Principles and Practice of Health

Promotion and Public Health

Principles and Practice of Health Promotion and Public Health brings together the dis-
ciplines and fields of study that inform the work of promoting health into one book
and provides many examples of practice.

It starts with understanding ourselves and our health and continues with chapters on
working in health promotion and public health; epidemiology; research methods and
evidence-based practice; health psychology; communicating health; health education;
health promotion; public health; health protection; arts and health; tackling tobacco,
alcohol and drugs; tackling overweight; promoting health in workplaces and promot-
ing health within the National Health Service. Together these communicate the core
principles of how to prevent disease and promote health when working with individuals,
communities and populations in any country across the world. The book focusses on
adults’ health and includes international and UK examples. Principles and Practice of
Health Promotion and Public Health complements Priorities for Health Promotion and
Public Health, published in 2021. Both are core texts for those studying health promo-
tion or public health and supplementary texts for students of healthcare and social
care. They are ideal for public health practitioners and members of the wider public
health workforce.

Sally Robinson is a Visiting Reader in Health Promotion and Public Health at Canterbury
Christ Church University.
Taylor & Francis
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Principles and Practice of Health
Promotion and Public Health

Edited by Sally Robinson

Designed cover image: © Getty Images
First published 2023
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Names: Robinson, Sally, editor.
Title: Principles and practice of health promotion and public health /
edited by Sally Robinson.
Description: Third edition. | Abingdon, Oxon ; New York, NY : Routledge,
2023. | Series: Canterbury public health series | Includes
bibliographical references and index. |
Identifiers: LCCN 2022032745 (print) | LCCN 2022032746 (ebook) | ISBN
9781032411248 (hbk) | ISBN 9780367423445 (pbk) | ISBN 9780367823696 (ebk)
Subjects: LCSH: Health promotion--United Kingdom. | Public health--United
Kingdom. | Medicine, Preventive--United Kingdom.
Classification: LCC RA427.8 .P7534 2023 (print) | LCC RA427.8 (ebook) |
DDC 362.10941--dc23/eng/20220729
LC record available at https://lccn.loc.gov/2022032745
LC ebook record available at https://lccn.loc.gov/2022032746

ISBN: 978-1-032-41124-8 (hbk)

ISBN: 978-0-367-42344-5 (pbk)
ISBN: 978-0-367-82369-6 (ebk)
DOI: 10.4324/9780367823696

Typeset in Times New Roman

by KnowledgeWorks Global Ltd.
Contents

List of figuresvii
List of tablesx
List of boxesxii
List of contributorsxiv
Prefacexvii
Acknowledgementsxviii

PART I
Fundamentals of health promotion and public health practice 1

1 Understanding ourselves and our health3

SALLY ROBINSON

2 Working in health promotion and public health28

LOUISE HOLDEN, EM RAHMAN, BRANWEN THOMAS AND SALLY ROBINSON

PART II
Disciplines and fields of study 61

3 Epidemiology63
RAJEEB KUMAR SAH AND GAIL SHEPPARD

4 Research methods and evidence-based practice89

ELISABETTA CORVO, JOANNE CAIRNS AND SALLY ROBINSON

5 Health psychology113
MURRAY ALLEN

6 Communicating health133
SALLY ROBINSON
vi Contents
7 Health education157
SALLY ROBINSON

8 Health promotion194
SALLY ROBINSON

9 Public health225
RAJEEB KUMAR SAH, DEVENDRA RAJ SINGH, LALITA KUMARI SAH
AND SALLY ROBINSON

10 Health protection249
MERADIN PEACHEY

11 Arts and health275

TRISH (PATRICIA) VELLA-BURROWS AND CHRISTINA DAVIES

PART III
Tackling priorities for health promotion and public health 295

12 Tackling tobacco, alcohol and drugs297

SALLY ROBINSON

13 Tackling overweight323
SALLY ROBINSON

PART IV
Promoting health within settings 353

14 Promoting health in workplaces355

SALLY ROBINSON

15 Promoting health in the National Health Service382

SALLY ROBINSON

Index 409
Figures

1.1 Neurons 4
1.2 The bioecological model of human development 6
1.3 Cultural messages influence the ideal self, self-concept and self-esteem 8
1.4 Maslow’s hierarchy of needs 10
1.5 The biopsychosocial model 14
1.6 Sustainable development goals 21
1.7 Interdependent healthy people in a healthy society and healthy planet 22
2.1 Public health domains and functions 29
2.2 The public health workforce 31
2.3 UK Public Health Skills and Knowledge Framework 43
2.4 WHO-ASPHER Competency Framework 45
2.5 The CompHP core competencies for health promotion 49
3.1 Life expectancy for males and females in the UK between 1980 to 1984
and 2018 to 2020 64
3.2 UK population pyramid, 2020 (n = 67,886,004) 65
3.3 A bill of mortality February 21st to 28th 1664 70
3.4 John Graunt’s data based on the bills of mortality 1647 to 1659 71
3.5 Number of male deaths in the UK by the leading causes, 2001 to 2018 73
3.6 Observational studies 77
3.7 Age-specific incidence rates of cancer in the UK, 2016 to 2018 78
3.8 Teenage pregnancies in Scotland by age at conception, 1994 to 2019 79
3.9 Cohort study design 81
3.10 Case-control study design 82
3.11 Experimental studies 83
5.1 The health belief model 117
5.2 The theory of reasoned action 118
5.3 The theory of planned behaviour 119
5.4 The transtheoretical model 121
5.5 The common-sense model 124
6.1 The communications continuum: moving audiences towards
health action 148
7.1 The General Board of Health, 1846 160
7.2 Broadsheet: cholera and water, 1866 161
7.3 Hygiene demonstration cabinet, 1895 162
7.4 A School for Mothers, 1907 163
7.5 Protests against COVID-19 coronavirus regulations in London 165
viii Figures
7.6 The health continuum 168
7.7 A sticker illustrates the preventive model/medical approach,
dated between 1950 and 1970 173
7.8 A poster illustrates the preventive model/behaviour change approach,
1988 175
7.9 A leaflet demonstrates a holistic approach to health and self-help 178
7.10 A poster illustrates a resource to support self-empowerment 187
8.1 Health promotion comprises four models 195
8.2 Ottawa Charter for Health Promotion 198
8.3 From community disempowerment to empowerment 211
8.4 Priorities for the European Healthy Cities Network 2019 to 2024 214
9.1 Sir Edwin Chadwick 226
9.2 Three domains of public health practice 230
9.3 Healthcare need, supply and demand 235
9.4 Five steps of a health needs assessment 236
9.5 Five stages of a health impact assessment 243
10.1 The disease triangle 250
10.2 Transmission cycle of malaria 250
10.3 Global disease burden by cause, 1990 to 2019, measured as
disability-adjusted-life years per year 251
10.4 Campylobacter gastroenteritis poisoning from restaurant pâté,
Scotland 2006 (n = 47 diners) 253
10.5 Control measures may be introduced at any step of managing
an outbreak 254
10.6 The body produces a specific antibody for every new antigen 257
10.7 Confirmed cases of measles in Wales from 1996 to 2020 258
10.8 Fatal injuries to employees and the self-employed by the most
common kinds of accidents, 2016/17 to 2020/21 266
10.9 Non-fatal injuries to employees by the most common kinds
of accidents, 2020 to 2021 267
10.10 Percentage uptake of cervical screening among women (25 to 64 years),
Scotland 2020 to 2021 271
11.1 Five art forms with examples 276
11.2 Arts engagement across primary, secondary and tertiary prevention 281
12.1 The UK national needle exchange symbol 300
12.2 Example of health warnings on a packet of cigarettes 312
12.3 Stoptober 2021 313
13.1 Energy balance 324
13.2 Gastrointestinal tract 325
13.3 Energy imbalance and gaining body fat 327
13.4 Energy imbalance and losing body fat 328
13.5 Eatwell Guide 336
13.6 Yo-yo dieting 337
13.7 Ice cream consumption in dieters and non-dieters 338
13.8 Liquid lunches 341
13.9 The microbiome, health and body fat 344
14.1 Quality of work by socio-economic classification, 2020 360
14.2 Nine hazard pictograms to indicate a hazardous chemical 363
 Figures ix
14.3 How the psychosocial work environment influences workers’ health 364
14.4 Demand/control model 365
14.5 Effort/reward imbalance at work 366
14.6 Work-related psychosocial experiences of workers in England
aged 50 to 69 years, 2018 367
14.7 CIPD wellbeing model 376
14.8 WHO Healthy workplace model 377
15.1 The health system should draw attention to the social and
environmental determinants of health 389
15.2 ‘Falling Leaves’ by Sian Tucker at Chelsea and Westminster Hospital,
London 390
15.3 ‘Jos’ by Jonathan Delafield Cook at Chelsea and Westminster Hospital,
London 391
15.4 ‘Assembly450’ by Joy Gerrard at Chelsea and Westminster Hospital,
London 391
15.5 ‘Radiance’ by Adam Nathaniel Furman at Chelsea and Westminster
Hospital, London 392
15.6 Zola’s river 395
15.7 Navigating Antonovsky’s river of life between ease and dis-ease 398
15.8 The salutogenic umbrella 399
Tables

1.1 Human values 5

1.2 Examples of disciplines, fields of study, sectors and agencies which
contribute to health 25
2.1 Examples of job roles within the UK public health workforce 34
2.2 Using PHSKF competencies to support a social prescriber’s work
objectives 44
2.3 WHO-ASPHER competencies relating to collaboration and
partnerships 46
2.4 A personal development plan referencing WHO-ASPHER
competencies 47
2.5 WHO-ASPHER competencies for working in health promotion and
addressing health inequity (EPHO 4) 48
2.6 Examples of career routes 57
3.1 Most common causes of female deaths in the UK, 1915 to 1975 74
3.2 Validity of a screening test 85
4.1 Glossary of research terms 91
4.2 Useful databases for searching for health promotion and public
health evidence 93
4.3 A critical appraisal tool 95
4.4 Philosophy, methodology, methods and question types 98
4.5 Types of questions 99
4.6 Advantages and disadvantages of online qualitative research 103
6.1 Verbal and non-verbal communication in therapeutic, person-centred,
one-to-one communication 140
7.1 Disease prevention versus health education 169
7.2 Preventive, educational and empowerment models 170
7.3 The preventive model 172
7.4 Methods to meet learning objectives 180
8.1 Models of health promotion 196
8.2 Global conferences on health promotion 200
8.3 Political ideologies 202
8.4 Comparing health promotion with public health 221
9.1 A summary of the five waves of public health 228
9.2 Examples of health indicators for England 233
10.1 Worldwide distribution, infections and deaths in recent pandemics 254
10.2 Preventing food poisoning from fruit and vegetables 260
 Tables xi
10.3 UK mass screening programmes offered through the National
Health Service 269
11.1 Examples of pivotal works in the arts and health field, 1996 to 2021 279
11.2 Healthy arts framework 282
12.1 UK drug penalties 298
12.2 Health promotion interventions to reduce substance-related harm 309
12.3 Health warnings on cigarette packets across the world, 2021 311
12.4 Health warnings and alcohol across the world, 2016 312
13.1 Estimated average requirements for energy 327
13.2 Comparison of calorie expenditure between sedentary behaviour
and moderate activity 329
13.3 UK Physical Activity Guidelines 330
13.4 Carbohydrates 330
13.5 Examples of recommended portion sizes 332
13.6 Factors which encourage and discourage excess body fat 346
14.1 Death rates by occupation in England and Wales, 2001 to 2011 359
14.2 Examples of causes of injuries, illness and death at work by British
industries 362
14.3 Current UK smokers by occupation, 2019 372
14.4 Heavy alcohol consumption among UK workers aged 40 to 46 years,
by occupation, 2006 to 2010 (n = 100,817) 372
14.5 UK average sitting times by occupation, 2019 (n = 1,200 workers;
10 worksites) 373
15.1 Comparison of the NHS in the 1950s to a modern health system 386
Boxes

