Associate Professor Christine Stephens

As long as you’ve got your health

Associate Professor Christine Stephens tells Malcolm Wood about what public health campaigns can and can’t do.


Health Promotion: A Psychosocial Approach
by Christine Stephens, ISBN13: 9780335222087,
ISBN10: 0335222080, Open University Press


When we get older

Christine Stephens is one of a number of Massey
researchers who are part of a massive and
ongoing study of the health of older people in the
transition from work to retirement.

The study’s first iteration, led by Massey’s
Professor Fiona Alpass and funded by the Health
Research Council, surveyed 6000 people aged
from 55 to 70 years old, 3000 of whom will take
part in a subsequent survey.

The study’s second iteration, this time funded by
the Foundation for Research, Science and
Technology, will fund two more rounds of data
collection and finish in 2012.

“We have more research partners, we have
extended the age range from 50 to 80, and we
are going to add a couple of thousand more
people in and carry on,” explains Stephens,
who also has some of her postdoctoral students
doing qualitative studies “around the edges”.

“I have a Chinese student in Auckland who is doing
a study with older first-generation immigrant
Chinese people, because typically they don’t get
picked up by our surveys. We are also doing
qualitative work with Pacific Island people.”

She hopes the work will help change the perception
of older workers. “My view is that people should go
on working if they are happy to. Not all of us are
happy at 65 to say, well that’s it I am off home to
the armchair.”

You began your working life working with the victims of trauma using individual approaches. What happened?

When I started teaching health promotion I used more traditional psychological models, ones very focused on individual behaviours. But after a while, based on my personal experience, that of my colleagues, and the literature, I came to see that one-to-one therapy could only do so much and I started looking at the broader social life of people and their health and their choices.

Why the switch in emphasis?

I think it came from accepting how strongly we are influenced by our families, our friends and our workmates. Our eating habits are likely to be those we were brought up with. If members of our immediate family smoke, then we are that much more likely to smoke ourselves. If our social group measures our worth by how much beer we can drink in one night, then our chances of drinking in moderation are much slimmer, no matter how strong our resolution is. The social setting is key.

So a television campaign that, say, simply exhorts us to get our 30 minutes of exercise may not do that much good?

It won’t work particularly well for you if the people you associate with are physically inactive. You need social support. And it won’t work well if the physical environment isn’t right.

Take someone who lives in an outer suburb. They may have to rise early to drive or catch public transport to get to work, and by the time they get home it is late in the evening. Will a television campaign change matters? Maybe, as they lie on their couch watching television after getting home from work and looking after the kids, they will think, ‘well, that looks like a good idea, throwing balls about joyfully’. But in practical terms, when are they going to get to do that?

Another problem with the sorts of health promotion that tell us to do what is good for us is that a lot of time people aren’t thinking about their health benefits in the future. The people who promulgate these messages are assuming that if they establish a link between how people behave now and their health at some time in the future, people will change their behaviours. But usually our actions do not take place with this sort of future outcome in mind. When we go to get a hamburger, what we think is “yum”, or “my friend’s having a hamburger”, or “my kids want to go to McDonald’s”. We aren’t thinking, “ahem, I might get heart disease 20 years in the future”.
It is often easier to have a campaign than to change people’s environments. It can be an easy way out.

In fact, sometimes, you say, the finger-wagging approach can be counterproductive.

It can be harmful to stigmatise people because of conditions that have to do with their social circumstances. If you make people feel bad about their diet or exercise habits and it is difficult for them to make changes, then all you are doing is putting pressure on them and making them feel unworthy. People who are overweight often find themselves the subject of moral judgments: they are overweight, therefore they are eating badly, therefore they have no self will.

There’s no harm in giving people information – telling them this is how to eat healthily or warning that cigarette smoking will damage their health or ultimately kill them – but if you are making people feel psychologically unwell, then they aren’t going to get physically well.

You also cite studies that show people will rebel against messages that are overly strident.

There has been research done showing that gay men have stopped using condoms as a form of resistance. In fact, condom use in general is a good example of how the health information delivered in a quite clinical way in the classroom fails to connect with the way people actually use condoms, which is social.

You use smoking as an example of how changes to the environment – taxation, limits on advertising, bans on smoking in public places – can change the incidence of the behaviour.

Smoking has been a great success story and I think it is generally understood that most of the effect of the antismoking work has come from changes to the environment. But then making rules around smoking is easy, because smoking is only bad for you – the case for rules is quite simple and clear-cut. You can’t really carry that approach into other areas. People may talk about fat taxes, but we need to eat, whereas we don’t need to smoke.

The antismoking message is one of those things that the middle classes took up with enthusiasm, but we still have what are called ‘recalcitrant’ smokers. And who are they? They are more likely to be poor people, people operating under stress.

After reading your book, it seems to me that by far the best way of achieving a long and healthy life is to have the right socio-economic status.

Yes, the research demonstrates this over and over again. There’s a study of the British civil service that shows that executives and administrators live longer than clerks and cleaners. There’s a Swedish study showing that people who hold doctorates live longer than people with masterates and they live longer than people who have bachelor’s degrees. There is even a study that shows that Oscar winners live longer on average than the runner-ups. These are all eccentrically memorable examples that show that it works at higher status as well as between rich and poor.

But this is also something I see in my day-to-day working life. In the study of the New Zealand’s ageing population I am involved in, we can show the same graded correlations between health and such things as income, level of educational qualification and ethnicity.

Can you tell me more about the apparent effect of ethnicity?

We can’t put ethnicity on the same gradient as those other factors. There is no scale of ethnicity that matches neatly with health status, but we can show that there is an effect. Even if people are poor, somehow ethnicity has an additional effect. We know this.

In our survey of New Zealanders aged 55 to 70 [see sidebar] we can show those ethnicity-related inequalities in health cut across income, across living standards.

Our health statistics for Maa-ori and Pacific Island people are a national embarrassment. The indigenous groups in our country have a clear gap in mortality and illness and they do need their own approaches. So, in New Zealand there are concerted public health efforts to address Maa-ori health. Think of the breast feeding, smoking, and cervical smear programmes.

For Maa-ori – and people like [Professor] Mason Durie have expressed this very well and clearly – health is not just about the individual, it’s about their family and their spirituality, about their land, and their identity as Maa-ori people. Mind you, I think this is true of all human beings to one extent or other.

How do you measure how successful a health promotion has been?

The health promotion perspective is about prevention; it’s a positive approach as opposed to the medical approach, which is about fixing people up once they become ill. We are always thinking about keeping people well. But the outcomes are still measured in illness or death.

We just want to drop those numbers down. Or at least even them out so that no one group is disadvantaged – that would help.

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