Re-visiting the relevance and importance of health psychology in South Africa

Health psychology as a discipline has existed for more than four decades and is primarily concerned with research, theory, and practice at the nexus of psychology and health. The discipline is well established across Europe, the United States, and Australia with health psychology societies, postgraduate programmes, conferences, and academic journals dedicated to the discipline in the majority of these countries. However, in South Africa, health psychology remains a broad umbrella term under which psychologists and other health care professionals conduct research. Health psychology is concerned with the biological, social, psychological, contextual, and structural drivers of health and illness, and relies on theory and empirically-driven research to identify and understand important links between health and behaviour. In South Africa, where a large proportion of the population faces multiple co-occurring disease epidemics, such as HIV/AIDS, TB, COVID-19, diabetes, and heart disease, there is a need for a uniting sub-discipline like health psychology to focus intervention efforts and to meet the sustainable development goals. The recent re-establishment of a special interest group in health psychology in the Psychological Society of South Africa (PsySSA) is an important first step. In this article, and as members of the newly re-established special interest group in health psychology, we call attention to the need to promote health psychology in South Africa. In this article, we describe the paradigmatic traditions and theoretical models that inform the discipline. We then argue why health psychology should be prioritised again and recommend future directions for health psychology in South Africa.

Health psychology is a well-established sub-discipline of psychology that explores the biological, social, psychological, contextual, and structural determinants of health (Yadav, 2020). Health psychology as a discipline is not to be confused with behavioural medicine/behavioural health. While both behavioural medicine and behavioural health are concerned with biological, social, and behavioural factors associated with health, health psychology is discipline-specific, whereas behavioural medicine is multidisciplinary. As such, behavioural medicine includes the contributions of public health specialists, epidemiologists, psychologists, and others while health psychology is focused on the unique contribution of psychologists and understanding behaviour from a psychological point of view and through psychological theory (Masters, 2013). In countries, such as the United States and United Kingdom, health psychology became a recognised sub-discipline of psychology through the establishment of the Society for Health Psychology (Division 38) in 1978 in the United States and the establishment of the British Psychological Society's Division of Health Psychology in 1997. The establishment of the Society for Health Psychology (Division 38) in the United States took place under the auspices of the American Psychological Association (APA) and is considered to be the public debut of health psychology. Other similar divisions were soon subsequently established (Schlebusch, 1996;Wallston, 1997). For example, psychologists in the United Kingdom began to advocate for health psychology in the 1970s, and by the mid-1980s began to meet at health psychology conferences, such as the first British Psychological Society (BPS) Health Psychology section conference in 1986 (Quinn et al., 2020). Roughly a decade later in 1997, the BPS formally established their Division of Health Psychology. Furthermore, in 1986, the European Health Psychology Society (EHPS) was established (Quinn et al., 2020) and has only recently (in 2019) established a special interest group in health psychology in low-and middleincome countries (LMICs) leading to the appointment of a South African representative (EHPS, n.d.). The EHPS is the largest society for health psychologists in the world. It hosts an annual conference and produces six publications, four of which are scientific peer-reviewed journals (EHPS, n.d.). Other health psychology societies include the Australian Society for Behavioural Health and Medicine (Australasian Society for Behavioural Health and Medicine [ASBHM], n.d.). Health psychology in the global north is further recognised in academic scholarship through the establishment of journals, such as Health Psychology, the British Journal of Health Psychology, the Journal of Health Psychology, the Journal of Psychology and Health, and the International Review of Health Psychology.
In South Africa, the route to establishing health psychology and establishing health psychology as a recognised division in its own right within the Psychological Society of South Africa (PsySSA) has been challenging (Yen, 2016;Yen & Vaccarino, 2018). In the 1970s and 1980s, similar to the rest of the world, infectious diseases in South Africa were giving way to epidemics of chronic and lifestyle-related diseases. Psychologists in those years increasingly began to focus on the psychological aspects of physical diseases, located within a particular socio-political and historical context 1 (Yen, 2016;Yen & Vaccarino, 2018). In 1989, a group of psychologists who worked at the interface of psychology and health sought permission to establish a division for health psychology in South Africa from the pre-democracy era Psychological Association of South Africa (Schlebusch, 1996).
The first special issue on health psychology in the South African Journal of Psychology (SAJP) was published in 2006. In this first issue, Kagee (2006) praises the efforts of the Division of Health and Sports Psychology of PsySSA for spearheading much of the efforts to place health psychology on the national agenda of the discipline. Kagee (2006) called attention to the need to offer more courses on health psychology at universities and to provide more mentoring of research in this area. However, despite these initial efforts and now more than 15 years since the first special issue, health psychology in South Africa still receives very little attention. The initial professional society division no longer exists and there are also no journals in South Africa that specifically publish under the theme of health psychology.