1.1 Health 11
1.2 1944 13
1.3 Stanley 16
1.4 Constitution of the World Health Organization 19
1.5 The social work setting 20
1.6 Health promotion in Nazi Germany 23
2.1 Health improvement lead for mental health 32
2.2 Registered principal public health practitioner 52
2.3 Registered psychologist and registered public health specialist 54
3.1 From outbreak to pandemic: COVID-19 coronavirus 66
3.2 Some epidemiological calculations 73
4.1 From researcher to student 93
4.2 Example of a questionnaire 100
4.3 Example of an interview guide 104
6.1 Assessing readability 135
6.2 Writing to express the experience of cancer 138
6.3 Mass communication and COVID-19 coronavirus in the UK 143
6.4 UK COVID-19 coronavirus media campaign 144
7.1 Power 158
7.2 Kitty Wilkinson, the ‘saint of the slums’ 161
7.3 Fresh air 162
7.4 Salutogenesis 169
7.5 Be Clear on Cancer 173
7.6 Five Ways to Wellbeing 181
7.7 Becoming a good listener 182
7.8 Learning to recognise we have choices 185
7.9 Being a self-empowered person 186
8.1 How health promotion models work together 197
8.2 Ethical health promotion practice 204
8.3 Singing to improve community cohesion in Italy during the COVID-19
pandemic, Spring 2020 208
8.4 Threats to community cohesion in the UK during the COVID-19
pandemic, January 2021 208
8.5 A community-based initiative using educational and empowerment
models of health promotion 210
8.6 Healthy living centres 211
 Boxes xiii
8.7 Examples of community action using an empowerment model of
health promotion 212
8.8 Belfast Healthy City 214
8.9 A Healthy New Town: Bicester, Oxfordshire 216
9.1 Techniques for prioritising needs 237
10.1 Bhopal: the world’s worst industrial disaster, 1984 262
10.2 Chernobyl: the world’s worst nuclear disaster, 1986 263
10.3 Emergency response to Novichok poisoning in Salisbury, 2018 263
11.1 BBC Music Day, 2019 283
11.2 Singing for breathing 284
11.3 Promesas y Traiciones (Promises and betrayals) 286
11.4 The Creative Arts Pilot Project 288
12.1 Biopsychosocial: drug, set and setting model 300
12.2 Historical overview of tackling alcohol, drug and tobacco use in the
United States of America and the United Kingdom 303
12.3 Weekly drinking guidelines 314
12.4 Cocaine Anonymous 317
13.1 Counting calories in crunchy nut peanut butter 333
13.2 Emotional eating as compulsive eating 334
13.3 The 2-Day Diet 343
14.1 Supporting a migrant workforce 369
14.2 Building workers’ resilience 371
14.3 Work Ready 375
15.1 The creation of the NHS as separate from public health
(the public’s health) 385
15.2 #Hello my name is 393
15.3 Social prescribing 397
15.4 Hospice ward manager 400
Contributors

Murray Allen was a clinical exercise physiologist in cardiac rehabilitation and morbid
obesity programmes for the National Health Service and a British Association of
Sport and Exercise Sciences accredited sport scientist. Murray delivered behaviour
change training for health professionals and applied his expertise to promote health
behaviour changes for patients with complex comorbidities. In 2018, he joined the
public health team at Canterbury Christ Church University. His teaching includes
physical activity and health, psychology and health, health promotion, and major
health and lifestyle issues.

Joanne Cairns is undertaking a research fellowship, funded by Yorkshire Cancer

Research at Hull York Medical School (HYMS), on inequalities and cancer screen-
ing uptake. Before moving to HYMS, Jo was a lecturer in health promotion and
public health at Canterbury Christ Church University (2017–2019). Previously, Jo
worked for Alcohol Research UK as a senior research and policy officer (2016–
2017). She also worked as a post-doctoral research associate and teaching fellow at
Durham University (2012–2016) upon successful completion of her PhD in health
geography. Jo’s research and teaching experience are interdisciplinary spanning
across social sciences, public health and medicine.

Elisabetta Corvo earned a degree in Jurisprudence before moving into public health
and health promotion. Her PhD explored the effectiveness and transferability of an
English model of health promotion to Italy. Afterwards she worked as a research
fellow for the Department of Public Health and Infectious Disease at Sapienza
University, Rome. She is course director of the MSc Global Public Health at
Canterbury Christ Church University and leads the Public Health and Wellbeing
Observatory. Her current research is focussed on health literacy, social capital and
arts and health. Her teaching includes research methods and social aspects of health.

Christina Davies is a senior research fellow at the University of Western Australia.

Her multi-award-winning research focusses on the areas of arts-health, health
promotion and mental wellbeing. For the past 20 years, Christina has worked in
academic, government and market research settings. Locally, nationally and inter-
nationally, she has successfully translated her arts-health research into policy and
practice, with a number of her publications ranked by Altmetric in the top 1% of
articles by attention internationally, e.g. The art of being mentally healthy and The
art of being healthy.
 Contributors xv
Louise Holden is a visiting lecturer at Canterbury Christ Church University and has
held numerous senior roles in the NHS, local government and Civil Service shaping
national and local workforce strategies and building the evidence for effective inter-
ventions. She is currently responsible for establishing a workforce programme to
improve the health of Londoners. As a registered public health practitioner, Louise
contributes to UKPHR’s quality assurance processes as a trained moderator. Her
interests include standards setting, curriculum design and quality improvement.

Meradin Peachey has worked in healthcare and public health for 40 years, recently as
director of public health for Kent and Berkshire West. Her career began as a nurse
and she became one of the first non-medical public health consultants in England. She
served as vice president of the Faculty of Public Health. Her health protection work
has included enhancing immunisation programmes, protection from tuberculosis,
leading emergency planning and the COVID-19 coronavirus response in Berkshire.
With Master’s degrees in Health Management and Global Public Health, Meradin
now works as an independent consultant supporting sustainability across the world.

Em Rahman leads public health workforce development for Health Education England
in South East England. His career has included developing behaviour change ser-
vices, capacity building, workforce development, sexual health and community
development; at local, regional and national levels. Em leads the Wessex UKPHR
public health practitioner scheme. As a registered health promotion practitioner with
IUHPE, Em is committed to supporting individuals and workforces through train-
ing and education, to recognise the role they have in addressing health inequalities.

Sally Robinson led the public health team at Canterbury Christ Church University from
2003 to 2018 and is now a visiting reader. She has developed, led and taught a wide
range of courses for undergraduates, postgraduates and professionals working in
public health, healthcare and education. She is an experienced supervisor of PhDs
and external examiner to other universities. Her research and scholarship have cen-
tred on public health nutrition, health promotion and children’s health and wellbeing.

Lalita Kumari Sah is a postgraduate researcher at Canterbury Christ Church

University. She completed her BSc Medicine and Bachelor of Surgery (MBBS) at
Zhengzhou University in China, followed by an MSc Public Health at London
Metropolitan University, UK. She has worked to promote the health and wellbeing
of diverse communities as a medical doctor in Nepal and within the UK National
Health Service. Her publications span mental health and wellbeing, maternal and
child health and global health inequalities.

Rajeeb Kumar Sah is a senior lecturer in public health at the University of Huddersfield.
Previously, he was the course director for MSc Global Public Health at Canterbury
Christ Church University. He has extensive experience in teaching public health to
diverse groups of undergraduate and postgraduate students. He trained as a medi-
cal doctor and is an interdisciplinary researcher with a particular interest in inter-
national aspects of health and education. His research and publications include
global public health, health inequalities, sexual and reproductive health/rights and
mental health.
xvi Contributors
Gail Sheppard worked as an exercise physiologist in NHS cardiac rehabilitation prior
to joining the public health team at Canterbury Christ Church University. Gail
has led the academic team since 2018 and is a senior fellow of Advance HE. Her
PhD research focusses on sedentary behaviour at work. Gail has been a member of
the British Association of Cardiovascular Prevention and Rehabilitation (BACPR)
since 2009, acting as Scientific Officer from 2011 to 2015. She is co-editor of
BACPR’s second edition of Cardiovascular Prevention and Rehabilitation in
Practice guidelines (2020).

Devendra Raj Singh is a postgraduate researcher at the University of Huddersfield.

He completed an MSc Health Promotion and Public Health at Canterbury Christ
Church University. He has more than ten years’ experience teaching and working in
global and public health. His work has spanned health needs assessments, maternal
and child health, sexual and reproductive health/rights and adolescent health. He
has worked for various national and international organisations, including United
Nations agencies. He has taught and supervised public health, nursing and phar-
macy students and published extensively in international peer-reviewed journals.

Branwen Thomas works for Health Education England as a public health workforce
lead for South East England. Her experience includes assuring the quality of edu-
cational programmes across the private sector, third sector, NHS and Civil Service,
and leading the refreshed public health practitioner programme across the Thames
Valley. More recently, she has supported the training of practitioners in response to
the COVID-19 coronavirus pandemic. She has a keen interest in mentoring, devel-
oping networks for shared learning, social mobility and inclusion.

Trish (Patricia) Vella-Burrows is a visiting principal research fellow at the Sidney De

Haan Research Centre for Arts and Health and a visiting lecturer in arts and health
at Canterbury Christ Church University. As director of research for the Canterbury
Cantata Trust, she is researching the impact of music on people living with degen-
erative neurological conditions. Trish is also director of Music4Wellbeing, a com-
munity interest company. Trish is interested in developing integrated models of
care for people with dementia that equally address the holistic needs of family car-
ers, care staff and those for whom they care.
Preface

In 2021, we published Priorities for Health Promotion and Public Health to support
learning about ‘what’ health concerns have the most damaging effects on many peo-
ple’s lives and need to be prioritised, particularly in the UK. Principles and Practice
of Health Promotion and Public Health is designed to explain ‘how’ we protect and
promote people’s health. These disciplines and fields of study inform practice within
all countries and can be applied to any public health concern. Both books focus on
working with adults and are designed to support those students and practitioners who
want to understand more about improving everyone’s health.
Acknowledgements

With thanks to Noah Silver for graphic design and Peter Main for his reading and
comments.
Part I

Fundamentals of health promotion

and public health practice
1 Understanding ourselves and
our health
Sally Robinson

Key points
• Introduction
• What is a person?
• Vision of a healthy society
• A concept of health
• Summary

Introduction
This chapter argues that understanding people is central to understanding their health.
It discusses a person as an evolving human being shaped by interactions between their
biology, psychology and socio-cultural context. A person’s life, their values and aspi-
rations are unavoidably entwined with what health means for them. People live within
societies where those with influence, and their vision of a healthy society, can power-
fully shape how people’s health is perceived and managed. We consider the influence
of the medical model, the biopsychosocial model and the World Health Organization.
Contemporary discussions suggest that health may be a person-centred, time-dependent,
positive and holistic concept, but these ideas continue to be debated.

What is a person?
There may be as many answers to the question, “What is a person?” as there are peo-
ple who have lived. It depends on perspective. In the 17th century, the philosopher
Descartes famously argued that a person was the union of a physical body and a
separate thinking mind. For many, metaphysical aspects such as the mind, soul or
spirit are essential components of personhood and may continue after the body has
died. Various scholars have distinguished a person from a ‘non-person’ by arguing a
person is conscious, self-aware, intelligent, able to reason, engage in moral judgements
and can be held accountable by other persons for their actions (White, 2013). Here, we
explore a person as a continuously evolving human being shaped by the interrelation-
ships between their biology, psychology and their social context.
A person may be described in terms of their nature, that is their genes; the water,
fat, protein and minerals that make up their body, and the brain as its control centre.
Nature is never static; it is influenced by the environment. For example, neuroscien-
tists point to the ever-changing patterns of neurons in the brain which grow or wither
DOI: 10.4324/9780367823696-2
4 Sally Robinson

Figure 1.1 Neurons

Source: OlgaReukova/Shutterstock.com

in response to a person’s physical, emotional and social experiences (Figure 1.1). The
brain’s ability to rewire, its plasticity, means we can learn and improve knowledge and
skills because with each repetition the exact neuronal pathway is reinforced. The brain
stores memories, some we can consciously recall, some we cannot. The oldest ‘memo-
ries’ relate to the instincts to ‘fight, flight or freeze’ in response to danger, seated in the
neurons at the base of the brain, inherited from humans’ reptile ancestors. The brain
contains the emotional memories of interpersonal experiences that help a person to
recognise and read faces and tune into the internal states of another person (Cozolino,
2006). These affect how a person reacts to events, situations and other people. For
example, negative experiences encourage the neurons of the brain to record certain
social interactions, perhaps certain people, as potentially threatening. When these
reappear, the brain sends alert signals throughout the body to be physically ready to
defend or attack. It simultaneously suppresses the functioning of the upper parts of
the brain that allow a person to think clearly and rationally. In turn, this can have a
negative impact on a person’s communication, such as ‘being lost for words’ and their
behaviour, such as aggression. Positive social experiences enable the brain to develop
in a way that helps a person to trust and to engage in thinking, problem-solving and
empathy so a person can communicate, learn and thrive.
Social psychologists also describe the human brain as being essentially social. They
argue that by living and working together, people improve their chances of fulfilling
their most basic needs: to survive and reproduce. It is people’s abilities to think and
 Understanding ourselves and our health 5
Table 1.1 Human values

