Week 4 assignment - Proficient Writers

Week-Four – Utilization of the Medical System and Managing Chronic Illness

What is the proper utilization of the medical system? How should Personal Care Physicians be used, and how should the Emergency Department be used. These are just two possible approaches to this topic. Refer to Ch 8 in attached book.

HEALTH
PSYCHOLOGY

Shel ley E . Taylor
10E

HEALTH PSYCHOLOGY

T E N T H E D I T I O N

SHELLEY E. TAYLOR
University of California, Los Angeles

HEALTH PSYCHOLOGY, TENTH EDITION

Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2018 by
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Library of Congress Cataloging-in-Publication Data
Names: Taylor, Shelley E., author.
Title: Health psychology / Shelley Taylor, University of California, Los Angeles.
Description: Tenth edition. | New York, NY : McGraw-Hill Education, [2018] |
Includes bibliographical references and indexes.
Identifiers: LCCN 2016044904| ISBN 9781259870477 | ISBN 1259870472
Subjects: LCSH: Clinical health psychology. | Medicine, Psychosomatic. | BISAC:
PSYCHOLOGY / General.
Classification: LCC R726.7 .T39 2017 | DDC 616.08—dc23
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For Nathaniel

SHELLEY E. TAYLOR is Distinguished Professor of Psychology at the
University of California, Los Angeles. She received her Ph.D. in social psychol-
ogy from Yale University. After a visiting professorship at Yale and assistant and
associate professorships at Harvard University, she joined the faculty of UCLA.
Her research interests concern the psychological and social factors that promote
or compromise mental and physical health across the life span. Professor Taylor
is the recipient of a number of awards—most notably, the American Psychological
Association’s Distinguished Scientific Contribution to Psychology Award, a
10-year Research Scientist Development Award from the National Institute of
Mental Health, and an Outstanding Scientific Contribution Award in Health Psy-
chology. She is the author of more than 350 publications in journals and books
and is the author of Social Cognition, Social Psychology, Positive Illusions, and
The Tending Instinct. She is a member of the National Academies of Science and
the National Academy of Medicine.

A B O U T T H E A U T H O R

vii

C O N T E N T S

P A R T 1

PREFACE XV

INTRODUCTION TO HEALTH PSYCHOLOGY 1

C H A P T E R 1

What Is Health Psychology? 2

Definition of Health Psychology 3
Why Did Health Psychology Develop? 3

The Mind-Body Relationship: A Brief History 4
The Rise of the Biopsychosocial Method 5

Psychosomatic Medicine 5
Advantages of the Biopsychosocial Model 5
Clinical Implications of the Biopsychosocial

Model 6
The Biopsychosocial Model: The Case History of

Nightmare Deaths 6
The Need for Health Psychology 6

Changing Patterns of Illness 7
Advances in Technology and Research 8
Expanded Health Care Services 8
Increased Medical Acceptance 9

Health Psychology Research 9
The Role of Theory in Research 9
Experiments 10
Correlational Studies 10
Prospective and Retrospective Designs 10
The Role of Epidemiology in Health Psychology 11
Methodological Tools 11
Qualitative Research 12

What Is Health Psychology Training For? 12

C H A P T E R 2

The Systems of the Body 14

The Nervous System 15
Overview 15
The Brain 15
B O X 2.1 Costs of War to the Brain 17

The Role of Neurotransmitters 17
Disorders of the Nervous System 17

The Endocrine System 19
Overview 19
The Adrenal Glands 19
Disorders Involving the Endocrine System 19

The Cardiovascular System 20
Overview 20
The Heart 20
Disorders of the Cardiovascular System 21
Blood Pressure 22
The Blood 22

The Respiratory System 23
Overview 23
The Structure and Functions of the Respiratory

System 23
Disorders Associated with the Respiratory System 24
Dealing with Respiratory Disorders 25

viii Contents

Genetics and Health 29
Overview 29
Genetics and Susceptibility to Disorders 29

The Immune System 31
Overview 31
Infection 31
The Course of Infection 31
B O X 2.2 Portraits of Two Carriers 32

Immunity 32
Disorders Related to the Immune System 34

The Digestive System and the Metabolism of Food 25
Overview 25
The Functioning of the Digestive System 25
Disorders of the Digestive System 25

The Renal System 27
Overview 27
Disorders of the Renal System 27

The Reproductive System 28
Overview 28
The Ovaries and Testes 28
Fertilization and Gestation 28
Disorders of the Reproductive System 28

P A R T 2

HEALTH BEHAVIOR AND PRIMARY PREVENTION 37

C H A P T E R 3

Health Behaviors 38

An Introduction to Health Behaviors 39
Role of Behavioral Factors in Disease and

Disorder 39
Health Promotion: An Overview 39

Health Behaviors and Health Habits 39
Practicing and Changing Health Behaviors:

An Overview 40
Barriers to Modifying Poor Health Behaviors 41
Intervening with Children and Adolescents 42
Intervening with At-Risk People 43
Health Promotion and Older Adults 44
Ethnic and Gender Differences in Health Risks

and Habits 45
Changing Health Habits 45

Attitude Change and Health Behavior 45
The Health Belief Model 47
The Theory of Planned Behavior 47
Criticisms of Attitude Theories 49
Self Regulation and Health Behavior 49
Self Determination Theory 49
Implementation Intentions 49
Health Behavior Change and the Brain 50

Cognitive-Behavioral Approaches to Health
Behavior Change 50

Cognitive-Behavior Therapy (CBT) 50
Self-Monitoring 50
Stimulus Control 51
The Self-Control of Behavior 51

B O X 3.1 Classical Conditioning 52
B O X 3.2 Operant Conditioning 53
B O X 3.3 Modeling 54

Social Skills and Relaxation Training 54
Motivational Interviewing 54
Relapse Prevention 55
Evaluation of CBT 56

The Transtheoretical Model of Behavior Change 56
Stages of Change 56
Using the Stage Model of Change 57

Changing Health Behaviors Through Social
Engineering 58
Venues for Health-Habit Modification 59

The Practitioner’s Office 59
The Family 59
Self-Help Groups 60
Schools 60
Workplace Interventions 60
Community-Based Interventions 60
The Mass Media 61
Cellular Phones and Landlines 61
The Internet 61

C H A P T E R 4

Health-Promoting Behaviors 64

Exercise 65
Benefits of Exercise 65
Determinants of Regular Exercise 66
Exercise Interventions 67

Contents ix

Evaluation of Cognitive-Behavioral Weight-Loss
Techniques 90

Taking a Public Health Approach 90
Eating Disorders 91

Anorexia Nervosa 91
B O X 5.3 The Barbie Beauty Battle 92

Bulimia 93
Binge Eating Disorder 94

Alcoholism and Problem Drinking 94
The Scope of the Problem 94
What Is Substance Dependence? 95
Alcoholism and Problem Drinking 95
Origins of Alcoholism and Problem Drinking 95
Treatment of Alcohol Abuse 96
Treatment Programs 97
B O X 5.4 After the Fall of the Berlin Wall 97
B O X 5.5 A Profile of Alcoholics Anonymous 98
B O X 5.6 The Drinking College Student 99

Evaluation of Alcohol Treatment Programs 100
Preventive Approaches to Alcohol Abuse 100
Drinking and Driving 101
Is Modest Alcohol Consumption a Health

Behavior? 101
Smoking 101

Synergistic Effects of Smoking 102
A Brief History of the Smoking Problem 102
Why Do People Smoke? 103
Nicotine Addiction and Smoking 105
Interventions to Reduce Smoking 106
Smoking Prevention Programs 109
B O X 5.7 The Perils of Secondhand Smoke 110

Accident Prevention 68
Home and Workplace Accidents 68
Motorcycle and Automobile Accidents 69

Vaccinations and Screening 69
Vaccinations 70
Screenings 70
Colorectal Cancer Screening 71

Sun Safety Practices 71
Developing a Healthy Diet 72

Changing Diet 73
Resistance to Modifying Diet 73

Sleep 75
What Is Sleep? 75
Sleep and Health 75

Rest, Renewal, Savoring 76

C H A P T E R 5

Health-Compromising Behaviors 79

Characteristics of Health-Compromising Behaviors 80
Obesity 81

What Is Obesity? 81
Obesity in Childhood 83
B O X 5.1 The Biological Regulation of Eating 85

SES, Culture, and Obesity 85
Obesity and Dieting as Risk Factors for Obesity 86
Stress and Eating 87
Interventions 87
B O X 5.2 Don’t Diet 88

Cognitive Behavioral Therapy (CBT) 88

P A R T 3

STRESS AND COPING 113

C H A P T E R 6

Stress 114

What Is Stress? 115
What Is a Stressor? 115
Appraisal of Stressors 115

Origins of the Study of Stress 115
Fight or Flight 115
Selye’s General Adaptation Syndrome 115
Tend-and-Befriend 117
How Does Stress Contribute to Illness? 117

The Physiology of Stress 118
Effects of Long-Term Stress 119
Individual Differences in Stress Reactivity 120
Physiological Recovery 121
Allostatic Load 121
B O X 6.1 Can Stress Affect Pregnancy? 122

What Makes Events Stressful? 122
Dimensions of Stressful Events 122
Must Stress Be Perceived as Such to Be Stressful? 123
Can People Adapt to Stress? 124

x Contents

Psychosocial Resources 140
B O X 7.2 Religion, Coping, and Well-Being 142

Resilience 142
Coping Style 143
Problem-Focused and Emotion-Focused Coping 144
B O X 7.3 The Brief COPE 145

Coping and External Resources 146
B O X 7.4 Coping with HIV 146

Coping Outcomes 147
Coping Interventions 147

Mindfulness Meditation and Acceptance/Commitment
Therapy 147

Expressive Writing 148
Self-Affirmation 149
Relaxation Training 149
Coping Skills Training 149

Social Support 151
What Is Social Support? 151
Effects of Social Support on Illness 152
B O X 7.5 Is Social Companionship an Important

Part of Your Life? 153
Biopsychosocial Pathways 153
Moderation of Stress by Social Support 154
What Kinds of Support Are Most Effective? 155
B O X 7.6 Can Bad Relationships Affect Your

Health? 156
Enhancing Social Support 157

P A R T 4

How Has Stress Been Studied? 124
Studying Stress in the Laboratory 124
Must a Stressor Be Ongoing to Be Stressful? 124
Inducing Disease 125
Stressful Life Events 125
B O X 6.2 Post-Traumatic Stress Disorder 126

Daily Stress 127
Sources of Chronic Stress 128

Effects of Early Stressful Life Experiences 128
B O X 6.3 Can an Exciting Sports Event Kill You?

Cardiovascular Events During World Cup
Soccer 128

B O X 6.4 A Measure of Perceived Stress 129
B O X 6.5 The Measurement of Daily Strain 130

Chronic Stressful Conditions 130
Stress in the Workplace 131
B O X 6.6 Can Prejudice Harm Your Health? 132

Some Solutions to Workplace Stressors 134
Combining Work and Family Roles 134

C H A P T E R 7

Coping, Resilience, and Social Support 137

Coping with Stress and Resilience 138
Personality and Coping 138
B O X 7.1 The Measurement of Optimism:

The LOT-R 140

SEEKING AND USING HEALTH CARE SERVICES 159

C H A P T E R 8

Using Health Services 160

Recognition and Interpretation of Symptoms 161
Recognition of Symptoms 161
Interpretation of Symptoms 162
Cognitive Representations of Illness 162
B O X 8.1 Can Expectations Influence Sensations?

The Case of Premenstrual Symptoms 163
Lay Referral Network 164
The Internet 164

Who Uses Health Services? 164
Age 164
Gender 164

Social Class and Culture 165
Social Psychological Factors 165

Misusing Health Services 165
Using Health Services for Emotional

Disturbances 165
Delay Behavior 166
B O X 8.2 The June Bug Disease: A Case of

Hysterical Contagion 167

C H A P T E R 9

Patients, Providers, and Treatments 170

Health Care Services 171
Patient Consumerism 171

Contents xi

Who Uses CAM? 192
Complementary and Alternative Medicine: An

Overall Evaluation 192
The Placebo Effect 193

History of the Placebo 193
What Is a Placebo? 193
Provider Behavior and Placebo Effects 194
B O X 9.6 Cancer and the Placebo Effect 194

Patient Characteristics and Placebo Effects 194
Patient-Provider Communication and Placebo

Effects 195
Situational Determinants of Placebo Effects 195
Social Norms and Placebo Effects 195
The Placebo as a Methodological Tool 196

C H A P T E R 1 0

The Management of Pain and
Discomfort 199

The Elusive Nature of Pain 201
B O X 10.1 A Cross-Cultural Perspective on Pain:

The Childbirth Experience 202
Measuring Pain 202
The Physiology of Pain 204
B O X 10.2 Headache Drawings Reflect Distress and

Disability 204
B O X 10.3 Phantom Limb Pain: A Case History 206
Neurochemical Bases of Pain and Its Inhibition 206

Clinical Issues in Pain Management 207
Acute and Chronic Pain 207
Pain and Personality 209

Pain Control Techniques 209
Pharmacological Control of Pain 210
Surgical Control of Pain 210
Sensory Control of Pain 211
Biofeedback 211
Relaxation Techniques 211
Distraction 212
Coping Skills Training 213
Cognitive Behavioral Therapy 214

Pain Management Programs 214
Initial Evaluation 215
Individualized Treatment 215
Components of Programs 215
Involvement of Family 215
Relapse Prevention 215
Evaluation of Programs 215

Structure of the Health Care Delivery System 171
Patient Experiences with Managed Care 172

The Nature of Patient-Provider Communication 173
Setting 173
Provider Behaviors That Contribute to Faulty

Communication 174
B O X 9.1 What Did You Say?: Language Barriers

to Effective Communication 175
Patients’ Contributions to Faulty Communication 175
Interactive Aspects of the Communication

Problem 176
Results of Poor Patient-Provider Communication 177

Nonadherence to Treatment Regimens 177
Good Communication 177
B O X 9.2 What Are Some Ways to Improve

Adherence to Treatment? 178
Improving Patient-Provider Communication and
Increasing Adherence to Treatment 178

Teaching Providers How to Communicate 178
B O X 9.3 What Can Providers Do to Improve

Adherence? 179
The Patient in the Hospital Setting 180

Structure of the Hospital 181
The Impact of Hospitalization on the Patient 182
B O X 9.4 Burnout Among Health Care

Professionals 183
Interventions to Increase Information in Hospital
Settings 184
The Hospitalized Child 184

B O X 9.5 Social Support and Distress from
Surgery 185

Preparing Children for Medical Interventions 185
Complementary and Alternative Medicine 186

Philosophical Origins of CAM 186
CAM Treatments 188

Dietary Supplements and Diets 188
Prayer 188
Acupuncture 189
Yoga 189
Hypnosis 190
Meditation 190
Guided Imagery 190
Chiropractic Medicine 191
Osteopathy 191
Massage 191

xii Contents

C H A P T E R 1 2

Psychological Issues in Advancing and
Terminal Illness 239

Death Across the Life Span 240
Death in Infancy and Childhood 240
Death in Adolescence and Young Adulthood 243
Death in Middle Age 244
Death in Old Age 244
B O X 12.1 Why Do Women Live Longer Than

Men? 245
Psychological Issues in Advancing Illness 246

Continued Treatment and Advancing Illness 246
B O X 12.2 A Letter to My Physician 247
Psychological and Social Issues Related to

Dying 247
B O X 12.3 Ready to Die: The Question of Assisted

Suicide 248
The Issue of Nontraditional Treatment 249

Are There Stages in Adjustment to Dying? 249
Kübler-Ross’s Five-Stage Theory 249
Evaluation of Kübler-Ross’s Theory 250

Psychological Issues and the Terminally Ill 251
Medical Staff and the Terminally Ill Patient 251
Counseling with the Terminally Ill 253
The Management of Terminal Illness in Children 253

Alternatives to Hospital Care for the Terminally Ill 253
Hospice Care 253
Home Care 254

Problems of Survivors 254
B O X 12.4 Cultural Attitudes Toward Death 255
The Survivor 255
Death Education 257

C H A P T E R 1 3

Heart Disease, Hypertension, Stroke,
and Type II Diabetes 259

Coronary Heart Disease 260
What Is CHD? 260
Risk Factors for CHD 260
Stress and CHD 261
Women and CHD 263
Personality, Cardiovascular Reactivity, and CHD 264

C H A P T E R 1 1

Management of Chronic Health
Disorders 218

Quality of Life 220
What Is Quality of Life? 220
Why Study Quality of Life? 220

Emotional Responses to Chronic Health Disorders 221
Denial 221
Anxiety 222
Depression 222

Personal Issues in Chronic Health Disorders 223
B O X 11.1 A Future of Fear 223
The Physical Self 223
The Achieving Self 224
The Social Self 224
The Private Self 224

Coping with Chronic Health Disorders 224
Coping Strategies and Chronic Health Disorders 224
Patients’ Beliefs About Chronic Health Disorders 225
B O X 11.2 Chronic Fatigue Syndrome and Other

Functional Disorders 226
Comanagement of Chronic Health Disorders 227

Physical Rehabilitation 227
B O X 11.3 Epilepsy and the Need for a Job

Redesign 228
Vocational Issues in Chronic Health Disorders 228
Social Interaction Problems in Chronic Health

Disorders 228
B O X 11.4 Who Works with People with Chronic

Health Disorders? 229
Gender and the Impact of Chronic Health

Disorders 232
Positive Changes in Response to Chronic Health

Disorders 232
When a Child Has A Chronic Health Disorder 232

Psychological Interventions and Chronic Health
Disorders 234

Pharmacological Interventions 234
Individual Therapy 234
Relaxation, Stress Management, and Exercise 235
Social Support Interventions 236
B O X 11.5 Help on the Internet 236
Support Groups 237

P A R T 5

MANAGEMENT OF CHRONIC AND TERMINAL
HEALTH DISORDERS 217

Contents xiii

Negative Affect and Immune Functioning 287
Stress, Immune Functioning, and Interpersonal

Relationships 288
Coping and Immune Functioning 288
Interventions to Improve Immune Functioning 289

HIV Infection and AIDS 290
A Brief History of HIV Infection and AIDS 290
HIV Infection and AIDS in the United States 291
The Psychosocial Impact of HIV Infection 292
Interventions to Reduce the Spread of HIV

Infection 293
Coping with HIV+ Status and AIDS 296
Psychosocial Factors That Affect the Course of HIV

Infection 297
Cancer 298

Why Is Cancer Hard to Study? 299
Who Gets Cancer? A Complex Profile 299
Psychosocial Factors and Cancer 299
Psychosocial Factors and the Course of Cancer 301
Adjusting to Cancer 301
Psychosocial Issues and Cancer 302
Post-traumatic Growth 302
Interventions 303
Therapies with Cancer Patients 304

Arthritis 304
Rheumatoid Arthritis 305
Osteoarthritis 306

Type I Diabetes 306
Special Problems of Adolescent Diabetics 307

B O X 13.1 Hostility and Cardiovascular Disease 265
Depression and CHD 266
Other Psychosocial Risk Factors and CHD 267
Management of Heart Disease 267
B O X 13.2 Picturing the Heart 269
Prevention of Heart Disease 271

Hypertension 272
How Is Hypertension Measured? 272
What Causes Hypertension? 272
Treatment of Hypertension 274
The Hidden Disease 275

Stroke 275
Risk Factors for Stroke 276
Consequences of Stroke 277
Rehabilitative Interventions 277

Type II Diabetes 278
Health Implications of Diabetes 280
Psychosocial Factors in the Development of

Diabetes 280
The Management of Diabetes 281
B O X 13.3 Stress Management and the Control of

Diabetes 281

C H A P T E R 1 4

Psychoneuroimmunology and
Immune-Related Disorders 284

Psychoneuroimmunology 285
The Immune System 285
Assessing Immune Functioning 285
Stress and Immune Functioning 285
B O X 14.1 Autoimmune Disorders 287

P A R T 6

TOWARD THE FUTURE 311

C H A P T E R 1 5

Health Psychology: Challenges
for the Future 312

Health Promotion 314
A Focus on Those at Risk 314
Prevention 314
A Focus on Older Adults 314
Refocusing Health Promotion Efforts 315
Promoting Resilience 315
Health Promotion and Medical Practice 316
Health Disparities 316

Stress and Its Management 318
Where Is Stress Research Headed? 318

Health Services 319
Building Better Consumers 319

Management of Serious Illness 320
Quality-of-Life Assessment 320
The Aging of the Population 320

Trends in Health and Health Psychology 321
The Research of the Future 321
The Changing Nature of Medical Practice 321

xiv Contents

GLOSSARY 328

REFERENCES 338

NAME INDEX 412

SUBJECT INDEX 438

Systematic Documentation of Cost Effectiveness
and Treatment Effectiveness 322

International Health 324
Becoming a Health Psychologist 325

Undergraduate Experience 325
Graduate Experience 325
Postgraduate Work 326
Employment 326

P R E F A C E

When I wrote the first edition of Health Psychology over 30 years ago, the task
was much simpler than it is now. Health psychology was a new field and was
relatively small. In recent decades, the field has grown steadily, and great research
advances have been made. Chief among these developments has been the use and
refinement of the biopsychosocial model: the study of health issues from the stand-
point of biological, psychological, and social factors acting together. Increasingly,
research has attempted to identify the biological pathways by which psychosocial
factors such as stress may adversely affect health and potentially protective factors
such as social support may buffer the impact of stress. My goal in the tenth edition
of this text is to convey this increasing sophistication of the field in a manner that
makes it accessible, comprehensible, and exciting to undergraduates.
Like any science, health psychology is cumulative, building on past research
advances to develop new ones. Accordingly, I have tried to present not only the
fundamental contributions to the field but also the current research on these
issues. Because health psychology is developing and changing so rapidly, it is
essential that a text be up to date. Therefore, I have not only reviewed the recent
research in health psychology but also obtained information about research proj-
ects that will not be available in the research literature for several years. In so
doing, I am presenting a text that is both current and pointed toward the future.
A second goal is to portray health psychology appropriately as being inti-
mately involved with the problems of our times. The aging of the population and
the shift in numbers toward the later years has created unprecedented health needs
to which health psychology must respond. Such efforts include the need for health
promotion with this aging cohort and an understanding of the psychosocial issues
that arise in response to aging and its associated chronic disorders. Because AIDS
is a leading cause of death worldwide, the need for health measures such as con-
dom use is readily apparent if we are to halt the spread of this disease. Obesity
is now one of the world’s leading health problems, nowhere more so than in the
United States. Reversing this dire trend that threatens to shorten life expectancy
worldwide is an important current goal of health psychology. Increasingly, health
psychology is an international undertaking, with researchers from around the
world providing insights into the problems that affect both developing and devel-
oped countries. The tenth edition includes current research that reflects the inter-
national focus of both health problems and the health research community.
Health habits lie at the origin of our most prevalent disorders, and this fact
underscores more than ever the importance of modifying problematic health behav-
iors such as smoking and alcohol consumption. Increasingly, research documents
the importance of a healthy diet, regular exercise, and weight control among other
positive health habits for maintaining good health. The at-risk role has taken on
more importance in prevention, as breakthroughs in genetic research have made
it possible to identify genetic risks for diseases long before disease is evident.
How people cope with being at risk and what interventions are appropriate for
them represent important tasks for health psychology research to address.
Health psychology is both an applied field and a basic research field. Accord-
ingly, in highlighting the accomplishments of the field, I present both the scientific

xvi Preface

progress and its important applications. Chief among these are efforts by clinical
psychologists to intervene with people to treat biopsychosocial disorders, such as
post-traumatic stress disorder; to help people manage health habits that have
become life threatening, such as eating disorders; and to develop clinical interven-
tions that help people better manage their chronic illnesses.
Finding the right methods and venues for modifying health continues to be a
critical issue. The chapters on health promotion put particular emphasis on the
most promising methods for changing health behaviors. The chapters on chronic
diseases highlight how knowledge of the psychosocial causes and consequences
of these disorders may be used to intervene with people at risk—first, to reduce
the likelihood that such disorders will develop, and second, to deal effectively
with the psychosocial issues that arise following diagnosis.
The success of any text depends ultimately on its ability to communicate the
content clearly to student readers and spark interest in the field. In this tenth
edition, I strive to make the material interesting and relevant to the lives of student
readers. Many chapters highlight news stories related to health. In addition, the
presentation of material has been tied to the needs and interests of young adults.
For example, the topic of stress management is tied directly to how students might
manage the stresses associated with college life. The topic of problem drinking
includes sections on college students’ alcohol consumption and its modification.
Health habits relevant to this age group—tanning, exercise, and condom use,
among others—are highlighted for their relevance to the student population. By
providing students with anecdotes, case histories, and specific research examples
that are relevant to their own lives, they learn how important this body of knowl-
edge is to their lives as young adults.
Health psychology is a science, and consequently, it is important to commu-
nicate not only the research itself but also some understanding of how studies
were designed and why they were designed that way. The explanations of par-
ticular research methods and the theories that have guided research appear
throughout the book. Important studies are described in depth so that students
have a sense of the methods researchers use to make decisions about how to gather
the best data on a problem or how to intervene most effectively.
Throughout the book, I have made an effort to balance general coverage of
psychological concepts with coverage of specific health issues. One method of
doing so is by presenting groups of chapters, with the initial chapter offering
general concepts and subsequent chapters applying those concepts to specific
health issues. Thus, Chapter 3 discusses general strategies of health promotion,
and Chapters 4 and 5 discuss those issues with specific reference to particular
health habits such as exercise, smoking, accident prevention, and weight control.
Chapters 11 and 12 discuss broad issues that arise in the context of managing
chronic health disorders and terminal illness. In Chapters 13 and 14, these issues
are addressed concretely, with reference to specific disorders such as heart disease,
cancer, and AIDS.
Rather than adopt a particular theoretical emphasis throughout the book,
I have attempted to maintain a flexible orientation. Because health psychology is
taught within all areas of psychology (for example, clinical, social, cognitive,
physiological, learning, and developmental), material from each of these areas is
included in the text so that it can be accommodated to the orientation of each
instructor. Consequently, not all material in the book is relevant for all courses.
Successive chapters of the book build on each other but do not depend on each

Preface xvii

other. Chapter 2, for example, can be used as assigned reading, or it can act as a
resource for students wishing to clarify their understanding of biological concepts
or learn more about a particular biological system or illness. Thus, each instruc-
tor can accommodate the use of the text to his or her needs, giving some chapters
more attention than others and omitting some chapters altogether, without under-
mining the integrity of the presentation.

■ NEW TO THIS EDITION

∙ Coverage of qualitative methods, such as how interviews and personal narra-
tives can enrich our understanding of health experiences (Chapter 1)

∙ Discussion of Alzheimer’s disease, its toll, and its increasing importance as
a disease of an aging population (Chapter 2)

∙ New section on the self-regulation of health behaviors, including the impact
of self affirmation on health behavior change (Chapter 3)

∙ Coverage of perceived barriers to health behavior change, one of the most
important reasons why people do not practice better health habits (Chapter 3)

∙ Coverage of the post childbirth period as a teachable moment (Chapter 3)
∙ Discussion of the health risks of being sedentary and sitting for long periods

of time (Chapters 4, 13)
∙ Expanded coverage of vaccinations and ways to overcome resistance to getting

children vaccinated for major diseases (Chapter 4)
∙ Coverage of new research on sleep and health (Chapter 4)
∙ Enhanced coverage of eating disorders, including binge eating disorder

(Chapter 5)
∙ Coverage of the newest research on the obesity epidemic (Chapter 5)
∙ New research on stress in childhood and adolescence (Chapter 6)
∙ Expanded converge on the effects of prejudice and discrimination on health

(Chapter 6)
∙ Expanded coverage of how mindfulness meditation can aid coping with stress

(Chapter 7)
∙ Coverage of dyadic coping, namely how partners can shape each other’s bio-

logical and psychological responses to stress (Chapter 7)
∙ Discussion of how people are using probiotics to enhance the microbiome of

the gut and its potential effects on health (Chapter 9)
∙ Coverage of the epidemic of opioid and heroin abuse and their effects on

health and on suicide (Chapters 10, 12)
∙ Change in orientation from disease and illness to health and chronic health

disorders (Chapters 3, 11)
∙ Discussion of the startling increase in the death rate of middle-aged adults

and the reasons why (Chapter 12)
∙ Intervening in childhood and adolescence to forestall chronic health disorders

in middle age (Chapter 13)
∙ Discussion of psychosocial factors in the development of Type II Diabetes

(Chapter 12)
∙ Coverage of post-traumatic growth (Chapter 14)
∙ Use of technology and the Internet to improve health and to assess and inter-

vene in the course of chronic health disorders (Chapters 1, 3, 13, 15)
∙ Impact of changes in healthcare coverage in the United States (Chapter 15)
∙ The changing face of health psychology (Chapter 15)

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concepts and ideas in each chapter.
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■ ACKNOWLEDGMENTS

My extensive gratitude goes to Emily Iseda, Jesse Solorzano, and Saskia Giebl
for the many hours they put in on the manuscript. I thank my editors at McGraw-
Hill, Jamie Laferrera, Erin Guendelsberger, and Sheila Frank, who devoted much
time and help to the preparation of the book. I also wish to thank the following
reviewers who commented on all or part of the book:

Marie-Joelle Estrada, University of Rochester
Jennifer Grewe, Utah State University
Marguerite D. Kermis, Canisius College
Rhonna Krouse, College of Western Idaho
Jeffrey M. Kunka, Roosevelt University
Max Levine, Siena College
Susan D. Lonborg, Central Washington University
Michelle Loudermilk, Fayetteville Technical Community College
Angelina Stacy MacKewn, University of Tennessee at Martin
H. Russell Searight, Lake Superior State University
Bert Uchino, University of Utah

Shelley E. Taylor

xx Preface

Introduction to Health
Psychology

1P A R T

C H A P T E R 1
C H A P T E R O U T L I N E

Definition of Health Psychology
Why Did Health Psychology Develop?

The Mind-Body Relationship: A Brief History
The Rise of the Biopsychosocial Method

Psychosomatic Medicine

Advantages of the Biopsychosocial Model

Clinical Implications of the Biopsychosocial Model

The Biopsychosocial Model: The Case History of
Nightmare Deaths

The Need for Health Psychology
Changing Patterns of Illness

Advances in Technology and Research

Expanded Health Care Services

Increased Medical Acceptance

Health Psychology Research
The Role of Theory in Research

Experiments

Correlational Studies

Prospective and Retrospective Designs

The Role of Epidemiology in Health Psychology

Methodological Tools

What Is Health Psychology Training For?

What Is Health Psychology?