In this article, we re-visit the relevance and importance of health psychology in South Africa. We begin this article with a description of the paradigmatic traditions and theoretical models that underlie and inform health psychology. Understanding the various paradigmatic traditions and theoretical models that have shaped and influenced health psychology over the years, allows us to contextualise health psychology in South Africa. We then go on to describe why health psychology in South Africa should be prioritised now. Finally, we provide potential directions for health psychology in South Africa over the next decade.

Paradigmatic traditions in health psychology
Similar to other branches of psychology, such as social and community psychology, two paradigmatic traditions have influenced the development of health psychology over the last few decades, namely the empirical and critical traditions. The empirical tradition in health psychology emphasises empirical evidence to inform behavioural interventions to enhance health (von Lengerke, 2001). Empirical psychology considers health behaviours and their psychological correlates as measurable phenomena. In this tradition, randomised controlled trials, systematic reviews, and meta-analyses are highly valued for producing evidence that can guide health interventions aimed at enhancing health (Marks & Yardley, 2004). The empirical tradition also emphasises the reproducibility or generalisability of research on psychological and behavioural factors in physical health and illness. Empirical psychology, however, is often criticised for its emphasis on advancing the science of health psychology through the testing of theory-driven hypotheses and its failure to consider the ontological and epistemological assumptions that inform the way health and illness are conceptualised, measured, and studied (Marks & Yardley, 2004).
The critical approach to health psychology, however, has typically been concerned with how people construct reality based on the dynamics of power and resistance. Similar to critical social psychology, critical health psychology is influenced by Marxist theory and its emphasis on social inequality, feminism, and commitment to gender equality; the psychoanalytic tradition and its concern with the unconscious processes of the mind; and social constructionism and its attention to the role of language in shaping reality (Gough et al., 2013). In addition, critical health psychology maintains a sceptical stance towards the empirical tradition with its emphasis on measurement and observation. For critical health psychologists, the lived experience is of central concern, and thus it relies on phenomenological approaches to gain access to the subjective, discursive, and hermeneutical realities that people construct for themselves (Edwards, 2004;Smith, 2017). To this extent, critical health psychology is concerned with the ways in which health and illness are embedded in broader social relations and structures. Rather than considering health behaviour as a matter of individual volition, there is an emphasis on how health and access to health care are influenced by economic arrangements, gender relations, cultural influences, and the experiences of marginality that minorities, and indigenous and colonised people have experienced (Gough et al., 2013).
In South Africa, health psychology has generally spanned the paradigmatic continuum from scientific and empirical methods to discursive and hermeneutical approaches, which in general reflects the epistemological diversity that characterises the field of psychology in general. The robust nature of epistemological debates among South African psychologists, including those who practice in the field of health psychology (Swartz, 2006), offers little potential for a singular paradigmatic approach to develop. On the one hand, this paradigmatic diversity in South African health psychology may reflect the dynamism of the field. On the other hand, the likelihood that any mutual influence exists in empirical health psychology and critical health psychology is unclear, considering that these paradigmatic traditions are seldom in conversation with each other. Kagee (2014) has called attention to the erroneous view that critical psychology has come to be seen as being synonymous with progressiveness, radicalism, and social change, while empirical psychology is considered by some to be conservative, traditional, and invested in the status quo (Kagee, 2014). We similarly reject the view that ideological fault lines should necessarily coincide with paradigmatic ones. For example, empirical science, rooted in Enlightenment thinking, has been criticised as abetting racism, eugenics, and social hierarchy (Langkjaer-Bain, 2019; Schumacher, 2019). Critical psychology, however, with its roots in Marxism, feminism, hermeneutics, and the analysis of social power, locates itself to the left of the political spectrum (Parker, 2021). Furthermore, health psychology is deeply embedded in a political context both in South Africa (Yen, 2016) and elsewhere, a fact that is clearly illustrated in the disproportionate disease burden in communities living under conditions of poverty and precarity. Considering this, a pragmatic approach to health psychology that engages multiple theoretical models may provide a comprehensive way of understanding health that is cognisant of the relevant social and political context.