Values Essential motivations within the value

Self-direction Freedom, independent thinking and actions, choosing, creating

Stimulation Excitement, challenge, novelty, daring
Hedonism Pleasure or sensuous gratification for oneself
Achievement Personal success, demonstrating competence and meeting cultural
standards
Power Prestige and social status, control over people and resources
Security Harmony, safety, stability within the self and with, and among, others
Conformity Restraint of actions and impulses which may harm or upset others or
violate social norms
Tradition Commitment, respect, acceptance of customs and ideas within one’s culture
Benevolence Preserving and enhancing the welfare of others
Universalism Understanding, tolerance, appreciation and protection of the welfare of
people and nature

Source: Schwartz (2012).

feel that enable them to interact with people and the world. More than being social
animals, Baumeister and Bushman (2014) argue people are cultural animals. Culture
represents a dynamic social system of shared ideas, beliefs and values, which include
those around food, language, customs and a shared sense of history. Where people’s
‘natural’ instincts and drives such as thirst, hunger, aggression, sex or avoiding
pain – to meet the primary needs of survival or reproduction – are activated, it is
culture that might apply the brakes through rules of restraint. Cultural rules include
laws, religious guidance, manners, codes of conduct and so forth. ‘Society’ refers to
the people who share the culture. At times, a person will experience internal conflict
between their impulses to fulfil personal values versus their need to adhere to the
cultural values of the society in which they live (Table 1.1). To avoid punishment, they
apply self-discipline, apply the cultural rules and control their own ‘selfish’/natural
impulses. For example, despite feeling hungry, we may avoid eating an apple because
we know the sound of crunching will disturb others. It would be culturally unaccept-
able. The benefits of people living within a culture are that it enables people to be
social, to live together, to share and to accumulate the knowledge and wisdom to help
them to live well for longer.

Thinking point:

Consider which one of the human values in Table 1.1 resonates most strongly with
your own personality and goals. How important is the fulfilment of this value to
your own health? Consider which values may conflict with one another. Which are
most evident among your family or friends?

Bioecological model
Bronfenbrenner, a developmental psychologist, described a person, like all liv-
ing things, as being at the heart of their own ecosystem. His bioecological model
(Bronfenbrenner and Ceci, 1994; Bronfenbrenner and Morris, 1998; Tudge et al., 2009)
was one of the first examples of a social-ecological model. He suggested that a person
6 Sally Robinson

Figure 1.2 The bioecological model of human development

develops through the synergistic interconnections between their personal charac-

teristics, their immediate socio-cultural context, their interactions and across time
(Figure 1.2).

• Person – an active biopsychosocial human organism comprising, for example, genes,

age, sex, gender, physical characteristics, personality, temperament, cognitive and
emotional intelligence, skills and personal resources such as their education
• Context – four interconnected systems of rules, norms, routines and the social
roles people play:

• microsystem, the immediate environment where the individual spends much

time, e.g. family, peers, people in the local neighbourhood
• mesosystem, how those in the microsystem interact with each other
• exosystem, indirect influences from the wider community, e.g. a peaceful or
violent neighbourhood, local employment levels and workplaces
• macrosystem, the broad culture with its shared values and beliefs, social
norms, political and socio-economic factors
 Understanding ourselves and our health 7

• Processes (proximal processes) – regular, reciprocal, enduring and increasingly

complex interactions between the person and people, objects and symbols in
their environment. The word ‘proximal’ implies interactions with elements close
to the person but, in the context of today’s world, this is questioned (Griffore
and Phenice, 2016). For example, we can be closely interacting via the Internet.
The young Swedish environmental activist Greta Thunberg directly interacted
with her microsystem, mesosystem and macrosystem. She went from discus-
sions with her family to being invited to address the World Economic Forum in
January 2020
• Time/chronosystem – interactions alter both the developing person and their
environment over time. Thunberg changed others and was also changed herself
(Hook, 2021). Time includes the time that interactions take and their repetition;
the frequency and patterns of interactions over weeks or years; the influence of
broader historical or cultural time periods such as living in the digital age; inter-
actions and transitions over a person’s lifespan and through generations

The self
Some psychologists look at the same process of a person’s development from the inside
by focussing on the person’s self. Baumeister and Bushman (2014) write,

“The self comes into being at the interface between the inner biological pro-
cesses of the human body and the socio-cultural network to which the person
belongs.”
(p. 74)

The self is created within a person’s interactions with others. It begins with Winnicott’s
observation that the mother’s face, and how it looks to her baby, is the mirror in which
the baby first begins to identify ‘his own self’ (Winnicott, 1971). If the baby sees
delight, the baby learns he is a delight. If the baby sees impatience, he learns he is an
irritation. The self is created and recreated as we move through life.

• A person’s self-concept is how they describe themselves. It is a motivator in that

a person usually behaves in ways that fit their own perception of who they are.
This includes identity, such as having a gender identity, a work identity, a religious
identity and a health identity
• A person’s self-concept is made up of their self-image and their ideal self (Figure 1.3)
• A person’s self-image is initially guided by the views and feedback of others. If a
person is repeatedly told that they are frail, they develop an image of themselves
as a frail person
• A person’s ideal self is what they aspire to becoming and this is often influenced
by what is desirable and valuable in their culture. For example, social pressures
to be fit and strong
• A person’s self-esteem is the difference between their self-image and their ideal
self. It is about how much a person values their self. Someone who has a self-image
of being frail and whose ideal self is to be fit and strong may have low self-esteem.
People have a strong need to be liked and feel valued to maintain or improve their
self-esteem, and this is dependent on their relationships with others
8 Sally Robinson

Figure 1.3 Cultural messages influence the ideal self, self-concept and self-esteem

Not only is a person’s self-concept influenced by society and its culture, but so is
their body. The sociologist Erving Goffman wrote about the body’s significance to
non-verbal communication (Jacobson and Kristiansen, 2015). Its expressions, ges-
tures, clothing and behaviours allow others to label and classify a person, to accept or
to alienate. The body is not only intrinsic to a person’s self-identity but also to their
social identity. A person is embodied because the body is both something that one
‘has’ and something one ‘is’. Fox (2018) writes,

“The lived body is a rich source of meaning for people, in sickness and in health;
people make sense of their lives by reflecting on their bodily experience.”
(p. 266)

He proposed that the body is both biological and social.

The biological body is

• about anatomical and physiological systems and processes such as circulation

and sensation
• a repository where cultural values of fitness, health, beauty and performance are
demonstrated
• a consumer of products
• a resource to support living life and engaging with the world

The social body

• is what we sense and experience every day

• is a repository of meaning shaped by others
 Understanding ourselves and our health 9

• is full of cultural symbolism, e.g. the heart as love; or the body as a tomb which
houses a soul which is freed at death or a temple through which we communicate
our inner worth
• presents a social identity, e.g. eco-warrior, police officer or rapper
• is a focus for self-observation, discipline and control, e.g. grooming or exercise
• is the object through which the powerful control, some might say ‘civilise’ others,
e.g. subjecting bodies to work routines governed by a clock, or to mass observa-
tion by closed-circuit television (CCTV)

Thinking point:

Think about your body and the way you present it to others. Consider how it looks
and how it behaves. How has this been shaped by the culture in which you live and
what does it tell others about you?

Therefore, the material body

• is always both biological and social

• is about what it can do and what it can produce, e.g. move an obstacle or produce
a solution
• comprises relations, which means the way things are connected
• has relations with that which is non-human, e.g. gravity, the air we breathe, chem-
icals and time which deteriorates the body
• has relations to that which is human. It engages with human culture and prod-
ucts, e.g. social institutions such as universities, economic and political systems,
people such as friends or a nation, social roles, the arts, clothes and historical
artefacts
• is a combination of its physical, psychological and social relations
• has capacities which may be called upon in different contexts at different times.
These capacities are dependent on the body’s physical, psychological and social
relations

Carl Rogers (1961), a humanistic psychologist and the founder of person-centred

counselling, writes that a person,

“… discovers that he exists only in response to the demands of others, that he

seems to have no self of his own, that he is only trying to think, feel and behave in
a way that others believe he ought to think, feel and behave.”
(p. 110)

Rogers argues that everyone, knowingly or not, is striving to become their true self,
the person they truly are. It is a life-long process of bringing together their self-image
with their ideal self. Maslow (1943) explains the process as a hierarchy comprising five
goals which are often, but not always, addressed in the same order (Figure 1.4). He
argues a person first needs to address their physiological needs, that is the food, air
and water we need to keep the biology of the body functioning. Then they become pre-
occupied with addressing their need for safety. Once this is satisfied, they are restless to
10 Sally Robinson

Figure 1.4 Maslow’s hierarchy of needs

fulfil their need for love and a sense of belonging with other people, and then they turn
to needing confidence, self-respect, self-esteem and the esteem of others. When these
four goals are met, Maslow suggests a person becomes restless again to reach their
potential. They are motivated to do what they are meant to do. He writes,

“A musician must make music, an artist must paint, a poet must write, if he is
to be ultimately happy. What a man can be, he must be. This need we may call
self-actualization.”
(Maslow, 1943, p. 382)

A person may be understood as a continuously evolving human being who devel-

ops over time, is shaped by interactions between their biology, psychology and their
socio-cultural context, and is striving towards their true self.

A person’s health
The true, self-actualised self, impelled by the whole human organism, is associated
with notions of optimal health for both Rogers and Maslow. Their work influenced the
work of Rosemarie Parse, a nursing theorist. Where Rogers wrote about ‘becoming a
person’, Parse wrote about ‘human becoming’, and she defined health as each person’s
own experience of valuing that can be known only to them. She proposed,

“Health is lived experience … one’s quality of life … because the person alone
knows what his or her own life is like, what is important, and what the possibilities
are … Quality of life can only be described by the person … living the life …”
(Pilkington, 1999, p. 22)
 Understanding ourselves and our health 11

Box 1.1 Health

“By health I mean the power to live a full, adult, living, breathing life in close
contact with what I love – the earth and the wonders thereof – the sea – the
sun. All that we mean when we speak of the external world. I want to enter
into it, to be part of it, to live in it, to learn from it, to lose all that is superficial
and acquired in me and to become a conscious direct human being. I want, by
understanding myself, to understand others. I want to be all that I am capable
of becoming so that I may be (and here I have stopped and waited and waited
and it’s no good – there’s only one phrase that will do) a child of the sun. About
helping others, about carrying a light and so on, it seems false to say a single
word. Let it be at that. A child of the sun.
Then I want to work. At what? I want so to live that I work with my hands and
my feeling and my brain. I want a garden, a small house, grass, animals, books,
pictures, music … warm, eager, living life – to be rooted in life – to learn, to
desire to know, to feel, to think, to act. That is what I want. And nothing less.”
(Source: Mansfield, 2006, pp. 250, 251, written in 1922)

A person’s view of what health means to them is unavoidably entwined with their
experience of being a living, and some would add ‘doing’ person and how they see
themselves biologically, psychologically and socially. It is shaped over their lifetime by
others, by the real and perceived power of others, and how the person thinks they are
seen by others. It is judged against their own values and against the values of others.
Peter Baelz, a professor of morals and theology, summarises,

“Physical and mental health have a social dimension, social and political well-being
have a value dimension, and values are rooted and grounded in some kind of a
vision of a healthy society.”
(Baelz, 1987, p. 27)

Thinking point:

Who decides the vision of a healthy society, community, group or family?

A person’s view of what health means to them is entwined with their experiences
as a fully living person, biologically, psychologically and socially. It is shaped, and
changed, over time by personal and social values.