Chapter 1 What Is Health Psychology? 3

Health psychologists focus on health promotion
and maintenance, which includes issues such as how
to get children to develop good health habits, how to
promote regular exercise, and how to design a media
campaign to get people to improve their diets.
Health psychologists study the psychological as-
pects of the prevention and treatment of illness. A
health psychologist might teach people in a high-
stress occupation how to manage stress effectively to
avoid health risks. A health psychologist might work
with people who are already ill to help them follow
their treatment regimen.
Health psychologists also focus on the etiology
and correlates of health, illness, and dysfunction.
Etiology refers to the origins or causes of illness.
Health psychologists especially address the behav-
ioral and social factors that contribute to health,
illness, and dysfunction, such as alcohol consumption,
smoking, exercise, the wearing of seat belts, and ways
of coping with stress.
Finally, health psychologists analyze and attempt
to improve the health care system and the formulation
of health policy. They study the impact of health insti-
tutions and health professionals on people’s behavior to
develop recommendations for improving health care.
In summary, health psychology examines the psy-
chological and social factors that lead to the enhance-
ment of health, the prevention and treatment of illness,
and the evaluation and modification of health policies
that influence health care.

Why Did Health Psychology Develop?
To many people, health is simply a matter of staying
well or getting over illnesses quickly. Psychological
and social factors might seem to have little to contrib-
ute. But consider some of the following puzzles that
cannot be understood without the input of health
psychology:
∙ When people are exposed to a cold virus, some

get colds whereas others do not.
∙ Men who are married live longer than men who

are not married.
∙ Throughout the world, life expectancy is

increasing. But in countries going through
dramatic social upheaval, life expectancy can
plummet.

∙ Women live longer than men in all countries
except those in which they are denied access to

“Life span may be as wide as your smile: The bigger
the smile, the longer the life” (March 29, 2010)
“Epidemic of drug overdose deaths ripples
across America” (January 20, 2016)
“Vaccination is a social responsibility”
( February 4, 2015)
“Smartphone apps help people quit smoking”
(January 23, 2015)
“Risk of concussions from youth sports”
( December 25, 2015)

Every day, we see headlines about health. We are told
that smoking is bad for us, that we need to exercise
more, and that we’ve grown obese. We learn about
new treatments for diseases about which we are only
dimly aware, or we hear that a particular herbal rem-
edy may make us feel better about ourselves. We are
told that meditation or optimistic beliefs can keep us
healthy or help us to get well more quickly. How do
we make sense of all these claims? Health psychology
addresses important questions like these.

■ DEFINITION OF HEALTH
PSYCHOLOGY

Health psychology is an exciting and relatively new
field devoted to understanding psychological influ-
ences on how people stay healthy, why they become
ill, and how they respond when they do get ill. Health
psychologists both study such issues and develop in-
terventions to help people stay well or recover from
illness. For example, a health psychology researcher
might explore why people continue to smoke even
though they know that smoking increases their risk
of cancer and heart disease. Understanding this
poor health habit leads to interventions to help peo-
ple stop smoking.
Fundamental to research and practice in health
psychology is the definition of health. Decades ago,
a forward-looking World Health Organization (1948)
defined health as “a complete state of physical,
mental, and social well-being and not merely the ab-
sence of disease or infirmity.” This definition is at
the core of health psychologists’ conception of
health. Rather than defining health as the absence of
illness, health is recognized to be an achievement
involving balance among physical, mental, and so-
cial well-being. Many use the term wellness to refer
to this optimum state of health.

4 Part One Introduction to Health Psychology

illness. Rather than ascribing illness to evil spirits, they
developed a humoral theory of illness. According to this
viewpoint, disease resulted when the four humors or
circulating fluids of the body—blood, black bile, yellow
bile, and phlegm—were out of balance. The goal of
treatment was to restore balance among the humors. The
Greeks also believed that the mind was important. They
described personality types associated with each of the
four humors, with blood being associated with a pas-
sionate temperament, black bile with sadness, yellow
bile with an angry disposition, and phlegm with a laid-
back approach to life. Although these theories are now
known not to be true, the emphasis on mind and body in
health and illness was a breakthrough at that time.
By the Middle Ages, however, the pendulum had
swung to supernatural explanations for illness. Disease
was regarded as God’s punishment for evildoing, and
cure often consisted of driving out the evil forces by
torturing the body. Later, this form of “therapy” was
replaced by penance through prayer and good works.
During this time, the Church was the guardian of medi-
cal knowledge, and as a result, medical practice assumed
religious overtones. The functions of the physician were
typically absorbed by priests, and so healing and the
practice of religion became virtually indistinguishable.
Beginning in the Renaissance and continuing
into the present day, great strides were made in
understanding the technical bases of medicine. These

health care. But women are more disabled, have
more illnesses, and use health services more.

∙ Infectious diseases such as tuberculosis, pneumonia,
and influenza used to be the major causes of
illness and death in the United States. Now chronic
diseases such as heart disease, cancer, and diabetes
are the main causes of disability and death.

∙ Attending a church or synagogue, praying, or
otherwise tending to spiritual needs is good for
your health.

By the time you have finished this book, you will
know why these findings are true.

■ THE MIND-BODY
RELATIONSHIP: A BRIEF
HISTORY

During prehistoric times, most cultures regarded the
mind and body as intertwined. Disease was thought to
arise when evil spirits entered the body, and treatment
consisted primarily of attempts to exorcise these spirits.
Some skulls from the Stone Age have small, symmetri-
cal holes that are believed to have been made intention-
ally with sharp tools to allow the evil spirit to leave the
body while the shaman performed the treatment ritual.
The ancient Greeks were among the earliest civili-
zations to identify the role of bodily factors in health and

Sophisticated, though not always successful, techniques for the treatment of illness were

developed during the Renaissance. This woodcut from the 1570s depicts a surgeon

drilling a hole in a patient’s skull, with the patient’s family and pets looking on.

Courtesy National Library of Medicine Prints and Photographs

Chapter 1 What Is Health Psychology? 5

Flanders Dunbar in the 1930s (Dunbar, 1943) and Franz
Alexander in the 1940s (Alexander, 1950). For exam-
ple, Alexander developed a profile of the ulcer-prone
personality as someone with excessive needs for depen-
dency and love.
Dunbar and Alexander maintained that conflicts
produce anxiety, which becomes unconscious and takes
a physiological toll on the body via the autonomic ner-
vous system. The continuous physiological changes
eventually produce an organic disturbance. In the case
of the ulcer patient, for example, repressed emotions
resulting from frustrated dependency and love-seeking
needs were thought to increase the secretion of acid in
the stomach, eventually eroding the stomach lining and
producing ulcers (Alexander, 1950).
Dunbar’s and Alexander’s work helped shape the
emerging field of psychosomatic medicine by offer-
ing profiles of particular disorders believed to be psy-
chosomatic in origin, that is, caused by emotional
conflicts. These disorders include ulcers, hyperthy-
roidism, rheumatoid arthritis, essential hypertension,
neurodermatitis (a skin disorder), colitis, and bron-
chial asthma.
We now know that all illnesses raise psychologi-
cal issues. Moreover, researchers now believe that a
particular conflict or personality type is not sufficient
to produce illness. Rather, the onset of disease is usu-
ally due to several factors working together, which
may include a biological pathogen (such as a viral or
bacterial infection) coupled with social and psycho-
logical factors, such as high stress, low social support,
and low socioeconomic status.
The idea that the mind and the body together deter-
mine health and illness logically implies a model for
studying these issues. This model is called the biopsy-
chosocial model. Its fundamental assumption is that
health and illness are consequences of the interplay of
biological, psychological, and social factors (Keefe,
2011).

Advantages of the
Biopsychosocial Model
How does the biopsychosocial model of health and
illness overcome the disadvantages of the biomedical
model? The biopsychosocial model maintains that
biological, psychological, and social factors are all
important determinants of health and illness. Both
macrolevel processes (such as the existence of social
support or the presence of depression) and microlevel
processes (such as cellular disorders or chemical

advances include the invention of the microscope in the
1600s and the development of the science of autopsy,
which allowed medical practitioners to see the organs
that were implicated in different diseases. As the science
of cellular pathology progressed, the humoral theory of
illness was put to rest. Medical practice drew increas-
ingly on laboratory findings and looked to bodily factors
rather than to the mind as bases for health and illness. In
an effort to break with the superstitions of the past, prac-
titioners resisted acknowledging any role for the mind in
disease processes. Instead, they focused primarily on
organic and cellular pathology as a basis for their diag-
noses and treatment recommendations.
The resulting biomedical model, which has gov-
erned the thinking of most health practitioners for the
past 300 years, maintains that all illness can be explained
on the basis of aberrant somatic bodily processes, such
as biochemical imbalances or neurophysiological
abnormalities. The biomedical model assumes that
psychological and social processes are largely irrele-
vant to the disease process. The problems with the bio-
medical model are summarized in Table 1.1.

TABLE 1.1 | The Biomedical Model: Why Is It
Ill-suited to Understanding Illness?

• Reduces illness to low-level processes such as
disordered cells and chemical imbalances

• Fails to recognize social and psychological processes as
powerful influences over bodily estates—assumes a
mind-body dualism

• Emphasizes illness over health rather than focusing on
behaviors that promote health

• Model cannot address many puzzles that face
practitioners: why, for example, if six people are
exposed to a flu virus, do only three develop the flu?

■ THE RISE OF THE
BIOPSYCHOSOCIAL MODEL

The biomedical viewpoint began to change with the
rise of modern psychology, particularly with Sigmund
Freud’s (1856–1939) early work on conversion hysteria.
According to Freud, specific unconscious conflicts can
produce physical disturbances that symbolize repressed
psychological conflicts. Although this viewpoint is no
longer central to health psychology, it gave rise to the
field of psychosomatic medicine.

Psychosomatic Medicine
The idea that specific illnesses are produced by peo-
ple’s internal conflicts was perpetuated in the work of

6 Part One Introduction to Health Psychology

was consistent with the genetic theory. But how and
why would such a defect be triggered during sleep?
As the number of cases increased, it became evi-
dent that psychological and cultural, as well as bio-
logical, factors were involved. Some family members
reported that the victim had experienced a dream fore-
telling the death. Among the Hmong of Laos, a refu-
gee group that was especially plagued by these
nightmare deaths, dreams are taken seriously as por-
tends of the future. Anxiety due to these dreams, then,
may have played a role in the deaths (Adler, 1991).
Another vital set of clues came from a few men
who were resuscitated by family members. Several of
them said that they had been having a severe night ter-
ror. One man, for example, said that his room had sud-
denly grown darker, and a figure like a large black dog
had come to his bed and sat on his chest. He had been
unable to push the dog off and had become quickly and
dangerously short of breath (Tobin & Friedman,
1983). This was also an important clue because night
terrors are known to produce abrupt and dramatic
physiologic changes.
Interviews with the survivors revealed that many
of the men had been watching violent TV shows
shortly before retiring, and the content of the shows
appeared to have made its way into some of the fright-
ening dreams. In other cases, the fatal event occurred
immediately after a family argument. Many of the
men were said by their families to have been exhausted
from combining demanding full-time jobs with a sec-
ond job or with night school classes to learn English.
The pressures to support their families had been tak-
ing their toll.
All these clues suggest that the pressures of ad-
justing to life in the United States played a role in the
deaths. The victims may have been overwhelmed by
cultural differences, language barriers, and difficul-
ties finding satisfactory jobs. The combination of this
chronic strain, a genetic susceptibility, and an imme-
diate trigger provided by a family argument, violent
television, or a frightening dream culminated in night-
mare death (Lemoine & Mougne, 1983). Clearly, the
biopsychosocial model unraveled this puzzle.

■ THE NEED FOR HEALTH
PSYCHOLOGY

What factors led to the development of health psy-
chology? Since the inception of the field of psychol-
ogy in the early 20th century, psychologists have made

imbalances) continually interact to influence health
and illness and their course.
The biopsychosocial model emphasizes both
health and illness. From this viewpoint, health be-
comes something that one achieves through attention
to biological, psychological, and social needs, rather
than something that is taken for granted (Suls, Krantz &
Williams, 2013).

Clinical Implications of the
Biopsychosocial Model
The biopsychosocial model is useful for people treat-
ing patients as well. First, the process of diagnosis can
benefit from understanding the interacting role of bio-
logical, psychological, and social factors in assessing
a person’s health or illness. Recommendations for
treatment can focus on all three sets of factors.
The biopsychosocial model makes explicit the
significance of the relationship between patient and
practitioner. An effective patient-practitioner rela-
tionship can improve a patient’s use of services, the
efficacy of treatment, and the rapidity with which
illness is resolved.

The Biopsychosocial Model: The Case
History of Nightmare Deaths
To see how completely the mind and body are inter-
twined in health, consider a case study that intrigued
medical researchers for nearly 15 years. It involved the
bewildering “nightmare deaths” among Southeast
Asians.
Following the Vietnam War, in the 1970s, refu-
gees from Southeast Asia, especially Laos, Vietnam,
and Cambodia, immigrated to the United States.
Around 1977, the Centers for Disease Control (CDC)
in Atlanta became aware of a strange phenomenon:
sudden, unexpected nocturnal deaths among male
refugees from these groups. Death often occurred in
the first few hours of sleep. Relatives reported that the
victim began to gurgle and move about in bed rest-
lessly. Efforts to awaken him were unsuccessful, and
shortly thereafter he died. Even more mysteriously,
autopsies revealed no specific cause of death.
However, most of the victims appeared to have a
rare, genetically based malfunction in the heart’s
pacemaker. The fact that only men of particular ethnic
backgrounds were affected was consistent with the
potential role of a genetic factor. Also, the fact that the
deaths seemed to cluster within particular families

Chapter 1 What Is Health Psychology? 7

declined because of treatment innovations and changes
in public health standards, such as improvements in
waste control and sewage.
Now, chronic illnesses—especially heart disease,
cancer, and respiratory diseases—are the main con-
tributors to disability and death, particularly in indus-
trialized countries. Chronic illnesses are slowly
developing diseases with which people live for many
years and that typically cannot be cured but rather are
managed by patient and health care providers. Table 1.3
lists the main diseases worldwide at the present time.
Note how the causes are projected to change over the
next decade or so.
Why have chronic illnesses helped spawn the
field of health psychology? First, these are diseases in
which psychological and social factors are implicated
as causes. For example, personal health habits, such as
diet and smoking, contribute to the development of
heart disease and cancer, and sexual activity is critical
to the likelihood of developing AIDS (acquired im-
mune deficiency syndrome).
Second, because people may live with chronic dis-
eases for many years, psychological issues arise in
their management. Health psychologists help chroni-
cally ill people adjust psychologically and socially to
their changing health state and treatment regimens,
many of which involve self-care. Chronic illnesses af-
fect family functioning, including relationships with a
partner or children, and health psychologists help ease
the problems in family functioning that may result.
Chronic illnesses may require medication use and
self-monitoring of symptoms, as well as changes in

important contributions to health, exploring how and
why some people get ill and others do not, how people
adjust to their health conditions, and what factors lead
people to practice health behaviors. In response to
these trends, the American Psychological Association
(APA) created a task force in 1973 to focus on psy-
chology’s potential role in health research. Partici-
pants included counseling, clinical, and rehabilitation
psychologists, many of whom were already employed
in health settings. Independently, social psycholo-
gists, developmental psychologists, and community/
environmental psychologists were developing concep-
tual approaches for exploring health issues (Friedman &
Silver, 2007). These two groups joined forces, and in
1978, the Division of Health Psychology was formed
within the APA. It is safe to say that health psychol-
ogy is one of the most important developments within
the field of psychology in the past 50 years. What
other factors have fueled the growing field of health
psychology?

Changing Patterns of Illness
An important factor influencing the rise of health psy-
chology has been the change in illness patterns in the
United States and other technologically advanced societ-
ies in recent decades. As Table 1.2 shows, until the
20th century, the major causes of illness and death in
the United States were acute disorders. Acute disor-
ders are short-term illnesses, often result of a viral or
bacterial invader and usually amenable to cure. The
prevalence of acute infectious disorders, such as tu-
berculosis, influenza, measles, and poliomyelitis, has

TABLE 1.2 | What Are the Leading Causes of Death in the United States? A Comparison of 1900 and 2015,
per 100,000 Population

1900 2015

Influenza and pneumonia 202.2 Heart disease 611.1

Tuberculosis, all forms 194.4 Cancer 584.9

Gastroenteritis 142.7 Chronic lower respiratory diseases 149.2

Diseases of the heart 137.4 Accidents (unintentional injuries) 130.6

Vascular lesions of the c.n.s. 106.9 Stroke 129.0

Chronic nephritis 81.0 Alzheimer’s disease 84.8

All accidents 72.3 Diabetes 75.6

Malignant neoplasms (cancer) 64.0 Influenza and pneumonia 57.0

Certain diseases of early infancy 62.6 Nephritis, nephrotic syndrome, and nephrosis 47.1

Diphtheria 40.3 Intentional self-harm (suicide) 41.1

Source: Murphy, 2000; Centers for Disease Control and Prevention, September 2015.

8 Part One Introduction to Health Psychology

under increasing scrutiny, as substantial increases in
health care costs have not brought improvement in
basic indicators of health.
Moreover, huge disparities exist in the United States
such that some individuals enjoy the very best health
care available in the world while others receive little
health care except in emergencies. Prior to the Afford-
able Care Act (known as Obamacare), 49.9 million
Americans had no health insurance at all (U.S. Census
Bureau, 2011). Efforts to reform the health care sys-
tem to provide all Americans with a basic health care
package, similar to what already exists in most
European countries, have resulted.
Health psychology represents an important per-
spective on these issues for several reasons:

∙ Because containing health care costs is so
important, health psychology’s main emphasis
on prevention—namely, modifying people’s
risky health behaviors before they become
ill—can reduce the dollars devoted to the
management of illness.

∙ Health psychologists know what makes people
satisfied or dissatisfied with their health care
(see Chapters 8 and 9) and can help in the design
of a user-friendly health care system.

∙ The health care industry employs millions of
people. Nearly every person in the country has
direct contact with the health care system as a
recipient of services. Consequently, its impact is
enormous.

behavior, such as altering diet and getting exercise.
Health psychologists develop interventions to help peo-
ple learn these regimens and promote adherence to them.

Advances in Technology and Research
New medical technologies and scientific advances
create issues that can be addressed by health psy-
chologists. Just in the past few years, genes have
been uncovered that contribute to many diseases in-
cluding breast cancer. How do we help a college stu-
dent whose mother has just been diagnosed with
breast cancer come to terms with her risk? If she
tests positive for a breast cancer gene, how will this
change her life? Health psychologists help answer
such questions.
Certain treatments that prolong life may severely
compromise quality of life. Increasingly, patients are
asked their preferences regarding life-sustaining mea-
sures, and they may require counseling in these mat-
ters. These are just a few examples of how health
psychologists respond to scientific developments.

Expanded Health Care Services
Other factors contributing to the rise of health psy-
chology involve the expansion of health care ser-
vices. Health care is the largest service industry in
the United States, and it is still growing rapidly.
Americans spend more than $3 trillion annually on
health care (National Health Expenditures, 2014).
In recent years, the health care industry has come

TABLE 1.3 | What Are the Worldwide Causes of Death?

2014 2030

Projected
Rank Disease or Injury Rank Disease or Injury

1 Ischemic heart disease 1 Ischemic heart disease

2 Stroke 2 Cerebrovascular disease

3 Chronic obstructive pulmonary disease 3 Chronic obstructive pulmonary disease

4 Lower respiratory infections 4 Lower respiratory infections

5 Trachea bronchus, lung cancers 5 Road traffic accidents

6 HIV/AIDS 6 Trachea, bronchus, lung cancers

7 Diarrhoeal diseases 7 Diabetes mellitus

8 Diabetes mellitus 8 Hypertensive heart disease

9 Road injury 9 Stomach cancer

10 Hypertensive heart disease 10 HIV/AIDS

Source: World Health Organization, May 2014.

Chapter 1 What Is Health Psychology? 9

those that target risk factors such as diet or smoking,
have contributed to the decline in the incidence of some
diseases, especially coronary heart disease.
To take another example, psychologists learned
many years ago that informing patients fully about the
procedures and sensations involved in unpleasant medi-
cal procedures such as surgery improves their adjust-
ment (Janis, 1958; Johnson, 1984). As a consequence of
these studies, many hospitals and other treatment cen-
ters now routinely prepare patients for such procedures.
Ultimately, if a health-related discipline is to
flourish, it must demonstrate a strong track record,
not only as a research field but as a basis for interven-
tions as well. Health psychology is well on its way to
fulfilling both tasks.

■ HEALTH PSYCHOLOGY
RESEARCH

Health psychologists make important methodological
contributions to the study of health and illness. The
health psychologist can be a valuable team member by
providing the theoretical, methodological, and statisti-
cal expertise that is the hallmark of good training in
psychology.

The Role of Theory in Research
Although much research in health psychology is
guided by practical problems, such as how to ease the
transition from hospital to home care, about one-third
of health psychology investigations are guided by the-
ory (Painter, Borba, Hynes, Mays, & Glanz, 2008). A
theory is a set of analytic statements that explain a set
of phenomena, such as why people practice poor
health behaviors. The best theories are simple and
useful. Throughout this text, we will see references to
many theories, such as the theory of planned behavior
that predicts and explains when people change their
health behaviors (Chapter 3).
The advantages of theory for guiding research
are several. Theories provide guidelines for how to do
research and interventions (Mermelstein & Revenson,
2013). For example, the general principles of cog-
nitive behavior therapy can tell one investigator what
components should go into an intervention with
breast cancer patients to help them cope with the af-
termath of surgery, and these same principles can
help a different investigator develop a weight loss in-
tervention for obese people.

For all these reasons, then, health care delivery has a
substantial social and psychological impact on people,
an impact that is addressed by health psychologists.

Increased Medical Acceptance
Another reason for the development of health psychol-
ogy is the increasing acceptance of health psychologists
within the medical community. Health psychologists
have developed a variety of short-term behavioral inter-
ventions to address health-related problems, including
managing pain, modifying bad health habits such as
smoking, and controlling the side effects of treatments.
Techniques that may take a few hours to teach can pro-
duce years of benefit. Such interventions, particularly

In the 19th and 20th centuries, great strides were made in the

technical basis of medicine. As a result, physicians looked more

and more to the medical laboratory and less to the mind as a

way of understanding the onset and progression of illness.

10 Part One Introduction to Health Psychology

trials are the gold standards of health psychology re-
search. However, sometimes it is impractical to study
issues experimentally. People cannot, for example, be
randomly assigned to diseases. In this case, other
methods, such as correlational methods, may be used.

Correlational Studies
Much research in health psychology is correlational
research, in which the health psychologist measures
whether changes in one variable correspond with
changes in another variable. A correlational study, for
example, might reveal that people who are more hos-
tile have a higher risk for cardiovascular disease.
The disadvantage of correlational studies is that it
is difficult to determine the direction of causality un-
ambiguously. For example, perhaps cardiovascular
risk factors lead people to become more hostile. On
the other hand, correlational studies often have advan-
tages over experiments because they are more adapt-
able, enabling us to study issues when variables
cannot be manipulated experimentally.

Prospective and Retrospective Designs
Some of the problems with correlational studies can be
remedied by using a prospective design. Prospective
research looks forward in time to see how a group of
people change, or how a relationship between two vari-
ables changes over time. For example, if we were to find
that hostility develops relatively early in life, but heart
disease develops later, we would be more confident that
hostility is a risk factor for heart disease and recognize
that the reverse direction of causality—namely, that
heart disease causes hostility—is less likely.
Health psychologists conduct many prospective
studies in order to understand the risk factors that re-
late to health conditions. We might, for example, in-
tervene in the diet of one community and not in
another and over time look at the difference in rates
of heart disease. This would be an experimental pro-
spective study. Alternatively, we might measure the
diets that people create for themselves and look at
changes in rates of heart disease, based on how good
or poor the diet is. This would be an example of a cor-
relational prospective study.
A particular type of prospective study is longitudi-
nal research, in which the same people are observed
at multiple points in time. For example, to understand
what factors are associated with early breast cancer in

Theories generate specific predictions, so they can
be tested and modified as the evidence comes in. For
example, testing theories of health behavior change re-
vealed that people need to believe they can change
their behavior, and so the importance of self-efficacy
was incorporated into theories of health behaviors.
Theories help tie together loose ends. Everyone
knows that smokers relapse, people go off their diets,
and alcoholics have trouble remaining abstinent. A
theory of relapse unites these scattered observations
into general principles of relapse prevention that can
be incorporated into diverse interventions. A wise
psychologist once said, “There is nothing so practical
as a good theory” (Lewin, 1946), and we will see this
wisdom repeatedly borne out.

Experiments
Much research in health psychology is experimental. In
an experiment, a researcher creates two or more condi-
tions that differ from each other in exact and predeter-
mined ways. People are then randomly assigned to these
different conditions, and their reactions are measured.
Experiments to evaluate the effectiveness of treatments
or interventions over time are also called randomized
clinical trials, in which a target treatment is compared
against the existing standard of care or a placebo con-
trol, that is, an organically inert treatment.
Medical interventions increasingly are based on
these methodological principles. Evidence-based
medicine means that medical and psychological inter-
ventions go through rigorous testing and evaluation of
their benefits, usually through randomized clinical trials,
before they become the standard of care (Rousseau &
Gunia, 2016). These criteria for effectiveness are also
frequently now applied to psychological interventions.
What kinds of experiments do health psycholo-
gists undertake? To determine if social support groups
improve adjustment to cancer, cancer patients might
be randomly assigned to participate in a support group
or to a comparison condition, such as an educational
intervention. The patients could be evaluated at a sub-
sequent time to pinpoint how the two groups differed
in their adjustment.
Experiments have been the mainstay of science,
because they typically provide more definitive
answers to problems than other research methods.
When we manipulate a variable and see its effects, we
can establish a cause-effect relationship definitively.
For this reason, experiments and randomized clinical

Chapter 1 What Is Health Psychology? 11

But morbidity is important as well. What is the
use of affecting causes of death if people remain ill
but simply do not die? Health psychology addresses
health- related quality of life. Indeed, some researchers
maintain that quality of life and symptom reduction
should be more important targets for our interventions
than mortality and other biological indicators (Kaplan,
1990). Consequently, health psychologists work to
improve quality of life so that people with chronic
disorders can live their lives as free from pain, disability,
and lifestyle compromise as possible.

Methodological Tools
This section highlights some of the methodological
tools that have proven valuable in health psychology
research.

Tools of Neuroscience The field of neurosci-
ence has developed powerful new tools such as func-
tional magnetic resonance imaging (fMRI) that permit
glimpses into the brain. This area of research has also
produced knowledge about the autonomic, neuroen-
docrine, and immune systems that have made a vari-
ety of breakthrough studies possible. For example,
health psychologists can now connect psychosocial
conditions, such as social support and positive beliefs,
to underlying biology in ways that make believers out
of skeptics. The knowledge and methods of neurosci-
ence also shed light on such questions as, how do pla-
cebos work? Why are many people felled by functional
disorders that seem to have no underlying biological
causes? Why is chronic pain so intractable to treat-
ment? We address these issues in later chapters. These
and other applications of neuroscience will help to
address clinical puzzles that have mystified practitio-
ners for decades (Gianaros & Hackman, 2013).

Mobile and Wireless Technologies The rev-
olution in technology has given rise to a variety of
tools to intervene in and assess the health environment
(Kaplan & Stone, 2013). Ecological momentary
interventions (EMI) (Heron & Smyth, 2010) make use
of cell phones, pagers, palm pilots, tablets, and other
mobile technologies to deliver interventions and
assess health-related events in the natural environ-
ment. Interventions using EMI have included studies
of smoking cessation, weight loss, diabetes manage-
ment, eating disorders, healthy diet, and physical ac-
tivity (Heron & Smyth, 2010).

women at risk, we might follow a group of young
women whose mothers developed breast cancer, iden-
tify which daughters developed breast cancer, and
identify factors reliably associated with that develop-
ment, such as diet, smoking, or alcohol consumption.
Investigators also use retrospective designs, which
look backward in time in an attempt to reconstruct the
conditions that led to a current situation. Retrospective
methods, for example, were critical in identifying the
risk factors that led to the development of AIDS. Ini-
tially, researchers saw an abrupt increase in a rare cancer
called Kaposi’s sarcoma and observed that the men who
developed this cancer often eventually died of general
failure of the immune system. By taking extensive his-
tories of the men who developed this disease, researchers
were able to determine that the practice of anal-
receptive sex without a condom is related to the devel-
opment of the disorder. Because of retrospective studies,
researchers knew some of the risk factors for AIDS even
before they had identified the retrovirus.

The Role of Epidemiology
in Health Psychology
Changing patterns of illness have been charted and fol-
lowed by the field of epidemiology, a discipline closely
related to health psychology in its goals and interests.
Epidemiology is the study of the frequency, distribu-
tion, and causes of infectious and noninfectious disease
in a population. For example, epidemiologists study not
only who has what kind of cancer but also why some
cancers are more prevalent than others in particular
geographic areas or among particular groups of people.
Epidemiological studies frequently use two im-
portant terms: “morbidity” and “mortality.” Morbidity
refers to the number of cases of a disease that exist at
some given point in time. Morbidity may be expressed
as the number of new cases (incidence) or as the total
number of existing cases (prevalence). Morbidity sta-
tistics, then, tell us how many people have what kinds
of disorders at any given time. Mortality refers to
numbers of deaths due to particular causes.
Morbidity and mortality statistics are essential to
health psychologists. Charting the major causes of
disease can lead to steps to reduce their occurrence.
For example, knowing that automobile accidents are a
major cause of death among children, adolescents,
and young adults has led to safety measures, such as
child-safety restraint systems, mandatory seat belt
laws, and raising the legal drinking age.

12 Part One Introduction to Health Psychology

individual person talk about his or her health needs and
experiences is, of course, beneficial for planning an in-
tervention for that person, such as help in losing weight.
But more broadly, guided interviews and narratives can
provide insights into health processes that summary
statistics may not provide. For example, interviews
with cancer patients about their chemotherapy experi-
ences may be more helpful in redesigning how chemo-
therapy is administered than are numerical ratings of
how satisfied patients are. Qualitative research can also
supplement insights from other research methods. For
example, surveys of college students can identify rates
of problem drinking, but interviews may be helpful for
identifying how to build responsible drinking skills
(deVisser et al., 2015). Quantitative and qualitative
methods can work hand-in-hand to develop the research
evidence for effective interventions.

■ WHAT IS HEALTH PSYCHOLOGY
TRAINING FOR?