Theoretical models in health psychology
At the same time as its inception in the 1970s and 1980s, psychologists and other health care professionals working within health psychology also called for theoretical models that considered not only the biological determinants of health but were also able to consider the social, psychological, structural, and contextual determinants of health. Traditionally models, such as the biomedical and psychosomatic models, were used to understand health and illness. However, these models have been widely criticised for failing to consider the many other factors that play a role in health and illness (Salicru, 2020;Williams, 2017). In 1977, health and other professionals began to use the biopsychosocial model (Engel, 1977) in their work which considers the many biological, psychological, social, and cultural variables play a role in health and illness. The biopsychosocial model was among the first theoretical models used by individuals working at the nexus of health and psychology. Since then, several other theories have been used in health psychology, all with a focus on identifying factors that inhibit or support behaviour change and are often referred to as behaviour change theories (Gillison et al., 2019;Presseau et al., 2022).
Popular behaviour change theories used by health psychologists globally and in South Africa are the Health Belief Model (Sheeran & Abraham, 1996) and the Theory of Planned Behaviour (Ajzen, 1991). Despite their prominence in the field and the extent to which they have influenced the course of health psychology over the past several decades, these theories have been criticised for proposing that health behaviours are volitional and that such volition rests within the individual at the level of cognition and affect. For example, the Theory of Planned Behaviour (Ajzen, 1991) states that individual behaviour is influenced by attitudes towards the behaviour, subjective norms concerning the behaviour, and perceived behavioural control concerning the desired health behaviour. These together influence a person's behavioural intentions, which in turn are closely associated with executing the behaviour. Similarly, the Health Belief Model (Sheeran & Abraham, 1996) states that people's beliefs about health problems, their perceptions of the benefits of action and barriers to action, and their selfefficacy with regard to the desired health behaviour will account for their engagement or lack thereof in the health behaviour. The Transtheoretical Model of Health Behaviour Change (Prochaska et al., 1993), a stage theory, suggests that behaviour change occurs first by pre-contemplation (where a person is not planning to change within the next 6 months), then contemplation (where a person may be thinking about behaviour change), preparation (where the person takes steps towards changing), action (where the person attempts and presumably succeeds in making the change), and maintenance (where the person is able to sustain the new behaviour for more than 6 months and works to prevent relapse).
All of the above theories, and others, are referred to as social-cognitive models of behaviour change. While these have been extensively researched and enjoy considerable empirical support, we argue that they are limited in a fundamental way, namely, that they do not take into account the ways in which the social context and structural factors shape, influence, and impose constraints on individual volition. Structural factors are economic, institutional, political, and cultural factors that collectively influence how individuals negotiate the challenges prohibiting their ability to engage in health behaviours (Shriver et al., 2000). These factors are especially salient in LMICs, including many African countries, where economic, social, and political realities are often more constraining on individual behaviour than in wealthy industrially developed nations. For example, exhorting people to engage in physical exercise or to follow a nutritious diet may have little effect in the absence of opportunities to engage in such behaviours. The absence of gyms, the presence of crime and violence in communities, and the fact that people work long hours and spend much time travelling between home and work, all limit opportunities to engage in regular exercise. Similarly, limited money to buy healthy food, limited access to clean running water, and an uneven and expensive electricity supply may reduce opportunities to cook and eat nutritious food. Thus, social-cognitive theories may have limited relevance in the context of the overwhelming structural factors that shape individual behaviour. To this extent, concepts, such as a health enabling environment (Rau et al., 2018) and social capital (Dubos, 2017), should ideally form part of the conceptual and theoretical apparatus that can assist in theorising health behaviours in LMICs. A clear example is the activism and advocacy work of the Treatment Action Campaign in making antiretroviral therapy available to those unable to afford them, first by challenging drug companies to abandon patents for these drugs and then by opposing AIDS denialism in the South African government (Nattrass, 2007). The present environmental crisis is a similar example. Among the various ways to address the health hazards associated with climate change is community activism (O'Brien et al., 2018), including pressuring government to implement green policies with respect to energy generation and consumption, reconfiguring food production to ensure food security (Gregory et al., 2005), and engaging in spatial planning that limits overcrowding and enhances green living spaces (Hurlimann & March, 2012).

Why do we need to prioritise health psychology now?
With less than a decade to go to achieve the Sustainable Development Goals (SDGs) (United Nations, 2015), one of which is the 'health and well-being' of all, there is an urgency to meet this goal and health psychology has an important role to play in the realisation of the SDGs. Re-visiting the relevance and importance of health psychology in South Africa is therefore timely for several reasons and we discuss each of these in turn. First, like many other countries across the world, South Africa is battling a surge in the onset of non-communicable diseases (NCD). In South Africa, NCDs are estimated to account for 51% of all deaths (World Health Organization, 2018) and are a leading cause of premature mortality (Nojilana et al., 2016). The increased prevalence of NCDs across the country has placed enormous pressure on both public and private health care facilities (Mayosi et al., 2009), resulting in reports of poor management of chronic diseases in the public health care system (Brand et al., 2013). The South African government has introduced several policies aimed at reducing NCDs through prevention, monitoring, and management (more than 40 policies between 1994 and 2015), for example, the 1993-Tobacco Products Control Act 21, the 2013 Salt Reduction Regulations, and the 2015 Strategy for Tackling Obesity. Despite these policies and several others, cancer, hypertension, and obesity remain among the largest contributors to morbidity and mortality rates in the country.