Vision of a healthy society

Those with inf luence shape the vision of a healthy society. Socially sanctioned
health-­related systems and interventions are underpinned by beliefs about what
health means and how it is best achieved. In the last 150 years, important influences
have included the medical model, the biopsychosocial model and the World Health
Organization.
12 Sally Robinson
Medical model
During the 20th century in Western societies, the guardians of the vision of a healthy
society were largely members of the medical scientific community who defined health
as an absence of disease. Influenced by the philosophy of Descartes, scientific meth-
ods had been used for over four centuries to understand the physical body of a person,
leaving the Church to focus on their mind and soul (Moon, 1995). Biomedical scien-
tists, doctors and professions allied to medicine developed, and continue to develop,
expertise in physical malfunctions which cause physical and mental disease. The cen-
tral tenets of the medical model of health and illness are that disease

• arises within the physical body, which is viewed as a machine

• is a malfunction of the body
• is a deviation from a norm or a standard that is agreed by the medical scientific
community
• includes the presence of a germ or a physical malfunction such as a blockage,
sprain or irregular blood chemistry
• can be prevented, diagnosed, treated and cured using the rules and rigour of
science
• can be understood by a reductionist approach which means studying the body’s
systems, organs and tissues at a microscopic level. Understanding the parts will
bring about an understanding of the whole
• can be explained with reference to physiology, the functioning of the body; and to
biochemistry, the chemicals within the body
• comprises observable physiological and biochemical measurements, which are
much more important than the person’s account of their experience, e.g. sociolo-
gists who observed antenatal clinics recorded,

“OBSTETRICIAN: [reading case notes] Ah, I see you’ve got a boy and a girl
PATIENT: No, two girls.
OBSTETRICIAN: Really. Are you sure? I thought it said … [checks in notes] oh no,
you’re quite right, two girls.”
(Graham and Oakley, 1991, p. 111)
(Robinson, 2021)

The process of detection, measurement, understanding and treatment of one

­malfunction/disease in one human is likely to be transferable to many humans, at
best, it is a ‘one size fits all’ universal approach with benefits for humankind. Similarly,
epidemiologists observe and measure disease in populations, identify common causes
or risk factors such as being sedentary or consuming alcohol, and encourage universal
changes to health-related behaviour to prevent disease in a population. Clean water,
reductions in smoking-related diseases, vaccinations, antibiotics, physiotherapy
and routine surgical procedures represent some of the great successes of using this
­science-based medical model. It has saved, and continues to save, very many lives
from disease and death.
 Understanding ourselves and our health 13

Box 1.2 1944

“He shivered in the sand with the shock and loss of blood. Hours went by. He
remembered lying semi-conscious on the famous Mulberry harbour, waiting to be
evacuated – planes and bombs and bullets whizzing by. Then he woke in Leicester
Infirmary in England. He was in a ward full of D-Day casualties. He was alive.
How had the filthy shrapnel wounds not poisoned him? He looked for his
precious binoculars beside his bed but they were gone. Damn. Someone had
pinched them. Yet he’d been given a gift far more rare and valuable. Every few
hours a nurse was injecting him with a new drug. Fleming’s miracle, fresh from
Brooklyn. Penicillin. In the ward, amazed servicemen gathered around each
other’s beds to show off their rapidly healing wounds. Their generation had
never seen its like before. A medical wonder. An antibiotic. They were the first
warriors in history to have their wounded bodies cleansed of internal infection
by this new medicine. He never forgot the gift. He’d later scoff at the compla-
cency of his children, who’d pop antibiotics for every tiny cough or cut. ‘You
don’t know you’re born,’ he’d say. He was right. Dad was born in an age when a
cut from a rose thorn could grow septic and kill – or when a simple streptococcal
infection could silently eat the heart. Now physical trauma had a new foe …”
(Source: McGann, 2017, p. 140)

The aim of the medical model is to achieve an absence of disease.

Bio-psychosocial model
During the 1970s, feminists (Phillips and Rakusen, 1978), theologians (Illich, 1977),
policymakers (Lalonde, 1981), disability rights campaigners (Finkelstein, 1980),
the World Health Organization (1978) and many ‘ordinary’ people expressed con-
cerns about the limitations of the disease-centred medical model. They recognised
its strengths, but from all sides came arguments that the vision of a healthy society
needed to reflect contemporary understandings of a person as a whole being in rela-
tion to others and encompass more than an absence of disease within the body.
Within the medical community, one contributor to the debate was George Engel,
an American psychiatrist with an interest in changing medical practice. In 1977, Engel
defined illness as being the human experience of a disease. He argued the most impor-
tant skill of a doctor is to listen and then analyse a person’s subjective account of their
illness; it is essential to making the diagnosis and providing appropriate treatment
and care. He also recognised that the person’s experience is strongly influenced by
the social context of their lives. For example, a person will only believe themselves to
be ill if their experience fits with their personal perception of what an illness is, and
this is likely to be informed by mainstream beliefs about illness in their family and
culture. People who live within a society that has a strong adherence to a traditional
model of health and illness may attribute their cough to a spirit or a sin; those who
live in a society that has a strong adherence to a social model of health and illness
14 Sally Robinson
may attribute the same cough to living in cold, damp housing; those within a society
that values the medical model of health and illness may attribute the cough to a germ
(Robinson, 2021). At a macro level, organisations and policies designed to protect and
support the public’s health are created and maintained according to what a society
values at that moment and in that place. A society that believes illness is the result of
spiritual distress may build a health system around spiritual resources such as tem-
ples or churches; one that believes illness is the result of poverty will invest in actions
such as rectifying poor housing; one that believes illness is something to be detected
by science may invest in laboratories and technology; one that believes illness is the
result of unhealthy personal behaviours may invest in counselling, education or social
marketing. It is not about which is right or wrong, it is about recognising how personal
and social values shape each person’s perceptions of their own experience. Engel rec-
ognised that a person’s experience of a physical or mental illness cannot be limited
to bodily measurements, it is a blend of the anatomical, physiological, biochemical,
psychological, cultural and social. The strict boundaries of the medical model do not
allow this. He wrote,

“The boundaries between health and disease, between well and sick, are far from
clear and never will be clear, for they are diffused by cultural, social and psycho-
logical considerations.”
(Engel, 1977, p. 132)

Engel proposed his biopsychosocial model (Figure 1.5) as a way for medical practi-
tioners to bring together the patient’s experience and the measurements that indicated
malfunction/disease. He hoped it would act as a blueprint for medical research, teach-
ing and care. Today we see it described as a model of clinical care, health, health and
illness, stress, disability, pain and so forth (Bolton and Gillett, 2019; Borrell-Carrió
et al., 2004; Karunamuni et al., 2020; Miaskowski et al., 2019; WHO, 2002) and it

Figure 1.5 The biopsychosocial model

 Understanding ourselves and our health 15
has become central to the work of some healthcare professions such as occupational
therapy. In contrast to the disease-centredness of the medical model, the biopsycho-
social model communicates the importance of a holistic and person-centred approach
to these matters; a blending of the psychological experience, human biology and the
social context in which people live.
In 2020, Karunamuni and colleagues published their investigation into whether the
biopsychosocial model can be supported by evidence. Their review of a large body of
research concluded that there is substantial evidence to demonstrate the relationships
between a person’s biology, psychology, social context and their subjective wellbeing.

• Biological factors include a person’s body including its organs and cells
• Psychological factors include a person’s lived/subjective experiences, feelings,
mental states, goals, attitudes, intentions and behaviour
• Social factors include a person’s interpersonal experiences, life events, social pol-
icies, culture and social circumstances

The authors found evidence for the six pathways:

• B-P Biological factors influence psychological factors, e.g. physical health con-
ditions and pain affect life satisfaction. Having access to shelter, water and good
nutrition protect the body and a person’s subjective wellbeing
• P-B Psychological factors influence biological factors, e.g. negative feelings, such
as stress, affect the nervous and immune systems, which can lead to low-grade
chronic inflammation in the body. Low-grade inflammation is associated with the
development of cardiovascular disease, some cancers and autoimmune diseases.
Repeatedly dwelling on a stressor, rumination, intensifies the effects on the body.
The ‘placebo effect’ refers to the way a person’s expectations of a ‘dummy’ treat-
ment can lead to physical, measurable changes in the body
• P-S Psychological factors influence social factors, e.g. positive feelings are more
likely to lead to social relationships and negative feelings to social conflict
• S-P Social factors influence psychological factors, e.g. abuse, unemployment and
social exclusion negatively affect a person’s subjective wellbeing; whereas social
belonging and social support are protective. Living in places where the rule of
law, human rights and political freedoms are protected are associated with higher
levels of subjective wellbeing
• S-B Social factors influence biological factors. This is usually mediated by psycho-
logical factors such as people’s thoughts, feelings and attitudes, e.g. early child-
hood experiences predict vulnerability to a range of physical and mental health
issues in later life. Persistent loneliness has negative biological consequences lead-
ing to adverse health outcomes. A change in the law, such as the compulsory wear-
ing of seatbelts, can have a large impact on accident prevention
• B-S Biological factors influence social factors. The impact of biological factors
on social factors is also usually mediated by psychological factors, e.g. a painful
injury or disease can reduce a person’s energy and motivation to join social events
and to exert social influence. A person’s body may conform or deviate from per-
ceptions of social norms and elicit social stigma or social praise, thus closing or
opening social opportunities for subjective wellbeing
16 Sally Robinson

Box 1.3 Stanley

Stanley arrived in the UK with his mother on HMT Empire Windrush in 1948
from Jamaica. It is 2017 and Stanley, now 72 years old, lives on a housing estate
in Glasgow. He has not worked in full-time employment since 1985 when he lost
his job at the coal mine. He is a heavy smoker and has a chronic cough. He hasn’t
been seen for a couple of weeks.
Biological – Stanley’s lungs are fragile, irritated and inflamed. He has chronic
bronchitis, which is likely to have been caused by tobacco smoke and coal dust.
He is addicted to nicotine.
Psychological – In 1975, Stanley experienced a major loss. His friend died of
pneumoconiosis, which he later found out was caused by inhaling coal dust. Since
then, he has worried about his own cough. Stanley knows that smoking tobacco
is harmful to health, but he feels twitchy and irritable if he doesn’t smoke and he
says that smoking helps him to have a really good cough which temporarily clears
his chest. Smoking represents a shared behaviour with his ex-miner mates. Their
friendship is very important to him, it’s where he most feels a sense of belonging
and remembers ‘the good days’ with pride. Although he sometimes feels a bit low,
he puts on a big smile and keeps going. Recently he hasn’t the motivation to get out
of bed. He smokes in bed, and his chest hurts. He feels his life is worthless.
Social – Stanley spent his early life in the UK living in poverty. He was often
cold, hungry and insecure. He found it difficult to make friends due to wide-
spread racial discrimination. At school, he was bullied and often felt isolated.
He found that smoking was a way to fit in with some of the other lads and he
would imagine himself as the film star Sidney Poitier lighting a cigarette. He left
school to work in the local coal mine. Among the mining community, he made
good friends. He had a stable weekly wage, a decent home and three square
meals a day. He joined the miners’ trade union and took a leading role, initially
fighting for better health and safety and later during the miners’ strikes. They
lost, and the mine was closed in 1985. The resulting high unemployment meant
the whole community became poorer financially, spiritually and socially. He has
heard rumours that he might be deported back to Jamaica because he doesn’t
have the required documents to prove he is a UK citizen.
B-P Being cold and hungry contributed to Stanley’s feelings of insecurity as a
child; having a really good cough, from inhaling tobacco smoke, makes Stanley feel
temporarily better; his painful chest is contributing to his current lack of motivation.
P-B Stanley’s feelings of isolation encouraged him to start smoking which
contributed to bronchitis; a lack of motivation encourages him to stay in bed
and smoke which inflames his lungs.
P-S Stanley’s need for acceptance encouraged his friendship with smokers at
school; motivated by bereavement he joined with other miners to fight for better
health and safety standards; anxieties about deportation evoke memories of
feeling excluded as a child and have led him to socially isolate himself in bed.
S-P Racial discrimination and bullying made Stanley feel isolated; poor
health and safety standards in the mines led to his bereavement; social inclusion
by mining friends encouraged his self-esteem and confidence to lead the miners;
unemployment and potential deportation has led to a loss of motivation.
 Understanding ourselves and our health 17
S-B Smoking in films and social isolation encouraged Stanley’s uptake of smoking;
poor health and safety standards in the mines led to respiratory illnesses and his
friend’s death.
B-S Stanley’s friend’s death led to a social movement to improve miners’
health; his bronchitis and painful chest encourages him to stay in bed and avoid
social engagement.

The aim of the holistic and person-centred biopsychosocial model is to understand a

person’s experience of health or illness in the context of the interconnections between
their biology, psychology and social context.