Students who are trained in health psychology on the
undergraduate level go on to many different occupa-
tions. Some students go into medicine, becoming phy-
sicians and nurses. Because of their experience in
health psychology, some of these health care practitio-
ners conduct research as well. Other health psychol-
ogy students go into the allied health professional
fields, such as social work, occupational therapy, di-
etetics, physical therapy, or public health. Social
workers in medical settings, for example, may assess
where patients go after discharge, decisions that are
informed by knowledge of the psychosocial needs of
patients. Dietetics is important in the dietary manage-
ment of chronic illnesses, such as cancer, heart dis-
ease, and diabetes. Physical therapists help patients
regain the use of limbs and functions that may have
been compromised by illness and its treatment.
Students who receive either a Ph.D. in health psy-
chology or a Psy.D. most commonly go into academic
research as faculty members or into private practice,
where they provide individual and group counseling.
Other Ph.D.s in health psychology practice in hospi-
tals and other health care settings. Many are involved
in the management of health care, including business
and government positions. Others work in medical
schools, hospitals and other treatment settings, and
industrial or occupational health settings to promote
healthy behavior, prevent accidents, and help control
health care costs. ∙

People in these studies typically participate through
an apparatus, such as a cell phone, that can provide
on-the-spot administration of a treatment or intervention,
as well as the collection of data. For example, text mes-
sages just before meals can remind people about their
intentions to consume a healthy diet. Short text messag-
ing has also been used to enhance smoking cessation pro-
grams and ensure maintenance to quitting (Berkman,
Dickenson, Falk, & Lieberman, 2011). Activity measures
and sensors can accurately assess how much exercise a
person is getting. Mobile technology can also help people
already diagnosed with disorders. People on medications
may receive reminders from mobile devices to take their
medications. Numerous other applications are likely.
Measuring biological indicators of health has usu-
ally required an invasive procedure such as a blood
draw. Now, however, mobile health technologies can as-
sess some biological processes. Ambulatory blood pres-
sure monitoring devices help people with high blood
pressure identify conditions when their blood pressure
goes up. People with diabetes can monitor their blood
glucose levels multiple times a day with far less invasive
technology than was true just a few years ago.
At present, evidence for the success of mobile
health-based interventions and assessments is mixed
(Kaplan & Stone, 2013), suggesting the need for more
research. But these procedures have greatly improved
health psychologists’ abilities to study health-related
phenomena in real time.

Meta-analysis For some topics in health psy-
chology, enough studies have been done to conduct a
meta-analysis. Meta-analysis combines results from
different studies to identify how strong the evidence is
for particular research findings. For example, a meta-
analysis might be conducted on 100 studies of dietary
interventions to identify which characteristics of these
interventions lead to more successful dietary change.
Such an analysis might reveal, for example, that only
those interventions that enhance self-efficacy, that is,
the belief that one will be able to modify one’s diet,
are successful. Meta-analysis is a particularly power-
ful methodological tool, because it uses a broad array
of diverse evidence to reach conclusions.

Qualitative Research
In addition to the methods just described, there is an
important role for qualitative research in health psy-
chology (Gough & Deatrich, 2015). Listening to an

Chapter 1 What Is Health Psychology? 13

1. Health psychology examines psychological
influences on how people stay healthy, why
they become ill, and how they respond when
they do get ill. The field focuses on health
promotion and maintenance; prevention
and treatment of illness; the etiology and
correlates of health, illness, and disability;
and improvement of the health care system
and the formulation of health policy.

2. The interaction of the mind and the body has
concerned philosophers and scientists for
centuries. Different models of the relationship
have predominated at different times in history.

3. The biomedical model, which has dominated
medicine, is a reductionistic, single-factor model
of illness that treats the mind and the body as
separate entities and emphasizes illness concerns
over health.

4. The biomedical model is currently being
replaced by the biopsychosocial model, which
regards any health disorder as the result of the
interplay of biological, psychological, and social
factors. The biopsychosocial model recognizes
the importance of interacting macrolevel and
microlevel processes in producing health and
illness. Under this model, health is regarded as
an active achievement.

5. The biopsychosocial model guides health
psychologists and practitioners in their research
efforts to uncover factors that predict states of
health and illness and in their clinical
interventions with patients.

6. The rise of health psychology can be tied to
several factors, including the increase in chronic
or lifestyle-related illnesses, the expanding role
of health care in the economy, the realization
that psychological and social factors contribute
to health and illness, the demonstrated
importance of psychological interventions to
improving people’s health, and the rigorous
methodological contributions of health
psychology researchers.

7. Health psychologists perform a variety of tasks.
They develop theories and conduct research
on the interaction of biological, psychological,
and social factors in producing health and
illness. They help treat patients with a variety
of disorders and conduct counseling for the
psychosocial problems that illness may create.
They develop worksite interventions to improve
employees’ health habits and work in medical
settings and other organizations to improve
health and health care delivery.

S U M M A R Y

K E Y T E R M S

acute disorders
biomedical model
biopsychosocial model
chronic illnesses
conversion hysteria
correlational research
epidemiology
etiology

evidence-based medicine
experiment
health
health psychology
longitudinal research
meta-analysis
morbidity
mortality

prospective research
psychosomatic medicine
randomized clinical trials
retrospective designs
theory
wellness

Disorders of the Cardiovascular System

Blood Pressure

The Blood

The Respiratory System
Overview

The Structure and Functions of the Respiratory System

Disorders Associated with the Respiratory System

Dealing with Respiratory Disorders

The Digestive System and the Metabolism of Food
Overview

The Functioning of the Digestive System

Disorders of the Digestive System

The Renal System
Overview

Disorders of the Renal System

The Reproductive System
Overview

The Ovaries and Testes

Fertilization and Gestation

Disorders of the Reproductive System

Genetics and Health
Overview

Genetics and Susceptibility to Disorders

The Immune System
Overview

Infection

The Course of Infection

Immunity

Disorders Related to the Immune System

C H A P T E R 2

C H A P T E R O U T L I N E

The Nervous System
Overview

The Brain

The Role of Neurotransmitters

Disorders of the Nervous System

The Endocrine System
Overview

The Adrenal Glands

Disorders Involving the Endocrine System

The Cardiovascular System
Overview

The Heart

The Systems of the Body

Chapter 2 The Systems of the Body 15

Regulation of the autonomic nervous system occurs
via the sympathetic nervous system and the parasympa-
thetic nervous system. The sympathetic nervous system
prepares the body to respond to emergencies, to strong
emotions such as anger or fear, and to strenuous activity.
As such, it plays an important role in reaction to stress.
The parasympathetic nervous system controls the
activities of organs under normal circumstances and acts
antagonistically to the sympathetic nervous system.
When an emergency has passed, the parasympathetic ner-
vous system helps to restore the body to a normal state.

The Brain
The brain is the command center of the body. It re-
ceives sensory impulses from the peripheral nerve
endings and sends motor impulses to the extremities
and to internal organs to carry out movement. The
parts of the brain are shown in Figure 2.2.

The Hindbrain and the Midbrain The hind-
brain has three main parts: the medulla, the pons, and
the cerebellum. The medulla is responsible for the regu-
lation of heart rate, blood pressure, and respiration. Sen-
sory information about the levels of carbon dioxide and
oxygen in the body also comes to the medulla, which, if
necessary, sends motor impulses to respiratory muscles
to alter the rate of breathing. The pons serves as a link
between the hindbrain and the midbrain and also helps
control respiration.
The cerebellum coordinates voluntary muscle move-
ment, the maintenance of balance and equilibrium, and

An understanding of health requires a working knowledge of human physiology, namely the
study of the body’s functioning. Having basic knowl-
edge of physiology clarifies how good health habits
make illness less likely, how stress affects the body,
how chronic stress can lead to hypertension or coro-
nary artery disease, and how cell growth is radically
altered by cancer.

■ THE NERVOUS SYSTEM

Overview
The nervous system is a complex network of intercon-
nected nerve fibers. As Figure 2.1 shows, the nervous
system is made up of the central nervous system, which
consists of the brain and the spinal cord, and the periph-
eral nervous system, which consists of the rest of the
nerves in the body, including those that connect to the
brain and spinal cord. Sensory nerve fibers provide in-
put to the brain and spinal cord by carrying signals from
sensory receptors; motor nerve fibers provide output
from the brain or spinal cord to muscles and other or-
gans, resulting in voluntary and involuntary movement.
The peripheral nervous system is made up of the so-
matic nervous system and the autonomic nervous system.
The somatic, or voluntary, nervous system connects nerve
fibers to voluntary muscles and provides the brain with
feedback about voluntary movement, such as a tennis
swing. The autonomic, or involuntary, nervous system
connects the central nervous system to all internal organs
over which people do not customarily have control.

FIGURE 2.1 | The Components of the Nervous System

The nervous system

Central nervous system
(carries voluntary nerve
impulses to skeletal muscles
and skin; carries involuntary
impulses to muscles and glands)

Brain Spinal cord

Peripheral nervous system

Somatic nervous
system
(controls voluntary
movement)

Autonomic nervous
system
(controls organs that
operate involuntarily)

Sympathetic nervous
system
(mobilizes the body
for action)

Parasympathetic
nervous system
(maintains and
restores
equilibrium)

16 Part One Introduction to Health Psychology

The cerebral cortex consists of four lobes: frontal,
parietal, temporal, and occipital. Each lobe has its own
memory storage area or areas of association. Through
these complex networks of associations, the brain is
able to relate current sensations to past ones, giving the
cerebral cortex its formidable interpretive capabilities.
In addition to its role in associative memory, each
lobe is generally associated with particular functions.
The frontal lobe contains the motor cortex, which co-
ordinates voluntary movement. The parietal lobe con-
tains the somatosensory cortex, in which sensations of
touch, pain, temperature, and pressure are registered
and interpreted. The temporal lobe contains the corti-
cal areas responsible for auditory and olfactory (smell)
impulses, and the occipital lobe contains the visual
cortex, which receives visual impulses.

The Limbic System The limbic system plays an
important role in stress and emotional responses. The
amygdala and the hippocampus are involved in the
detection of threat and in emotionally charged memories,
respectively. The cingulate gyrus, the septum, and areas
in the hypothalamus are related to emotional functioning
as well.
Many health disorders implicate the brain. One
important disorder that was overlooked until recently
is chronic traumatic encephalopathy, whose causes
and consequences are described in Box 2.1.

the maintenance of muscle tone and posture. Damage
to this area can produce loss of muscle tone, tremors,
and disturbances in posture or gait.
The midbrain is the major pathway for sensory
and motor impulses moving between the forebrain and
the hindbrain. It is also responsible for the coordina-
tion of visual and auditory reflexes.

The Forebrain The forebrain includes the
thalamus and the hypothalamus. The thalamus is in-
volved in the recognition of sensory stimuli and the
relay of sensory impulses to the cerebral cortex.
The hypothalamus helps regulate cardiac function-
ing, blood pressure, respiration, water balance, and
appetites, including hunger and sexual desire. It is an
important transition center between the thoughts gener-
ated in the cerebral cortex of the brain and their impact
on internal organs. For example, embarrassment can lead
to blushing via the hypothalamus through the vasomotor
center in the medulla to the blood vessels. Together with
the pituitary gland, the hypothalamus helps regulate the
endocrine system, which releases hormones that affect
functioning in target organs throughout the body.
The forebrain also includes the cerebral cortex,
the largest portion of the brain, involved in higher-
order intelligence, memory, and personality. Sensory
impulses that come from the peripheral areas of the
body are received and interpreted in the cerebral cortex.

FIGURE 2.2 | The Brain (Source: Lankford, 1979, p. 232)

Corpus callosum

Cerebellum

Spinal cord

Pons

Reticular formation

Hypothalamus

Thalamus

Pituitary

Cerebellum

Visual
cortex

Somatosensory cortex
Motor cortex

Temporal lobe

Occipital
lobe

Frontal
lobe

Auditory cortex

Parietal lobe

(a) Surface diagram (b) Cross-sectional diagram

Cerebral
cortex

such as coronary artery disease and hypertension,
discussed in greater detail in Chapter 13.
Parasympathetic functioning is a counterregulatory
system that helps restore homeostasis following sympa-
thetic arousal. The heart rate decreases, the heart’s capil-
laries constrict, blood vessels dilate, respiration rate
decreases, and the metabolic system resumes its activities.

Disorders of the Nervous System
Approximately 25 million Americans have some dis-
order of the nervous system. The most common
forms of neurological dysfunction are epilepsy and
Parkinson’s disease. Cerebral palsy, multiple sclerosis,
and Huntington’s disease also affect substantial num-
bers of people.

Epilepsy A disease of the central nervous system
affecting 1 in 26 people in the United States (Epilepsy
Foundation, 2014), epilepsy is often idiopathic, which
means that no specific cause for the symptoms can be
identified. Symptomatic epilepsy may be traced to

The Role of Neurotransmitters
The nervous system functions by means of chemi-
cals, called neurotransmitters, that regulate nervous
system functioning. Stimulation of the sympathetic
nervous system prompts the secretion of two neu-
rotransmitters, epinephrine and norepinephrine, to-
gether termed the catecholamines. These substances
are carried through the bloodstream throughout the
body, promoting sympathetic activation.
The release of catecholamines prompts important
bodily changes. Heart rate increases, the heart’s capil-
laries dilate, and blood vessels constrict, increasing
blood pressure. Blood is diverted into muscle tissue.
Respiration rate goes up, and the amount of air flow-
ing into the lungs is increased. Digestion and urina-
tion are generally decreased. The pupils of the eyes
dilate, and sweat glands are stimulated to produce
more sweat. These changes are critically important in
responses to stressful circumstances. Chronic or recur-
rent arousal of the sympathetic nervous system can
accelerate the development of several chronic disorders,

B O X 2.1Costs of War to the Brain

A 27-year-old former Marine who had done two tours
of Iraq returned home, attempting to resume his fam-
ily life and college classes. Although he had once had
good grades, he found he could not remember small
details or focus his attention any longer. He became
irritable, snapping at his family, and eventually, his
wife initiated divorce proceedings. He developed an
alcohol problem, and a car crash caused him to lose
his driver’s license. When his parents hadn’t heard
from him, they phoned the police, who found him, a
suicide victim of hanging.
Chronic traumatic encephalopathy (CTE) is a de-
generative brain disorder that strikes people who have
had repeated or serious head injuries. Former boxers
and football players, for example, have high rates of
CTE. In CTE, an abnormal form of a protein accumu-
lates and eventually destroys cells in the brain, includ-
ing the frontal and temporal lobes, which are critical
for decision making, impulse control, and judgment.
Autopsies suggest that CTE may also be present
at high levels among returning veterans, and that blasts
from bombs or grenades may have produced these
serious effects, including irreversible losses in mem-
ory and thinking abilities. More than 27,000 cases
of traumatic war injury were reported by the U.S.
military in 2009 alone, and CTE is a likely contributor

(Congressional Research Service, 2010). CTE is sus-
pected in some cases that have been diagnosed as
post-traumatic stress disorder (see Chapter 6).
Whether the military will find ways to reduce expo-
sure to its causes or ways to retard the processes CTE
sets into effect remains to be seen. Health psycholo-
gists can play an important role in addressing the cog-
nitive and social costs of this degenerative disorder.

Source: Kristof, April 25, 2012.

18 Part One Introduction to Health Psychology

The effects of multiple sclerosis result from the
disintegration of myelin, a fatty membrane that sur-
rounds nerve fibers and facilitates the conduction of
nerve impulses. Multiple sclerosis is an autoimmune
disorder, so called because the immune system fails to
recognize its own tissue and attacks the myelin sheath
surrounding nerve fibers.

Huntington’s Disease A hereditary disorder of
the central nervous system, Huntington’s disease is
characterized by chronic physical and mental deterio-
ration. Symptoms include involuntary muscle spasms,
loss of motor abilities, personality changes, and other
signs of mental disintegration.
The disease affects about 30,000 people directly,
and 200,000 more are at risk in the United States (Hun-
tington’s Disease Society of America, 2016). The gene
for Huntington’s has been isolated, and a test is now
available that indicates not only if one is a carrier of the
gene but also at what age (roughly) one will succumb to
the disease. As will be seen later in this chapter, genetic
counseling with this group of at-risk people is important.

Polio Poliomyelitis is a highly infectious viral dis-
ease that affects mostly young children. It attacks the
spinal nerves and destroys the cell bodies of motor
neurons so that motor impulses cannot be carried from
the spinal cord outward to the peripheral nerves or
muscles. Depending on the degree of damage that is
done, the person may be left with difficulties in walk-
ing and moving properly, ranging from shrunken and
ineffective limbs to full paralysis. Polio cases have de-
creased substantially worldwide, although polio is still
a major health issue in Pakistan and Afghanistan.

Paraplegia and Quadriplegia Paraplegia is
paralysis of the lower extremities of the body; it re-
sults from an injury to the lower portion of the spinal
cord. Quadriplegia is paralysis of all four extremities
and the trunk of the body; it occurs when the upper
portion of the spinal cord is severed. People who have
these conditions usually lose bladder and bowel con-
trol and the muscles below the cut area may lose their
tone, becoming weak and flaccid.

Dementia Dementia (meaning “deprived of
mind”) is a serious loss of cognitive ability beyond
what might be expected from normal aging. A history
of brain injuries or a genetically-based propensity may
be involved in long-term decline. Although dementia

harm during birth, severe injury to the head, infec-
tious disease such as meningitis or encephalitis, or
metabolic or nutritional disorders. Risk for epilepsy
may also be inherited.
Epilepsy is marked by seizures, which range from
barely noticeable to violent convulsions accompanied
by irregular breathing and loss of consciousness. Epi-
lepsy cannot be cured, but it can often be controlled
through medication and behavioral interventions de-
signed to manage stress (see Chapters 7 and 11).

Parkinson’s Disease Patients with Parkinson’s
disease have progressive degeneration of the basal
ganglia, a group of nuclei in the brain that control
smooth motor coordination. The result of this deterio-
ration is tremors, rigidity, and slowness of movement.
As many as one million Americans have Parkinson’s
disease, which primarily strikes people age 50 and
older (Parkinson’s Disease Foundation, 2016); men
are more likely than women to develop the disease. Al-
though the cause of Parkinson’s is not fully known, de-
pletion of the neurotransmitter dopamine may be
involved. Parkinson’s patients may be treated with med-
ication, but large doses, which can cause undesirable side
effects, are often required for control of the symptoms.

Cerebral Palsy Currently, more than 764,000
people in the United States have or experience symp-
toms of cerebral palsy (CerebralPalsy.org, 2016). Ce-
rebral palsy is a chronic, nonprogressive disorder
marked by lack of muscle control. It stems from brain
damage caused by an interruption in the brain’s oxy-
gen supply, usually during childbirth. In older chil-
dren, a severe accident or physical abuse can produce
the condition. Apart from being unable to control mo-
tor functions, those who have the disorder may (but
need not) also have seizures, spasms, mental retarda-
tion, difficulties with sensation and perception, and
problems with sight, hearing, and/or speech.

Multiple Sclerosis Approximately 2.3 million
people worldwide have multiple sclerosis (National
Multiple Sclerosis Society, 2016). This degenerative
disease can cause paralysis and, occasionally, blind-
ness, deafness, and mental deterioration. Early symp-
toms include numbness, double vision, dragging of
the feet, loss of bladder or bowel control, speech dif-
ficulties, and extreme fatigue. Symptoms may appear
and disappear over a period of years; after that, dete-
rioration is continuous.

Chapter 2 The Systems of the Body 19

stimulating and inhibiting each other’s activities. The
nervous system is chiefly responsible for fast-acting,
short-duration responses to changes in the body,
whereas the endocrine system mainly governs slow-
acting responses of long duration.
The endocrine system is regulated by the hypothala-
mus and the pituitary gland. Located at the base of the
brain, the pituitary has two lobes. The posterior pituitary
lobe produces oxytocin, which controls contractions dur-
ing labor and lactation and is also involved in social af-
filiation, and vasopressin, or antidiuretic hormone (ADH),
which controls the water-absorbing ability of the kidneys,
among other functions. The anterior pituitary lobe of the
pituitary gland secretes hormones responsible for growth:
somatotropic hormone (STH), which regulates bone,
muscle, and other organ development; gonadotropic hor-
mones, which control the growth, development, and se-
cretions of the gonads (testes and ovaries); thyrotropic
hormone (TSH), which controls the growth, develop-
ment, and secretion of the thyroid gland; and adrenocorti-
cotropic hormone (ACTH), which controls the growth
and secretions of the cortex region of the adrenal glands.

The Adrenal Glands
The adrenal glands are small glands located on top of
each of the kidneys. Each adrenal gland consists of an
adrenal medulla and an adrenal cortex. The hormones
of the adrenal medulla are epinephrine and norepi-
nephrine, which were described earlier.
As Figure 2.4 implies, the adrenal glands are criti-
cally involved in physiological and neuroendocrine re-
actions to stress. Catecholamines, secreted in conjunction
with sympathetic arousal, and corticosteroids are impli-
cated in biological responses to stress. We will consider
these stress responses more fully in Chapter 6.

Disorders Involving the Endocrine System
Diabetes Diabetes is a chronic endocrine disorder
in which the body is not able to manufacture or properly
use insulin. It is the fourth most common chronic illness
in this country and one of the leading causes of death.
Diabetes consists of two primary forms. Type I diabetes
is a severe disorder that typically arises in late childhood
or early adolescence. At least partly genetic in origin,
Type I diabetes is an autoimmune disorder, possibly pre-
cipitated by an earlier viral infection. The immune sys-
tem falsely identifies cells in the islets of Langerhans in
the pancreas as invaders and destroys those cells, com-
promising or eliminating their ability to produce insulin.

is most common among older adults, it may occur at
any stage of adulthood. Memory, attention, language,
and problem solving are affected early in the disorder
and often lead to diagnosis.
The most common form of dementia is Alzheimer’s,
accounting for 60–70% of the cases. In most people,
symptoms appear in their mid-60s, and the disease
progresses irreversibly, due to plaques and tangles in
the progressively shrinking brain. In addition to the
early signs of cognitive decline, especially difficulty
with short term memory, social functioning, and use
of language, are disrupted as the disease progresses.
About 48 million people worldwide have Alzheimer’s
(Alzheimer’s Association, 2016).

■ THE ENDOCRINE SYSTEM

Overview
The endocrine system, diagrammed in Figure 2.3,
complements the nervous system in controlling bodily
activities. The endocrine system is made up of a num-
ber of ductless glands that secrete hormones into the
blood, stimulating changes in target organs. The endo-
crine and nervous systems depend on each other,

FIGURE 2.3 | The Endocrine System

Thyroid

Ovaries

Adrenal glands

Testes

Pituitary gland

20 Part One Introduction to Health Psychology

body. Blood carries oxygen from the lungs to the tissues
and carbon dioxide from the tissues to the lungs. Blood
also carries nutrients from the digestive tract to the indi-
vidual cells so that the cells may extract nutrients for
growth and energy. The blood carries waste products from
the cells to the kidneys, from which the waste is excreted
in the urine. It also carries hormones from the endocrine
glands to other organs of the body and transports heat to
the surface of the skin to control body temperature.

The Heart
The heart functions as a pump, and its pumping action
causes the blood to circulate throughout the body. The
left side of the heart, consisting of the left atrium and
left ventricle, takes in oxygenated blood from the lungs
and pumps it out into the aorta (the major artery leaving
the heart), from which the blood passes into the smaller
vessels (the arteries, arterioles, and capillaries) to reach
the cell tissues. The blood exchanges its oxygen and
nutrients for the waste materials of the cells and is then
returned to the right side of the heart (right atrium and
right ventricle), which pumps it back to the lungs via the
pulmonary artery. Once oxygenated, the blood returns
to the left side of the heart through the pulmonary veins.
The anatomy of the heart is pictured in Figure 2.5.

Type II diabetes, which typically occurs after age
40, is the more common form. In Type II diabetes,
insulin may be produced by the body, but there may
not be enough of it, or the body may not be sensitive
to it. It is heavily a disease of lifestyle, and risk factors
include obesity and stress, among other factors.
Diabetic patients have high rates of coronary heart
disease, and diabetes is the leading cause of blindness
among adults. It accounts for almost 50 percent of all the
patients who require renal dialysis for kidney failure
(National Institute on Diabetes and Digestive and Kidney
Disorders, 2007). Diabetes can also produce nervous
system damage, leading to pain and loss of sensation. In
severe cases, amputation of the extremities, such as toes
and feet, may be required. As a consequence of these
complications, people with diabetes have a considerably
shortened life expectancy. In later chapters, we will con-
sider Type I (Chapter 14) and Type II (Chapter 13) diabe-
tes, and the issues associated with their management.

■ THE CARDIOVASCULAR
SYSTEM

Overview
The cardiovascular system comprises the heart, blood
vessels, and blood and acts as the transport system of the

FIGURE 2.4 | Adrenal Gland Activity in Response to Stress

Secretion of catecholamines
(epinephrine and norepinephrine)
– Heart rate increases and heart capillaries dilate
– Blood pressure increases via vasoconstriction
– Blood is diverted to muscle tissue
– Breathing rate increases
– Digestion slows down
– Pupils of eyes dilate

Secretion of
corticosteroids
– Increases protein and

fat mobilization
– Increases access to

bodily energy storage
– Inhibits antibody

formation and inflammation
– Regulates sodium

retention

Stress

Pituitary
gland

Sympathetic
nervous system

Adrenal
cortex

Adrenal
medulla

Chapter 2 The Systems of the Body 21

defects—that is, defects present at birth—and others,
to infection. By far, however, the major threats to the
cardiovascular system are due to lifestyle factors, in-
cluding stress, poor diet, lack of exercise, and smoking.

Atherosclerosis The major cause of heart dis-
ease is atherosclerosis, a problem that becomes worse
with age. Atherosclerosis is caused by deposits of cho-
lesterol and other substances on the arterial walls,
which form plaques that narrow the arteries. These
plaques reduce the flow of blood through the arteries
and interfere with the passage of nutrients from the cap-
illaries into the cells—a process that can lead to tissue
damage. Damaged arterial walls are also potential sites
for the formation of blood clots, which can obstruct a
vessel and cut off the flow of blood.
Atherosclerosis is associated with several pri-
mary clinical manifestations:
∙ Angina pectoris, or chest pain, which occurs

when the heart has insufficient supply of oxygen
or inadequate removal of carbon dioxide and
other waste products.

∙ Myocardial infarction (MI), or heart attack,
which results when a clot has developed in a
coronary vessel and blocks the flow of blood to
the heart.

The heart performs these functions through regular
rhythmic phases of contraction and relaxation known as
the cardiac cycle. There are two phases in the cardiac
cycle: systole and diastole. During systole, blood is
pumped out of the heart, and blood pressure in the blood
vessels increases. As the muscle relaxes during diastole,
blood pressure drops, and blood is taken into the heart.
The flow of blood into and out of the heart is con-
trolled by valves at the inlet and outlet of each ventri-
cle. These heart valves ensure that blood flows in one
direction only. The sounds that one hears when listen-
ing to the heart are the sounds of these valves closing.
These heart sounds make it possible to time the car-
diac cycle to determine how rapidly or slowly blood is
being pumped into and out of the heart.
A number of factors influence the rate at which
the heart contracts and relaxes. During exercise, emo-
tional excitement, or stress, for example, the heart
speeds up, and the cardiac cycle is completed in a
shorter time. A chronically or excessively rapid heart
rate can decrease the heart’s strength, which may
reduce the volume of blood that is pumped.

Disorders of the Cardiovascular System
The cardiovascular system is subject to a number
of disorders. Some of these are due to congenital

FIGURE 2.5 | The Heart

Tricuspid
valve

Right atrium

Right
ventricle

Aorta

Mitral valve

Left atrium

Aortic valve

Left
ventricle

Pulmonary valve
Pulmonary
artery

Aorta

22 Part One Introduction to Health Psychology

blood (oxygen and nutrients or carbon dioxide and
waste materials). The blood also helps to regulate skin
temperature.
Blood cells are manufactured in the bone marrow
in the hollow cavities of bones. Bone marrow con-
tains five types of blood-forming cells: myeloblasts
and monoblasts, both of which produce particular
white blood cells; lymphoblasts, which produce lym-
phocytes; erythroblasts, which produce red blood
cells; and megakaryocytes, which produce platelets.
Each of these types of blood cells has an important
function.
White blood cells play an important role in heal-
ing by absorbing and removing foreign substances
from the body. They contain granules that secrete di-
gestive enzymes, which engulf and act on bacteria and
other foreign particles, turning them into a form con-
ducive to excretion. An elevated white cell count sug-
gests the presence of infection.
Lymphocytes produce antibodies—agents that
destroy foreign substances. Together, these groups of
cells play an important role in fighting infection and
disease. We will consider them more fully in our dis-
cussion of the immune system in Chapter 14.
Red blood cells are important mainly because
they contain hemoglobin, which is needed to carry
oxygen and carbon dioxide throughout the body.
Anemia, which involves below-normal numbers of
red blood cells, can interfere with this transport
function.
Platelets serve several important functions. They
clump together to block small holes that develop in
blood vessels, and they also play an important role in
blood clotting.

Clotting Disorders Clots (or thromboses) can
sometimes develop in the blood vessels. This is most
likely to occur if arterial or venous walls have been
damaged or roughened because of the buildup of
cholesterol. Platelets then adhere to the roughened
area, leading to the formation of a clot. A clot can
have especially serious consequences if it occurs in
the blood vessels leading to the heart (coronary
thrombosis) or brain (cerebral thrombosis), because
it will block the vital flow of blood to these organs.
When a clot occurs in a vein, it may become de-
tached and form an embolus, which can become
lodged in the blood vessels to the lungs, causing pul-
monary obstruction. Death is a common conse-
quence of these conditions.

∙ Ischemia, a condition characterized by lack of
blood flow and oxygen to the heart muscle. As
many as 3 to 4 million Americans have silent
ischemic episodes without knowing it, and they
may consequently have a heart attack with no
prior warning.

Other major disorders of the cardiovascular system
include the following.
∙ Congestive heart failure (CHF), which occurs

when the heart’s delivery of oxygen-rich blood is
inadequate to meet the body’s needs.

∙ Arrhythmia, irregular beatings of the heart,
which, at its most severe, can lead to loss of
consciousness and sudden death.

Blood Pressure
Blood pressure is the force that blood exerts against
the blood vessel walls. During systole, the force on the
blood vessel walls is greatest; during diastole, it falls
to its lowest point. The measurement of blood pres-
sure includes these two pressures.
Blood pressure is influenced by several factors.
The first is cardiac output—pressure against the arte-
rial walls is greater as the volume of blood flow in-
creases. A second factor is peripheral resistance, or
the resistance to blood flow in the small arteries of the
body (arterioles), which is affected by the number of
red blood cells and the amount of plasma the blood
contains. In addition, blood pressure is influenced by
the structure of the arterial walls: If the walls have
been damaged, if they are clogged by deposits of
waste, or if they have lost their elasticity, blood pres-
sure will be higher. Chronically high blood pressure,
called hypertension, is the consequence of too high a
cardiac output or too high a peripheral resistance. We
will consider the management of hypertension in
Chapter 13.