Second, the recent Covid-19 pandemic has highlighted the importance of using behaviour change approaches, a key focus of the work of health psychologists, in reducing transmission of communicable diseases. With an emphasis on prevention, behaviour change strategies form an essential part of containing the pandemic (Pillay & Barnes, 2020). Health psychologists, through research and by means of drawing on evidence-based theoretical approaches to behaviour change, such as the Behaviour Change Wheel (Michie et al., 2014a), the Capability Opportunity Motivation and Behaviour Model (COM-B model) (Michie et al., 2011), and the Theoretical Domains Framework (Michie et al., 2014b), may offer valuable insights into factors supporting and hindering behaviour change strategies. Understanding the barriers and facilitators to these transmission-related behaviours (e.g., washing hands and wearing a mask) is a key component in the management of the virus. Beyond behavioural recommendations that health psychologists can make, their role extends to other psychological and social aspects. These aspects, which can be investigated through formal scientific research, include investigating and exploring resistance to preventive behaviours, such as wearing a mask, practising social distancing, adhering to isolation recommendations, and resisting vaccination (Freedland et al., 2020). As such, health psychologists have an important contribution to make in terms of research regarding these aspects, which can be explored through either qualitative, quantitative, or mixed methods research designs. For example, quantitative studies whether cross-sectional, observational, or longitudinal might provide evidence on the prevalence of preventive behaviours, such as mask-wearing, social distancing, and sanitising in South Africa. Furthermore, qualitative studies might be used to explore barriers and facilitators to disease containment measures or factors influencing vaccine hesitancy across various groups of participants, such as among health care workers, individuals with co-morbidities, children, and their parents.
Finally, health psychology is likely to have an important role to play in the planned National Health Insurance (NHI). The NHI is aimed at redressing the inequity currently afflicting health care in South Africa, where the legacy of apartheid has resulted in two very different health care systems in South Africa. Health psychology/psychologists can play an important role in supporting the NHI system by advocating for theoretically informed behaviour change approaches for the prevention of illness and disease. Health psychologists can work alongside the Department of Health to understand factors related to the health system that impedes behaviour change. For example, with the roll-out of Covid-19 vaccines and the low uptake of vaccination among individuals in South Africa (Cooper et al., 2021), health psychologists can play a crucial role in developing interventions at primary, secondary, and tertiary levels of prevention to address vaccine hesitancy (Fridman et al., 2021). At the primary level, interventions may be aimed at identifying, addressing, and reducing vaccine hesitancy. Furthermore, these interventions may be informed by exploring factors associated with vaccine hesitancy among individuals, their family members, and the broader community. Furthermore, at the secondary level, developing interventions that specifically address vaccination concerns among at-risk and high-risk groups (such as those with co-morbidities, and the elderly) will be important. The interventions may be educational in nature and may promote awareness around how vaccines are formulated and how they work. And finally, at the tertiary level, prevention efforts might be focused on those who may already have the disease and require intervention to obtain a vaccination and prevent re-infection. Understanding and addressing vaccine hesitancy at these levels is likely to increase vaccine uptake. It is expected that an increase in vaccine uptake will result in fewer infections, reduce the burden on the health care system, and decrease mortality (Department of Health, 2021).
In countries, such as the United Kingdom, health psychologists are employed within the National Health Service (NHS) and receive formal training to assist patients with the psychological and emotional sequelae of their illness. A similar approach to integrating health psychology within our South African NHI may, therefore, also be beneficial to the public. Indeed, South Africa is faced with several health-related challenges that are somewhat unique to our context, such as the increasing problem of syndemics where individuals are living with two or more diseases, such as TB, HIV, cancer, and depression (Mendenhall, 2014;Singer & Clair, 2003). South African health psychologists could offer support to these patients through identifying factors that affect treatment adherence and providing psychosocial interventions aimed at improving quality of life, treatment adherence, and behaviour change that may support good health. Several systematic reviews have demonstrated that psychosocial interventions can result in positive patient outcomes, such as improved well-being in patients with diabetes (Pascoe et al., 2017), reduced cardiac mortality and psychological distress in patients with coronary heart disease (Richards et al., 2018), improved quality of life in advanced cancer patients (Teo et al., 2019), and improved ART treatment adherence in women with HIV (Pellowski et al., 2019).