World Health Organization

During the 20th century, another vision of a healthy society emerged from the World
Health Organization whose primary role is to coordinate health across the world. It
was also seeking something more holistic and person-centred than the absence of dis-
ease. The World Health Organization has argued health is,

“… not merely the absence of disease or infirmity …”

(WHO, 1946, p. 1)

It is a,

“… positive concept emphasizing social and personal resources, as well as physi-

cal capacities.”
(WHO, 1986, p. 1)

Health is,

“… a resource for everyday life, not the objective of living,”

(WHO, 1986, p. 1)

and it includes,

“… physical, mental and social wellbeing,”

(WHO, 1946, p. 1; 1986, p. 1)

where ‘wellbeing’ is defined as a positive, subjective state. This is associated with a

person’s quality of life which comprises six domains: physical, psychological, level of
independence, spiritual beliefs, social relations and the environment. Quality of life is,

“An individual’s perception of their position in life in the context of the culture and
value systems in which they live and in relation to their goals, expectations, stand-
ards and concerns. It is a broad ranging concept affected in a complex way by the
person’s physical health, psychological state, personal beliefs, social relationships
and their relationship to salient features of their environment … [this] subjective
evaluation … is embedded in a cultural, social and environmental context.”
(WHO, 1998, p. 3)
18 Sally Robinson
Health is person-centred and linked to personal values. To achieve health,

“An individual or group must be able to identify and realize aspirations, to satisfy
needs,”
(WHO, 1986, p. 1)

rather like moving up Maslow’s hierarchy. It requires skills to be able to achieve it.
People need the ability,

“… to change of cope with the environment,”

(WHO, 1986, p. 1)

which recognises people do not live in a bubble but within a culture, a society and a
physical environment which can be enabling or constraining. Health is,

“… a complete state of physical, mental and social wellbeing.”

(WHO, 1946, p. 1; WHO, 1986, p. 1)

The words ‘complete state’ have been criticised by many authors for making health
into an unattainable and idealistic concept. Perhaps no one would achieve health, it is
too illusive. However, in the context of understanding health as including a ­person’s
subjective wellbeing, being a person-centred aspiration, about achieving one’s true
self, being self-actualised, being what a person feels they were meant to be, and then
being able to use this health as a resource to support their lives, it makes more sense.
For the World Health Organization, health is less a definitive, objective, universal,
measurable outcome and more about the processes and conditions of enablement which
will allow each person to achieve whatever ‘a complete state of physical, mental and
social wellbeing’ means for them. Enablement is associated with individual autonomy,
democracy, equality and human rights (WHO, 1946; 1986; 1998; 2009).

Health for all

In 1981, the World Health Organization launched its Global Strategy for Health for All
by the Year 2000, which declared the international community would work towards all
people across the world being healthy by 2000. This meant people being able to work
productively; participate in their communities; be free from avoidable disease and
disability; growing up, living and dying with grace; enjoying a fair distribution of the
resources that support health and having the power to shape their own lives. The year
2000 has passed, but the ‘health for all’ movement continues at the centre of the World
Health Organization’s approach to health promotion.

Health as a human right

Today, the World Health Organization’s vision of a healthy society clearly states that
health is a universal human right (WHO, 2017). The right to health means that a person
has the right to control their own health. For example, they have sexual and reproductive
rights and they have the right to protect their health, including their body, from being
violated, such as from non-consensual medical treatment, forced institutionalisation
and torture. A person also has the right to enjoy optimum health through opportunities
 Understanding ourselves and our health 19

Box 1.4 Constitution of the World Health Organization

“… the following principles are basic to the happiness, harmonious relations
and security of all peoples:
Health is a state of complete physical, mental and social wellbeing and not
merely the absence of disease or infirmity.
The enjoyment of the highest attainable standard of health is one of the
fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition.
The health of all peoples is fundamental to the attainment of peace and secu-
rity and is dependent upon the fullest cooperation of individuals and [member]
States.
The achievement of any [member] State in the promotion and protection of
health is of value to all.
Unequal development in different countries in the promotion of health and
control of disease, especially communicable disease, is a common danger.
Healthy development of the child is of basic importance; the ability to live
harmoniously in a changing total environment is essential to such development.
The extensions of all peoples of the benefits of medical, psychological and
related knowledge are essential to the fullest attainment in health.
Informed opinion and active cooperation on the part of the public are of the
utmost importance in the improvement of the health of the people.
Governments have a responsibility for the health of their peoples which can
be fulfilled only by the provision of adequate health and social measures.”
(Source: WHO, 2020a, p. 1. This is the 1946 version with subsequent
amendments included. Reproduced with permission from the
World Health Organization)

that are available equally to all other persons. Achieving health equity, fairness across
a society, means prioritising the needs of those who are the most disadvantaged and
ensuring health is not subject to discrimination on the grounds of race, age, ethnicity,
sexuality, disability and so forth. It means targeting discriminatory practices and abuses
of power as well as having policies and legal systems to ensure rights are respected. The
right to health is indivisible from other human rights, such as the right to food, sani-
tation, housing, clean and accessible water, clean air and education. A human rights
approach is person-centred, which includes enabling people to gain the knowledge and
skills they need to fully participate in matters that affect their health. More widely, a
region, state, nation or country must enable a range of key agencies, stakeholders and
sectors beyond government to participate in developing, planning and evaluating the
work needed to achieve a healthy society for all. This is summed up in the title of the
World Health Organization’s 2019 global action plan Stronger Collaboration, Better
Health (WHO, 2019).
20 Sally Robinson
Healthy settings
The World Health Organization has been drawing attention to the physical and social
quality of the settings in which people live, learn, play and work for almost 40 years.
These include cities, villages, workplaces, homes, islands, hospitals, universities and
prisons (WHO, 2022) (see Chapters 8 and 15). Settings are places, or social contexts,
where we see physical, social, organisational or environmental factors influencing
people’s health (Box 1.5). For example, in a workplace, the ‘settings approach’ draws
attention to buildings, facilities, culture and the degree to which employees can influ-
ence their quality of life at work.
During the 21st century, the World Health Organization, as part of the United
Nations, committed to the 2030 Agenda for Sustainable Development which aims to
address the global challenges of climate change, environmental degradation, poverty,
inequality, peace and justice (UN, 2015) (Figure 1.6). There is a symbiotic relation-
ship between health and development because people’s health is shaped by personal,
social and environmental factors over time, across their life course, and because
the ultimate healthy setting is a healthy planet. A healthy society is only possible
within a healthy planet, and both create and depend upon healthy people. The means

Box 1.5 The social work setting

Jermaine Ravalier was aware of a high level of sickness absence across the UK
social care sector and the reputation for social work being a very stressful occu-
pation. He carried out research with 1,333 social workers to understand their
working conditions. He found low job satisfaction and presenteeism, which
means working when unwell. Many social workers were thinking of leaving
their job. The causes of their significant stress and related outcomes included
experiencing

• high workload, e.g. having a high number of cases, many of which were
complex cases; having too few social workers to deal with the demand and
excessive administration
• poor managerial support, e.g. managers who did not fully understand the
role of the social worker and managers who set unrealistic time scales along-
side unrealistic expectations
• lack of regular supervision from experienced colleagues
• a culture of blame which included a lack of respect for their work from
politicians and the public and a poor understanding of the difficulties of
the job
• ‘hot desking,’ not having a permanent desk and computer
• lack of opportunities for flexible working and, for some, inadequate pay

At the heart of the social workers’ stress was the combination of highly demanding
work, feeling they had little control and poor managerial support.
(Source: Ravalier, 2019)
 Understanding ourselves and our health 21

Figure 1.6 Sustainable development goals

Source: ALX1618/Shutterstock.com

to achieving a healthy society is through people working in partnership with one

another.

“Health and wellbeing are shaped by the conditions in which people are born,
grow, work and age, and these are in turn shaped by social, economic and envi-
ronmental factors. The reverse is also true. Health and well-being drive broader
sustainable development including reductions in poverty and inequality, better
educational outcomes, and inclusive economic growth. Health and well-being
promote resilience, sustainability, equity and human security.”
(WHO, 2019, p. 65. Reproduced with permission from
the World Health Organization)

The World Health Organization views health as a human right. People have the right to
control their health based on their own values, it is person-centred. Health is a resource
for living not the reason for life. It is a holistic concept, comprising absence of disease and
quality of life. It is more achievable when people are fully enabled within a healthy setting.

A concept of health
A concept of health may be

• person-centred – a human right which reflects each person’s life and their values
• time dependent – health changes over the life course, across generations and eras
• positive – health is being able to achieve aspirations and meet needs; subjective
wellbeing and a good quality of life
• holistic – health is created through interactions between the biological, psychologi-
cal and social. These may be further broken down into physical, mental, emotional,
sexual, social and spiritual dimensions, which are discussed in Chapter 7. In turn,
these are influenced by a person’s interactions with their wider social and physical
environment. This may be represented as a social-ecological model (Figure 1.7)

These ideas provide a useful start, but they also present challenges.
22 Sally Robinson

Figure 1.7 Interdependent healthy people in a healthy society and healthy planet

Person-centred

• A person-centred approach to health means we must first understand people, their

beliefs, self-concept, values, needs, aspirations and the context in which their lives
have been and are being lived. Listening, learning and responding appropriately
takes time, skills and other resources which may not be available or which people
choose not to make available
• A person-centred approach may lead to tensions when one person’s actions to
protect or promote their own health impacts negatively on others
• Health is often determined by power. For example, the power of governments,
professional bodies or commercial businesses who promote, deliver or enforce
their own circumscribed vision of a healthy society versus the power of the indi-
vidual to know and assert their own wishes in accordance with their own values

Thinking point:

Thinking about current advertising and the messages they convey, what does
health mean to a pharmaceutical company, to a company selling holidays, a busi-
ness selling a diet product and a fitness guru on social media? See Box 1.6 and
consider what health meant to the Nazi party in the early 1940s.
 Understanding ourselves and our health 23

Box 1.6 Health promotion in Nazi Germany

Dr Leonard Conti, the leader of health within the Third Reich, became aware
of German research which indicated smoking was related to lung cancer.
Antismoking propaganda was disseminated by the Hitler Youth and the League of
German Girls, soldiers were forbidden to smoke on the streets, and smoking was
banned in schools and, by 1943, in public places for anyone under 18 years. By 1944
it was banned on trains and buses and in workplaces, public buildings, care homes
and hospitals. There were discussions about whether those with self-inflicted
smoking-related illnesses should be given medical care. Along with smoking, the
German healthy lifestyle campaigns also discouraged the drinking of alcohol.
Adolf Hitler was vehemently against smoking and did not drink alcohol.
The promotion of a healthy lifestyle was part of the racial hygiene movement. It
was believed that tobacco and alcohol would poison genes and damage the purity
of the German people, the Aryan ‘master race’. Other racial hygiene activities
included persecuting Jews, homosexuals and those with learning disabilities; ‘pre-
ventive death sentences’ for those identified as potential murderers and euthanasia
programmes which murdered 70,000 people deemed to be ‘mentally or physically
defective.’ The message from Hitler was that every German was responsible for all
Germans and they did not have the right to damage their body with drugs.
(Source: Smith, 2004; Smith et al., 1994)

• A person-centred approach means enabling people with the knowledge, skills and
resources to reach their personal goals for health. However, person-centredness
may be interpreted as health being a personal matter and divorced from health as
a social concept. For example, disability can be understood as a personal attribute
or a socially constructed one. Many argue it is how society is organised that is
­‘dis-abling’, not any individual within it. A social concept of health can complement
and facilitate person-centredness

Time

• Health is dependent on time. The urgency to attend to the health emergencies of

today may conflict with attending to the health emergencies of tomorrow. The for-
mer is often high value, visible, known and immediate; the latter is often low value,
not yet fully known, invisible and arguably can be delayed. It is difficult to win a
political election by promising to prevent health problems that have not yet arrived
• Personal concepts of health change over lifetimes, generations, eras and some-
times daily. Health-related decisions and actions need to be understood in their
contemporary context