The Blood
An adult’s body contains approximately 5 liters of
blood, which consists of plasma and cells. Plasma, the
fluid portion of blood, accounts for approximately
55 percent of the blood volume. The remaining
45 percent of blood volume is made up of cells. The
blood cells are suspended in the plasma, which con-
tains plasma proteins and plasma electrolytes (salts)
plus the substances that are being transported by the

Chapter 2 The Systems of the Body 23

The inspiration of air is an active process, brought
about by the contraction of muscles. Inspiration
causes the lungs to expand inside the thorax (the chest
wall). Expiration, in contrast, is a passive function,
brought about by the relaxation of the lungs, which
reduces the volume of the lungs within the thorax.
The lungs fill most of the space within the thoracic
cavity and are very elastic, depending on the thoracic
walls for support. If air gets into the space between
the thoracic wall and the lungs, one or both lungs will
collapse.
Respiratory movements are controlled by a re-
spiratory center in the medulla. The functions of
this center depend partly on the chemical composi-
tion of the blood. For example, if the blood’s carbon
dioxide level rises too high, the respiratory center
will be stimulated and respiration will be increased.
If the carbon dioxide level falls too low, the respira-
tory center will slow down until the carbon dioxide
level is back to normal.
The respiratory system is also responsible for
coughing. Dust and other foreign materials are in-
haled with every breath. Some of these substances are
trapped in the mucus of the nose and the air passages
and are then conducted back toward the throat, where
they are swallowed. When a large amount of mucus
collects in the large airways, it is removed by cough-
ing (a forced expiratory effort).

■ THE RESPIRATORY SYSTEM

Overview
Respiration, or breathing, has three main functions: to
take in oxygen, to excrete carbon dioxide, and to regu-
late the composition of the blood.
The body needs oxygen to metabolize food. Dur-
ing the process of metabolism, oxygen combines
with carbon atoms in food, producing carbon dioxide
(CO2). The respiratory system brings in oxygen
through inspiration; it eliminates carbon dioxide
through expiration.

The Structure and Functions of the
Respiratory System
Air is inhaled through the nose and mouth and then
passes through the pharynx and larynx to the trachea.
The trachea, a muscular tube extending downward
from the larynx, divides at its lower end into two
branches called the primary bronchi. Each bronchus
enters a lung, where it then subdivides into secondary
bronchi, still-smaller bronchioles, and, finally, micro-
scopic alveolar ducts, which contain many tiny clus-
tered sacs called alveoli. The alveoli and the capillaries
are responsible for the exchange of oxygen and carbon
dioxide. A diagram of the respiratory system appears
in Figure 2.6.

FIGURE 2.6 | The Respiratory System (Source: Lankford, 1979, p. 467)

Nasal passages

Larynx
Trachea

Pulmonary artery
Pulmonary vein
Bronchi

Alveoli
Bronchiole

Pharynx

Esophagus

Lobes of
the lung

Diaphragm

24 Part One Introduction to Health Psychology

amounts of mucus are produced in bronchitis, leading
to persistent coughing.
A serious viral infection of the respiratory system
is influenza, which can occur in epidemic form. Flu
viruses attack the lining of the respiratory tract, kill-
ing healthy cells. Fever and inflammation of the respi-
ratory tract may result. A common complication is a
secondary bacterial infection, such as pneumonia.

Bacterial Infections The respiratory system is
also vulnerable to bacterial disorders, including strep
throat, whooping cough, and diphtheria. Usually,
these disorders do not cause permanent damage to the
upper respiratory tract. The main danger is the possi-
bility of secondary infection, which results from low-
ered resistance. However, these bacterial infections
can cause permanent damage to other tissues, includ-
ing heart tissue.

Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD), in-
cluding chronic bronchitis and emphysema, is the
fourth-leading killer of people in the United States.
Some 12 million Americans have COPD (COPD In-
ternational, 2015). Although COPD is not curable, it is
preventable. Its chief cause is smoking, which accounts
for over 80 percent of all cases of COPD (COPD
International, 2015).

Pneumonia There are two main types of pneu-
monia. Lobar pneumonia is a primary infection of the
entire lobe of a lung. The alveoli become inflamed,
and the normal oxygen–carbon dioxide exchange be-
tween the blood and alveoli can be disrupted. Spread
of infection to other organs is also likely.
Bronchial pneumonia, which is confined to the
bronchi, is typically a secondary infection that may oc-
cur as a complication of other disorders, such as a se-
vere cold or flu. It is not as serious as lobar pneumonia.

Tuberculosis and Pleurisy Tuberculosis (TB)
is an infectious disease caused by bacteria that invade
lung tissue. When the invading bacilli are surrounded
by macrophages (white blood cells of a particular
type), they form a clump called a tubercle. Eventually,
through a process called caseation, the center of the
tubercle turns into a cheesy mass, which can produce
cavities in the lung. Such cavities, in turn, can give
rise to permanent scar tissue, causing chronic difficul-
ties in oxygen and carbon dioxide exchange between

Disorders Associated with the
Respiratory System
Asthma Asthma is a severe allergic reaction typi-
cally to a foreign substance, including dust, dog or cat
dander, pollens, or fungi. An asthma attack can also
be touched off by emotional stress or exercise. These
attacks may be so serious that they produce bronchial
spasms and hyperventilation.
During an asthma attack, the muscles surround-
ing air tubes constrict, inflammation and swelling of
the lining of the air tubes occur, and increased mucus
is produced, clogging the air tubes. The mucus secre-
tion, in turn, may then obstruct the bronchioles, reduc-
ing the supply of oxygen and increasing the amount of
carbon dioxide.
Statistics show a dramatic increase in the preva-
lence of allergic disorders, including asthma, in the past
20–30 years. Currently, approximately 235 million peo-
ple worldwide have asthma, 25 million of them in the
United States (Centers for Disease Control and Preven-
tion, May 2011; World Health Organization, May 2011).
The numbers are increasing, especially in industrialized
countries and in urban as opposed to rural areas. Asthma
rates are especially high in low income areas, and
psychosocial stressors may play a role in aggravating
an underlying vulnerability (Vangeepuram, Galvez,
Teitelbaum, Brenner, & Wolff, 2012). However, the
reasons for these dramatic changes are not yet fully
known. Children who have a lot of infectious disorders
during childhood are less likely to develop allergies,
suggesting that exposure to infectious agents plays a
protective role. Thus, paradoxically, the improved hy-
giene of industrialized countries may actually be contrib-
uting to the high rates of allergic disorders currently seen.

Viral Infections The respiratory system is vul-
nerable to infections, especially the common cold, a
viral infection of the upper and sometimes the lower
respiratory tract. The infection that results causes
discomfort, congestion, and excessive secretion of
mucus. The incubation period for a cold—that is, the
time between exposure to the virus and onset of
symptoms—is 12–72 hours, and the typical duration
is a few days. Secondary bacterial infections may
complicate the illness. These occur because the pri-
mary viral infection causes inflammation of the mu-
cous membranes, reducing their ability to prevent
secondary infection.
Bronchitis is an inflammation of the mucosal
membrane inside the bronchi of the lungs. Large

Chapter 2 The Systems of the Body 25

The Functioning of the
Digestive System
Food is first lubricated by saliva in the mouth, where
it forms a soft, rounded lump called a bolus. It passes
through the esophagus by means of peristalsis, a uni-
directional muscular movement toward the stomach.
The stomach produces various gastric secretions, in-
cluding pepsin and hydrochloric acid, to further the
digestive process. The sight or even the thought of
food starts the flow of gastric juices.
As food progresses from the stomach to the duo-
denum (the intersection of the stomach and lower in-
testine), the pancreas becomes involved in the digestive
process. Pancreatic juices, which are secreted into the
duodenum, contain enzymes that break down proteins,
carbohydrates, and fats. A critical function of the pan-
creas is the production of the hormone insulin, which
facilitates the entry of glucose into the bodily tissues.
The liver also plays an important role in metabolism by
producing bile, which enters the duodenum and helps
break down fats. Bile is stored in the gallbladder and is
secreted into the duodenum as needed.
Most metabolic products are water soluble and
can be easily transported in the blood, but some sub-
stances, such as lipids, are not soluble in water and so
must be transported in the blood plasma. Lipids in-
clude fats, cholesterol, and lecithin. An excess of lipids
in the blood is called hyperlipidemia, a condition com-
mon in diabetes, some kidney diseases, hyperthyroid-
ism, and alcoholism. It is also a causal factor in the
development of heart disease (see Chapters 5 and 13).
The absorption of food takes place primarily in
the small intestine, which produces enzymes that
complete the breakdown of proteins to amino acids.
The motility of the small intestine is under the control
of the sympathetic and parasympathetic nervous sys-
tems, such that parasympathetic activity speeds up
metabolism, whereas sympathetic nervous system
activity reduces it.
Food then passes into the large intestine which
acts largely as a storage organ for the accumulation of
food residue and helps in the reabsorption of water.
The entry of feces into the rectum leads to the expul-
sion of solid waste. The organs involved in the me-
tabolism of food are pictured in Figure 2.7.

Disorders of the Digestive System
The digestive system is susceptible to a number of
disorders.

the blood and the alveoli. Once the leading cause of
death in the United States, it has been in decline for
several decades. However, worldwide, it remains
common and deadly, affecting one-third of the world’s
population (Centers for Disease Control, 2015).
Pleurisy is an inflammation of the pleura, the
membrane that surrounds the organs in the thoracic
cavity. The inflammation, which produces a sticky
fluid, is usually a consequence of pneumonia or tuber-
culosis and can be extremely painful.

Lung Cancer Lung cancer is a disease of uncon-
trolled cell growth in tissues of the lung. The affected
cells begin to divide in a rapid and unrestricted man-
ner, producing a tumor. Malignant cells grow faster
than healthy cells. This growth may lead to metasta-
sis, which is the invasion of adjacent tissue and infil-
tration beyond the lungs. The most common symptoms
are shortness of breath, coughing (including coughing
up blood), and weight loss. Smoking is one of the
primary causes.

Dealing with Respiratory Disorders
A number of respiratory disorders can be addressed
by health psychologists. For example, smoking is im-
plicated in both pulmonary emphysema and lung can-
cer. Dangerous substances in the workplace and air
pollution are also factors that contribute to the inci-
dence of respiratory problems.
As we will see in Chapters 3–5, health psycholo-
gists have conducted research on many of these prob-
lems and discussed the clinical issues they raise.
Some respiratory disorders are chronic conditions.
Consequently, issues of long-term physical, voca-
tional, social, and psychological rehabilitation be-
come important. We cover these issues in Chapters
11, 13, and 14.

■ THE DIGESTIVE SYSTEM AND
THE METABOLISM OF FOOD

Overview
Food, essential for survival, is converted through the
process of metabolism into heat and energy, and it
supplies nutrients for growth and the repair of tissues.
But before food can be used by cells, it must be
changed into a form suitable for absorption into the
blood. This conversion process is called digestion.

26 Part One Introduction to Health Psychology

Gastroesophageal reflux disease Gastro-
esophageal reflux disease (GERD), also known as
acid reflux disease, results from an abnormal reflux in
the esophagus. This is commonly due to changes in
the barrier between the esophagus and the stomach.
As much as 60 percent of the U.S. adult population
experiences acid reflux at least occasionally (U.S.
Healthline, 2012).

Gastroenteritis, Diarrhea, and Dysentery
Gastroenteritis is an inflammation of the lining of the
stomach and small intestine. It may be caused by exces-
sive amounts of food or drink, contaminated food or
water, or food poisoning. Symptoms appear approxi-
mately 2–4 hours after the ingestion of food and include
vomiting, diarrhea, abdominal cramps, and nausea.
Diarrhea, characterized by watery and frequent
bowel movements, occurs when the lining of the small
and large intestines cannot properly absorb water or
digested food. Chronic diarrhea may result in serious
disturbances of fluid and electrolyte (sodium, potas-
sium, magnesium, calcium) balance.
Dysentery is similar to diarrhea except that mu-
cus, pus, and blood are also excreted. It may be caused

by a protozoan that attacks the large intestine (amoe-
bic dysentery) or by a bacterial organism. Although
these conditions are only rarely life threatening in in-
dustrialized countries, in developing countries, they
are among the most common causes of death.

Peptic Ulcer A peptic ulcer is an open sore in the
lining of the stomach or the duodenum. It results from
the hypersecretion of hydrochloric acid and occurs
when pepsin, a protein-digesting enzyme secreted in
the stomach, digests a portion of the stomach wall or
duodenum. A bacterium called H. pylori is believed to
contribute to the development of many ulcers. Once
thought to be primarily psychological in origin, ulcers
are now believed to be aggravated by stress, but not
caused by it.

Appendicitis Appendicitis is a common condi-
tion that occurs when wastes and bacteria accumulate
in the appendix. If the small opening of the appendix
becomes obstructed, bacteria can easily proliferate.
Soon this condition gives rise to pain, increased peri-
stalsis, and nausea. If the appendix ruptures and the
bacteria are released into the abdominal cavity or
peritoneum, they can cause further infection (peritoni-
tis) or even death.

Hepatitis Hepatitis means “inflammation of the
liver,” and the disease produces swelling, tenderness,
and sometimes permanent damage. When the liver is
inflamed, bilirubin, a product of the breakdown of he-
moglobin, cannot easily pass into the bile ducts. Conse-
quently, it remains in the blood, causing a yellowing of
the skin known as jaundice. Other common symptoms
are fatigue, fever, muscle or joint aches, nausea, vomit-
ing, loss of appetite, abdominal pain, and diarrhea.
There are several types of hepatitis, which differ
in severity and mode of transmission. Hepatitis A,
caused by viruses, is typically transmitted through
food and water. It is often spread by poorly cooked
seafood or through unsanitary preparation or storage
of food. Hepatitis B is a more serious form, with
2 billion people infected worldwide and 1 million
deaths annually (Hepb.org, 2016). Also known as
serum hepatitis, it is caused by a virus and is transmit-
ted by the transfusion of infected blood, by improperly
sterilized needles, through sexual contact, and through
mother-to-infant contact. It is a particular risk among
intravenous drug users. Its symptoms are similar to
those of hepatitis A but are far more serious.

FIGURE 2.7 | The Digestive System
(Source: Lankford, 1979, p. 523)

Esophagus

Stomach

Pancreas

Transverse
colon

Descending
colon

Jejunum

Sigmoid
colon

Rectum
Ileum

Appendix

Cecum

Ascending
colon

Duodenum

Liver

Gallbladder

Oral cavity

Chapter 2 The Systems of the Body 27

One of the chief functions of the kidneys is to
control the water balance in the body. For example, on
a hot day, when a person has been active and has per-
spired profusely, relatively little urine will be pro-
duced so that the body may retain more water. On the
other hand, on a cold day, when a person is relatively
inactive or has consumed a good deal of liquid, urine
output will be higher so as to prevent overhydration.
Urine can offer important diagnostic clues to many
disorders. For example, an excess of glucose may indi-
cate diabetes, and an excess of red blood cells may in-
dicate a kidney disorder. This is one of the reasons that
a medical checkup usually includes a urinalysis.
To summarize, the urinary system regulates
bodily fluids by removing surplus water, surplus elec-
trolytes, and the waste products generated by the me-
tabolism of food.

Disorders of the Renal System
The renal system is vulnerable to a number of disorders.
Among the most common are urinary tract infections, to
which women are especially vulnerable and which can
result in considerable pain, especially on urination. If
untreated, they can lead to more serious infection.
Nephrons are the basic structural and functional
units of the kidneys. In many types of kidney disease,
such as that associated with hypertension, large num-
bers of nephrons are destroyed or damaged so severely
that the remaining nephrons cannot perform their nor-
mal functions.
Glomerular nephritis involves the inflammation
of the glomeruli in the nephrons of the kidneys that
filter blood. Nephritis can be caused by infections,
exposure to toxins, and autoimmune diseases, espe-
cially lupus. Nephritis is a serious condition linked to
a large number of deaths worldwide.
Another common cause of acute renal shutdown is
tubular necrosis, which involves destruction of the epi-
thelial cells in the tubules of the kidneys. Poisons that
destroy the tubular epithelial cells and severe circulatory
shock are the most common causes of tubular necrosis.
Kidney failure is a severe disorder because the in-
ability to produce an adequate amount of urine will
cause the waste products of metabolism, as well as sur-
plus inorganic salts and water, to be retained in the body.
An artificial kidney, a kidney transplant, or kidney
dialysis may be required in order to rid the body of its
wastes. Although these technologies can cleanse the
blood to remove the excess salts, water, and metabolites,

Hepatitis C, also spread via blood and needles, is
most commonly caused by blood transfusions; 130–150
million people worldwide have the disorder, which ac-
counts for half a million deaths annually. Hepatitis D is
found mainly in intravenous drug users who are also
carriers of hepatitis B, necessary for the hepatitis D
virus to spread. Finally, hepatitis E resembles hepatitis
A but is caused by a different virus.

■ THE RENAL SYSTEM

Overview
The renal system consists of the kidneys, ureters, uri-
nary bladder, and urethra. The kidneys are chiefly
responsible for the regulation of bodily fluids; their
principal function is to produce urine. The ureters con-
tain smooth muscle tissue, which contracts, causing
peristaltic waves to move urine to the bladder, a muscu-
lar bag that acts as a reservoir for urine. The urethra then
conducts urine from the bladder out of the body. The
anatomy of the renal system is pictured in Figure 2.8.
Urine contains surplus water, surplus electrolytes,
waste products from the metabolism of food, and sur-
plus acids or alkalis. By carrying these products out of
the body, urine maintains water balance, electrolyte
balance, and blood pH. Of the electrolytes, sodium
and potassium are especially important because they
are involved in muscular contractions and the conduc-
tion of nerve impulses, among other vital functions.

FIGURE 2.8 | The Renal System
(Source: Lankford, 1979, p. 585)

Kidney

Ureter

Bladder

Urethra

28 Part One Introduction to Health Psychology

hair. Progesterone, which is produced during the sec-
ond half of the menstrual cycle to prepare the body for
pregnancy, declines if pregnancy fails to occur.
In males, testosterone is produced by the intersti-
tial cells of the testes under the control of the anterior
pituitary lobe. It brings about the production of sperm
and the development of secondary sex characteristics,
including growth of the beard, deepening of the voice,
distribution of body hair, and both skeletal and mus-
cular growth.

Fertilization and Gestation
When sexual intercourse takes place and ejaculation
occurs, sperm are released into the vagina. These
sperm, which have a high degree of motility, proceed
upward through the uterus into the fallopian tubes,
where one sperm may fertilize an ovum. The fertilized
ovum then travels down the fallopian tube into the uter-
ine cavity, where it embeds itself in the uterine wall and
develops over the next 9 months into a human being.

Disorders of the Reproductive System
The reproductive system is vulnerable to a number of
diseases and disorders. Among the most common and
problematic are sexually transmitted diseases (STDs),
which occur through sexual intercourse or other forms
of sexually intimate activity. STDs include herpes,

they are highly stressful medical procedures. Kidney
transplants carry many health risks, and kidney dialysis
can be extremely uncomfortable for patients. Conse-
quently, health psychologists have been involved in ad-
dressing these problems.

■ THE REPRODUCTIVE SYSTEM

Overview
The development of the reproductive system is con-
trolled by the pituitary gland. The anterior pituitary
lobe produces the gonadotropic hormones, which
control development of the ovaries in females and the
testes in males. A diagrammatic representation of the
human reproductive system appears in Figure 2.9.

The Ovaries and Testes
The female has two ovaries located in the pelvis. Each
month, one of the ovaries releases an ovum (egg),
which is discharged at ovulation into the fallopian
tubes. If the ovum is not fertilized (by sperm), it re-
mains in the uterine cavity for about 14 days and is
then flushed out of the system with the uterine endo-
metrium and its blood vessels (during menstruation).
The ovaries also produce the hormones estrogen
and progesterone. Estrogen leads to the development
of secondary sex characteristics in females, including
breasts and the distribution of both body fat and body

FIGURE 2.9 | The Reproductive System (Sources: Green, 1978, p. 122; Lankford, 1979, p. 688)

Female

Fallopian tube Uterus

Ovum
Right ovary

Vagina

Cervix

Left ovary

Male

Urinary
bladder

Ejaculatory
duct Seminal vesicle

Prostate
gland

Cowper’s
gland

Urethra

Ductus deferens

Epididymis

Scrotum
TestisSeminiferous

tubules

Prepuce
(foreskin)

Glans
penis

Penis

Chapter 2 The Systems of the Body 29

than protecting against these disorders, HT may actu-
ally increase some of these risks. As a result of this
new evidence, most women and their doctors are re-
thinking the use of HT, especially over the long term.

■ GENETICS AND HEALTH

Overview
The fetus starts life as a single cell, which contains the
inherited information from both parents that will de-
termine its characteristics. The genetic code regulates
such factors as eye and hair color, as well as behav-
ioral factors. Genetic material for inheritance lies in
the nucleus of the cell in the form of 46 chromosomes,
23 from the mother and 23 from the father. Two of
these 46 are sex chromosomes, which are an X from
the mother and either an X or a Y from the father. If
the father provides an X chromosome, a female child
will result; if he provides a Y chromosome, a male
child will result.

Genetics and Susceptibility to Disorders
Genetic studies have provided valuable information
about the inheritance of susceptibility to disease. For
example, scientists have bred strains of rats, mice, and
other laboratory animals that are sensitive or insensitive
to the development of particular diseases and then used
these strains to study illness onset and the course of ill-
ness. For example, a strain of rats that is susceptible to
cancer may shed light on the development of this dis-
ease and what other factors contribute to its occurrence.
The initial susceptibility of the rats ensures that many
of them will develop malignancies when implanted
with carcinogenic (cancer-causing) materials.
In humans, several types of research help demon-
strate whether a characteristic is genetically acquired.
Studies of families, for example, can reveal whether
members of the same family are more likely to de-
velop a disorder, such as heart disease, than are unre-
lated individuals in a similar environment. If a factor
is genetically determined, family members will show
it more frequently than will unrelated individuals.
Twin research is another method for examining
the genetic basis of a characteristic. If a characteristic
is genetically transmitted, identical twins share it more
commonly than do fraternal twins or other brothers
and sisters. This is because identical twins share the
same genetic makeup, whereas other brothers and sisters
have only partially overlapping genetic makeup.

gonorrhea, syphilis, genital warts, chlamydia, and,
most seriously, AIDS.
For women, a risk from several STDs is chronic
pelvic inflammatory disease (PID), which may pro-
duce severe abdominal pain and infections that may
compromise fertility. Other gynecologic disorders to
which women are vulnerable include vaginitis, endo-
metriosis (in which pieces of the endometrial lining of
the uterus move into the fallopian tubes or abdominal
cavity, grow, and spread to other sites), cysts, and fi-
broids (nonmalignant growths in the uterus that may
nonetheless interfere with reproduction). Women are
vulnerable to disorders of the menstrual cycle, includ-
ing amenorrhea, which is the absence of menses, and
oligomenorrhea, which is infrequent menstruation.
The reproductive system is also vulnerable to
cancer, including testicular cancer in men and gyne-
cologic cancers in women. Every 6 minutes, a woman
in the United States is diagnosed with a gynecologic
cancer, including cancer of the cervix, uterus, and
ovaries (American Cancer Society, 2012a). Endome-
trial cancer is the most common female pelvic malig-
nancy, and ovarian cancer is the most lethal.
Approximately 10 percent of U.S. couples experi-
ence fertility problems, defined as the inability to
conceive a pregnancy after 1 year of regular sexual
intercourse without contraception (Centers for Disease
Control and Prevention, June 2011). Although physi-
cians once believed that infertility has emotional ori-
gins, researchers now believe that distress may
complicate but does not cause infertility. Fortunately,
over the past few decades, the technology for treating
infertility has improved. A variety of drug treatments
have been developed, as have more invasive technolo-
gies. In vitro fertilization (IVF) is the most widely used
method of assistive reproductive technology, and the
success rate for IVF can be as high as 40% per cycle
(Resolve: The National Fertility Association, 2013).
Menopause is not a disorder of the reproductive
system; rather, it occurs when a woman’s reproductive
life ends. Because of a variety of noxious symptoms
that can occur during the transition into menopause,
including sleep disorders, hot flashes, joint pain, for-
getfulness, and dizziness, some women choose to take
hormone therapy (HT), which typically includes estro-
gen or a combination of estrogen and progesterone. HT
was once thought not only to reduce the symptoms of
menopause but also to protect against the development
of coronary artery disease, osteoporosis, breast cancer,
and Alzheimer’s disease. It is now believed that, rather

30 Part One Introduction to Health Psychology

health would be fruitless if genes are implicated
(Dar-Nimrod & Heine, 2011). Such erroneous beliefs
may deter health behavior change and information
seeking about one’s risk (Marteau & Weinman, 2006).
Genetic risk information may also evoke defensive pro-
cesses whereby people downplay their risk (Shiloh,
Drori, Orr-Urtreger, & Friedman, 2009). Genetic risks
may also interact with stress or trauma to increase risks
for certain disorders (Zhao, Bremner, Goldberg,
Quyyumi, & Vaccarino, 2013). Accordingly, making
people aware of genetic risk factors should be accom-
panied by educational information to offset these po-
tential problems (Smerecnik et al., 2009).
Another role for health psychologists involves
genetic counseling. Prenatal diagnostic tests permit
the detection of some genetically based disorders, in-
cluding Tay-Sachs disease, cystic fibrosis, muscular
dystrophy, Huntington’s disease, and breast cancer.
Helping people decide whether to be screened and
how to cope with genetic vulnerabilities if they test
positive represents an important role for health psy-
chologists (Mays et al., 2014). For example, belief in a
genetic cause can lead people to take medical actions
that may be medically unwarranted (Petrie et al., 2015).
In addition, people who have a family history of
genetic disorders, those who have already given birth
to a child with a genetic disorder, or those who have
recurrent reproductive problems, such as multiple
miscarriages, often seek such counseling. In some
cases, technological advances have made it possible
to treat some of these problems before birth through
drugs or surgery. However, if the condition cannot be
corrected, the parents often must make the difficult
decision of whether to abort the pregnancy.
Children, adolescents, and young adults some-
times learn of a genetic risk to their health, as research
uncovers such causes. Breast cancer, for example,
runs in families, and among young women whose
mothers, aunts, or sisters have developed breast can-
cer, vulnerability is higher. Families that share genetic
risks may need special attention through family coun-
seling (Mays et al., 2014). Some of the genes that con-
tribute to the development of breast cancer have been
identified, and tests are now available to determine
whether a genetic susceptibility is present. Although
this type of cancer accounts for only 5 percent of
breast cancer, women who carry these genetic suscep-
tibilities are more likely to develop the disease at an
earlier age; thus, these women are at high risk and
need careful monitoring and assistance in making

Examining the characteristics of twins reared to-
gether as opposed to twins reared apart is also informa-
tive regarding genetics. Attributes that emerge for twins
reared apart are suspected to be genetically determined,
especially if the rate of occurrence between twins
reared together and those reared apart is the same.
Finally, studies of adopted children also help iden-
tify which characteristics are genetic and which are en-
vironmentally produced. Adopted children will not
manifest genetically transmitted characteristics from
their adoptive parents, but they may manifest environ-
mentally transmitted characteristics.
Consider, for example, obesity, which is a risk
factor for a number of disorders, including coronary
artery disease and diabetes. If twins reared apart show
highly similar body weights, then we would suspect
that body weight has a genetic component. If, on the
other hand, weight within a family is highly related,
and adopted children show the same weight as their
parents and any natural offspring, then we would look
to the family diet as a potential cause of obesity. For
many attributes, including obesity, both environmental
and genetic factors are involved.
Research like this has increasingly uncovered
the genetic contribution to many health disorders
and behavioral factors that may pose risks to health.
Such diseases as asthma, Alzheimer’s disease, cystic
fibrosis, muscular dystrophy, Tay-Sachs disease, and
Huntington’s disease have a genetic basis. There is
also a genetic basis for coronary heart disease and
for some forms of cancer, including some breast and
colon cancers. This genetic basis does not preclude
the important role of the environment, however.
Genetics will continue to be of interest as the con-
tribution of genes to health continues to be uncovered.
For example, genetic contributions to obesity and alco-
holism have emerged in recent years. Moreover, the
contributions of genetics studies to health psychology
are broadening. Even some personality characteristics,
such as optimism, which is believed to have protective
health effects, have genetic underpinnings (Saphire-
Bernstein, Way, Kim, Sherman, & Taylor, 2011).

Genetics and Health Psychology Health psy-
chologists have important roles to play with respect to
genetic contributions to health disorders. One question
concerns whether people need to be alerted to genetic
risks (Smerecnik, Mesters, de Vries, & de Vries, 2009).
Many people think that genetic risks are immutable and
that any efforts they might undertake to affect their

Chapter 2 The Systems of the Body 31

∙ Mechanical transmission is the passage of a
microbe to an individual by means of a carrier
that is not directly involved in the disease
process. Dirty hands, bad water, rats, mice, and
flies can be implicated in mechanical
transmission. Box 2.2 tells about two people
who were carriers of deadly diseases.

Infection
Once a microbe has reached the body, it penetrates
into bodily tissue via any of several routes, including
the skin, the throat and respiratory tract, the digestive
tract, or the genitourinary system. Whether the invad-
ing microbes gain a foothold in the body and produce
infection depends on three factors: the number of or-
ganisms, the virulence of the organisms, and the
body’s defensive capacities. The virulence of an or-
ganism is determined by its aggressiveness (i.e., its
ability to resist the body’s defenses) and by its toxige-
nicity (i.e., its ability to produce poisons, which invade
other parts of the body).

