Normativity And Health Promotion Across Biopsychosocial Ecosystems

Federica Mauro^1,2*Paul Greenman^3,4Michela Di Trani^1,2

• ¹Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
• ²Sapienza University of Rome, Rome, Lazio, Italy
• ³University of Quebec in Outaouais, Gatineau, Quebec, Canada
• ⁴Département de Psychoéducation et de Psychologie, Université du Québec Outaouais, Gatineau, Quebec, Canada

Over the years, there have been many definitions of "health psychology," each of which represents an attempt to delineate the boundaries of this complex and multifaceted field (see Tab. 1).[Table 1 goes about here] Despite some differences, all definitions emphasize the intricate relationship between psychological processes and physical health. Interventions in the realm of health psychology generally involve holistic and multifaceted strategies to address a wide range of health challenges. Integrating mind and body involves understanding how psychological and social factors influence physical health and illness, thereby enabling practitioners to develop more effective interventions.Collective health, on the other hand, can be viewed as both a scientific field that produces various forms of knowledge about the concept of health, and a "social space" (Vieira-da-Silva et al., 2014; Silva et al., 2019) where practices involving actions are carried out across different organizations and institutions. This field has evolved to adopt an interdisciplinary approach that transcends the biomedical and pathology paradigms. Collective health embraces a broader perspective, considering material conditions and social factors that shape health outcomes. Its basic disciplines are epidemiology, health planning/management, and social sciences in health. Collective health provides a framework for understanding how social determinants, such as income inequality, education, and access to healthcare, affect health at a population level (Marmot & Wilkinson, 2006).Within the framework of collective health, health psychology represents a comprehensive approach that bridges individual psychological processes with biological and broader social determinants of health. Whereas collective health highlights the structural and systemic factors that shape populationlevel outcomes, health psychology focuses on understanding the psychological and behavioral mechanisms that influence health. This integration stresses the necessity of addressing health challenges at multiple levels: individual, community, and social. To meet this need, in the course of time, distinct areas have arisen in the field of health psychology, including clinical health psychology, public health psychology, community health psychology, cultural health psychology, and critical health psychology (Marks, 2002;Atala, 2012). This variety of approaches highlights the importance of adapting theories and application models to specific contexts and needs, while maintaining a unifying paradigm for health that provides coherence and allows different theories and models to derive meaning and interconnect. (Marks et al., 2024).In 1946, the World Health Organization (WHO) defined health as "a state of complete physical, social, and spiritual well-being, not merely the absence of illness." This definition emphasizes the multidimensional nature of health and acknowledges the need to integrate psychological and social dimensions alongside physical well-being.Aligned with this broader perspective, Engel (1977) introduced the Biopsychosocial Model (BPSM) to address the shortcomings of the traditional biomedical model. Engel proposed that all natural phenomena exist within a hierarchy of interconnected systems, ranging from the biosphere at one end to societal and individual behavior in the middle and down to the cellular and subatomic levels. He argued that understanding health and illness requires considering these interrelated levels, focusing on the interaction among biological, psychological, and social factors.While not without critics (e.g., Atala, 2012; Marks et al., 2024), BPSM is largely considered a cornerstone of health psychology. As a holistic framework for understanding the complexities of health and disease, it marks a deliberate effort within the field to challenge the dominance of the biomedical model while highlighting psychology's critical role in addressing health and illness comprehensively, integrating various dimensions of human experience (Murray, 2014).A more general multi-level framework has since been proposed, which synthesizes both the biological determinants and the social context of health-related experience and behavior (Marks, 1996;Marks et al., 2024). This offers a broader perspective than the narrow focus of traditional psychological models of health, recognizing the variable nature of health and the need for a multidisciplinary approach. The "onion model," adapted from Dahlgren & Whitehead (1991) Defining health and well-being remains a complex challenge (Christoforou et al., 2024). Beyond the WHO's definition, two primary concepts of health have been identified: a biomedical perspective, which views health as the absence of abnormalities, and a functional perspective, which describes health as "the strength to be" and the ability to overcome challenges (Misselbrook, 2014). Broader interpretations of health also emphasize fulfilling social roles, maintaining independence, fostering optimism, and, in some cases, integrating spirituality. Moreover, both internal factors, such as personal adaptation, and external elements, including socio-economic and environmental policies, have been considered essential components of health (Christoforou et al., 2024).Similarly, defining well-being poses challenges. Well-being is a multifaceted construct with definitions that vary by domain, often described as a more emotional and social concept than a healthrelated one, encompassing positive feelings, effective functioning, and contributions to society (Bautista et al., 2023).A related concept is quality of life (QoL), which