Positive

• Working with a negative definition of health, meaning health is defined as only

the ‘absence of disease’, has advantages compared to working with a more com-
plex, positive definition of health. Researching malfunctions in the body using
highly valued, rigorous and respected scientific methods which produce data
that can be generalised to every human is very different to researching the more
24 Sally Robinson
contested concept of health. The latter necessitates the use of quantitative and
qualitative social scientific research methods such as questionnaires, interviews,
case studies and social observations. Historically, these have been perceived as
lower status than scientific research, partly because they do not always produce
findings that can be generalised to others. This has had implications for funding
and acceptance. However, awareness of the limitations of scientific research and
of the potential insights to be gained from social scientific research are increas-
ingly recognised as vital for working with a positive definition of health
• Treating disease or injury is often given higher priority by society than disease
prevention; and preventing disease and injury is often given higher priority than
the social and educational actions that will enable people to achieve their aspira-
tions for wellbeing and a good quality of life. It is difficult to measure disease that
has been prevented, but it is even harder to measure and demonstrate the health
benefits of a long-term investment in people’s lives
• Working with a positive definition of health means allowing it into mainstream,
socially inclusive thinking. A positive concept of health includes the individual
who reports being healthy, feeling fulfilled, achieving their aspirations and living
as their true self in the presence of an identified disease or infirmity, which they
have successfully learnt to live with. There are many people; some with disabilities,
some with a chronic or terminal illness, and some with neither; for whom health
‘as a positive concept’ is a much more meaningful way to think about health and
how we can achieve it, but this is more rarely represented in culture, for example
in films, television drama and documentaries, than the fight against disease

Holistic

• If health is as broad as life, there are no experts. The health of a society becomes
everyone’s business and no practitioner, professional, agency or government can
claim unquestioning expertise or authority over people’s health. Yet practitioners,
professionals, agencies and governments are often given this authority
• A holistic approach can be interpreted as pertaining to the ‘whole person’, as if
they lived in a bubble, without recognising the wider context in which a person
lives and dies. By focussing only on one person at a time, we fail to see that poor
health, illness, disease and early death are not random but often predictable and,
to some extent, preventable
• A holistic approach requires a broad understanding of all the factors that influ-
ence health, it is inherently an interdisciplinary field of study like education. Yet,
historically, single disciplines have enjoyed a higher status in UK research and
wider academia
• A holistic approach to an individual’s health may involve interprofessional work-
ing among, for example, a nurse, social worker, occupational therapist and a hos-
pital chaplain. While each brings their knowledge and experience, they also bring
their own professional visions of health associated with the professional bodies
which guide their professional education and allow them to practise. Successful
interprofessional working takes skill, mutual respect, time and patience
• A holistic approach to a population’s health requires multi-disciplinary, mul-
ti-agency, multi-sectoral and international partnerships to understand people’s
health and to work towards improvements, but such a broad remit may permit
unwelcome encroachments into every aspect of everyone’s lives
 Understanding ourselves and our health 25
Table 1.2 E
 xamples of disciplines, fields of study, sectors and agencies which contribute to
health

Disciplines/fields of Sectors UK national/regional International agencies

study agencies

Arts and health Business Cancer Research UK Bill & Melinda Gates
Biomedical science Criminal justice Department for the Foundation
Education Education Environment, Food & Befrienders Worldwide
Environmental Health and care Rural Affairs Centers for Disease
science Hospitality Department of Health Control and
Epidemiology Housing (NI) Prevention (USA)
Geography and Local government Department of Health Center for Reproductive
health Sport and leisure and Social Care (UK) Rights
Health economics Voluntary Food Standards Agency Elton John AIDS
Health promotion Health Protection Foundation
Philosophy Scotland European Commission
Politics Local authorities Food and Agriculture
Psychology Local health boards Organization
Social anthropology Mind International Monetary
Social policy NHS Wales Fund
Public health Oxfam
observatories Water Aid
The Health Foundation World Bank
World Health
Organization

There is no definitive definition of health. Contemporary thinking suggests it may

be person-centred, time-dependent, positive and holistic. We need to recognise and
respect individuals’ values and their lives, and to work in partnership with them and
others, if we are to support and improve people’s health.

Summary
This chapter has

• explored a person as a biological, psychological and social being who changes

over time and in relation with their own ecosystem
• suggested that a person’s view of what health means to them is tied up with their
experience of living in a society with its culture, and by their personal needs, val-
ues and aspirations
• provided examples of how people with influence and their vision of a healthy
­society can shape how individuals and populations understand and resource
their health
• explored some contemporary ideas about health as a person-centred, time-­
dependent, holistic and positive concept

Further reading
Buchanan, D.R. (2020) A humanistic approach to health promotion. Newcastle upon Tyne:
Cambridge Scholars
Duncan, P. (2006) Critical perspectives on health. London: Macmillan
Nettleton, S. (2020) The sociology of health and illness. 4th edn. Cambridge: Polity Press
26 Sally Robinson
Useful website
World Health Organization. Available at: www.who.int

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Belmont: Wadsworth, Cengage Learning
Bolton, D. and Gillett, G. (2019) ‘Biopsychosocial conditions of health and disease’, in Bolton,
D. and Gillett, G. (eds) The biopsychosocial model of health and disease: new philosophical and
scientific developments. London: Palgrave/Macmillan, pp. 109–145
Borrell-Carrió, F., Suchman, A.L. and Epstein, R.M. (2004) ‘The biopsychosocial model
25 years later: principles, practice and scientific enquiry’, Annals of Family Medicine, 2(6),
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perspective: a bioecological model’, Psychological Review, 101(4), pp. 568–586
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Understanding ourselves and our health
Buchanan, D.R. (2020) A humanistic approach to health promotion. Newcastle upon Tyne: Cambridge
Scholars
Duncan, P. (2006) Critical perspectives on health. London: Macmillan
Nettleton, S. (2020) The sociology of health and illness. 4th edn. Cambridge: Polity Press
Useful website
World Health Organization. Available at: www.who.int
Baelz, P.R. (1987) ‘Philosophy of health education’, in Sutherland, I. (ed) Health education: perspectives and
choices. Cambridge: National Extension College Trust Ltd, pp. 20–38
Baumeister, R.F. and Bushman, B.J. (2014) Social psychology and human nature. 3rd edn. Belmont:
Wadsworth, Cengage Learning
Bolton, D. and Gillett, G. (2019) ‘Biopsychosocial conditions of health and disease’, in Bolton, D. and Gillett,
G. (eds) The biopsychosocial model of health and disease: new philosophical and scientific developments.
London: Palgrave/Macmillan, pp. 109–145
Borrell-Carrió, F. , Suchman, A.L. and Epstein, R.M. (2004) ‘The biopsychosocial model 25 years later:
principles, practice and scientific enquiry’, Annals of Family Medicine, 2(6), pp. 576–582
Bronfenbrenner, U. and Ceci, S.J. (1994) ‘Nature-nurture reconceptualized in developmental perspective: a
bioecological model’, Psychological Review, 101(4), pp. 568–586
Bronfenbrenner, U. and Morris, P.A. (1998) ‘The ecology of developmental processes’, in Damon, W. and
Lerner, R.M. (eds) Handbook of child psychology: theoretical models of human development. 5th edn. New
York: John Wiley and Sons, pp. 993–1028
Cozolino, L.J. (2006) The neuroscience of human relationships. London: W.W. Norton and Co.
Engel, G.L. (1977) ‘The need for a new medical model: a challenge for biomedicine’, Science, 196(4286), pp.
129–136
Finkelstein, V. (1980) Attitudes and disabled people: issues for discussion. New York: World Rehabilitation
Fund. Available at: https://disability-studies.leeds.ac.uk/wp-content/uploads/sites/40/library/finkelstein-
attitudes.pdf (Accessed 21st June 2022)
Fox, N.J. (2018) ‘Reconceptualising bodies’, in Scambler, G. (ed) Sociology as applied to health and
medicine. London: Macmillan/Palgrave, pp. 263–276
Graham, H. and Oakley, A. (1991) ‘Competing ideologies of reproduction: medical and maternal
perspectives on pregnancy’, in Currer, C. and Stacey, M. (eds) Concepts of health, illness and disease. A
comparative perspective. Oxford: Berg, pp. 97–115
Griffore, R.J. and Phenice, L.A. (2016) ‘Proximal processes and causality in human development’, European
Journal of Educational and Development Psychology, 4(1), pp. 10–16
Hook, L. (2021) ‘FT Magazine. Greta Thunberg: “It just spiralled out of control.”’ Financial Times, March 31st.
Available at: https://www.ft.com/content/6ee4bb03-3039-446a-997f-91a7aef5f137 (Accessed 21st June
2022)
Illich, I. (1977) Limits to medicine: medical nemesis: the expropriation of health and medicine. 2nd edn.
Harmondsworth: Penguin
Jacobson, M.H. and Kristiansen, S. (2015) The social thought of Erving Goffman, London: Sage
Karunamuni, N. , Imayama, I. and Goonetilleke (2020) ‘Pathways to well-being; untangling the causal
relationships among biopsychosocial variables’, Social Science and Medicine, 112846 doi:
10.1016/j.socscimed.2020.112846
Lalonde, M. (1981) A new perspective on the health of Canadians. Ottawa: Government of Canada
Mansfield, K. (2006) Journal of Katherine Mansfield. London: Persephone Books
Maslow, A. (1943) ‘A theory of human motivation’, Psychological Review, 50(4), pp. 370–396.
McGann, S. (2017) Flesh and blood. A history of my family in seven sicknesses. London: Simon and Shuster
Miaskowski, C. , Blyth, F. , Nicosia, F. , Haan, M. , Keefe, F. , Smith, A. and Ritchie, C. (2019) ‘A
biopsychosocial model of chronic pain for older adults’, Pain Medicine, 21(9), pp. 1793–1805
Moon, G. (1995) ‘Health care and society’, in Moon, G. and Gillespie, R. (eds) Society and health. An
introduction to social science for health professionals. London: Routledge, pp. 49–64
Phillips, A. and Rakusen, J. (1978) Our bodies ourselves. A health book by and for women. London: Viking
Pilkington, F.B. (1999) ‘An ethical framework for nursing practice: Parse's human becoming theory’, Nursing
Science Quarterly, 12(1), pp. 21–25
Ravalier, J.M. (2019) ‘Psycho-social working conditions and stress in UK social workers’, British Journal of
Social Work, 49(9), pp. 371–390
Robinson, S. (2021) ‘Social context of health and illness’ in Robinson, S. (ed) Priorities for health promotion
and public health. Explaining the evidence for disease prevention and health promotion. London: Routledge,
pp. 3–33
Rogers, C. (1961) On becoming a person. A therapist's view of psychotherapy. London: Constable and Co.
Schwartz, S.H. (2012) ‘An overview of the Schwartz theory of basic values’, Online Readings in Psychology
and Culture, 2(1) doi:10.9707/2307-0919.1116
Smith, D.G. (2004) ‘Lifestyle, health and health promotion in Nazi Germany’, BMJ (Clinical Research Edn.),
329(7480), pp. 1424–1425
Smith., D.G. , Ströbele, S.A. and Egger, M. (1994) ‘Smoking and health promotion in Nazi Germany’, Journal
of Epidemiology and Community Health, 48(3), pp. 220–223
Tudge, J.R.H. , Payir, A. , Merçon-Vargas, E. , Cao, H. , Liang, Y. , Li, J. and O'Brian, L. (2009) ‘Still misused
after all these years? A reevaluation of the uses of Bronfenbrenner's bioecological theory of human
development’, Journal of Family Theory and Review, 8(4), pp. 427–445
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https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%2
0Development%20web.pdf (Accessed 21st June 2022)
White, F.J. (2013) ‘Personhood: an essential characteristic of the human species’, The Linacre Quarterly,
80(1), pp. 74–97
Winnicott, D. (1971) Playing and reality. London: Routledge
World Health Organization (1946) Constitution. Geneva: World Health Organization
World Health Organization (1978) Declaration of Alma-Ata. International conference on primary health care,
Alma-Ata, USSR, 6–12 September 1978. Available at:
https://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf (Accessed 21st June 2022)
World Health Organization (1981) Global strategy for health for all by the year 2000. Geneva: World Health
Organization
World Health Organization (1986) Ottawa charter for health promotion. Available at:
https://www.canada.ca/content/dam/phac-aspc/documents/services/health-promotion/population-
health/ottawa-charter-health-promotion-international-conference-on-health-promotion/charter.pdf (Accessed
21st June 2022)
World Health Organization (1998) WHOQOL user manual. Available at:
https://www.who.int/publications/i/item/WHO-HIS-HSI-Rev.2012.03 (Accessed 21st June 2022)
World Health Organization (2002) Towards a common language for functioning, disability and health.
Geneva: World Health Organization
World Health Organization (2009) Milestones in health promotion. Statements from global conferences.
Geneva: World Health Organization
World Health Organization (2017) Human rights and health. Available at: https://www.who.int/news-
room/fact-sheets/detail/human-rights-and-health (Accessed 21st June 2022)
World Health Organization (2019) Stronger collaboration, better health. Global action plan for healthy lives
and well-being for all. Geneva: World Health Organization
World Health Organization (2020) Basic documents. 49th edn. Geneva: World Health Organization
World Health Organization (2022) Healthy settings. Available at: https://www.who.int/teams/health-
promotion/enhanced-wellbeing/healthy-settings (Accessed 21st June 2022)