The Course of Infection
Assuming that the invading organism does gain a
foothold, the natural history of infection follows a spe-
cific course. First, there is an incubation period be-
tween the time the infection is contracted and the time
the symptoms appear.
Next, there is a period of nonspecific symptoms,
such as headaches and general discomfort, which pre-
cedes the onset of the disorder. During this time, the
microbes are actively colonizing and producing tox-
ins. The next stage is the acute phase, when the illness
and its symptoms are at their height. Unless the infec-
tion proves fatal, a period of decline follows the acute
phase. During this period, the organisms are expelled
from the mouth and nose in saliva and respiratory se-
cretions, as well as through the digestive tract and the
genitourinary system in feces and urine.
Infections may be localized, focal, or systemic. Lo-
calized infections remain at their original site and do not
spread throughout the body. Although a local infection
is confined to a particular area, it sends toxins to other
parts of the body, causing other disruptions. Systemic
infections affect a number of areas or body systems.
The primary infection initiated by the microbe
may also lead to secondary infections. These occur be-
cause the body’s resistance is lowered from fighting

treatment-related decisions. With whole genome test-
ing becoming available to individuals, knowledge of
genetic risks may increase (Drmanac, 2012).
Carriers of genetic risks may experience great dis-
tress (Hamilton, Lobel, & Moyer, 2009). Should people
be told about their genetic risks if nothing can be done
to treat them? Growing evidence suggests that people at
risk for treatable disorders benefit from genetic testing
and do not suffer long-term psychological distress (e.g.,
Hamilton et al., 2009). People who are chronically anx-
ious, though, may require special attention and counsel-
ing (Rimes, Salkovskis, Jones, & Lucassen, 2006).
In some cases, genetic risks can be offset by behav-
ioral interventions to address the risk factor. For exam-
ple, one study (Aspinwall, Leaf, Dola, Kohlmann, &
Leachman, 2008) found that being informed that one
had tested positive for a gene implicated in melanoma
(a serious skin cancer) and receiving counseling led to
better skin self-examination practices at a 1-month follow-
up. Thus health psychologists have an important role to
play in research and counseling related to genetic risks,
especially if they can help people modify their risk
status and manage their distress (Aspinwall, Taber,
Leaf, Kohlmann, & Leachman, 2013).

■ THE IMMUNE SYSTEM

Overview
Disease is caused by a variety of factors. In this sec-
tion, we address the transmission of disease by infec-
tion, that is, the invasion of microbes and their growth
in the body. The microbes that cause infection are
transmitted to people in several ways:
∙ Direct transmission involves bodily contact, such

as handshaking, kissing, and sexual intercourse.
For example, genital herpes is typically
contracted by direct transmission.

∙ Indirect transmission (or environmental
transmission) occurs when microbes are passed
to an individual via airborne particles, dust,
water, soil, or food. Influenza is an example of
an environmentally transmitted disease.

∙ Biological transmission occurs when a transmitting
agent, such as a mosquito, picks up microbes,
changes them into a form conducive to growth in
the human body, and passes them on to the
human. Yellow fever, for example, is transmitted
by this method.

Natural and Specific Immunity How does im-
munity work? The body has a number of responses to
invading organisms, some nonspecific and others spe-
cific. Nonspecific immune mechanisms are a gen-
eral set of responses to any kind of infection or
disorder; specific immune mechanisms, which are
always acquired after birth, fight particular microor-
ganisms and their toxins.
Natural immunity is involved in defense against
pathogens. The cells involved in natural immunity
provide defense not against a particular pathogen, but
rather against many pathogens. The largest group of
cells involved in natural immunity is granulocytes,
which include neutrophils and macrophages; both are
phagocytic cells that engulf target pathogens. Neutro-
phils and macrophages congregate at the site of an
injury or infection and release toxic substances. Mac-
rophages release cytokines that lead to inflammation
and fever, among other side effects, and promote
wound healing. Natural killer cells are also involved in

the primary infection, leaving it susceptible to other
invaders. In many cases, secondary infections, such as
pneumonia, pose a greater risk than the primary one.

Immunity
Immunity is the body’s resistance to invading organ-
isms. It may develop either naturally or artificially.
Some natural immunity is passed from the mother to
the child at birth and through breast-feeding, although
this type of immunity is only temporary. Natural im-
munity is also acquired through disease. For example,
if you have measles once, you are unlikely to develop it
a second time; you will have built up an immunity to it.
Artificial immunity is acquired through vaccina-
tions and inoculations. For example, most children and
adolescents receive shots for a variety of diseases—
among them, diphtheria, whooping cough, smallpox,
poliomyelitis, and hepatitis—so that they will not con-
tract these diseases, should they be exposed.

Carriers are people who transmit a disease to others
without actually contracting that disease themselves.
They are especially dangerous because they are not ill
and so they can infect dozens, hundreds, or even thou-
sands of people while going about the business of ev-
eryday life.

“TYPHOID MARY”
Perhaps the most famous carrier in history was “Ty-
phoid Mary,” a young Swiss immigrant to the United
States who infected thousands of people during her
lifetime. During her ocean crossing, Mary was taught
how to cook, and eventually, some 100 individuals
aboard the ship died of typhoid, including the cook
who trained her. Once Mary arrived in New York, she
obtained a series of jobs as a cook, continually passing
on the disease to those for whom she worked without
contracting it herself.
Typhoid is precipitated by a salmonella bacte-
rium, which can be transmitted through water, food,
and physical contact. Mary carried a virulent form of
the infection in her body but was herself immune to
the disease. It is believed that she was unaware she
was a carrier for many years. Toward the end of her
life, however, she began to realize that she was
responsible for the many deaths around her.

Mary’s status as a carrier also became known to
medical authorities, and she spent the latter part of her
life in and out of institutions in a vain attempt to iso-
late her from others. In 1930, Mary died not of ty-
phoid but of a brain hemorrhage (Federspiel, 1983).

“HELEN”
The CBS News program 60 Minutes profiled an
equally terrifying carrier: a prostitute, “Helen,” who is
a carrier of HIV, the virus that causes AIDS (acquired
immune deficiency syndrome). Helen has never had
AIDS, but her baby was born with the disease. As a
prostitute and heroin addict, Helen is not only at risk
for developing the illness herself but also poses a
threat to her clients and anyone with whom she shares
a needle.
Helen represents a dilemma for medical and crim-
inal authorities. She is a known carrier of AIDS, yet
there is no legal basis for preventing her from coming
into contact with others. Although she can be arrested
for prostitution or drug dealing, such incarcerations are
usually short-term and have a negligible impact on her
ability to spread the disease to others. For potentially
fatal diseases such as AIDS, the carrier represents a
nightmare, and medical and legal authorities have been
almost powerless to intervene (Moses, 1984).

Portraits of Two CarriersB O X 2.2

Chapter 2 The Systems of the Body 33

increases at the site of inflammation because of the
increased flow of blood. Usually, a clot then forms
around the inflamed area, isolating the microbes and
keeping them from spreading to other parts of the
body. Familiar examples of the inflammatory re-
sponse are the reddening, swelling, discharge, and
clotting that result when you accidentally cut your
skin and the sneezing, runny nose and teary eyes
that result from an allergic response to pollen.
Specific immunity is acquired after birth by
contracting a disease or through artificial means,
such as vaccinations. It operates through the antigen-
antibody reaction. Antigens are foreign substances
whose presence stimulates the production of
antibodies in the cell tissues. Antibodies are pro-
teins produced in response to stimulation by
antigens, which combine chemically with the anti-
gens to overcome their toxic effects.
Specific immunity is slower and, as its name im-
plies, more specific than natural immunity. The lym-
phocytes involved in specific immunity have receptor
sites on their cell surfaces that fit with one, and only
one, antigen, and thus, they respond to only one kind
of invader. When they are activated, these antigen-
specific cells divide and create a population of cells
called the proliferative response.
Essentially, natural and specific immunity work
together, such that natural immunity contains an in-
fection or wound rapidly and early on following the
invasion of a pathogen, whereas specific immunity
involves a delay of up to several days before a full
defense can be mounted. Figure 2.10 illustrates the
interaction between lymphocytes and phagocytes.

natural immunity; they recognize “nonself” material
(such as viral infections or cancer cells) and lyse
(break up and disintegrate) those cells by releasing
toxic substances. Natural killer cells are believed to
be important in signaling potential malignancies and
in limiting early phases of viral infections.
Natural immunity occurs through four main ways:
anatomical barriers, phagocytosis, antimicrobial sub-
stances, and inflammatory responses. Anatomical
barriers prevent the passage of microbes from one
section of the body to another. For example, the skin
functions as an effective anatomical barrier to many
infections, and the mucous membranes lining the nose
and mouth also provide protection.
Phagocytosis is the process by which certain
white blood cells (called phagocytes) ingest microbes.
Phagocytes are usually overproduced when there is a
bodily infection, so that large numbers can be sent to
the site of infection to ingest the foreign particles.
Antimicrobial substances are chemicals produced
by the body that kill invading microorganisms. Inter-
feron, hydrochloric acid, and enzymes such as lyso-
zyme are some antimicrobial substances that help
destroy invading microorganisms.
The inflammatory response is a local reaction to
infection. At the site of infection, the blood capillaries
first enlarge, and a chemical called histamine is re-
leased into the area. This chemical causes an increase
in capillary permeability, allowing white blood cells
and fluids to leave the capillaries and enter the tissues;
consequently, the area becomes reddened and fluids
accumulate. The white blood cells attack the microbes,
resulting in the formation of pus. Temperature

FIGURE 2.10 | Interaction Between Lymphocytes and Phagocytes B lymphocytes release antibodies, which
bind to pathogens and their products, aiding recognition by phagocytes. Cytokines released by T cells activate
phagocytes to destroy the material they have taken up. In turn, mononuclear phagocytes can present antigen to
T cells, thereby activating them. (Source: Roitt, Brostoff, & Male, 1998)

Lymphocytes Phagocytes

Aid recognition
Antibodies

Cytokines

Activation

Antigen
presentation

34 Part One Introduction to Health Psychology

Additional discussion of immunity can be found
in Chapter 14, where we consider the rapidly developing
field of psychoneuroimmunology and the role of im-
munity in the development of AIDS.

Disorders Related to the Immune
System
The immune system is subject to a number of disor-
ders and diseases. One very important one is AIDS,
which is a progressive impairment of immunity. An-
other is cancer, which is now believed to depend heavily
on immunocompromise. We defer extended discussion
of AIDS and cancer to Chapter 14.
Lupus affects approximately 1.5 million Amer-
icans, most of them women (WebMD, 2015). The
disease acquired the name lupus, which means
“wolf,” because of the skin rash that can appear on
the face. It leads to chronic inflammation, produc-
ing pain, heat, redness, and swelling, and can be
life-threatening when it attacks the connective tis-
sue of the body’s internal organs. Depending on the
severity of the disease, it may be managed by anti-
inflammatory medications or immunosuppressive
medications.
A number of infections attack lymphatic tissue.
For example, tonsillitis is an inflammation of the ton-
sils that interferes with their ability to filter out bacte-
ria. Infectious mononucleosis is a viral disorder

FIGURE 2.11 | Components of the Immune System (Source: Roitt, Brostoff, & Male, 1998)

Lymphocytes

Leucocytes

Phagocytes Auxiliary cells Other

Cytokines Complement

B cell

Antibodies

T cell

Large
granular

lymphocyte

Interferons,
cytokines

Mononuclear
phagocyte Neutrophil Eosinophil Basophil Mast cell Platelets

Tissue
cells

Inflammatory
mediators

Humoral and Cell-Mediated Immu-
nity There are two basic immunologic reactions—
humoral and cell mediated. Humoral immunity is
mediated by B lymphocytes. The functions of B lym-
phocytes include providing protection against bacte-
ria, neutralizing toxins produced by bacteria, and
preventing viral reinfection. B cells confer immunity
by the production and secretion of antibodies.
Cell-mediated immunity, involving T
lymphocytes from the thymus gland, is a slower-acting
response. Rather than releasing antibodies into the
blood, as humoral immunity does, cell-mediated im-
munity operates at the cellular level. When stimulated
by the appropriate antigen, T cells secrete chemicals
that kill invading organisms and infected cells. Compo-
nents of the immune system are shown in Figure 2.11.

The Lymphatic System’s Role in Immunity
The lymphatic system, which is a drainage system of
the body, is involved in important ways in immune
functioning. There is lymphatic tissue throughout the
body, consisting of lymphatic capillaries, vessels, and
nodes. Lymphatic capillaries drain water, proteins,
microbes, and other foreign materials from spaces be-
tween the cells into lymph vessels. This material is
then conducted in the lymph vessels to the lymph
nodes, which filter out microbes and foreign materials
for ingestion by lymphocytes. The lymphatic vessels
then drain any remaining substances into the blood.

Chapter 2 The Systems of the Body 35

times and was selected because it was adaptive. For
example, among hunter-gatherer societies, natural
selection would have favored people with vigorous
inflammatory responses because life expectancy was
fairly short. Few people would have experienced any
long-term costs of vigorous or long-lasting in-
f lammatory responses, which now seem to play
such an important role in the development of chronic
diseases. Essentially, an adaptive pattern of earlier
times has become maladaptive, as life expectancy
has lengthened.
Autoimmunity occurs when the body attacks the
body’s own tissues. Examples of autoimmune disor-
ders include certain forms of arthritis, multiple sclero-
sis, and lupus, among others.
In autoimmune disease, the body fails to recog-
nize its own tissue, instead interpreting it as a for-
eign invader and producing antibodies to fight it.
Many viral and bacterial pathogens have, over time,
developed the ability to fool the body into granting
them access by mimicking basic protein sequences
in the body. This process of molecular mimicry
eventually fails but then leads the immune system to
attack not only the invader but also healthy tissues.
A person’s genetic makeup may exacerbate this pro-
cess. Stress can aggravate autoimmune disease. Ap-
proximately 50 million Americans suffer from
autoimmune diseases. Women are more likely than
men to be affected (American Autoimmune Related
Diseases Association, 2015). Although the causes
of autoimmune diseases are not fully known, re-
searchers have discovered that a viral or bacterial
infection often precedes the onset of an autoimmune
disease. ∙

marked by an unusually large number of monocytes;
it can cause enlargement of the spleen and lymph
nodes, as well as fever, sore throat, and general lack
of energy.
Lymphoma is a tumor of the lymphatic tissue.
Hodgkin’s disease, a malignant lymphoma, involves
the progressive, chronic enlargement of the lymph
nodes, spleen, and other lymphatic tissues. As a
consequence, the nodes cannot effectively produce
antibodies, and the phagocytic properties of the
nodes are lost. If untreated, Hodgkin’s disease can
be fatal.
Infectious disorders were at one time thought to
be acute problems that ended when their course had
run. A major problem in developing countries, in-
fectious disorders were thought to be largely under
control in developed nations. Now, however, infec-
tious diseases merit closer looks (Morens, Folkers,
& Fauci, 2004). First, as noted in the discussion of
asthma, the control of at least some infectious disor-
ders through hygiene may have paradoxically in-
creased the rates of allergic disorders. A second
development is that some chronic diseases, once
thought to be genetic in origin or unknown in origin,
are now being traced back to infections. For exam-
ple, Alzheimer’s disease, multiple sclerosis, schizo-
phrenia, and some cancers appear to have infectious
triggers, at least in some cases (Zimmer, 2001). The
development of bacterial strains that are resistant to
treatment has raised an alarm. The overuse of anti-
biotics is an active contributor to the development
of increasingly lethal strains. Infectious agents have
also become an increasing concern in the war on ter-
rorism, with the possibility that smallpox and other
infectious agents may be used as weapons.
The inflammatory response that is so protective
against provocations ranging from mosquito bites and
sunburn to gastritis in response to spoiled food is
coming under increasing investigation as a contributor
to chronic disease. The destructive potential of in-
flammation is evident in diseases such as rheumatoid
arthritis and multiple sclerosis, but inflammation also
underlies many other chronic diseases including ath-
erosclerosis, diabetes, Alzheimer’s disease, asthma,
cirrhosis of the liver, some bowel disorders, cystic fi-
brosis, heart disease, depression, and even some can-
cers (Table 2.1).
The inflammatory response, like stress responses
more generally, likely evolved in early prehistoric

TABLE 2.1 | Some Consequences of Chronic
Low-Level Inflammation

Inflammation is believed to play an important role in
several diseases of aging. They include:
• Heart Disease
• Stroke
• Diabetes
• Alzheimer’s Disease (and cognitive decline more

generally)
• Cancer
• Osteoporosis
• Depression

36 Part One Introduction to Health Psychology

1. The nervous system and the endocrine system
act as the control systems of the body, mobilizing
it in times of threat and otherwise maintaining
equilibrium and normal functioning.

2. The nervous system operates primarily through
the exchange of nerve impulses between the
peripheral nerve endings and internal organs and the
brain, thereby providing the integration necessary
for voluntary and involuntary movement.

3. The endocrine system operates chemically via
the release of hormones stimulated by centers in
the brain. It controls growth and development
and augments the functioning of the nervous
system.

4. The cardiovascular system is the transport
system of the body, carrying oxygen and nutrients
to cell tissues and taking carbon dioxide and
other wastes away from the tissues for expulsion
from the body.

5. The heart acts as a pump to control circulation
and is responsive to regulation via the nervous
system and the endocrine system.

6. The heart, blood vessels, and blood are vulnerable
to a number of problems—most notably,
atherosclerosis—which makes diseases of the
cardiovascular system the major cause of death
in this country.

7. The respiratory system is responsible for taking
in oxygen, expelling carbon dioxide, and
controlling the chemical composition of the blood.

8. The digestive system is responsible for producing
heat and energy, which—along with essential
nutrients—are needed for the growth and repair
of cells. Through digestion, food is broken down
to be used by the cells for this process.

9. The renal system aids in metabolic processes by
regulating water balance, electrolyte balance,
and blood acidity-alkalinity. Water-soluble
wastes are flushed out of the system in the urine.

10. The reproductive system, under the control of the
endocrine system, leads to the development of
primary and secondary sex characteristics.
Through this system, the species is reproduced,
and genetic material is transmitted from parents to
their offspring.

11. With advances in genetic technology and the
mapping of the genome has come increased
understanding of genetic contributions to disease.
Health psychologists play important research and
counseling roles with respect to these issues.

12. The immune system is responsible for warding off
infection from invasion by foreign substances. It
does so through the production of infection-fighting
cells and chemicals.

S U M M A R Y

K E Y T E R M S

adrenal glands
angina pectoris
atherosclerosis
autoimmunity
blood pressure
cardiovascular system
catecholamines
cell-mediated immunity
cerebellum
cerebral cortex
endocrine system

humoral immunity
hypothalamus
immunity
ischemia
kidney dialysis
lupus
lymphatic system
medulla
myocardial infarction (MI)
nervous system
neurotransmitters

nonspecific immune mechanisms
parasympathetic nervous system
phagocytosis
pituitary gland
platelets
pons
renal system
respiratory system
specific immune mechanisms
sympathetic nervous system
thalamus

Health Behavior and
Primary Prevention

2P A R T

C H A P T E R 3

C H A P T E R O U T L I N E

An Introduction to Health Behaviors
Role of Behavioral Factors in Disease and Disorder

Health Promotion: An Overview
Health Behaviors and Health Habits

Practicing and Changing Health Behaviors: An
Overview

Barriers to Modifying Poor Health Behaviors

Intervening with Children and Adolescents

Intervening with At-Risk People

Health Promotion and Older Adults

Ethnic and Gender Differences in Health Risks
and Habits

Changing Health Habits
Attitude Change and Health Behavior

The Health Belief Model

Health Behaviors

The Theory of Planned Behavior

Criticisms of Attitude Theories

Self Regulation and Health Behavior

Self Determination Theory

Implementation Intentions

Health Behavior Change and the Brain

Cognitive-Behavioral Approaches to Health
Behavior Change
Cognitive-Behavior Therapy (CBT)

Self Monitoring

Stimulus Control

The Self Control of Behavior

Social Skills and Relaxation Training

Motivational Interviewing

Relapse Prevention

Evaluation of CBT

The Transtheoretical Model of Behavior Change
Stages of Change

Using the Stage Model of Change

Changing Health Behaviors Through Social
Engineering

Venues for Health-Habit Modification
The Practitioner’s Office

The Family

Self-Help Groups

Schools

Workplace Interventions

Community-Based Interventions

The Mass Media

Cellular Phones and Landlines

The Internet

Chapter 3 Health Behaviors 39

health promotion involves teaching people how to
achieve a healthy lifestyle and helping people at risk for
particular health problems offset or monitor those risks.
For the health psychologist, health promotion involves
the development of interventions to help people practice
healthy behaviors. For community and national policy
makers, health promotion involves emphasizing good
health and providing information and resources to help
people change poor health habits.
Successful modification of health behaviors will
have several beneficial effects. First, it will reduce
deaths due to lifestyle-related diseases. Second, it may
delay time of death, thereby increasing life expectancy.
Third and most important, the practice of good health
behaviors may expand the number of years during
which a person may enjoy life free from the complica-
tions of chronic disease. Finally, modification of health
behaviors may begin to make a dent in the more than
$3.0 trillion that is spent yearly on health and illness
(National Health Expenditures, 2014).

Health Behaviors and Health Habits
Health behaviors are behaviors undertaken by people
to enhance or maintain their health. A health habit is a
health behavior that is firmly established and often per-
formed automatically, without awareness. These habits
usually develop in childhood and begin to stabilize
around age 11 or 12 (Cohen, Brownell, & Felix, 1990).
Wearing a seat belt, brushing one’s teeth, and eating a
healthy diet are examples of these behaviors. Although
a health habit may develop initially because it is rein-
forced by positive outcomes, such as parental approval,
it eventually becomes independent of the reinforcement
process. For example, you may brush your teeth auto-
matically before going to bed. As such, habits can be
highly resistant to change. Consequently, it is important
to establish good health behaviors and to eliminate poor
ones early in life.
An illustration of the importance of good health
habits is provided by a classic study of people living
in Alameda County, California, conducted by Belloc
and Breslow (1972). These scientists focused on sev-
eral important health habits:
∙ Sleeping 7 to 8 hours a night
∙ Not smoking
∙ Eating breakfast each day
∙ Having no more than one or two alcoholic drinks

each day

In Chapter 3, we address health behaviors. At the core of this chapter is the idea that good health is
achievable through health behaviors that are practiced
conscientiously.

■ AN INTRODUCTION TO
HEALTH BEHAVIORS

Role of Behavioral Factors in Disease
and Disorder
In the past century, patterns of disease in the United States
have changed substantially. As noted in Chapter 1, there
has been a decline in acute infectious disorders due to
changes in public health standards, but there has been an
increase in the preventable disorders, including lung
cancer, cardiovascular disease, alcohol and drug abuse,
and vehicular accidents. The role of behavioral factors
in the development of these disorders is clear ( Table 3.1).
Nearly half the deaths in the United States are caused by
preventable factors, with smoking, obesity, and problem
drinking being three of the main causes (Centers for
Disease Control and Prevention, 2009a).

■ HEALTH PROMOTION:
AN OVERVIEW

Research on preventable risk factors adopts the per-
spective of health promotion. Health promotion is a
philosophy that has at its core the idea that good health,
or wellness, is a personal and collective achievement.
For the individual, it involves developing a program of
good health habits. For the medical practitioner,

TABLE 3.1 | Risk Factors for the Leading Causes
of Death in the United States

Disease Risk Factors

Heart disease Tobacco, high cholesterol, high
blood pressure, physical inactivity,
obesity, diabetes, stress

Cancer Smoking, unhealthy diet,
environmental factors

Stroke High blood pressure, tobacco,
diabetes, high cholesterol,
physical inactivity, obesity

Accidental injuries On the road (failure to wear seat
belts), in the home (falls, poison, fire)

Chronic lung disease Tobacco, environmental factors
(pollution, radon, asbestos)

Sources: American Cancer Society, 2009a; American Heart Association,
2009a; Centers for Disease Control and Prevention, April 2009.

40 Part Two Health Behavior and Primary Prevention

Values Values affect the practice of health habits.
For example, exercise for women may be considered
desirable in one culture but undesirable in another
(Guilamo-Ramos, Jaccard, Pena, & Goldberg, 2005).

Personal Control People who regard their health
as under their personal control practice better health
habits than people who regard their health as due to
chance. The health locus of control scale (Table 3.2)
(Wallston, Wallston, & DeVellis, 1978) measures the de-
gree to which people perceive their health to be under
personal control, control by the health practitioner, or
chance.

Social Influence Family, friends, and workplace
companions influence health-related behaviors, some-
times in a beneficial direction, other times in an ad-
verse direction (Blumberg, Vahratian, & Blumberg,
2014). For example, peer pressure often leads to
smoking in adolescence but may influence people to
stop smoking in adulthood.

Personal Goals and Values Health habits are
tied to personal goals. If personal fitness is an impor-
tant goal, a person is more likely to exercise.

Perceived Symptoms Some health habits are
controlled by perceived symptoms. For example, a
smoker who wakes up with a smoker’s cough and
raspy throat may cut back in the belief that he or she is
vulnerable to health problems at that time.

Access to the Health Care Delivery System
Access to the health care delivery system affects
health behaviors. For example, obtaining a regular
Pap smear, getting mammograms, and receiving im-
munizations for childhood diseases depend on access
to health care. Other behaviors, such as losing weight
and stopping smoking, may be indirectly encouraged
by the health care system through lifestyle advice.

Knowledge and Intelligence The practice of
health behaviors is tied to cognitive factors, such as
knowledge and intelligence (Mõttus et al., 2014).
More knowledgeable and smarter people typically
take better care of themselves. People who are identi-
fied as intelligent in childhood have better health-
related biological profiles in adulthood, which may be
explained by their practice of better health behaviors
in early life (Calvin, Batty, Lowe, & Deary, 2011).

∙ Getting regular exercise
∙ Not eating between meals
∙ Being no more than 10 percent overweight

The scientists asked nearly 7,000 county residents to
indicate which of these behaviors they practiced. Resi-
dents were also asked about the illnesses they had had,
what their energy level had been, and how disabled they
had been (for example, how many days of work they
had missed) over the previous 6-to-12-month period.
The researchers found that the more good health habits
people practiced, the fewer illnesses they had had, the
better they had felt, and the less disabled they had been.
A follow-up of these people 9–12 years later found
that mortality rates were dramatically lower for people
practicing the seven health habits. Men following these
practices had a mortality rate of only 28 percent and
women had a mortality rate of 43 percent, compared to
men and women who practiced zero to three of these
health habits (Breslow & Enstrom, 1980).

Primary Prevention Instilling good health
habits and changing poor ones is the task of primary
prevention. This means taking measures to combat
risk factors for illness before an illness has a chance
to develop. There are two general strategies of pri-
mary prevention. The first and most common strat-
egy is to get people to alter their problematic health
behaviors, such as helping people lose weight
through an intervention. The second, more recent ap-
proach is to keep people from developing poor health
habits in the first place. Smoking prevention pro-
grams with young adolescents are an example of this
approach, which we will consider in Chapter 5.

Practicing and Changing Health
Behaviors: An Overview
What factors lead one person to live a healthy life and
another to compromise his or her health?

Demographic Factors Younger, more affluent,
better-educated people with low levels of stress and
high levels of social support typically practice better
health habits than people under higher levels of stress
with fewer resources (Hanson & Chen, 2007).

Age Health habits are typically good in childhood,
deteriorate in adolescence and young adulthood, but
improve again among older people.

Chapter 3 Health Behaviors 41

and feel a false sense of security (Halpern-Felsher
et al., 2001).

Instability of Health Behaviors Health habits
are only modestly related to each other. The person
who exercises faithfully does not necessarily wear a
seat belt, for example. Therefore, health behaviors
must often be tackled one at a time. Health habits are
unstable over time. A person may stop smoking for a
year but take it up again during a period of high stress.
Why are health habits relatively independent of
each other and unstable? First, different health habits
are controlled by different factors. For example, smok-
ing may be related to stress, whereas exercise depends
heavily on ease of access to athletic facilities. Second,
different factors may control the same health behavior
for different people. One person’s overeating may be
“social,” and she may eat primarily in the presence of
other people, whereas another person may overeat
only when under stress.
Third, factors controlling a health behavior may
change over the history of the behavior (Costello,
Dierker, Jones, & Rose, 2008). For example, although
peer group pressure (social factors) is important in initi-
ating smoking, over time, smoking may be maintained
because it reduces feelings of stress.
Fourth, factors controlling a health behavior may
change across a person’s lifetime. In childhood,

Barriers to Modifying Poor
Health Behaviors
There is often little immediate incentive for practicing
good health behaviors, however. Health habits de-
velop during childhood and adolescence when most
people are healthy. Smoking, a poor diet, and lack of
exercise have no apparent effect on health for years,
and few children and adolescents are concerned about
what their health will be like when they are 40 or
50 years old (Johnson, McCaul, & Klein, 2002). As a
result, bad habits have a chance to make inroads.

Emotional Factors Emotions may lead to or
perpetuate unhealthy behaviors (Conner, McEachan,
Taylor, O’Hara, & Lawton, 2015). Poor health be-
haviors can be pleasurable, automatic, addictive, and
resistant to change. Moreover, threatening messages
designed to change health behaviors can produce
psychological distress and lead people to respond de-
fensively, distorting risks to their health (Beckjord,
Rutten, Arora, Moser, & Hesse, 2008; Good &
Abraham, 2007). People may perceive a health threat
to be less relevant than it really is, and they may
falsely see themselves as less vulnerable than or dis-
similar to other people with the same habit (Roberts,
Gibbons, Gerrard, & Alert, 2011; Thornton, Gibbons,
& Gerrard, 2002). Continuing to practice a risky be-
havior may itself lead people to minimize their risks

TABLE 3.2 | Health Locus of Control

Health locus of control assesses whether you think you control your health or whether you believe it’s controlled by health care
professionals or by chance. Here are some examples of items that assess health locus of control. For each item, circle the
number that represents the extent to which you agree or disagree with that statement.

1 Strongly Disagree (SD) 4 Slightly Agree (A)

2 Moderately Disagree (MD) 5 Moderately Agree (MA)

3 Slightly Disagree (D) 6 Strongly Agree (SA)

SD MD D A MA SA

1. If I get sick, it is my own behavior that 1 2 3 4 5 6
determines how soon I get well again.

2. Most things that affect my health happen to me 1 2 3 4 5 6
by accident.

3. Whenever I don’t feel well, I should consult a 1 2 3 4 5 6
medically trained professional.

4. I am in control of my health. 1 2 3 4 5 6

5. Health professionals control my health. 1 2 3 4 5 6

6. My good health is largely a matter of good fortune. 1 2 3 4 5 6

7. If I take the right actions, I can stay healthy. 1 2 3 4 5 6

Source: Wallston, Wallston, & DeVellis, 1978; see http://www.vanderbilt.edu/nursing/kwallston/mhlcscales.htm for the complete scale.