Directions for health psychology in South Africa for the next decade
We propose a number of future directions for health psychology in South Africa. First, we propose establishing the health psychology special interest group (HPSIG) within PsySSA. The establishment of an HPSIG will create a hub where clinicians, academics, researchers, and students interested in health psychology can collaborate, share their work, ideas and experiences, and ultimately contribute to building a healthy nation. Since 2020, PsySSA has approved an HPSIG, under the leadership of Dr. Rizwana Roomaney of Stellenbosch University, which now has more than 30 members. The HPSIG consists of three working groups which focus on research, news, and events, and each of these working groups have their goals, leaders, and committee members. The research group aims to contribute to research outputs in the field of health psychology, providing cognisance of the daily use of health psychology practices and theorems in the South African context. The news group focuses on creating awareness on important health topics, while also serving as a platform to promote and communicate different events and milestones achieved by South Africans in the field of health psychology. Finally, the events working group hosts a number of virtual and in-person events (e.g., podcasts, speakers, etc.) to engage the general public in conversation on important topics of wellness and health-related behaviours. As previously mentioned, researchers drawing on different theoretical perspectives in South Africa are seldomly in conversation with each other. The HPSIG can create opportunities for these researchers to engage with one another, such as symposia and collaborative projects, thereby making key contributions to the field of health psychology and benefitting the public at large.
As a whole, the HPSIG strives to promote the presence and influence of health psychology in the health care provided to South Africa. We aim to achieve this goal by creating a platform where psychologists who are concerned with aspects of health can engage and collaborate with one another. By organising opportunities, such as symposia and collaborative projects, the HPSIG will create opportunities for researchers to engage with one another, which does not happen otherwise, thereby making key contributions to the field of health psychology and benefitting the public at large. In addition, the HPSIG continues to play a mentoring role for aspiring health psychology researchers. The HPSIG working groups provide informal mentorship opportunities for students, with groups being led by emerging researchers and supported and mentored by more established ones.
Second, we would like to encourage tertiary institutions and departments associated with psychology and health sciences to promote health psychology in undergraduate and postgraduate programmes. Schlebusch (1996) called for an increase in the training of health psychologists as he foresaw the need for the adaption of content and the development of internships in health psychology to ensure that the necessary training could occur. This call was echoed by Kagee (2006), who called attention to the need for more courses related to psychology and health (on an undergraduate and postgraduate level). Furthermore, he postulates that health psychology conferences, specific research programmes focused on health psychology issues, and mentoring to researchers and teachers in the health psychology field are required (Kagee, 2006). Offering a masters in health psychology at the postgraduate level may be an attractive option to many students who work within this field. While the journey may be long and arduous, our hope is that health psychology will be confirmed as a professional registration category with the Health Professions Council of South Africa (HPCSA).
Third, we propose building partnerships and promoting collaboration across various disciplines to address barriers across the broader health care context. Although significant progress has been made in developing psychology as a South African profession, this does not always translate into relevant employment opportunities (Pillay, 2016). One reason may be that those outside the field of psychology do not always understand the role psychologists can play in multidisciplinary teams. As in the case of clinical psychologists (Miller & Swartz, 1990;Siyothula, 2019), the inclusion of health psychologists in health care teams may be met with reservation. The HPSIG would, therefore, also focus on developing acceptance of health psychology in the broader health care context by building partnerships and promoting collaboration with other health care professionals. In addition, the HPSIG seeks to develop a database of psychologists who are working in or have an interest in health psychology that can be used to develop local or international partnerships. These partnerships may eventually ensure better integration of health psychologists as part of multidisciplinary health teams and their acceptance within the health services landscape of South Africa.
In light of the need for health psychology that is argued for in this article, these calls are more relevant than ever. The role that health psychologists can play in the South African health care landscape is being hampered by barriers to the sub-discipline being recognised for the role that it plays. These barriers hinder the progression towards professional registration as a health psychologist with the HPCSA. Taking this into account, the establishment of the HPSIG bolsters the aim of the sub-discipline to effectively contribute to the growth of health psychology, first at the university level and second as a recognised professional registration.

Conclusion
The aim of our article was to call attention to the need to promote health psychology as a discipline in South Africa. The establishment of a special interest group within PsySSA is one potential way of promoting the importance of health psychology. In South Africa, particularly with reference to the escalating burden of infectious diseases, chronic diseases, and more recently Covid-19, health psychology has a valuable role to play at an individual, community, and population level. While the focus of this article has predominantly been on promoting health psychology within the South African context, we hope that this will extend to promoting the development of the discipline on the African continent.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.