Working in health promotion and public health

Sim, F. and Wright, J. (2015) Working in public health. An introduction to careers in public health. London:
Routledge
Useful websites
Faculty of Public Health. Available at: www.fph.org.uk
International Union for Health Promotion and Education (IUHPE). Available at: www.iuhpe.org
Public health (careers). Available at: www.healthcareers.nhs.uk/explore-roles/public-health-careers
UK Public Health Register (UKPHR). Available at: https://ukphr.org
Barry, M. M. , Battel-Kirk, B. , Davison, H. , Dempsey, C. , Parish, R. , Schipperen, M. , Speller, V. , van der
Zanden, G. , and Zilnyk, A. on behalf of the CompHP Partners (2012) The CompHP project handbooks.
International union for health promotion and education (IUHPE). Available at:
https://www.iuhpe.org/images/PROJECTS/ACCREDITATION/CompHP_Project_Handbooks.pdf. (Accessed
4th April 2022)
Centre for Workforce Intelligence (2015) Understanding the wider public health workforce. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/507752/Cf
WI_Understanding_the_wider_public_health_workforce.pdf (Accessed 4th April 2022)
Department of Health (2012) Healthy lives, healthy people: towards a workforce strategy for the public health
system. Consultation document. Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/164228/consultation_doc.pdf
(Accessed 4th April 2022)
Faculty of Public Health (2020) Functions and standards of a public health system. Available at:
https://www.fph.org.uk/media/3031/fph_systems_and_function-final-v2.pdf (Accessed 4th April 2022)
Professional Standards Authority (2021) UK public health register. Available at:
https://www.professionalstandards.org.uk/what-we-do/accredited-registers/find-a-register/detail/uk-public-
health-register (Accessed 4th April 2022)
Public Health England (2019) The wider public health workforce. A review. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/783867/T
he_wider_public_health_workforce.pdf (Accessed 4th April 2022)
Public Health England/Public Health Agency/Public Health Wales/NHS Scotland (2016) Public health skills
and knowledge framework 2016. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/584408/p
ublic_health_skills_and_knowledge_framework.pdf (Accessed 4th April 2022)
Skills for Health (2004) National occupational standards for the practice of public health guide. Available at:
http://www.wales.nhs.uk/sitesplus/documents/888/englishnos.pdf (Accessed 4th April 2022)
UK Public Health (2020) People in UK public health. Available at: https://ukphr.org/wp-
content/uploads/2020/11/Report-PinUKPH-to-Select-Committees-Nov-2020.pdf (Accessed 4th April 2022)
UK Public Health Register (2014) UKPHR code of conduct. 2nd edn. Available at:
https://ukphr.org/registration/code-of-conduct (Accessed 4th April 2022)
UK Public Health Register (2020) Public health practitioner standards for registration. Available at:
https://www.ukphr.org/wp-content/uploads/2014/08/UKPHR-Practitioner-Standards-14.pdf (Accessed 4th
April 2022)
UK Public Health Register (2022) Guidance. Revalidation of UKPHR's specialist registrants. 4th edn.
Available at: Revalidation-Guidance-Specialist-registrants-March-2022-edition-4.pdf (ukphr.org) (Accessed
4th April 2022)
WHO-ASPHER (2020) WHO-ASPHER competency framework for the public health workforce in the
European region. Available at: https://www.euro.who.int/__data/assets/pdf_file/0003/444576/WHO-
ASPHER-Public-Health-Workforce-Europe-eng.pdf (Accessed 4th April 2022)
Yorkshire and Humber Public Health Network (2021) Public health careers. Available at:
https://www.yhphnetwork.co.uk/links-and-resources/public-health-careers (Accessed 4th April 2022)

Epidemiology
Bhopal, R.S. (2016) Concepts of epidemiology: integrating the ideas, theories, principles, and methods of
epidemiology. 3rd edn. Oxford: Oxford University
Carneiro, I. (2017) Introduction to epidemiology. 3rd edn. Maidenhead: Open University Press
Celentano, D.D. and Szklo, M. (2019) Gordis epidemiology. 6th edn. London: Elsevier
Webb, P. , Bain, C. , and Page, A. (2020) Essential epidemiology: an introduction for students and health
professionals. 4th edn. Cambridge: Cambridge University Press
Useful websites
Gapminder. Available at: https://www.gapminder.org
Office for National Statistics. Available at: https://www.ons.gov.uk
United Kingdom Health Security Agency. Available at: https://www.gov.uk/government/organisations/uk-
health-security-agency
Bonita, R. , Beaglehole, R. and Kjellström, R. (2006) Basic epidemiology. 2nd edn. Geneva: World Health
Organization
Boyce, N. (2020) ‘Bills of mortality: tracking disease in early modern London’, The Lancet, 395(10231), pp.
1186–1187
Cancer Research UK (2021) Cancer incidence by age. Available at:
https://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age#heading-Zero
(Accessed 14th April 2022)
Ciccacci, F. , Orlando, S. , Majid, N. and Marazzi, C. (2020) ‘Epidemiological transition and double burden of
diseases in low-income countries: the case of Mozambique’, The Pan African Medical Journal, 37(49)
doi:10.11604/pamj.2020.37.49.23310
Connor, H. (2022) ‘John Graunt F.R.S. (1620–74): the founding father of human demography, epidemiology
and vital statistics’, Journal of Medical Biography, 30 doi:10.1177/09677720221079826
Doll, R. and Hill, A. (1950) ‘Smoking and carcinoma of the lung in physicians’, British Medical Journal,
2(4682), pp. 739–748
Doll, R. and Hill, A. (1954) ‘The mortality of doctors in relation to their smoking habits’, British Medical
Journal, 1(4877), pp. 1451–1455
Friis, R.H. (2018) Epidemiology 101. Burlington: Jones and Bartlett
Graunt, J. (1676) Natural and political observations made upon the bills of mortality. 5th edn. London: Royal
Society
Hill, A. (1965) ‘The environment and disease: association or causation?’, Proceedings of the Royal Society
of Medicine, 58(5), pp. 295–300
John Hopkins University (2022) COVID-19 Dashboard. Available at: https://coronavirus.jhu.edu/map.html
(Accessed 31st March 2022)
Kayali, G. (2017) ‘The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the
Islamic golden era’, Eastern Mediterranean Health Journal, 23(12), pp. 854–857.
Marmot, M. , Allen, J. , Boyce, T. , Goldblatt, P. and Morrison, J. (2020) Health equity in England: the
Marmot review 10 years on. London: Institute of Health Equity
Mercer, A.J. (2018) ‘Updating the epidemiological transition model’, Epidemiology and Infection, 146(6), pp.
680–687
Merrill, R.M. (2017) Introduction to epidemiology. 7th edn. Burlington: Jones and Bartlett
Morris, J.N. (1955) ‘Uses of epidemiology’, British Medical Journal, 2(4936), pp. 395–401
Munnangi, S. and Boktor, S.W. (2021) Epidemiology of study design. StatPearls publishing. Available at:
https://pubmed.ncbi.nlm.nih.gov/29262004 (Accessed 14th April 2022)
National Health Service (2021) NHS Screening. Available at: https://www.nhs.uk/conditions/nhs-screening
(Accessed 14th April 2022)
O'Donnell, T. (1936) ‘History of life insurance in its formative years. By Terence O'Donnell (pp.844 American
conservation company, Chicago. 1936)’, Journal of the Staple Inn Actuarial Society, 7(3), pp. 182–184
Office for National Statistics (2017) Causes of death over 100 years. Available at:
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/causesofd
eathover100years/2017-09-18 (Accessed 10th April 2022)
Office for National Statistics (2020) Leading causes of death, UK: 2011 to 2018. Available at:
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/articles/leadingc
ausesofdeathuk/2001to2018 (Accessed 10th April 2022)
Office for National Statistics (2021) National life tables – life expectancy in the UK: 2018 to 2020. Available
at:
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/
nationallifetablesunitedkingdom/2018to2020 (Accessed 14th April 2022)
Omran, A.R. (1971) ‘The epidemiologic transition. A theory of the epidemiology of population change’, The
Milbank Memorial Fund Quarterly, 49(4), pp. 509–538
Parascandola, M. and Weed, D. (2001) ‘Causation in epidemiology’, Journal of Epidemiology and
Community Health, 55(12), pp. 905–912
Petty, W. (1899) The economic writings of Sir William Petty (volume 2). Edited by Hull C.H. Cambridge
University Press. Available at: https://oll.libertyfund.org/title/hull-the-economic-writings-of-sir-william-petty-
vol-2 (Accessed April 10th 2022)
Populationpyramid.net (2020) Population pyramids of the world from 1950 to 2100. Available at:
www.populationpyramid.net/united-kingdom/2020 (Accessed 10th April 2022)
Porta, M. (ed.) (2014) A dictionary of epidemiology. Oxford: Oxford University Press
Public Health Scotland (2021) Teenage pregnancies. Year of conception, ending 31 December 2019.
Available at: https://publichealthscotland.scot/publications/teenage-pregnancies/teenage-pregnancies-year-
of-conception-ending-31-december-
2019/#::text=The%20teenage%20pregnancy%20rate%20in,28%20per%201%2C000%20in%202019
(Accessed 14th April 2022)
Rothman, K.J. (1976) ‘Causes’, American Journal of Epidemiology, 104(6), pp. 587–592
Seedat, F. , Cooper, J. , Cameron, L. , Stranges, S. , Kandala, N. , Burton, H. and Taylor-Phillips, S. (2014)
International comparisons of screening policy-making: a systematic review. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/444227/FI
NAL_REPORT_International_Screening.pdf (Accessed 14th April 2022)
Shu, Y. , He, H. , Shi, X. , Lei, Y. and Li, J. (2021) ‘Coronavirus disease-2019 (review)’, World Academy of
Sciences Journal, 3(2) doi:10.3892/wasj.2021.83
Snow, J. (1855) On the mode of communication of cholera. London: John Churchill
Sutton, G. (2003) ‘Putrid gums and “dead men's cloaths”: James Lind aboard the Salisbury’, Journal of the
Royal Society of Medicine, 96(12), pp. 605–608
United Kingdom Health Security Agency (2022) Coronavirus (COVID-19) in the UK. Available at:
https://coronavirus.data.gov.uk (Accessed March 31st 2022).
World Health Organization (2021) Malaria. Available at: https://www.afro.who.int/health-
topics/malaria#::text=Most%20were%20in%20the%20WHO,%2C%20and%20Uganda%20(4%25)
(Accessed 14th April 2022)
Wu, Y. , Chen, C. and Chan, Y. (2020) ‘The outbreak of COVID-19: an overview’, Journal of the Chinese
Medical Association, 83(3), pp. 217–220