42 Part Two Health Behavior and Primary Prevention

Using the Teachable Moment Some times are
better than others for modifying health practices. Health
promotion efforts capitalize on these teachable
moments. Many teachable moments arise in early child-
hood. Parents can teach their children basic safety
behaviors, such as looking both ways before crossing the
street, and basic health habits, such as drinking milk
instead of soda with dinner.
Other teachable moments are built into the health
care system. For example, many infants in the United
States are covered by well-baby care. Pediatricians
can make use of these visits to teach motivated new
parents the basics of accident prevention and home
safety. Many school systems require a physical at the
beginning of the school year and require documenta-
tion of immunizations.
But what can children really learn about health
habits? Surprisingly, quite a bit. Interventions with
children indicate that choosing healthy foods, brushing
teeth regularly, using car seats and seat belts, participat-
ing in exercise, crossing the street safely, and behaving
appropriately in real or simulated emergencies (such as
earthquake drills) are all within the ability of children
as young as age 3 or 4, as long as the behaviors are ex-
plained concretely and the children know what to do
(Maddux, Roberts, Sledden, & Wright, 1986).
Middle school is an important time for learning
several health-related habits. For example, food choices,
snacking, and dieting all crystallize around this time
(Cohen et al., 1990). There is also a window of
vulnerability for smoking and drug use during middle

regular exercise is practiced because it is built into the
school curriculum, but in adulthood, this behavior
must be practiced intentionally.
In summary, health behaviors are elicited and
maintained by different factors for different people,
and these factors change over the lifetime as well as
over the course of the health habit. Consequently,
health habit interventions have focused heavily on
those who may be helped the most—namely, children
and adolescents (Patton et al., 2012).

Intervening with Children and
Adolescents
Socialization Health habits are strongly affected by
early socialization, especially the influence of parents as
both teachers and role models (Morrongiello, Corbett, &
Bellissimo, 2008). Parents instill certain habits in their
children (or not) that become automatic, such as brush-
ing teeth regularly and eating breakfast every day. None-
theless, in many families, even these basic health habits
are not taught. Especially in families in which parents are
separated or there is chronic family stress, health habits
may slip through the cracks (Menning, 2006).
Moreover, as children move into adolescence, they
sometimes ignore the early training they received from
their parents. In addition, adolescents are exposed to
alcohol consumption, smoking, drug use, and sexual
risk taking, particularly if their parents aren’t monitor-
ing them very closely and their peers practice these
behaviors (Andrews, Tildesley, Hops, & Li, 2002).

The foundations for health promotion develop in early childhood, when children are

taught to practice good health behaviors.

Chapter 3 Health Behaviors 43

for calcium consumption for the prevention of osteo-
porosis. Risk factors of other disorders such as coro-
nary heart disease may also be strongly affected by
health habits in childhood and adolescence as well.

Intervening with At-Risk People
I’m a walking time bomb.

— 37-year-old woman whose female relatives
had breast cancer.

Another vulnerable group is people who are at risk for
particular health problems. For example, people from fam-
ilies with a familial disorder may know that their personal
risk is higher (Glenn et al., 2011). For example, a pediatri-
cian may work with obese parents to control the diet of
their offspring so that obesity in the children can be avoided.

Benefits of Focusing on At-Risk People
Working with at-risk populations can be an efficient
and effective use of health promotion dollars. First,
disease may be prevented altogether. For example,
helping men with a family history of heart disease to
stop smoking can prevent coronary heart disease.
When a risk factor has implications for only some peo-
ple, it makes sense to target those people for whom the
risk factor is relevant. For example, people who have
hypertension that implicates salt sensitivity need to be
especially vigilant about controlling their salt intake.

school, when students are first exposed to these habits
among their peers (D’Amico & Fromme, 1997). Inter-
ventions through the schools may reduce these risks.
Teachable moments are not confined to childhood
and adolescence. Pregnancy is a teachable moment for
stopping smoking and improving diet (Heppner et al.,
2011; Levitsky, 2004). The time period immediately af-
ter giving birth is also a teachable moment for increasing
physical activity and regular exercise, as many new
mothers want to get back to their previous level of fitness
and appearance; but, barriers to physical activity need to
be addressed as well, because new mothers may have
many new responsibilities, leaving little time for behav-
ior seen as optional (Fjeldsoe, Miller, & Marshall, 2013;
Rhodes et al., 2014). Adults with newly diagnosed coro-
nary artery disease are especially motivated to change
contributing health habits such as smoking and poor diet.

Adolescent Health Behaviors and Adult
Health An important reason for intervening with
adolescents is that precautions taken in adolescence
may affect disease risk after age 45 more than do adult
health behaviors. The health habits a person practices
as a teenager or college student may determine which
chronic diseases he or she develops and what the per-
son ultimately dies of in adulthood. For adults who
make changes in their lifestyle, it may already be too
late. This is true for sun exposure and skin cancer and

Adolescence is a window of vulnerability for many poor health habits.

Consequently, intervening to prevent health habits from developing is a high priority

for children in late elementary and middle school.

44 Part Two Health Behavior and Primary Prevention

Focusing on at-risk people helps to identify other
factors that may increase risk. For example, not every-
one who has a family history of hypertension will de-
velop hypertension, but by focusing especially on
people who are at risk, other factors that contribute to
its development, such as diet, may be identified.

Problems of Focusing on At-Risk People
Clearly, however, there are difficulties in working
with people at risk. People do not always perceive
their risk correctly (Croyle et al., 2006). Most people
are unrealistically optimistic and view their poor
health behaviors as widely shared but their healthy
behaviors as more distinctive. For example, smokers
overestimate the number of other people who smoke.
Sometimes testing positive for a risk factor leads
people into needless worry or hypervigilant behavior
(DiLorenzo et al., 2006). People can become defensive,
minimize the significance of their risk factor, and avoid
using appropriate services or monitoring their condition.

Ethical Issues At what point is it appropriate to
alarm at-risk people if their personal risk is unknown?
Not everyone at risk for a particular disorder will develop
the problem and, in many cases, only many years later.
For example, should adolescent daughters of breast can-
cer patients be alerted to their risk and alarmed at a time
when they are coming to terms with their emerging sexu-
ality and needs for self-esteem? Psychological distress
may be created in exchange for instilling risk reduction
behaviors (Croyle, Smith, Botkin, Baty, & Nash, 1997).
Some people, such as those predisposed to depression,
may react especially poorly to information about their
risks. Moreover, in cases involving genetic risk factors,
there may not be any effective intervention. For example,
alcoholism has a genetic component, particularly among
men, and yet exactly how to intervene with the offspring
of adult alcoholics is not yet clear.
Emphasizing risks that are inherited can raise
complicated issues of family dynamics. For example,
daughters of breast cancer patients may suffer stress
and exhibit behavior problems, due in part to the en-
hanced recognition of their risk (Taylor, Lichtman, &
Wood, 1984a). Intervening with at-risk populations
remains a controversial issue.

Health Promotion and Older Adults
John Rosenthal, 92, starts each morning with a brisk
walk. After a light breakfast of whole wheat toast and
orange juice, he gardens for an hour or two. Later,
he joins a couple of friends for lunch, and if he can

persuade them to join him, they fish during the early
afternoon. Reading a daily paper and always having a
good book to read keeps John mentally sharp. Asked
how he maintains such a busy schedule, John says,
“Exercise, friends, and mental challenge” are the keys
to his long and healthy life.

Rosenthal’s lifestyle is right on target. A chief focus of
recent health promotion efforts has been older adults.
At one time, it was thought that health promotion ef-
forts are wasted in old age. However, policy makers
now recognize that a healthy older adult population is
essential not only for quality of life but also for con-
trolling health care spending.
Health promotion efforts with older adults focus on
several behaviors: maintaining a healthy, balanced diet;
maintaining a regular exercise regimen; taking steps to
reduce accidents; controlling alcohol consumption;
eliminating smoking; reducing the inappropriate use of
prescription drugs; obtaining vaccinations against in-
fluenza; and remaining socially engaged. Often, older
adults have multiple issues or health habits that need
modification, requiring an integrative biopsychosocial
approach to their health care needs (Wild et al., 2014).

Among older adults, health habits are a major determinant of

whether an individual will have a vigorous or an infirmed old age.
© Marcy Maloy/Getty Images RF

Chapter 3 Health Behaviors 45

Exercise keeps older adults mobile and able to
care for themselves, and it does not have to be strenu-
ous. Participating in social activities, running errands,
and engaging in light housework or gardening reduce
the risk of mortality, perhaps by providing social sup-
port or a general sense of self efficacy (Glass, deLeon,
Marottoli, & Berkman, 1999). Among the very old,
exercise has particularly strong benefits (Kahana
et al., 2002).
Controlling alcohol consumption is important for
good health among older adults as well. Some older
adults develop drinking problems in response to age-
related issues, such as loneliness (Brennan & Moos,
1995). Others may try to maintain the drinking habits
they had throughout their lives, which become more
risky in old age. Metabolic changes related to age may
reduce the capacity for alcohol. Moreover, many older
people are on medications that may interact danger-
ously with alcohol, leading to accidents.
Proper medication use is essential to good health.
Older adults who are poor may cut back on their med-
ications to save money. Unfortunately, those who do
are more likely to experience health problems within
the next few years (Reitman, 2004, June 28).
Flu vaccination for older adults is an important
health priority. Flu is a major cause of death among
older adults, and it increases the risk of heart disease
and stroke (Nichol et al., 2003).
Depression and loneliness are problems for older
adults. They compromise health habits, leading to ac-
celerated physical decline. Consequently, addressing
these issues can have effects on physical health
(Newall, Chipperfield, Bailis, & Stewart, 2013).
Related problems of loneliness and social isolation
can take a health toll on older adults, and so interven-
tions to increase social engagement can promote this
important health behavior (Thomas, 2011).
The emphasis on health habits among older
adults is well placed. By age 80, health habits are the
major determinant of whether a person will have a
vigorous or an infirmed old age (McClearn et al.,
1997). Moreover, the efforts to change older adults’
health habits seem to be working: The health of our
older adult population is improving (Lubitz, Cai,
Kramarow, & Lentzner, 2003), and consequently, so
is their well-being (Gana et al., 2013).

Ethnic and Gender Differences in Health
Risks and Habits
Health promotion addresses ethnic and gender differ-
ences in vulnerability to health risks. For example,

African American and Hispanic women get less exer-
cise than do Anglo women and are more likely to be
overweight (Pichon et al., 2007). Anglo and African
American women are more likely to smoke than His-
panic women. Alcohol consumption is a greater prob-
lem among men than women, and smoking is a
somewhat greater problem for Anglo men than for
other groups.
Health promotion efforts with different ethnic
groups need to take account of culturally different social
norms. Culturally appropriate interventions include con-
sideration of health practices in the community, infor-
mal networks of communication that can make
interventions more successful, and language (Barrera,
Toobert, Strycker, & Osuna, 2012; Toobert et al., 2011).
Even efficient low-cost interventions such as text mes-
saging and automated telephone messages can be suc-
cessfully implemented when the messages are culturally
adapted to the target group (Migneault et al., 2012).
Health promotion programs for ethnic groups
also need to take account of co-occurring risk factors.
The combined effects of low socioeconomic status
and a biologic predisposition to particular illnesses,
for example, put certain groups at great risk. Exam-
ples are diabetes among Hispanics and hypertension
among African Americans, which we will consider in
more detail in Chapter 13.

■ CHANGING HEALTH HABITS

Habit is habit, and not to be flung out of the window
by any man, but coaxed downstairs a step at a time.

—Mark Twain

In the remainder of this chapter, we address how
health behaviors can be changed.

Attitude Change and Health Behavior
Educational Appeals Educational appeals
make the assumption that people will change their
health habits if they have good information about their
habits. Early and continuing efforts to change health
habits have consequently focused heavily on educa-
tion and changing attitudes. Table 3.3 lists the charac-
teristics that make health communications especially
persuasive. More recently, though, the fact that atti-
tude change may not lead to behavior change has
prompted research on what additional factors may be
involved (Siegel, Navarro, Tan, & Hyde, 2014). Also,
the important automatic aspect of health habits has
been incorporated into interventions, as unconscious

46 Part Two Health Behavior and Primary Prevention

and nonconscious influences on the practice of health
habits have become increasingly apparent.

Fear Appeals Attitudinal approaches to chang-
ing health habits often make use of fear appeals. This
approach assumes that if people are afraid that a par-
ticular habit is hurting their health, they will change
their behavior to reduce their fear. However, this rela-
tionship does not always hold.
Persuasive messages that elicit too much fear may
actually undermine health behavior change (Becker &
Janz, 1987). Moreover, fear alone may not be suffi-
cient to change behavior. Specific action recommen-
dations, such as where and how one can obtain a flu
shot, may be needed (Self & Rogers, 1990). More-
over, as already noted, fear can increase defensive-
ness, which reduces how effective an appeal will be.

Message Framing A health message can be
phrased in positive or negative terms. For example, a
reminder card to get a flu immunization can stress the
benefits of being immunized or stress the discomfort
of the flu itself (Gallagher, Updegraff, Rothman, &
Sims, 2011). Which of these methods is more success-
ful? Messages that emphasize problems seem to work
better for behaviors that have uncertain outcomes, for
health behaviors that need to be practiced only once,
such as vaccinations (Gerend, Shepherd, & Monday,
2008), and for issues about which people are fearful

TABLE 3.3 | Educational Appeals

• Communications should be colorful and vivid rather
than steeped in statistics and jargon. If possible, they
should also use case histories (Arkes & Gaissmaier,
2012).

• The communicator should be expert, prestigious,
trustworthy, likable, and similar to the audience.

• Strong arguments should be presented at the beginning
and end of a message, not buried in the middle.

• Messages should be short, clear, and direct.
• Messages should state conclusions explicitly.
• Extreme messages produce more attitude change, but

only up to a point. Very extreme messages are
discounted. For example, a message that urges people
to exercise for half an hour a day will be more effective
than one that recommends 3 hours a day.

• For illness detection behaviors (such as HIV testing
or obtaining a mammogram), emphasizing problems if
the behaviors are not undertaken will be most
effective. For health promotion behaviors (such as
sunscreen use), emphasizing the benefits may be
more effective.

• If the audience is receptive to changing a health habit,
then the communication should include only favorable
points, but if the audience is not inclined to accept the
message, the communication should discuss both sides
of the issue.

• Interventions should be sensitive to the cultural norms
of the community to which they are directed. For
example, family-directed interventions may be
especially effective in Latino communities (Pantin
et al., 2009).

Fear appeals often alert people to a health problem but do not necessarily

change behavior.

Chapter 3 Health Behaviors 47

are serious. Thus, for example, people may change
their diet to include low cholesterol foods if they value
health, feel threatened by the possibility of heart dis-
ease, and perceive that the personal threat of heart
disease is severe (Brewer et al., 2007).

Perceived Threat Reduction Whether a per-
son believes a health measure will reduce threat has
two subcomponents: whether the person thinks the
health practice will be effective, and whether the cost
of undertaking that measure exceeds its benefits
(Rosenstock, 1974). For example, the man who is con-
sidering changing his diet to avoid a heart attack may
believe that dietary change alone would not reduce his
risk of a heart attack and that changing his diet would
interfere with his enjoyment of life too much to justify
taking the action. So, even if his perceived vulnerabil-
ity to heart disease is great, he would probably not
make any changes. A diagram of the health belief
model applied to smoking is presented in Figure 3.1.

Support for the Health Belief Model Many
studies have used the health belief model to increase
perceived risk and increase perceived effectiveness of
steps to modify a broad array of health habits, ranging
from health screening programs to smoking (e.g.,
Goldberg, Halpern-Felsher, & Millstein, 2002). The
health belief model does, however, leave out an impor-
tant component of health behavior change, and that is
a sense of self efficacy: the belief that one can control
one’s practice of a particular behavior ( Bandura, 1991).
For example, smokers who believe they cannot stop
smoking are unlikely to make the effort.
Other theories of health behavior change use a
similar conceptual analysis of behavior change. For
example, Protection Motivation Theory (Rogers,
1975) examines how people appraise health threats
and how they appraise their abilities to manage
threats. This theory, too, has guided many health in-
terventions (Milne, Sheeran, & Orbell, 2000).

The Theory of Planned Behavior
Health beliefs go some distance in predicting when
people will change their health habits. A theory that
attempts to link health beliefs directly to behavior is
Ajzen’s theory of planned behavior (Ajzen & Madden,
1986; Fishbein & Ajzen, 1975).
According to this theory, a health behavior is the
direct result of a behavioral intention. Behavioral inten-
tions are themselves made up of three components:

(Gerend & Maner, 2011). Messages that stress bene-
fits are more persuasive for behaviors with certain
outcomes (Apanovitch, McCarthy, & Salovey, 2003).
A meta-analysis of 94 studies indicated that messages
stressing benefits are more effective than messages
stressing risks for encouraging health behaviors, such
as skin cancer prevention, smoking cessation, and
physical activity (Gallagher & Updegraff, 2012).
However, negative (loss) framing may stimulate
thought about the health behavior (Bassett-Gunter,
Martin Ginis, & Latimer-Cheung, 2013).
Which kind of message framing will most affect
behavior also depends on people’s personal charac-
teristics (Covey, 2014). For example, people who
have a promotion or approach orientation that empha-
sizes maximizing opportunities are more influenced
by messages phrased in terms of benefits (“calcium
will keep your bones healthy”), whereas people who
have a prevention or avoidance orientation that em-
phasizes minimizing risks are more influenced by
messages that stress the risks of not performing a
health behavior (“low calcium intake will increase
bone loss”) (Updegraff, Emanuel, Mintzer, & Sher-
man, 2015). On the whole, promotion-oriented mes-
sages may be somewhat more successful in getting
people to initiate behavior change, and prevention
messages may be more helpful in getting them to
maintain behavior change over time (Fuglestad, Roth-
man, & Jeffery, 2008).

The Health Belief Model
Attitudinal approaches to health behavior change have
been formalized in several specific theories that have
guided interventions to change health behaviors. An
early influential attitude theory of why people prac-
tice health behaviors is the health belief model
(Hochbaum, 1958; Rosenstock, 1966). According to
this model, whether a person practices a health behav-
ior depends on two factors: whether the person per-
ceives a personal health threat, and whether the person
believes that a particular health practice will be effec-
tive in reducing that threat.

Perceived Health Threat The perception of a
personal health threat is influenced by at least three
factors: general health values, which include interest
in and concern about health; specific beliefs about
personal vulnerability to a particular disorder ( Dillard,
Ferrer, Ubel, & Fagerlin, 2012); and beliefs about the
consequences of the disorder, such as whether they

48 Part Two Health Behavior and Primary Prevention

and the motivation to comply with those normative be-
liefs. Perceived behavioral control is the perception that
one can perform the action and that the action will have
the intended effect; this component of the model is sim-
ilar to self efficacy. These factors combine to produce a
behavioral intention and, ultimately, behavior change.

attitudes toward the specific action, subjective norms
regarding the action, and perceived behavioral control
(Figure 3.2). Attitudes toward the action center on the
likely outcomes of the action and evaluations of those
outcomes. Subjective norms are what a person believes
others think that person should do (normative beliefs)

FIGURE 3.2 | The Theory of Planned Behavior Applied to Adopting a Healthy Diet (Sources: Ajzen & Fishbein, 1980;
Ajzen & Madden, 1986)

Attitudes toward the specific action

— Beliefs about the outcomes of the
behavior (If I change my diet, I will
lose weight, improve my health,
and be more attractive.)

— Evaluations of the outcomes of
the behavior (Being healthy and
looking good are desirable.)

Subjective norms regarding the action

— Normative beliefs (My family and
friends think I should change my diet.)

— Motivation to comply (I want to do
what they want me to do.)

Perceived behavioral control

— (I will be able to change my diet.)

Behavioral
intention
(intending to
change my diet)

Health behavior
(adopting a healthier
diet)

FIGURE 3.1 | The Health Belief Model Applied to the Health Behavior of Stopping Smoking

Belief in health threat

— General health values
(I am concerned about my health.)

— Specific beliefs about vulnerability
(As a smoker, I could get lung cancer.)

— Beliefs about severity of the disorder
(I would die if I developed lung cancer.)

Belief that specific health behavior can reduce threat

— Belief that specific measure can be effective
against specific threat
(If I stop smoking now, I will not develop lung cancer.)

— Belief that benefits of health measure exceed costs
(Even though it will be hard to stop smoking, it is
worth it to avoid the risk of lung cancer.)

Health behavior
(I will stop smoking.)

Chapter 3 Health Behaviors 49

regulation is conscious, designed to meet personal goals
and control thoughts, emotions, and behavior in service
of those goals. Enhancing health behaviors requires ef-
fective self regulation (Mann, de Ridder, & Fujita, 2013)
and interventions may need to be aimed at both the
automatic and the conscious, controlled processes
(Conroy, Maher, Elavsky, Hyde, & Doerksen, 2013).

Self Determination Theory
Self determination theory (SDT), a theory that also
guides health behavior modification, builds on the
idea that people are actively motivated to pursue their
goals (Deci & Ryan, 1985; Ryan & Deci, 2000). The
theory targets two important components as funda-
mental to behavior change, namely autonomous moti-
vation and perceived competence. People are
autonomously motivated when they experience free
will and choice when making decisions. Competence
refers to the belief that one is capable of making the
health behavior change.
Accordingly, if a woman changes her diet because
her physician tells her to, she may not experience a sense
of autonomy and instead may experience her actions as
under another’s control. This may undermine her com-
mitment to behavior change. However, if her dietary
change is autonomously chosen, she will be intrinsically
motivated to persist. SDT has given rise to interventions
that target these beliefs, namely autonomous motivation
and competence, and have shown some success in
changing behaviors including smoking and adherence to
medications (Bruzzese et al., 2014). A meta-analysis of
184 studies indicates support for self-determination the-
ory and the importance of autonomous motivation for
changing health behaviors (Ng et al., 2012).

Implementation Intentions
A theoretical model that emphasizes implementation
intentions (Gollwitzer, 1999) integrates conscious
processing with automatic behavioral enactment
(Gollwitzer & Oettingen, 1998). When a person de-
sires to practice a health behavior, it can be achieved
by making a simple plan that links critical situations
or environmental cues to goal-directed responses. For
example, a person might tell herself, “When I finish
breakfast, I will take out the dog’s leash and walk her.”
The theory underscores the importance of planning ex-
actly how, when, and where to implement a health
behavior. Without these explicit links to action, the
good intention might remain at the intention stage.

To take a simple example, smokers who believe
that smoking causes serious health outcomes, who be-
lieve that other people think they should stop smok-
ing, who are motivated to comply with those normative
beliefs, who believe that they are capable of stopping
smoking, and who form a specific intention to do so
will be more likely to stop smoking than people who
do not hold these beliefs.

Evidence for the Theory of Planned Behavior
The theory of planned behavior predicts a broad array
of health behaviors, and change in health behaviors
(Montanaro & Bryan, 2014; McEachan, Conner,
Taylor, & Lawton, 2011). Its components predict such
behaviors as risky sexual activity among heterosexuals
(Tyson, Covey, & Rosenthal, 2014; Davis et al., 2016),
consumption of soft drinks (Kassem & Lee, 2004) and
food safety practices (Milton & Mullan, 2012). More-
over, communications targeted to particular parts of
the model, such as social norms, have been found to
change behaviors (Reid & Aiken, 2013).

Criticisms of Attitude Theories
Because health habits are often deeply ingrained and
difficult to modify, attitude-change interventions may
provide the informational base for altering health
habits but not always the impetus to take action
(Ogden, 2003). Moreover, attitude change techniques
assume that behavior changes are guided by con-
scious motivation, and these approaches ignore the
fact that some behavior change occurs automatically
and is not subject to awareness. That is, a general
limitation of health behavior change models is the
fact that they heavily emphasize conscious delibera-
tive processes in practicing health behaviors; there is
an important role for implicit automatic processes as
well. Perhaps the most obvious example concerns
health habits that are accomplished automatically in
response to a minimal cue, such as putting on a seat-
belt when one gets into a car.

Self Regulation and Health Behavior
Thus far, we have discussed changing health behaviors
primarily through interventions designed to get people
to alter their behavior. But people also change on their
own. Self regulation refers to the fact that people con-
trol their own actions, emotions, and thoughts (Fiske &
Taylor, 2013). A lot of self regulation is automatic, oc-
curring without awareness or thought. But much self

50 Part Two Health Behavior and Primary Prevention

Harrison, & Lieberman, 2010) gave people persuasive
messages promoting sunscreen use. People who showed
significant activation in two particular brain regions,
the medial prefrontal cortex (mPFC) and posterior cin-
gulate cortex (pCC), in response to the messages in-
creased their sunscreen use. Most important, attitude
change about sunscreen use in response to the persua-
sive message only weakly predicted people’s intentions
to use sunscreen, but activity in these two brain regions
quite strongly predicted sunscreen use, independent of
attitudes and behavioral intentions. In other words, pro-
cesses apparently not accessible to consciousness none-
theless significantly predicted changes in sunscreen use
(Falk, Berkman, Whalen, & Lieberman, 2011).
What this pattern of brain activity means is not yet
fully known. One possibility is that activity in mPFC
and pCC reflects behavioral intentions at an implicit
level that is not consciously accessible (Falk et al.,
2010). Alternatively, activity in mPFC may be related
to behavior change primarily because participants link
the persuasive communication to the self. In any case,
health behavior change can occur unconsciously, but
the brain may detect these processes nonetheless.

■ COGNITIVE-BEHAVIORAL
APPROACHES TO HEALTH
BEHAVIOR CHANGE

Cognitive-Behavior Therapy (CBT)
Cognitive-behavior approaches to health habit modi-
fication focus on the target behavior itself, the condi-
tions that elicit and maintain it, and the factors that
reinforce it (Dobson, 2010). The most effective ap-
proach to health habit modification often comes from
cognitive-behavior therapy (CBT). CBT interven-
tions use several complementary methods to inter-
vene in the modification of a target problem and its
context. CBT may be implemented individually,
through therapy in a group setting, or even on the In-
ternet, and so it is a versatile as well as effective way
of intervening to modify poor health habits.

Self Monitoring
Many programs of cognitive-behavioral modification
use self monitoring as the first step toward behavior
change. The rationale is that a person must understand
the dimensions of the poor health habit before change
can begin. Self monitoring assesses the frequency of a
target behavior and the antecedents and consequences
of that behavior.

A second important feature of the theory is the idea
that, by forming an implementation intention, a person
can delegate the control of goal-directed responses to
situational cues (e.g., completing breakfast), which
may then elicit the behavior automatically (in this case,
the action of taking out the leash to walk the dog). Over
time, the link from the implementation to the goal-
directed response becomes automatic and need not be
brought into conscious awareness to be enacted.
Forming implementation intentions can be a simple
but effective way to promote health behaviors (Martin,
Sheeran, Slade, Wright, & Dibble, 2009). When a person
has a particular health goal, such as remembering to use
sunscreen, he or she can strategically engage automatic
processes in an effort to make good on that goal. So, for
example, a person wanting to practice better sun safety
behaviors might say, “Whenever I am going to the beach,
I will put on sunscreen first.” Having created this imple-
mentation intention, she then delegates the control of
sunscreen use to anticipated situational cues, in this case,
getting ready to go to the beach (Gollwitzer, 1999). Thus,
although the original implementation intention is con-
sciously framed, the relation of the health behavior itself
to the situation in which it is relevant becomes an auto-
matic process (Sheeran, Gollwitzer, & Bargh, 2013).
Adding implementation intentions to attitude models
of health behavior has improved their ability to predict
behavior (Milne, Orbell, & Sheeran, 2002). Results of
a meta-analysis support the idea that changes in inten-
tions lead to changes in behavior (Webb & Sheeran,
2006).

Self Affirmation Self affirmation occurs when
people reflect upon their important values, personal
qualities, or social relationships. When people are self
affirmed, they become less defensive about personally
relevant risk-related information (Schüz, Schüz, & Eid,
2013), which can set the stage for behavior change. A
meta-analysis of 144 studies has shown that inducing
self awareness when people are exposed to persuasive
health information leads to positive changes in inten-
tions and in actual health behaviors (Epton et al., 2015;
Sweeney & Moyer, 2015).

Health Behavior Change and the Brain
Some successful health behavior change in response to
persuasive messages occurs outside of awareness. De-
spite being inaccessible to conscious awareness, this
change may be reflected in patterns of brain activation.
Emily Falk and colleagues (Falk, Berkman, Mann,

Chapter 3 Health Behaviors 51

avoiding eating while engaged in other activities, such
as watching television. Other stimuli might be intro-
duced in the environment to indicate that controlled eat-
ing will now be followed by reinforcement. For example,
people might place signs in strategic locations around
the home, reminding them of reinforcements to be
obtained after successful behavior change.

The Self Control of Behavior
Cognitive-behavior therapy focuses heavily on the be-
liefs that people hold about their health habits. People
often generate internal monologues that interfere with
their ability to change their behavior. For example, a per-
son who wishes to give up smoking may derail the quit-
ting process by generating self doubts (“I will never be
able to give up smoking”). Unless these internal mono-
logues are modified, the person will be unlikely to change
a health habit and maintain that change over time.
Recognition that people’s cognitions about their
health habits are important in producing behavior
change highlights another insight about the behavior
change process: the importance of involving the client
as co-therapist in the behavior-change intervention. Cli-
ents need to actively monitor their own behaviors and
apply the techniques of cognitive-behavioral therapy
to bring about change. As such, CBT emphasizes
self control. The person acts as his or her own therapist
and, together with outside guidance, learns to control
the antecedents and consequences of the target behavior.
Cognitive restructuring trains people to recognize
and modify their internal monologues to promote health
behavior change. Sometimes the modified cognitions
are antecedents to a target behavior. For example, if a
smoker’s urge to smoke is preceded by an internal
monologue that he is weak and unable to control his
smoking urges, these beliefs are targeted for change.
The smoker would substitute a monologue that would
help him stop smoking (for example, “I can do this” or
“I’ll be so much healthier”). Cognitions can also be the
consequences of a target behavior. For example, an
obese woman trying to lose weight might undermine her
weight-loss program by reacting with hopelessness to
every small dieting setback. She might learn, instead, to
engage in self reinforcing cognitions following success-
ful resistance to temptation and constructive self
criticism following setbacks (“Next time, I’ll keep those
tempting foods out of my refrigerator”).

Self Reinforcement Self reinforcement involves
systematically rewarding oneself to increase or decrease

The first step in self monitoring is to learn to dis-
criminate the target behavior. For some behaviors, this
step is easy. A smoker obviously can tell whether he
or she is smoking. However, an urge to smoke may be
less easily discriminated; therefore, the person may be
trained to monitor internal sensations closely so as to
identify the target behavior more readily.
A second stage in self monitoring is charting the
behavior. For example, a smoker may keep a detailed
record of smoking-related events, including when a ciga-
rette is smoked, the time of day, the situation in which the
smoking occurred, and the presence of other people (if
any). She may also record the subjective feelings of crav-
ing that existed prior to lighting the cigarette, the emo-
tional responses that preceded the lighting of the cigarette
(such as anxiety or tension), and the feelings that were
generated by the actual smoking of the cigarette. In this
way, she can begin to get a sense of the conditions under
which she is most likely to smoke. Each of these condi-
tions can be a discriminative stimulus that is capable of
eliciting the target behavior. For example, the sight and
smell of food act as discriminative stimuli for eating. The
sight of a pack of cigarettes or the smell of coffee may act
as discriminative stimuli for smoking. The discrimina-
tive stimulus is important because it signals that a posi-
tive reinforcement will subsequently occur. CBT aims to
eliminate or modify these discriminative stimuli. Al-
though self monitoring is usually only a beginning step
in behavior change, it may itself produce some behavior
change (Quinn, Pascoe, Wood, & Neal, 2010). In fact,
even being asked questions about a health behavior can
launch behavior change (Rodrigues, O’Brien, French,
Glidewell, & Sniehotta, 2015).

