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Application of theory in a lifespan approach to mental health promotion

It is not possible to make categorical statements about mental health promotion theory and any distinctiveness it may have from general health promotion. All disciplines continue to develop their theoretical foundations and this is particularly the case with relatively new ones such as mental health promotion. We can tentatively suggest that psychological theory maintains a higher profile in mental health than in general health promotion.

In a discipline with philosophical differences around what should take place in its name there will be differing preferences in the selection of theory. For example, those who conceive of mental health promotion as combining policy and educational work informed by an empowerment model will tend to draw on a different combination of theories than those with a narrower focus on health education informed by a preventive medical model. If working in accordance with a lifespan approach theory relevant to the whole of the lifespan as well as to its differing phases will need to be used. In general the particular theory or combination of theories used in mental health promotion practice will depend on the specific issue to be addressed. The importance of adopting a critical approach to selection and use of theory was noted earlier. Space precludes any detailed consideration of the critique of the theories used in mental health promotion.

In a lifespan book reflections on the notion of lifespan development and developmental theories are particularly relevant. One theory, for example, which has been subject to criticism is Piaget’s theory of cognitive development. The general progression of thinking which Piaget described leading from ego-centric through to formal operational is generally supported but the rather rigid presentation of the progression through stages has been questioned through later work (Donaldson 1978). Children, it transpires, can think at more sophisticated levels in relation to some areas of their lives than others and in relation to situations which make sense to them and where they are particularly motivated to understand.

Given the emphasis that is placed in health promotion on fostering children’s active participation in the decisions that affect them it is important to draw on cognitive developmental theory but not to use it so rigidly that children’s competencies are strictly age related. The usefulness of social cognition models of health related decision-making and behaviour change has been regularly reviewed. Some of these models have been modif ied over time in response to empirical findings and developments in thinking. For example the Health Belief Model (HBM) and the Theory of Planned Behaviour have incorporated the concept of self-efficacy in response to research evidence (Conner and Norman 1995; Bennet and Murphy 1997). Some models are relatively easy to understand and this facilitates their rapid adoption. The Health Belief Model (HBM) and Transtheoretical Stages of Change (Prochaska et al. 1997) are particularly good examples but the ease of adoption may not always lead to appropriate use. In the case of the HBM it has become clear that the model, while providing a useful theoretical framework which has underpinned many studies, has its shortcomings. It is economic in including a relatively small number of factors, but the downside is that it is most useful in relation to less complex behaviours which are actually governed by the particular beliefs contained within the model (Sheeran and Abraham 1995). The evidence in support of the Transtheoretical Stages of Change Model does not appear in the light of some research to be particularly strong and a number of critiques have been offered (Whitelaw et al. 2000; Adams and White 2005). Some of the critiques of theoretical models can be misplaced. Many models seek for economy by incorporating only sufficient factors to meet their purposes such as to explain and predict. That they could include further factors to explain more fully or predict more accurately will often be acknowledged but a balance is needed between elaboration of a model and its capacity to fulfil a stated purposes. Green et al. (1994) provided a useful contribution on this matter. They commented on the position that theories or models are unusable or unsatisfactory because they are less than comprehensive in accounting for all the variable operating in a situation, or do not relate explicitly to the precise problem and circumstances in which practitioners find themselves. This, they said, misses the point of theory. The first demands models or theories of such complexity that they would seldom be read, much less used. The second demands a cook book. Theory must strive for a level of abstraction that generalizes beyond the specific case and a level of simplification that achieves efficiency of explanation without distortion. Taking up the question of what theory actually is used widely in health promotion, in contrast with what could be used, there does not appear to be a comprehensive survey of this for mental health promotion. Some systematic reviews of mental health promotion interventions have documented the theory base of included studies and these have tended to be theories derived from psychology, as noted earlier.

What such reviewers also note is a lack of reported theory, a comment regularly made in reviews of other health promotion areas. In some cases the theoretical underpinnings can be deduced through a careful reading of papers but in others it is not apparent that considerations of theory had a part in decision-making. For example Wight et al. (1998) observed with reference to sexual health programmes that few were theoretically based and those that were relied almost exclusively on social cognitive theory. Trifiletti et al. (2004) reviewed the theories used in research geared to injury prevention. They specif ied a list of behavioural and social science theories, not intending to map fully health promotion theory, but found few applications of main theories to their topic of interest. Theory was most often used, they concluded, to guide programme design and implementation and the development of evaluation measures. The most citations were found for the Health Belief Model, Theory of Reasoned Action/Theory of Planned Behaviour, Social Learning Theory and the PRECEED–PROCEED model. Other theories reported in only one or two articles included precaution adoption process model; protection motivation theory; community organization; communication of innovations; and social marketing.

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