Research methods and evidence-based practice

Bowling, A. (2014) Research methods in health: investigating health and health services. 4th edn.
Maidenhead: Open University Press
Greetham, B. (2019) How to write your undergraduate dissertation. Basingstoke: Macmillan
Thomas, G. (2017) How to do your research project: a guide for students. London: Sage
Useful websites
Centre for Health Promotion Research (CHPR). Leeds Beckett University. Available at:
www.leedsbeckett.ac.uk/research/centre-for-health-promotion
National Institute for Health Research. Available at: www.nihr.ac.uk
Beauchamp, T.L. and Childress, J.E. (2019) Principles of biomedical ethics. 8th edn. Oxford: Oxford
University Press
Blaxter, L. , Hughes, C. and Tight, M. (2006) How to research. 3rd edn. New York: McGraw-Hill Education
Bowling, A. (2014) Research methods in health: investigating health and health services. Maidenhead: Open
University Press
British Psychological Society. (2021) BPS code of human research ethics. Available at:
https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-
%20Files/BPS%20Code%20of%20Human%20Research%20Ethics.pdf (Accessed 26th April 2022)
Denzin, N.K. and Lincoln, Y.S. (2005) The sage handbook of qualitative research. 3rd edn. London: Sage
DePoy, E. and Gitlin, L.N. (2020) Introduction to research. Understanding and applying multiple strategies.
6th edn. London: Elsevier Mosby
Dileo, C. and Bradt, J. (2009) ‘On creating the discipline, profession and evidence in the field of arts and
healthcare’, Arts and Health, 1(2), pp. 168–182
Gov.UK. (2021) Data protection. Available at: www.gov.uk/data-protection (Accessed 26th April 2022)
Gray, D.E. (2013) Doing research in the real world. London: Sage
Green, J. and Thorogood, N. (2018) Qualitative methods for health research. 4th edn. London: Sage
Gregory, D. , Johnston, R. , Pratt, G. , Watts, M. and Whatmore, S. (2009) The dictionary of human
geography. 5th edn. Chichester: Wiley-Blackwell
Grønmo, S. (2020) Social research methods: qualitative, quantitative and mixed methods approaches.
London: Sage
Hek, G. and Moule, P. (2006) Making sense of research. An introduction for health and social care
practitioners. London: Sage
Houser, J. (2016) Nursing research: reading, using and creating evidence. 4th edn. Burlington: Jones and
Bartlett Learning
Kitzinger, J. (1995) ‘Qualitative research: introducing focus groups’, BMJ, 311(7000), pp. 299–302
Kozinets, R.V. (2015) ‘Netnography: understanding networked communication society’, in Quan-Haase, A.
and Sloan, L. (eds) The sage handbook of social media research methods. Available at:
www.researchgate.net/publication/319613944_Netnography (Accessed 26th April 2022)
Mann, S. (2016) The research interview: reflective practice and reflexivity in research processes. London:
Palgrave Macmillan
Moule, P. and Goodman, M. (2009) Nursing research. An introduction. London: Sage
Rychetnik, L. , Hawe, P. , Waters, E. , Barratt, A. and Frommer, M. (2004) ‘A glossary for evidence-based
public health’, Journal of Epidemiology and Community Health, 58(7), pp. 538–545
Silverman, D. (ed.) (2011) Qualitative research. London: Sage
Health psychology
Anisman, H. (2021) Health psychology: a biopsychosocial approach. 2nd edn. London: Sage
Ogden, J. (2019) Health psychology. 6th edn. London: McGraw-Hill Education
Useful websites
American Psychological Association. Available at: www.apa.org
British Psychological Society. Available at: www.bps.org.uk
The Behavioural Insights Team. Available at: www.bi.team
Adams, J. and White, M. (2005) ‘Why don't stage-based activity promotion interventions work?’, Health
Education Research, 20(2), pp. 237–243
Ajzen, I. (1991) ‘The theory of planned behaviour’, Organisational Behaviour and Human Decision
Processes, 50(2), pp. 179–211
Ajzen, I. and Fishbein, M. (1977) ‘Attitude-behaviour relations: a theoretical analysis and review of empirical
research’, Psychological Bulletin, 84(5), pp. 888–918
American Psychological Association (2022) APA dictionary of psychology. Available at:
https://dictionary.apa.org/psychology (Accessed 23rd February 2022).
Armitage, C.J. and Connor, M. (2001) ‘Efficacy of the theory of planned behaviour: a meta-analytic review’,
British Journal of Social Psychology, 40(4), pp. 471–499
Brandes, K. and Mullan, B. (2014) ‘Can the common-sense model predict adherence in chronically ill
patients? A meta-analysis’, Health Psychology Review, 8(2), pp. 129–153
Breland, J.Y. , McAndrew, L.M. , Burns, E. , Leventhal, E.A. and Leventhal, H. (2013) ‘Using the common
sense model of self-regulation to review the effects of self-monitoring of blood glucose on glycaemic control
for non-insulin treated adults with type 2 diabetes’, The Diabetes Educator, 39(4), pp. 541–559
British Psychological Society (2022a) What is psychology? Available at: https://www.bps.org.uk/public/what-
is-psychology (Accessed 23rd February 2022)
British Psychological Society (2022b) Your journey into psychology. Available at: https://careers.bps.org.uk
(Accessed 23rd February 2022)
British Psychological Society (2022c) Division of health psychology. Available at:
https://www.bps.org.uk/member-microsites/division-health-psychology (Accessed 23rd February 2022)
Brug, J. , Conner, M. , Harre, N. , Kremers, S. , McKellar, S. and Whitelaw, S. (2005) ‘The transtheoretical
model and stages of change: a critique’, Health Education Research, 20(2), pp. 244–258
Cahill, K. , Lancaster, T. and Green, N. (2010) ‘Stage-based interventions for smoking cessation’, Cochrane
Database of Systematic Reviews, 11 doi:10.1002/14651858.CD004492.pub4
Carpenter, C.J. (2010) ‘A meta-analysis of the effectiveness of health belief model variables in predicting
behaviour’, Health Communication, 25(8), pp. 661–669
Damghanian, M. , Mahmoodzadeh, H. , Khakbazan, Z. , Khorsand, B. and Motaharinexhad, M. (2020) ‘Self-
care behaviours in high-risk women for breast cancer: a randomized clinical trial using health belief model
education’, Journal of Education and Health Promotion, 9(265) doi:10.4103/jehp.jehp_76_20
de Quintana Medina, J. (2021) ‘What is wrong with nudges? Addressing normative objections to the aims
and means of nudges’, Gestión y Análisis de Políticas Públicas, 25, pp. 23–37
Department of Health and Social Care (2018) Prevention is better than cure. Our vision to help you live well
for longer. Available at:
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evention_is_better_than_cure_5-11.pdf (Accessed 23rd February 2022)
Doyle, F. and Mullan, B. (2017) ‘Does the CSM really provide a consistent framework for understanding self-
management?’, Journal of Behavioural Medicine, 40(2) doi:10.1007/s10865-016-9806-y
Ejlerskov, K.T. , Harp, S.J. , Stead, M. , Adamson, A.J. , White, M. and Adams, J. (2018) ‘Supermarket
policies on less-healthy food at checkouts: natural experimental evaluation using interrupted time series
analyses of purchases’, PLoS Medicine, 15(12) doi:10.1371/journal.pmed.1002712
Engel, G.L. (1977) ‘The need for a new medical model: a challenge for biomedicine’, Science, 196(4286), pp.
129–136
Ewert, B. (2020) ‘Moving beyond the obsession with nudging individual behaviour: towards a broader
understanding of behavioural public policy’, Public Policy Administration, 35(3), pp. 337–360
Fall, E. , Chakroun-Baggioni, N. , Bohme, P. , Maqdasy, S. , Izaute, M. and Tauveron, I. (2021) ‘Common
sense model of self-regulation for understanding adherence and quality of life in type 2 diabetes with
structural equation modelling’, Patient Education and Counselling, 104(1), pp. 171–178
Ghaffari, M. , Esfahani, S.N. , Rakhshanderou, S. and Koukamari, P.H. (2019) ‘Evaluation of health belief
model-based intervention on breast cancer screening behaviours among health volunteers’, Journal of
Cancer Education, 34(5), pp. 904–912
Guilford, K. , McKinley, E. and Turner, L. (2017) ‘Breast cancer knowledge, beliefs, and screening
behaviours of college women: application of the health belief model’, American Journal of Health Education,
48(4), pp. 256–263
Hagger, M.S. and Orbell, S. (2021) ‘The common sense model of illness self-regulation: a conceptual review
and proposed extended model’, Health Psychology Review, 1 doi:10.1080/17437199.2021.1878050
Halpern, D. (2016) Behavioural insights and healthier lives. VicHealth's inaugural leading thinkers residency.
A report by David Halpern. Melbourne: Victorian Health Promotion Foundation. Available at:
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(Accessed 20th February 2022)
Hardman, A.E. and Stensel, D.J. (2009) Physical activity and health: the evidence explained. London:
Routledge
Health and Care Professions Council (2022) Professions and protected titles. Available at: https://www.hcpc-
uk.org/about-us/who-we-regulate/the-professions/ (Accessed 23rd February 2022)
HM Government (2010) Healthy lives, healthy people. Our strategy for public health in England. London: The
Stationery Office
Huang, J. , Wang, J. , Pang, T. , Chan, M. , Leung, S. , Chen, X. , Leung, C. , Zhang, Z.-J. and Wong, M.
(2020) ‘Does the theory of planned behaviour play a role in predicting uptake of colorectal cancer screening?
A cross-sectional study in Hong Kong’, BMJ Open, 10(8) doi:10.1136/bmjopen-2020-037619
Jackson, C. (2019) A history of psychology in the United Kingdom. Meeting of minds – the road to
professional practice. The British Psychological Society. Available at:
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chology%20in%20the%20United%20Kingdom%20-%20Claire%20Jackson.pdf (Accessed 6th April 2022)
Janz, N.K. and Becker, M.H. (1984) ‘The health belief model: a decade later’, Health Education Quarterly,
11(1), pp. 1–47
Jones, C.J. , Smith, H. and Llewellyn, C. (2014) ‘Evaluating the effectiveness of health belief model
interventions in improving adherence: a systematic review’, Health Psychology Review, 8(3), pp. 253–269
La Barbera, F. and Ajzen, I. (2020) ‘Control interactions in the theory of planned behaviour: rethinking the
role of subjective norm’, Europe's Journal of Psychology, 16(3), pp. 401–417
Leventhal, H. , Leventhal, E.A. and Breland, J.Y. (2011) ‘Cognitive science speaks to the “common-sense” of
chronic illness management’, Annals of Behavioural Medicine, 41(2), pp. 152–163
Leventhal, H. , Meyer, D. and Nerenz, D. (1980) ‘The common-sense representation of illness danger’,
Contributions to Medical Psychology, 2, pp. 17–30
Leventhal, H. , Phillips, A. and Burns, E. (2016) ‘The common-sense model of self-regulation (CSM): a
dynamic framework for understanding illness self-management’, Journal of Behavioural Medicine, 39(6), pp.
935–946
Local Government Association and The Behavioural Insights Team (2019) Using behavioural insights to
reduce sugar consumption in Liverpool. Available at:
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ary.pdf (Accessed 20th February 2022)
Madden, T. , Ellen, P.S. and Ajzen, I. (1992) ‘A comparison of the theory of planned behaviour and the
theory of reasoned action’, Personality and Social Psychology Bulletin, 18(1), pp. 3–9
Marmot, M. , Allen, J. , Boyce, T. , Goldblatt, P. and Morrison, J. (2020) Health equity in England: the
Marmot review 10 years on. Available at: http://www.instituteofhealthequity.org/resources-reports/marmot-
review-10-years-on/the-marmot-review-10-years-on-executive-summary.pdf (Accessed 21st February 2022)
Martinasek, M. , Tamulevicius, N. , Gibson-Young, L. , McDaniel, J. , Moss, S.J. , Pfeffer, I. and Lipski, B.
(2021) ‘Predictors of vaping behaviour change in young adults using the transtheoretical model: a multi-
country study’, Tobacco Use Insights, 14 doi:10.1177/1179173X20988672
McGuire, B. and Walsh, J.C. (2006) ‘Diabetes self–management: facilitating behaviour change’,
Diabeteswise, 3(1), pp. 2–6
McLeod, S. (2019) What is psychology? Available at:
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Murray, C.J. , Aravkin, A.Y. , Zheng, P. , et al. (2020) ‘Global burden of 87 risk factors in 204 countries and
territories, 1990-2019: a systematic analysis for the global burden of disease study 2019’, The Lancet,
396(10258), pp. 1223–1249
National Health Service (2019) The NHS long term plan. Available at:
https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan (Accessed 21st February 2022)
National Institute for Health and Care Excellence (2014) Behaviour change: individual approaches. Available
at: https://www.nice.org.uk/guidance/ph49 (Accessed 25th April 2022)
National Institute for Health and Care Excellence (2015) Type 2 diabetes in adults: management. Available
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Arts and health

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White, M. (2009) Arts development in community health: a social tonic. Oxford: Radcliffe
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Corbin, J. , Sanmartino, M. , Hennessy, E.A. and Urke, H.B. (eds) (2021) Arts and health promotion. Tools
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Davies, C. (2016) The impact and effectiveness of the 2015 St John of God health cCare creative arts pilot
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Tackling tobacco, alcohol and drugs

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