Stimulus Control
Once the circumstances surrounding the target behav-
ior are well understood, the factors in the environment
that maintain poor health habits such as smoking,
drinking, and overeating, can be modified. Stimulus-
control interventions involve ridding the environ-
ment of discriminative stimuli that evoke the problem
behavior, and creating new discriminative stimuli,
signaling that a new response will be reinforced.
For example, eating is typically under the control of
discriminative stimuli, including the presence of desir-
able foods and activities (such as watching television).
People desiring to lose weight can be encouraged to
eliminate these discriminative stimuli for eating, such as
ridding their home of rewarding and fattening foods,
restricting their eating to a single place in the home, and

reduction in her smoking as a target (such as 15 ciga-
rettes a day). When that target is reached, she would
administer a reinforcement (the movie or dinner out).
The next step might be reducing smoking to 10 ciga-
rettes a day, at which time she would receive another
reinforcement. The target then might be cut progres-
sively to 5, 4, 3, 2, 1, and none. Through this process,
the target behavior of abstinence would eventually be
reached.
Like self reward, self punishment is of two types.
Positive self punishment involves the administration of
an unpleasant stimulus to punish an undesirable behav-
ior. For example, a person might self administer a mild
electric shock each time he or she experiences a desire

the occurrence of a target behavior. Positive self reward
involves rewarding oneself with something desirable
after successful modification of a target behavior, such
as going to a movie following successful weight loss.
Negative self reward involves removing an aversive fac-
tor in the environment after successful modification of
the target behavior. An example of negative self reward
is taking the Miss Piggy poster off the refrigerator once
regular controlled eating has been achieved.
For example, suppose Mary smokes 20 cigarettes a
day. She might first define a set of reinforcers that can
be administered when particular smoking-reduction
targets are met—reinforcements such as going out to
dinner or seeing a movie. Mary may then set a particular

First described by Russian physiologist Ivan Pavlov in
the early 20th century, classical conditioning is the
pairing of an unconditioned reflex with a new stimu-
lus, producing a conditioned reflex. Classical condi-
tioning is represented in Figure 3.3.
Classical conditioning was one of the first methods
used for health behavior change. For example, consider
its use in the treatment of alcoholism. Antabuse (un-
conditioned stimulus) is a drug that produces extreme
nausea, gagging, and vomiting (unconditioned re-
sponse) when taken in conjunction with alcohol. Over

time, the alcohol becomes associated with the nausea
and vomiting caused by the Antabuse and elicits the
same nausea, gagging, and vomiting response (condi-
tioned response) without the Antabuse being present.
Classical conditioning approaches to health habit
modification do work, but clients know why they
work. Alcoholics, for example, know that if they do not
take the drug they will not vomit when they consume
alcohol. Thus, even if classical conditioning has suc-
cessfully produced a conditioned response, it is heavily
dependent on the client’s willing participation.

B O X 3.1 Classical Conditioning

FIGURE 3.3 | A Classical Conditioning Approach to the Treatment of Alcoholism

Unconditioned
response

(nausea, gagging,
vomiting)

Unconditioned
response

(nausea, gagging,
vomiting)

Conditioned
response

(nausea, gagging,
vomiting)

Phase one Phase two Phase three

The unconditioned stimulus
produces a reflexive response.

The unconditioned stimulus
is paired with a new stimulus.

The conditioned stimulus
evokes the response.

Unconditioned
stimulus

(Antabuse)

Unconditioned
stimulus

(Antabuse)

Conditioned
stimulus
(alcohol)

to smoke. Negative self punishment consists of with-
drawing a positive reinforcer in the environment each
time an undesirable behavior is performed. For exam-
ple, a smoker might rip up money each time he or she
has a cigarette that exceeds a predetermined quota.
Self punishment is effective only if people actually
perform the punishing activities. If self punishment
becomes too aversive, people often abandon their efforts.
One form of self punishment that is effective in
behavior modification is contingency contracting. In
contingency contracting, an individual forms a contract
with another person, such as a therapist or one’s spouse,
detailing what rewards or punishments are contingent
on the performance or nonperformance of a behavior.
For example, a person who wants to stop drinking
might deposit a sum of money with a therapist and ar-
range to be fined each time he or she has a drink and to
be rewarded each day that he or she abstained.

Behavioral Assignments A technique for in-
creasing client involvement is behavioral assign-
ments, home practice activities that support the goals
of a therapeutic intervention. Behavioral assignments
are designed to provide continuity in the treatment
of a behavior problem. For example, if an early session
with an obese client involved training in self monitoring,
the client would be encouraged to keep a log of his
eating behavior, including the circumstances in which
it occurred. This log could then be used by the thera-
pist and the patient at the next session to plan future

behavioral interventions. Figure 3.4 gives an example
of the behavioral assignment technique. Note that it
includes homework assignments for both client and

B O X 3.2Operant Conditioning

In contrast to classical conditioning, which pairs an
automatic response with a new stimulus, operant con-
ditioning pairs a voluntary behavior with systematic
consequences. The key to operant conditioning is
reinforcement. When a person performs a behavior
and that behavior is followed by positive reinforce-
ment, the behavior is more likely to occur again. Sim-
ilarly, if an individual performs a behavior and
reinforcement is withdrawn or the behavior is pun-
ished, the behavior is less likely to be repeated. Over
time, these contingencies build up those behaviors
paired with positive reinforcement, whereas behaviors
that are punished or not rewarded decline.
Many health habits can be thought of as operant
responses. For example, drinking may be maintained
because mood is improved by alcohol, or smoking

may occur because peer companionship is associated
with it. In these cases, reinforcement maintains the
poor health behavior. Thus, using this principle to
change behavior requires altering the reinforcement.
An important feature of operant conditioning is
the reinforcement schedule. A continuous reinforce-
ment schedule means that a behavior is reinforced
every time it occurs. However, continuous reinforce-
ment is vulnerable to extinction: If the behavior is
occasionally not paired with reinforcement, the indi-
vidual may cease performing the behavior, having
come to anticipate reinforcement each time. Psychol-
ogists have learned that behavior is often more resis-
tant to extinction if it is maintained by a variable or
an intermittent reinforcement schedule than a con-
tinuous reinforcement schedule.

FIGURE 3.4 | Example of a Systematic Behavioral
Assignment for an Obese Client

(Source: Shelton & Levy, 1981, p. 6)

Homework for Tom [client]

Using the counter, count bites taken.

Record number of bites, time,
location, and what you ate.

Record everything eaten for 1 week.

Call for an appointment.

Bring your record.

Homework for John [therapist]

Reread articles on obesity.

and blood pressure and increases oxygenation of the
blood. People typically engage in deep breathing spon-
taneously when they are relaxed. In progressive mus-
cle relaxation, an individual learns to relax all the
muscles in the body progressively to discharge tension
or stress.

Motivational Interviewing
Motivational interviewing (MI) is increasingly used in
health promotion interventions. Originally developed to
treat addiction, the techniques have been adapted to tar-
get smoking, dietary improvements, exercise, cancer
screening, and sexual behavior, among other habits
(Miller & Rose, 2009). Motivational interviewing is a
client-centered counseling style designed to get people
to work through any ambivalence they experience about
changing their health behaviors. It may be especially
effective for people who are initially wary about whether
to change their behavior (Resnicow et al., 2002).
In motivational interviewing, the interviewer
adopts a nonjudgmental, nonconfrontational, encour-
aging, and supportive style. The goal is to help the
client express the positive or negative thoughts he or
she has regarding the behavior in an atmosphere that
is free of negative evaluation (Baldwin, Rothman,
Vander Weg, & Christensen, 2013). Typically, clients
talk at least as much as counselors during MI sessions.
In motivational interviewing, there is no effort to
dismantle the denial or irrational beliefs that often ac-
company bad health behaviors or even to persuade a
client to stop drinking, quit smoking, or otherwise im-
prove health. Rather, the goal is to get the client to
think through and express some of his or her own rea-
sons for and against behavior change. The interviewer
listens and provides encouragement in lieu of giving
advice (Miller & Rose, 2009).

therapist. This technique can ensure that both parties
remain committed to the behavior-change process and
that each is aware of the other’s commitment.
The chief advantages of behavioral assignments
are that (1) the client becomes involved in the treat-
ment process, (2) the client produces an analysis of
the behavior that is useful in planning further inter-
ventions, (3) the client becomes committed to the
treatment process through a contractual agreement to
discharge certain responsibilities, (4) responsibility
for behavior change is gradually shifted to the client,
and (5) the use of homework assignments increases
the client’s sense of self control.

Social Skills and Relaxation Training
Some poor health habits develop in response to the anx-
iety people experience in social situations. For example,
adolescents often begin to smoke to reduce their ner-
vousness in social situations by trying to communicate a
cool, sophisticated image. Drinking and overeating may
also be responses to social anxiety. Social anxiety can
then act as a cue for the maladaptive habit, necessitating
an alternative way of coping with the anxiety.
Consequently, many health habit modification
programs include either social skills training or
assertiveness training, or both, as part of the inter-
vention package. People are trained in methods that
help them deal more effectively with social anxiety.

Relaxation Training Many poor health habits are
caused or maintained by stressful circumstances, and
so managing stress is important to successful behavior
change. A mainstay of stress reduction is relaxation
training involving deep breathing and progressive
muscle relaxation. In deep breathing, a person takes
deep, controlled breaths, which decreases heart rate

Modeling is learning that occurs from witnessing an-
other person perform a behavior (Bandura, 1969). Ob-
servation and subsequent modeling can be effective
approaches to changing health habits. For example, in
one study high school students who observed others
donating blood were more likely to do so themselves
(Sarason, Sarason, Pierce, Shearin, & Sayers, 1991).
Similarity is an important principle in model-
ing. To the extent that people perceive themselves

as similar to the type of person who engages in a
risky behavior, they are likely to do so themselves;
if people see themselves as similar to the type of
person who does not engage in a risky behavior,
they may change their behavior (Gibbons &
Gerrard, 1995). For example, a swimmer may de-
cline a cigarette from a friend because she per-
ceives that most great swimmers do not smoke.

ModelingB O X 3.3

Chapter 3 Health Behaviors 55

find themselves in situations where they used to
smoke or drink, such as a party, and relapse at that
vulnerable moment. People with low self efficacy for
the behavior change initially are more likely to re-
lapse. Sometimes, people think they have beaten the
health problem, and so giving in to a temptation would
have few costs (e.g., “a couple drinks would relax
me”).
A potent catalyst for relapse is negative affect
(Witkiewitz & Marlatt, 2004). Relapse is more likely
when people are depressed, anxious, or under stress.
For example, when people are breaking off a relation-
ship or encountering difficulty at work, they are vulner-
able to relapse. Peter Jennings, the national newscaster
who died of lung cancer in 2005, had relapsed to smok-
ing after the September 11, 2001 terrorist attacks.
Figure 3.5 illustrates the relapse process. Because of
the high risk of relapse, behavioral interventions build
in techniques to try to reduce its likelihood.
Relapse prevention should be integrated into
treatment programs from the outset. Enrolling people
who are initially committed and motivated to change
their behavior reduces the risk of relapse and weeds
out people who are not truly committed to behavior
change. Although prescreening people for an

Relapse Prevention
One of the biggest problems faced in health habit
modification is the tendency for people to relapse.
Following initial successful behavior change, people
often return to their old bad habits. Relapse is a par-
ticular problem with the addictive disorders of alco-
holism, smoking, drug addiction, and overeating
(Brownell, Marlatt, Lichtenstein, & Wilson, 1986), but
it can be a problem for all behavior change efforts.
What do we mean by “relapse”? A single cigarette
smoked at a party or the consumption of a pint of ice
cream on a lonely Saturday night need not lead to full-
blown relapse. However, that one cigarette or that sin-
gle pint of ice cream can produce what is called an
abstinence violation effect—that is, a feeling of loss
of control that results when a person has violated self
imposed rules. The result can be a more serious relapse,
as the person’s resolve falters. This is especially true for
addictive behaviors because the person must also cope
with the reinforcing impact of the substance itself.

Reasons for Relapse Why do people relapse?
Initially when people change their behaviors, they are
vigilant, but over time, vigilance fades and the likeli-
hood of relapse increases. For example, people may

Decreased
probability
of relapse

Increased
self efficacy

High-risk
situation

Decreased
self efficacy

and
positive
outcome

expectancies
for effects of

alcohol

Increased
probability
of relapse

Abstinence
violation
effect and
perceived
positive

effects of
alcohol

Ineffective
coping

response

Lapse (initial
use of

alcohol)

Effective coping
response

FIGURE 3.5 | A Cognitive-Behavioral Model of the Relapse Process This figure shows what happens when
a person is trying to change a poor health habit and faces a high-risk situation. With adequate coping responses,
the person may be able to resist temptation, leading to a low likelihood of relapse. Without adequate coping
responses, however, perceptions of self efficacy may decline and perceptions of the rewarding effects of the poor
health behavior may increase, leading to an increased likelihood of relapse. (Source: Larimer, Palmer, & Marlatt, 1999)

56 Part Two Health Behavior and Primary Prevention

situations, and integrate their behavior change into a gen-
erally healthy lifestyle. In a meta-analysis of 26 studies
with more than 9,000 participants treated for alcohol,
tobacco, cocaine, and other substance use, Irvin and
colleagues (Irvin, Bowers, Dunn, & Wang, 1999) con-
cluded that relapse prevention techniques were effective
for reducing substance use and improving psychosocial
functioning.

Evaluation of CBT
The advantages of CBT for health behavior change are
several. First, a carefully selected set of techniques
can deal with all aspects of a problem (van Kessel
et al., 2008): Self observation and self monitoring define
the dimensions of a problem; stimulus control enables
a person to modify antecedents of behavior; self rein-
forcement controls the consequences of a behavior;
and social skills and relaxation training may replace
the maladaptive behavior, once it has been brought
under some degree of control.
A second advantage is that the therapeutic plan
can be tailored to each individual’s problem. Each per-
son’s faulty health habit and personality are different, so,
for example, the particular package identified for one
obese client may not be the same as that developed for
another obese client (Schwartz & Brownell, 1995).
Third, the range of skills imparted by multimodal inter-
ventions may enable people to modify several health
habits simultaneously, such as diet and exercise, rather
than one at a time (Persky, Spring, Vander Wal, Pagoto, &
Hedeker, 2005; Prochaska & Sallis, 2004). Overall,
CBT interventions have shown considerable success in
modifying a broad array of health behaviors.

■ THE TRANSTHEORETICAL
MODEL OF BEHAVIOR CHANGE

Changing a bad health habit does not take place all at
once. People go through stages while they are trying to
change their health behaviors (Prochaska, 1994; Rothman,
2000).

Stages of Change
J. O. Prochaska and his associates (Prochaska, 1994;
Prochaska, DiClemente, & Norcross, 1992) devel-
oped the transtheoretical model of behavior change,
a model that analyzes the stages and processes people
go through in bringing about a change in behavior and

intervention may seem ethically problematic, includ-
ing people who are likely to relapse may demoralize
other participants in a behavior-change program, de-
moralize the practitioner, and ultimately make it more
difficult for the relapser to change his or her behavior.
Relapse prevention techniques include asking peo-
ple to identify the situations that may lead to relapse so
they can help them develop coping skills that will help
them to manage that stressful event. For example, over-
coming the temptation to drink at bars might be fos-
tered by scheduling lunches with friends instead. Or, at
parties, a person might have a sham drink of club soda,
instead of an alcoholic beverage. Mentally rehearsing
coping responses in a high-risk situation can promote
feelings of self efficacy. For example, some programs
train participants to engage in constructive self talk that
will help them talk themselves through tempting situa-
tions (Brownell et al., 1986).
Cue elimination involves restructuring the environ-
ment to avoid situations that evoke the target behavior
(Bouton, 2000). For example, the alcoholic who drank
exclusively in bars can avoid bars. For other habits,
however, cue elimination is impossible. For example,
smokers are usually unable to completely eliminate the
circumstances in their lives that led them to smoke.
Consequently, some relapse prevention programs de-
liberately expose people to situations that evoke the old
behavior to give them practice in using their coping
skills (Marlatt, 1990). Making sure that the new habit
(such as exercise or alcohol abstinence) is practiced in
as many new contexts as possible also ensures that it
endures (Bouton, 2000).

Lifestyle Rebalancing Long-term maintenance of
behavior change can be promoted by leading the person
to make other health-oriented lifestyle changes, a tech-
nique termed lifestyle rebalancing. Lifestyle changes,
such as adding an exercise program or using stress man-
agement techniques, may promote a healthy lifestyle
more generally and help reduce the likelihood of relapse.
The role of social support in maintaining behav-
ior change is equivocal. At present, some studies sug-
gest that enlisting the aid of family members in
maintaining behavior change is helpful, but other
studies suggest not (Brownell et al., 1986). Possibly,
research has not yet identified the exact ways in which
social support may help maintain behavior change.
Overall, relapse prevention is most successful when
people perceive their behavior change to be a long-term
goal, develop coping techniques for managing high-risk

Chapter 3 Health Behaviors 57

successfully. In some cases, they have modified the
target behavior somewhat, such as smoking fewer cig-
arettes than usual, but have not yet made the commit-
ment to eliminate the behavior altogether.

Action The action stage occurs when people mod-
ify their behavior to overcome the problem. Action
requires the commitment of time and energy to mak-
ing real behavior change. It includes stopping the be-
havior and modifying one’s lifestyle and environment
to rid one’s life of cues associated with the behavior.

Maintenance In the stage of maintenance, people
work to prevent relapse and to consolidate the gains they
have made. For example, if a person is able to remain free
of an addictive behavior for more than 6 months, he or she
is assumed to be in the maintenance stage (Wing, 2000).
Because relapse is the rule rather than the excep-
tion with many health behaviors, this stage model is
conceptualized as a spiral. As Figure 3.6 indicates, a
person may take action, attempt maintenance, relapse,
return to the precontemplation phase, cycle through
the subsequent stages to action, repeat the cycle again,
and do so several times until they have eliminated the
behavior (Prochaska et al., 1992).

Using the Stage Model of Change
At each stage, particular types of interventions may
be most appropriate. Specifically, providing people
in the precontemplation stage with information about

suggested treatment goals and interventions for each
stage. Originally developed to treat addictive disor-
ders, such as smoking, drug use, and alcohol addic-
tion, the stage model has now been applied to a broad
range of health habits, including exercising and sun
protection behaviors (Adams, Norman, Hovell,
Sallis, & Patrick, 2009; Hellsten et al., 2008).

Precontemplation The precontemplation stage
occurs when a person has no intention of changing
his or her behavior. Many people in this stage are not
aware that they have a problem, although families,
friends, neighbors, or coworkers may well be. An ex-
ample is the problem drinker who is largely oblivious
to the problems he creates for his family. Sometimes
people in the precontemplative phase seek treatment
if they have been pressured by others to do so. Not
surprisingly, these people often revert to their old be-
haviors and so make poor targets for intervention.

Contemplation Contemplation is the stage in
which people are aware that they have a problem and
are thinking about it but have not yet made a commit-
ment to take action. Many people remain in the con-
templation stage for years. Interventions aimed at
increasing receptivity to behavior change can be help-
ful at this stage (Albarracín, Durantini, Earl, Gunnoe, &
Leeper, 2008).

Preparation In the preparation stage, people in-
tend to change their behavior but have not yet done so

Readiness to change a health habit is a prerequisite to health habit change.

58 Part Two Health Behavior and Primary Prevention

Lack of time, stress, competing goals, and inaccessi-
bility of the health care system may be almost inevi-
table for some people (Gerend et al., 2013; Presseau,
Tait, Johnston, Francis, & Sniehotta, 2013). But
breaking down perceived barriers is paramount to get-
ting people to practice good health behaviors.

■ CHANGING HEALTH
BEHAVIORS THROUGH
SOCIAL ENGINEERING

Much health behavior change occurs not through pro-
grams such as CBT interventions, but through social
engineering. Social engineering modifies the environ-
ment in ways that affect people’s abilities to practice a
particular health behavior. Often, social engineering
solutions are legally mandated. Some examples include
requiring vaccinations for school entry, which has led
to 90 percent of children in the United States receiving
most of the vaccinations they need (Center for the Ad-
vancement of Health, December, 2002). Others include
banning certain drugs, such as heroin and cocaine, and
controlling the disposal of toxic wastes. Still others in-
clude taxation that may reduce, although not eliminate,
poor health habits such as consumption of sugared soft
drinks (The Economist, November 28, 2015).
Social engineering solutions to health problems
can be more successful than individual behavior mod-
ification. For example, lowering the speed limit has
had more impact on death and disability than inter-
ventions to get people to change their driving habits.
Raising the legal drinking age and banning smoking

their problem may move them to the contemplation
phase. To move people from the contemplation phase
into preparation, an appropriate intervention may in-
duce them to assess how they feel and think about the
problem and how stopping it will change them. Inter-
ventions designed to get people to make explicit
commitments as to when and how they will change
their behavior may bridge the gap between prepara-
tion and action. Interventions that emphasize provid-
ing self reinforcement, social support, stimulus
control, and coping skills should be most successful
with individuals moving through the action phase
into long-term maintenance. The transtheoretical
model has also been used to modify multiple health
behaviors simultaneously (Johnson et al., 2014).

Perceived Barriers Perceived barriers are as-
pects of one’s life that interfere with practicing good
health behaviors. The person with two jobs may not
have enough time to sleep 7–8 hours. A woman who
wants to exercise may perceive her neighborhood to
be too unsafe for walking or running. A family with-
out health insurance may not vaccinate their children.
Perceived barriers are a main reason why people
don’t practice good health behaviors (Gerend, Shep-
herd, & Shepherd, 2013), and it can be hard to help
people overcome them. In the case of health insur-
ance, social engineering has stepped in, requiring
people to have insurance and to vaccinate their chil-
dren. For the woman who wants to exercise, driving to
or getting off a bus where there is a park with other
people walking or running may solve the safety issue.

FIGURE 3.6 | A Spiral Model of the Stages of Change (Source: Prochaska et al., 1992)

Precontemplation Contemplation, preparation, action

Contemplation, preparation, action
Precontemplation

Maintenance

Termination

Chapter 3 Health Behaviors 59

individual treatment a person receives makes success
more likely, and second, the intervention can be tailored
to the needs of the particular person. However, only one
person’s behavior can be changed at a time.
Nonetheless, the one-to-one approach reduces
only one person’s risk at a time. Managed care facili-
ties sometimes run clinics to help people stop smok-
ing, change their diet, and make other healthy lifestyle
changes. Advantages are that a number of people can
be reached simultaneously, and there is a direct link
from knowledge of a person’s health risks to the type
of intervention that person receives.

The Family
Increasingly, health practitioners intervene with families
to improve health (Fisher et al., 1998). People from intact
families have better health habits than those who live
alone or in fractured families. Families typically have
more organized, routinized lifestyles than single people
do, so family life can be suited to building in healthy be-
haviors, such as eating three meals a day, sleeping eight
hours each night, and brushing teeth twice daily.
Children learn their health habits from their par-
ents, so committing the entire family to a healthy
lifestyle gives children the best chance at a healthy
start in life. Multiple family members are affected by
any one member’s health habits, and so modifying
one family member’s behavior, such as diet, is likely
to affect other family members.

in the workplace have had major effects on these
health problems. Controlling what is contained in
vending machines at school and controlling advertise-
ment of high fat and high cholesterol products to chil-
dren may help to reduce the obesity epidemic.
Still, most health behavior change cannot be le-
gally mandated, and people will continue to engage in
bad habits even when their freedoms to do so are lim-
ited by social engineering. Consequently, health psy-
chology interventions have a very important role in
health behavior change.

■ VENUES FOR HEALTH-HABIT
MODIFICATION

What is the best venue for changing health habits?
There are several possibilities:

The Practitioner’s Office
Many people have regular contact with a physician or
other health care professional who knows their medi-
cal history and can help them modify their health hab-
its. Physicians are highly credible sources for instituting
health habit change, and their recommendations have
the force of expertise behind them.
Some health-habit modification is conducted by
psychologists and other health practitioners privately on
a one-to-one basis, usually using cognitive- behavioral
techniques. This approach has two advantages. First, the

A stable family life is health promoting, and interventions are increasingly being

targeted to families rather than individuals to ensure the greatest likelihood of

behavior change.

60 Part Two Health Behavior and Primary Prevention

2012). Workplace interventions include on-the-job
health promotion programs that help employees stop
smoking, reduce stress, change their diet, exercise
regularly, lose weight, control hypertension, and limit
drinking, among other problems. Workplace interven-
tions can be linked to those in other sites, for example,
if the workplace frees up parents to participate in
school interventions with their children (Anderson,
Symoniak, & Epstein, 2014). Some workplaces pro-
vide health clubs, restaurants that serve healthy foods,
and gyms that underscore the importance of good
health habits (Figure 3.7). On the whole, workplace
interventions have benefits, including higher morale,
greater productivity, and reduced health care costs to
organizations (Berry, Mirabito, & Baun, 2010).

Community-Based Interventions
There are many kinds of community interventions. A
community-based intervention could be a door-to-
door campaign about a breast cancer screening pro-
gram, a media blitz alerting people to the risks of
smoking, a grassroots community program to en-
courage exercise, a dietary modification program
that recruits through community institutions, or a
mixed intervention involving both media and per-
sonal contact.
There are several advantages of community-
based interventions. First, such interventions reach
more people than individually based interventions or
interventions in limited environments, such as a sin-
gle workplace or classroom. Second, community-based
interventions can build on social support for rein-
forcing adherence to recommended health changes.
For example, if all your neighbors have agreed to
switch to a low-cholesterol diet, you are more likely
to do so as well. Finally, much evidence already shows
that neighborhoods can have profound effects on
health practices, especially those of adolescents.
Monitoring behavior within neighborhoods has been
tied to a lower rate of smoking and alcohol abuse
among adolescents, for example (Chuang, Ennett,
Bauman, & Foshee, 2005).
But community interventions can be expensive
and bring about only modest behavior change
(Leventhal, Weinman, Leventhal, & Phillips, 2008).
Partnering with existing community organizations
such as health maintenance organizations may sus-
tain gains from an initial community intervention and
reduce costs.

Finally, and most important, if behavior change
is introduced at the family level, all family members
are on board, ensuring greater commitment to the
behavior-change program and providing social
support for the person whose behavior is the target.
Family interventions may be especially helpful in
cultures that place a strong emphasis on family.
Latinos, Blacks, Asians, and southern Europeans may
be especially persuaded by health interventions that
emphasize the good of the family (Han & Shavitt,
1994; Klonoff & Landrine, 1999).

Self-Help Groups
Millions of people in the United States modify their
health habits through self-help groups. Self-help
groups bring together people with the same health
habit problem, and often with the help of a coun-
selor, they attempt to solve their problem together.
Some prominent self-help groups include Overeaters
Anonymous and TOPS (Take Off Pounds Sensibly)
for obesity, Alcoholics Anonymous for alcoholics,
and Smokenders for smokers. Many group leaders
employ cognitive-behavioral principles in their pro-
grams. The social support provided in these groups
also contributes to their success. At the present time,
self-help groups constitute the major venue for
health-habit modification in the United States.

Schools
Interventions to encourage good health behaviors can be
implemented through the school system (Facts of Life,
November 2003). The school population is young, and
consequently, we may be able to intervene before
children have developed poor health habits. Schools have
a natural intervention vehicle, namely, classes of approx-
imately an hour’s duration, and many health interven-
tions can fit into this format. Moreover, interventions can
change the social climate in a school regarding particular
health habits in ways that foster behavior change.
Even in college, social networks continue to be
good targets for health interventions. As one or two
people change their behavior, their friends may begin
to do so as well.

Workplace Interventions
Approximately 60 percent of the adult population is
employed, and consequently, the workplace can reach
much of this population (Bureau of Labor Statistics,

Chapter 3 Health Behaviors 61

0%
Gym

membership
discount

20%

40%

60%

80%

Smoking
cessation
program

Web-based
resources

for healthy
living

Wellness
newsletter

Personal
health

coaching

Weight
loss

programs

Classes in
nutrition,
healthy
living

Small Firms Large Firms

FIGURE 3.7 | Percentage of Companies Offering a Particular Wellness Program to Their Employees, by Firm Size, 2011
(Source: Kaiser Family Foundation and Health Research and Education Trust, “Employer Health Benefits: Annual Survey 2011,” September 27, 2011)
Note: “Small firms” are those with 3–199 workers; “large firms” are those with 200 or more workers.

The Mass Media
A goal of health promotion is to reach as many people
as possible, and consequently, the mass media have
great potential. Generally, mass media campaigns
bring about modest attitude change but less long-term
behavior change. Nonetheless, the mass media can
alert people to health risks that they would not other-
wise know about.
Recently, health psychologists have studied the ef-
fects of health behaviors of characters in soap operas,
dramas, and comedies. Characters who smoke, for ex-
ample, can act as role models, increasing the likelihood
that adolescents will begin to smoke (Heatherton &
Sargent, 2009). By contrast, characters who engage in
healthy activities can encourage healthy behavior change
in their viewers.
By presenting a consistent media message over
time, the mass media can also have a cumulative ef-
fect in changing the values associated with health
practices. For example, the cumulative effects of anti-
smoking mass media messages on social norms about
smoking have been substantial.

Cellular Phones and Landlines
Venues for low-cost interventions include cell phones
and landlines (Eakin, Reeves, Winkler, Lawler, &
Owen, 2010). For example, automated phone inter-
ventions can prompt people to maintain health behavior

change (Kaplan & Stone, 2013; King et al., 2014).
Personalized text messages can help smokers quit
(Rodgers et al., 2005), and so texting represents an-
other potentially effective low-cost intervention. Pro-
grams to contact older adults by telephone each day
can make sure their needs are being met, and recent
efforts have incorporated lifestyle advice into these
volunteer programs, such as recommending physical
activity (Castro, Pruitt, Buman, & King, 2011). More-
over, such daily contact can also increase the older
adult’s experience of social support.

