro-

vide essential information to suggest new opportunities

for tailoring interventions to the intermediate range

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between the unique individual and larger cohorts of the

population. Tailored interventions have been defined as

follows: ‘Any combination of information or change

strategies intended to reach one specific person, based

on characteristics that are unique to that person, related

to the outcome of interest, and have been derived from

an individual assessment’ (Kreuter and Skinner, 2000,

p. 1; italics in original). For our purposes, this may be an

unattainable ideal considering the amount of resources

required. At the other end of the continuum, health pro-

motion that is specific to cohorts, though economically

more manageable, may risk not reaching all the mem-

bers of the targeted population. Consequently, we prefer

an intermediate range at which to target the population

of retirees. In other words, understanding how individ-

uals with different orders of mind experience well-being

differently allows programme developers to tailor psy-

chologically spacious programmes while avoiding indi-

vidual time-consuming assessments. Moreover, health

care and welfare professionals will benefit from an

awareness of structural development, lest they under- or

overshoot their communication with the target popula-

tion concerning health promotion activities. Therefore,

our research may also help to provide these profes-

sionals with knowledge of lifelong development and

learning as well as active ageing.

CONCLUSION

In this article we have outlined perspectives which have

as yet not been combined. We have emphasized the no-

tion of adding more life to years as well as the potential

for structural developmental thinking in health promo-

tion initiatives. This is an area largely untouched in the

health promotion literature, and we see its inclusion as a

contribution to extending the positive period of the third

age while also aiding the compression of the fourth age.

We have underscored the reciprocity of well-being

and lifestyle and have argued that the experience of

well-being may have quite different manifestations for

different persons when seen through the lenses of a

structural development approach. We have sketched a

feasible mid-range approach to tailoring health promo-

tion initiatives. This approach attends to the orders of

the mind within the target group and has the potential

to overcome the practical difficulties of developing

unique individual health promotion initiatives.

We have presented one structural developmental the-

ory within the neo-Piagetian tradition as a contrasting

view to the current phase theories employed in ageing

research, but there are many others which we have not

discussed. Notable examples of others in this tradition

are Kohlberg (1969), Fowler (1981), Commons et al.

(1998), Gilligan (1982), Basseches and Mascolo (2009),

Cook-Greuter (1999) and Loevinger and Blasi (1976).

Kegan’s theory of adult development in health promo-

tion serves our purpose well, which is why we have not

focused on other potentially appropriate theories of

adult development or mental growth. We conclude that

a sensitivity towards the complexity of mind with re-

spect to the experience of well-being will provide health-

care professionals and policy-makers with a powerful

tool in their health promotion toolbox.

ACKNOWLEDGEMENTS

We wish to thank the two reviewers for their insightful com-

ments and specific points of improvements for the article.

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