refers to an individual's perception of their life The interconnection between health and well-being is frequently discussed, with some definitions, such as the WHO's, including well-being as an integral part of health, and strong evidence has linked higher SWB to better health outcomes and longer life, highlighting its critical role in well-being (Marks et al., 2024).However, definitions of health and well-being differ across disciplines, cultures, and individuals and are shaped by personal characteristics and needs. This subjectivity complicates efforts to establish a general definition, which, however, is needed (Davies, 2009). While some studies focus on defining these concepts for specific age groups, an interdisciplinary approach addressing risk and resilience factors may provide a more inclusive foundation for defining health and well-being across diverse populations (Marks, 2024).Going toward this direction, homeostasis theories of well-being (Marks, 2024) were proposed to understand the links between subjective well-being and health, offering theoretical frameworks that conceptualize well-being as a dynamic state of equilibrium within an individual. Drawing from the biological principle of homeostasis, referred to as the body's ability to maintain internal stability despite external changes, these models suggest that individuals strive to maintain a stable level of well-being through adaptive processes, offering descriptions of the dynamic interplay between subjective well-being, health, and contextual factors.As shown in Table 1, the concept of illness rooted in the traditional biomedical model still plays a central role in defining health psychology. Within this view, health is equated with statistical "normality," and illness is seen as a deviation from the norm (Braibanti et al., 2015).However, Canguilhem (1966) proposed a broader understanding of "norm," emphasizing the relationship between the organism and its environment. Health, in this perspective, is not the absence of disease but the ability to create and adapt to new norms. The pathological is not the opposite of the normal, but a different mode of normativity-revealing how illness alters the quality of life by limiting interaction with the environment and imposing new rhythms. Medicine, then, is rooted in the lived experience of disruption caused by illness.Health becomes less about fixed states and more about normative flexibility-life's capacity to adapt creatively. Even illness, while it restricts this creativity, is part of a broader process of adaptation. In extreme cases, such as prolonged hospitalization, this process can stagnate, leading to a monotony that mirrors the loss of vitality.This view of normativity underscores the dynamic regulation of human functioning within biopsychosocial ecosystems, framing health not as a static outcome but as a salutogenic process.Adaptability and experiential richness are essential for individuals to navigate life meaningfullylike a wanderer shaping their path through the challenges of existence (Bertini, 2012).In The conceptualization of health as a salutogenic process, rather than merely the absence of disease, highlights the critical role of health psychology and, more specifically, health promotion within the framework of collective health. Defining health as an ongoing process rather than a fixed outcome offers a unified understanding of health and well-being. This may, moreover, facilitate the integration of health psychology practices across diverse contexts, addressing the specific needs and challenges present within various biopsychosocial ecosystems.This proposed framework is moreover grounded in the principles of Patient-Centered Care (PCC), a foundational model in contemporary healthcare that recognizes the patient as a whole person, taking into account not only biomedical aspects but also psychological, social, and existential dimensions.At its core, PCC is based on building a therapeutic alliance that honors the patient's values, needs, preferences, and autonomy (Mead & Bower, 2000), emphasizing that "the patient's experience of illness should be the starting point of clinical practice" (Stewart et al., 2014).PCC has been associated with improved clinical outcomes, higher patient satisfaction, increased treatment adherence, and reduced healthcare costs (Epstein & Street, 2011). Furthermore, it aligns with the ethical principles of autonomy, beneficence, and respect.According to the World Health Organization (2007), health promotion empowers individuals to gain greater control over and improve their health. Unlike disease prevention, which targets specific conditions, or health education, which aims to inform, health promotion addresses both individual and contextual factors shaping behavior. It seeks not only to prevent illness but also to enhance overall well-being by equipping individuals with the resources and skills necessary to actively manage and shape their health (WHO, 2007;Nutbeam, 2000;Kickbusch, 1995).This holistic approach, integrating physical, mental, and social dimensions of health, fosters resilience and quality of life, highlighting the transformative potential of health promotion in advancing global public health goals (Marks et al., 2018). As such, it becomes essential to embed health promotion practices within all settings-beginning with healthcare systems and expanding to schools, workplaces, and communities.As Marks (2024) notes, diverse tools and strategies are required within health psychology to address the specific needs of various contexts. Despite their differences, these approaches can be unified under the view of health and well-being as normative processes, shifting the focus from disease causation to strengthening individuals' capacity to pursue and sustain health (Antonovsky, 1996). The integration of quantitative, qualitative, and participatory research methods within this paradigm allows for a more comprehensive understanding of health as a lived, dynamic, and context-sensitive experience.