The Internet
The Internet provides information and low-cost access
to health interventions for millions of people (Cohen &
Adams, 2011). Websites for smoking cessation (Wang
& Etter, 2004) and other health habits have been de-
veloped (Linke, Murray, Butler, & Wallace, 2007),
and Internet-delivered, computer-tailored lifestyle in-
terventions targeting multiple risk factors simultane-
ously, for example, diet, exercise, and smoking, have
shown some success (Oenema, Brug, Dijkstra, de
Weerdt, & de Vries, 2008). The Internet can also be
used to augment the effectiveness of other interven-
tions, such as school-based smoking cessation pro-
grams (Norman, Maley, Skinner, & Li, 2008) or
interventions with patient groups (Williams, Lynch,
& Glasgow, 2007). Tailored e-coaching that provides

62 Part Two Health Behavior and Primary Prevention

van Straten, & Andersson, 2008; Mohr et al., 2010).
The Internet also enables researchers to recruit a large
number of participants for studies at relatively low
cost, thus enabling data collection related to health
habits (Lenert & Skoczen, 2002).
The choice of venue for health-habit change is an
important issue. Understanding the particular strengths
and disadvantages of each venue helps to define inter-
ventions that can reach the most people for the least
expense. ∙

individualized feedback can supplement standardized
interventions for health-related behavior change, such
as weight loss (Gabriele, Carpenter, Tate, & Fisher,
2011).
CBT interventions for health habit modification
delivered via the Internet can be as effective as face-to-
face interventions, and they have advantages of low
cost, saving therapists’ time, reducing waitlist and travel
time, and providing interventions to people who might
not seek out a therapist on their own (Cuijpers,

To reach the largest number of people most effectively, researchers are increasingly

designing interventions to be implemented on a community basis through existing

community resources.

Chapter 3 Health Behaviors 63

1. Health promotion enables people to increase
control over and improve their health. It involves
the practice of good health behaviors and the
avoidance of health-compromising ones.

2. Health habits are determined by demographic
factors (such as age and SES), social factors (such
as early socialization in the family), values and
cultural background, perceived symptoms, access
to medical care, and cognitive factors (such as health
beliefs). Health habits are only modestly related to
each other and are highly unstable over time.

3. Health-promotion efforts target children and
adolescents before bad health habits are in place.
They also focus on people at risk for disorders to
prevent those disorders from occurring. A focus
on health promotion among older adults may help
contain the soaring costs of health care late in life.

4. Research based on the health belief model and
the theory of planned behavior have identified
attitudes related to health-habit modification,
including the belief that a threat to health is
severe, that one is personally vulnerable to the
threat, that one is able to perform the response
needed to reduce the threat (self efficacy), that
the response will be effective in overcoming the
threat (response efficacy), and that social norms
support one’s practice of the behavior.

5. Attitudinal approaches to health behavior change
can instill knowledge and motivation. But by
themselves, approaches such as fear appeals and
information appeals can have limited effects on
behavior change.

6. Cognitive-behavioral approaches to health-habit
change use principles of self monitoring, classical
conditioning, operant conditioning, modeling, and
stimulus control to modify the antecedents and
consequences of a target behavior. CBT brings
clients into the treatment process by drawing on
principles of self control and self reinforcement.

7. Social skills training and relaxation training
methods can be incorporated into cognitive-
behavioral interventions to deal with the anxiety or
social deficits that underlie some health problems.

8. Increasingly, interventions focus on relapse
prevention. Practicing coping techniques for
managing high-risk-for-relapse situations is a
major component of such interventions.

9. Successful modification of health habits does not
occur all at once. People go through stages,
which they may cycle through several times.
When interventions are targeted to the stage an
individual is in, they may be more successful.

10. Some health habits are best changed through
social engineering, such as mandated childhood
immunizations or smoking bans in the workplace.

11. The venue for intervening in health habits is
changing. Expensive methods that reach one
individual at a time are giving way to group
methods that are cheaper, including self help
groups, and school and workplace interventions.
The mass media can reinforce health campaigns
by alerting people to health risks. Telephone
interventions, Internet interventions, and texting all
show promise as health behavior change venues.

S U M M A R Y

K E Y T E R M S

abstinence violation effect
assertiveness training
at risk
behavioral assignments
classical conditioning
cognitive-behavior therapy (CBT)
cognitive restructuring
contingency contracting
discriminative stimulus
fear appeals
health behaviors
health belief model
health habit

health locus of control
health promotion
lifestyle rebalancing
modeling
operant conditioning
primary prevention
relapse prevention
relaxation training
self control
self determination theory (SDT)
self efficacy
self monitoring
self regulation

self reinforcement
self talk
social engineering
social skills training
socialization
stimulus-control interventions
teachable moment
theory of planned behavior
transtheoretical model of behavior

change
window of vulnerability

C H A P T E R 4

C H A P T E R O U T L I N E

Exercise
Benefits of Exercise

Determinants of Regular Exercise

Exercise Interventions

Accident Prevention
Home and Workplace Accidents

Motorcycle and Automobile Accidents

Vaccinations and Screening
Vaccinations

Screenings

Sun Safety Practices
Developing a Healthy Diet

Changing Diet

Resistance to Modifying Diet

Interventions to Modify Diet

Sleep
What Is Sleep?

Sleep and Health

Rest, Renewal, Savoring

Health-Promoting Behaviors

Chapter 4 Health-Promoting Behaviors 65

Chapter 4 examines how the principles described in Chapter 3 apply to health-promoting behaviors,
including exercise, accident prevention, cancer preven-
tion, healthy diet, and sleep. Each of these important
behaviors has been related to at least one major cause
of illness and death in industrialized countries. As peo-
ple in third-world countries adopt the lifestyles of in-
dustrialized nations, these health habits will assume
increasing importance throughout the world.

■ EXERCISE

A recent headline reads, “Sedentary behavior trumps fat
as a killer” (Healy, 2015). In fact, a recent review of 47
studies found that the risk of several chronic diseases
and early death increases with long periods of sitting
(Alter et al., 2015); even taking breaks from sitting does
not fully offset the risk. Adequate physical fitness
among adolescents is only 42%, with girls worse than
boys (Gahche et al., 2014). Consequently, a high level of
physical activity is an important health behavior.
Exercise helps to maintain mental and physical
health. At one time, scientists believed that only
aerobic exercise has health benefits, but now evi-
dence suggests that any kind of exercise has benefits,
especially for middle-aged and older adults.

Benefits of Exercise
The health benefits of exercise are substantial. A mere
30 minutes of exercise a day can decrease the risk of
several chronic diseases, including heart disease, diabe-
tes, and some cancers. Exercise accelerates wound

healing in those with injuries (Emery, Kiecolt-Glaser,
Glaser, Malarkey, & Frid, 2005), and can be critical to
recovery from disabilities, such as hip fracture (Resnick
et al., 2007). Other health benefits are listed in Table 4.1.
However, over two-thirds of American adults do
not engage in the recommended levels of physical ac-
tivity, and about two-thirds of American adults do not
engage in any regular leisure-time physical activity
(National Center for Health Statistics, 2011). Physical
activity is more common among men than women,
among Whites than African-Americans and Hispan-
ics, among younger than older adults, and among
those with higher versus lower incomes (National
Center for Health Statistics, 2011b).

How Much Exercise? The typical exercise pre-
scription for a normal adult is 30 minutes or more of
moderate-intensity activity on most or all days of the
week or 20 minutes or more of vigorous or aerobic ac-
tivity at least 3 days a week (U.S. Department of Health
and Human Services, 2009). Aerobic exercise is marked
by high intensity, long duration, and the need for endur-
ance, and it includes running, bicycling, rope jumping,
and swimming. A person with low cardiopulmonary
fitness may derive benefits from even less exercise each
week. Even short walks or just increasing activity level
has physical and psychological benefits for older adults
(Ekkekakis, Hall, VanLanduyt, & Petruzzello, 2000;
Schechtman, Ory, & the FICSIT group, 2001).

Effects on Psychological Health Regular exer-
cise improves not only physical health but also mood and
emotional well-being (Gallegos-Carrillo et al., 2013;
Maher et al., 2013). Many people seem to be unaware of
these hidden benefits of exercise (Ruby, Dunn, Perrino,
Gillis, & Viel, 2011). Some of the positive effects of ex-
ercise on mood may stem from factors associated with
exercise, such as social activity or being outside (Dunton,
Liao, Intille, Huh, & Leventhal, 2015). An improved
sense of self-efficacy can also underlie some of the mood
effects of exercise (McAuley et al., 2008).
Because of its beneficial effects on mood and self-
esteem, exercise has even been used as a treatment for
depression (Herman et al., 2002). Several interventions
have now shown that exercise can prevent depression in
women (Babyak et al., 2000; Wang et al., 2011), and
stopping exercise can lead to an increase in symptoms
of depression (Berlin, Kop, & Deuster, 2006).
Health psychologists have also found beneficial
effects of exercise on cognitive functioning, especially

TABLE 4.1 | Health Benefits of Regular Exercise

• Helps you control your weight
• Reduces your risk of cardiovascular disease
• Reduces your risk for Type II diabetes and metabolic

syndrome
• Reduces your risk of some cancers
• Strengthens your bones and muscles
• Decreases resting heart rate and blood pressure and

increases strength and efficiency of heart
• Improves sleep
• Increases HDL (good) cholesterol
• Improves immune system functioning
• Promotes the growth of new neurons in the brain

• Promotes cognitive functioning

Sources: Centers for Disease Control and Prevention, February, 2011;
Hamer & Steptoe, 2007; Heisz & Vandermorris, Wu, McIntosh, &
Ryan, 2015.

66 Part Two Health Behavior and Primary Prevention

(Gagné & Harnois, 2013) as even very young children
start watching TV and using tablets and computers
early in life. Currently, only about half of youth meet
physical activity requirements of 60 minutes a day
(Institute of Medicine, 2013). Children get regular ex-
ercise through required physical education classes in
school, but even these classes have faced budget cut-
backs. Moreover, by adolescence, the practice of regu-
lar exercise has declined substantially, especially
among girls (Davison, Schmalz, & Downs, 2010) and
among boys not involved in formal athletics (Crosnoe,
2002). Adults report lack of time, stress, interference
with daily activities, and fatigue as barriers to obtain-
ing exercise (Kowal & Fortier, 2007).

Who Exercises? People who come from families
in which exercise is practiced, who have positive atti-
tudes toward physical activity, who have a strong sense
of self-efficacy for exercising (Peterson, Lawman,
Wilson, Fairchild, & Van Horn, 2013), who have energy,
and who are extroverted and sociable (Kern, Reynolds,
& Friedman, 2010) are more likely to exercise. People
who perceive themselves as athletic or as the type of
person who exercises (Salmon, Owen, Crawford,
Bauman, & Sallis, 2003), who have social support from
friends to exercise (Marquez & McAuley, 2006), who
enjoy their form of exercise (Kiviniemi, Voss-Humke, &
Seifert, 2007), and who believe that people should take
responsibility for their health are also more likely to get
exercise than people who do not have these attitudes.

Characteristics of the Setting Convenient and
easily accessible exercise settings promote exercise
(Gay, Saunders, & Dowda, 2011). Vigorous walking in
your neighborhood can be maintained more easily than
participation in an aerobics class in a crowded health
club 5 miles from your home. Lack of safe places to do
exercise is a particular barrier for people who live in
low socioeconomic status neighborhoods (Estabrooks,
Lee, & Gyurcsik, 2003; Feldman & Steptoe, 2004).
Improving environmental options for exercise,
such as walking trails and recreational facilities, in-
creases rates of exercise (Siceloff, Coulon, & Wilson,
2014). When people believe their neighborhoods are
safe, when they are not socially isolated, and when
they know what exercise opportunities are available to
them in their area, they are more likely to engage in
physical activity (Hawkley, Thisted, & Cacioppo,
2009; Sallis, King, Sirard, & Albright, 2007; van
Stralen, de Vries, Bolman, Mudde, & Lechner, 2010).

on executive functioning involved in planning and
higher-order reasoning (Heisz & Vandermorris, Wu,
McIntosh, & Ryan, 2015). Exercise appears to promote
memory and healthy cognitive aging (Erickson et al.,
2011; Pereira et al., 2007) and may improve cognitive
functioning and executive control in children as well
(Heisz & Vandermorris, Wu, McIntosh, & Ryan, 2015).
Even modest exercise or increases in activity level can
have these beneficial effects on cognitive functioning.
Exercise may offer economic benefits as well. Em-
ployee fitness programs can reduce absenteeism, increase
job satisfaction, and reduce health care costs, especially
among women employees (Rodin & Plante, 1989).

Determinants of Regular Exercise
Most people’s participation in exercise is erratic.
Starting young, even in preschool, is important

Regular aerobic exercise produces many physical and emo tional

benefi ts, including reduced risk for cardiovascular disease.

Chapter 4 Health-Promoting Behaviors 67

as regaining fitness, it can be especially successful
(Hunt, McCann, Gray, Mutrie, & Wyke, 2013).
As is true with other health behaviors, factors that
affect the adoption of exercise are not necessarily the
same as those that predict long-term maintenance of
an exercise program. Believing that physical activity
is important predicts initiation of an exercise program,
whereas barriers, such as no time or few places to get
exercise, predict maintenance (Rhodes, Plotnikoff, &
Courneya, 2008). Self efficacy about one’s ability to
overcome barriers is a predictor of maintenance
(Higgins, Middleton, Winner, & Janelle, 2014).
Family-based interventions designed to induce all
family members to be more active have shown some
success (Rhodes, Naylor, & McKay, 2010). Worksite
interventions to promote exercise have small but posi-
tive effects on increased physical activity (Abraham &
Graham-Rowe, 2009). Even minimal interventions
such as sending mailers encouraging physical exercise
to older adults can increase exercise. Text messaging
also shows success in promoting exercise such as
brisk walking (Prestwich, Perugini, & Hurling, 2010).
The advantages of these interventions, of course, are
low cost and ease of implementation.
Relapse prevention techniques increase long-term
adherence to exercise programs. For example, helping
people figure out how to overcome barriers to obtain-
ing regular exercise, such as stress, fatigue, and a hec-
tic schedule, improves adherence (Blanchard et al.,
2007; Fjeldsoe, Miller, & Marshall, 2012).
Incorporating exercise into a more general pro-
gram of healthy lifestyle change can be beneficial as
well. Motivation to engage in one health behavior can
spill over into another (Mata et al., 2009). For exam-
ple, among adults at risk for coronary heart disease
(CHD), brief behavioral counseling matched to stage
of readiness helped them maintain physical activity,
as well as reduce smoking and fat intake (Steptoe,
Kerry, Rink, & Hilton, 2001). Setting personal goals
for exercise can improve commitment (Hall et al.,
2010), and forming explicit implementation inten-
tions regarding exactly when and how to exercise fa-
cilitates practice as well; planning when to exercise
can facilitate the link between intention and actual
behavior (Conner, Sandberg, & Norman, 2010).
Exercise interventions may promote more general
lifestyle changes. This issue was studied in an intriguing
manner with 60 Hispanic and Anglo families, half of
whom had participated in a 1-year intervention program
of dietary modification and exercise. All the families

Social support can foster exercise. Making a
commitment to another person to meet for exercise
increases the likelihood that it will happen
(Prestwich et al., 2012). People who participate in
group exercise programs such as jogging or walk-
ing say that social support and group cohesion are
two of the reasons why they participate (Floyd &
Moyer, 2010). This support may be especially im-
portant for exercise participation among Hispanics
(Marquez & McAuley, 2006). Even just seeing oth-
ers engaging in exercise around one’s neighborhood
or on a running path can increase how much time a
person puts into exercise (Kowal & Fortier, 2007).
The best predictor of regular exercise is regular ex-
ercise (Phillips & Gardner, 2016). Long-term practice
of regular exercise is heavily determined by habit
(McAuley, 1992). The first 3–6 months appear to be
critical, and people who will drop out usually do so in
that time period (Dishman, 1982). Developing a regular
exercise program, embedding it in regular activities, and
doing it regularly means that it begins to become auto-
matic and habitual. However, habit has its limits. Unlike
such habitual behaviors as wearing a seat belt or brush-
ing teeth, exercise takes willpower and a belief in per-
sonal responsibility in order to be enacted on a regular
basis. In summary, if people participate in activities that
they like, that are convenient, that they are motivated to
pursue, and for which they can develop goals, exercise
adherence will be greater (Papandonatos et al., 2012).

Exercise Interventions

Several types of interventions have shown success in
getting people to exercise. Interventions that incorpo-
rate principles of self-control (enhancing beliefs in
personal efficacy) and that muster motivation can be
successful in changing exercise habits (Conroy, Hyde,
Doerksen, & Riebeiro, 2010). Helping people to form
implementation intentions, and following up with
brief text messages can promote activity as well
(Prestwich, Perugini, & Hurling, 2010). Several stud-
ies confirm the usefulness of the transtheoretical
model of behavioral change (that is, the stages of
change model) for increasing physical activity. Inter-
ventions designed to increase and maintain physical
activity that are matched to stage of readiness are
more successful than interventions that are not
(Blissmer & McAuley, 2002; Dishman, Vandenberg,
Motl, & Nigg, 2010; Marshall et al., 2003). When an
exercise intervention promotes personal values, such

68 Part Two Health Behavior and Primary Prevention

is $518 billion per year (World Health Organization,
2009). Nationally, bicycle accidents cause more than
900 deaths per year, prompt more than 494,000 emer-
gency room visits, and constitute the major cause of
head injury, making helmet use an important issue
(Centers for Disease Control and Prevention, 2015).
Over 2,000 people a day are accidentally poisoned in the
United States, usually by prescription or illegal drugs,
and more than 40,000 people die of poisoning each year
(Centers for Disease Control and Prevention, March
2012a; Warner, Chen, Makuc, Anderson, & Miniño,
2011). Occupational accidents and their resulting dis-
ability are a particular health risk for working men.

Home and Workplace Accidents
Accidents in the home, such as accidental poisonings
and falls, are the most common causes of death and
disability among children under age 5 (Barton &
Schwebel, 2007). Interventions to reduce home acci-
dents are typically conducted with parents because
they have control over the child’s environment. Put-
ting safety catches and gates in the home, placing poi-
sons out of reach, and teaching children safety skills
are components of these interventions.
Pediatricians and their staff often incorporate such
training into visits with new parents (Roberts & Turner,
1984). Parenting classes help parents to identify the
most common poisons in the home and to keep these
away from young children. Evaluations of interventions
that train parents how to childproof a home (Morrongi-
ello, Sandomierski, Zdzieborski, & McCollam, 2012)
show that such interventions can be successful. Even
young children can learn about safety in the home. For
example, an intervention using a computer game (The
Great Escape) improved children’s knowledge of fire
safety behaviors (Morrongiello, Schwebel, Bell, Stewart,
& Davis, 2012). Virtual environmental training on web-
sites can help children learn to cross the street safely
(Schwebel, McClure, & Severson, 2014).
At one time, workplace accidents were a primary
cause of death and disability. However, statistics sug-
gest that overall, accidents in the workplace have de-
clined since the 1930s. This decline may be due, in
part, to better safety precautions by employers. How-
ever, accidents at home have actually increased. Social
engineering solutions, such as safety caps on medica-
tions and required smoke detectors in the home, have
mitigated the increase, but the trend is worrisome.

Accidents and Older Adults More than 12,800
older adults die each year of fall-related injuries, and

were taken to the San Diego Zoo as a reward for partici-
pating in the program, and while they were there, their
food intake and amount of walking were recorded. Fam-
ilies that had participated in the intervention consumed
fewer calories, ate less sodium, and walked more than
the families in the control condition, suggesting that the
intervention had been integrated into their lifestyle
(Patterson et al., 1988). The family-based approach of
this intervention may have contributed to its success as
well (Martinez, Ainsworth, & Elder, 2008).
Physical activity websites would seem to hold
promise for inducing people to participate in regular ex-
ercise (Napolitano et al., 2003). Of course, if one is on
the Internet, one is by definition not exercising. Indeed,
thus far, the evidence is mixed that physical activity
websites provide the kind of individually tailored rec-
ommendations that are needed to get people to exercise
on a regular basis (Carr et al., 2012) and initial gains
may not be maintained (Carr et al., 2013). However,
automated exercise advice can help maintain a physical
activity program, once it is initiated (King et al., 2014).
Despite the problems health psychologists have en-
countered in getting people to exercise and to do so
faithfully, the exercise level in the U.S. population has
increased substantially in recent decades. A physician’s
recommendation is one of the factors that lead people
to increase their exercise, and trends show that physi-
cians increasingly are advising their patients to begin or
continue exercise (Barnes & Schoenborn, 2012). The
number of people who participate in regular exercise
has increased by more than 50 percent in the past few
decades. Increasingly, it is not just sedentary healthy
adults who are becoming involved in exercise but also
the elderly and chronically ill patients (Courneya &
Friedenreich, 2001). These findings suggest that, al-
though the population may be aging, it may be doing so in
a healthier way than was true in recent past generations.

■ ACCIDENT PREVENTION

No wonder that so many cars collide;
Their drivers are accident prone,
When one hand is holding a coffee cup,
And the other a cellular phone.

—Art Buck

This rhyme captures an important point. Accidents
represent one of the major causes of preventable death,
both worldwide and in the United States. Moreover,
this cause of death is increasing. Worldwide, nearly
1.3 million people die as a result of road traffic
injuries, and the estimated economic cost of accidents

Chapter 4 Health-Promoting Behaviors 69

accidents. These include the way people drive, the
speed at which they drive, and the use of preventive
measures to increase safety, such as interventions to
reduce cell phone usage while driving (Weller, Shack-
leford, Dieckmann, & Slovic, 2013).
For example, many Americans still do not use seat
belts, a problem especially common among adolescents,
which accounts, in part, for their high rate of fatal acci-
dents (Facts of Life, May 2004). Community-wide
health education programs aimed at increasing seat belt
usage and infant restraint devices can be successful. One
such program increased the use from 24 to 41 percent,
leveling off at 36 percent over a 6-month follow-up pe-
riod (Gemming, Runyan, Hunter, & Campbell, 1984).
On the whole, though, social engineering solu-
tions may be more effective. Seat belt use is more
prevalent in states with laws that mandate their use,
and states that enforce helmet laws for motorcycle rid-
ers have reduced deaths and lower health care costs
related to disability due to motorcycle accidents (Wall
Street Journal, 2005, August 9).

■ VACCINATIONS AND SCREENING

Vaccinations and screening represent two ways of
avoiding or detecting early some of the main causes
of death in the United States. Yet many people fail to
use these health resources, which makes behavior
change important for health psychologists.

many more are disabled. At least 25 percent of older
adults may remain hospitalized for at least a year due
to injuries from a fall (Facts of Life, March 2006).
Consequently, strategies to reduce accidents
among older adults have increasingly been a focus of
health psychology research and interventions. Dietary
and medication intervention to reduce bone loss can
affect risk of fracture. Physical activity training involv-
ing balance, mobility, and gait training reduces the risk
of falls. Teaching older adults to make small changes
in their homes that reduce tripping hazards can help,
including nonslip bathmats, shower grab bars, hand
rails on both sides of stairs, and better lighting (Facts
of Life, March 2006). The evidence suggests that fall
prevention programs, often led by health psycholo-
gists, can reduce mortality and disability among older
adults substantially (Facts of Life, March 2006).

Motorcycle and Automobile Accidents
You know what I call a motorcyclist who doesn’t wear
a helmet? An organ donor.

—Emergency room physician

The single greatest cause of accidental death is motor-
cycle and automobile accidents (Centers for Disease
Control and Prevention, 2009a). Although social en-
gineering solutions such as speed limits and seat belts
have major effects on accident rates, psychological
interventions can also address factors associated with

Automobile accidents represent a major cause of death, especially among the young.

Legislation requiring child safety restraint devices has reduced fatalities dramatically.

70 Part Two Health Behavior and Primary Prevention

cancer; having genes implicated in breast cancer)
should be monitored. Otherwise, routine PSA screen-
ing is not recommended and a mammogram is recom-
mended every year between ages 45 and 55 and every
other year for women between the ages of 55 and 74.
In older women, the value of the test is less clear.
Why is screening through mammography impor-
tant for high-risk women? The reasons are several:

∙ One in every eight women in the United States
develops breast cancer.

∙ The majority of breast cancers are detected in
women over age 40, and so screening this age
group is cost effective.

∙ Early detection, as through mammograms, can
improve survival rates.

Unfortunately, compliance with mammography
recommendations is low. Fear of radiation, embarrass-
ment over the procedure, anticipated pain, anxiety, fear

Vaccinations
Parents are urged to get their children vaccinated
against measles, polio, diphtheria, whooping cough,
and tetanus, among other childhood diseases. Most
do, because school registration typically requires
these vaccines. However, some do not and instead are
freeriders; that is, if most children are vaccinated, the
minority that is not are protected by those who are
(Betsch, Böhm, & Korn, 2013). In some cases, refus-
ing to get vaccinations for one’s children comes from
the mistaken beliefs that a vaccine actually causes the
disease or that the vaccine causes another disorder,
such as autism. Interventions have attempted to cor-
rect the incorrect beliefs that can undermine vaccina-
tion and stressed the social benefits of vaccination in
the hopes of keeping rates high (Betsch et al., 2013).
Vaccinations of girls and boys against HPV (human
papillomavirus) by age 13 is now recommended by the
National Institutes of Health. HPV is a sexually trans-
mitted virus tied to cervical as well as other cancers. The
Centers for Disease Control and Prevention report, how-
ever, that as of 2016, only 40% of girls and 21% of boys
had received it. This rate compares very unfavorably to
many other countries, including Australia (75%), the
United Kingdom (about 88%) and Rwanda (93%)
(Winslow, 2016). Family-focused messages aimed at
parents and adolescents have been suggested as one fo-
cus of public health interventions to increase vaccina-
tion rates (Alexander et al., 2014), and direct payments
to adolescents in the UK have been tried (Mantzari,
Vogt, & Marteau, 2015). As yet, the most effective way
to encourage this behavior has not been found.

Screenings
The two most common cancers in the United States are
breast cancer in women and prostate cancer in men. Until
recently, routine screening was the frontline against these
cancers. At present, however, routine screening through
mammography for women and the PSA (prostate-
specific antigen) test for men is no longer recommended
for all adults; false positives (when the test falsely sug-
gests the presence of cancer) has led to unnecessary
treatment, including surgeries. Moreover, although diag-
nosed cases from both tests increased, there has been
little to no impact on mortality from these causes.
At present, men who are symptomatic or at high
risk (who have a family history of prostate cancer;
Watts et al., 2014) and women who are symptomatic
or at high risk (having a family history of breast

Mammograms are an important way of detecting breast cancer

in women over 50. Finding ways to reach older women to

ensure that they obtain mammograms is a high priority for

health scientists.

Chapter 4 Health-Promoting Behaviors 71

to people’s resistance to colorectal screening can
increase the likelihood of obtaining screening as well
(Menon et al., 2011). Hispanics are at particular risk
for colorectal cancer, and so it is especially important
to reach them (Gorin, 2005).
■ SUN SAFETY PRACTICES

The past 30 years have seen a nearly fourfold increase in
the incidence of skin cancer in the United States. Al-
though basal cell and squamous cell carcinomas do not
typically kill, malignant melanoma takes over 9,000
lives each year (Centers for Disease Control and Preven-
tion, August 2015). In the past two decades, melanoma
incidence has risen by 155 percent. Moreover, these
cancers are among the most preventable. The chief risk
factor for skin cancer is well known: excessive exposure
to ultraviolet (UV) radiation. Living or vacationing in
southern latitudes, participating in outdoor activities,
and using tanning salons all contribute to dangerous sun
exposure. Less than one-third of American children ad-
equately protect themselves against the sun, and more
than three-quarters of American teens get at least one
sunburn each summer (Facts of Life, July 2002).
As a result, health psychologists have developed
interventions to promote safe sun practices. Typically,
these efforts begin with educational interventions to
alert people to the risks of skin cancer and to the effec-
tiveness of sunscreen use for reducing risk (Lewis et al.,
2005; Stapleton, Turrisi, Hillhouse, Robinson, & Abar,
2010). However, education alone is not entirely suc-
cessful (Jones & Leary, 1994). Tans are still perceived
to be attractive (Blashill, Williams, Grogan, & Clark-
Carter, 2015), and many people are oblivious to the
long-term consequences of tanning (Orbell &
Kyriakaki, 2008). Many people use sunscreens with an
inadequate sun protection factor (SPF), and few people
apply sunscreen often enough during outdoor activities
(Wichstrom, 1994). Effective sunscreen use requires
knowledge about skin cancer, perceived need for sun-
screen, perceived efficacy of sunscreen as protection
against skin cancer, and social norms that favor sun-
screen use (Stapleton, Turrisi, Hillhouse, Robinson, &
Abar, 2010; Turrisi, Hillhouse, Gebert, & Grimes,
1999). All of these factors change only grudgingly.
Parents play an important role in ensuring that
children reduce sun exposure (Turrisi, Hillhouse,
Robinson, & Stapleton, 2007). Parents’ own sun pro-
tection habits influence how attentive they are to their
children’s practices and what their children do when
they are on their own (Turner & Mermelstein, 2005).

of cancer (Gurevich et al., 2004; Schwartz, Taylor, &
Willard, 2003), and, most importantly, especially among
poorer women, concern over costs act as deterrents to
getting regular mammograms (Lantz, Weigers, &
House, 1997). Lack of awareness of the importance of
mammograms, little time, and lack of available services
also contribute to low screening rates.
Changing attitudes toward mammography can in-
crease the likelihood of obtaining a mammogram. For
example, the theory of planned behavior predicts the
likelihood of obtaining regular mammograms: Women
who have positive attitudes regarding mammography
and who perceive social norms as favoring their ob-
taining a mammogram are more likely to participate
in a mammography program (Montano & Taplin,
1991). Social support predicts use of mammograms
and may be especially important for low-income and
older women (Messina et al., 2004). If your friends
are getting mammograms, you are more likely to do
so as well. Interventions are more successful if they
are geared to the stage of readiness of prospective
participants (Champion & Springston, 1999; Lauver,
Henriques, Settersten, & Bumann, 2003).

Colorectal Cancer Screening

In Western countries, colorectal cancer is the second-
leading cause of cancer deaths. In recent years, medi-
cal guidelines have recommended routine colorectal
screening for older adults (Wardle, Williamson,
McCaffery et al., 2003).
Factors that predict the practice of other health
behaviors also predict participation in colorectal can-
cer screening, including self-efficacy, perceived ben-
efits of the procedure, a physician’s recommendation
to participate, social norms favoring participation, and
few barriers to taking advantage of a screening
program (Hays et al., 2003; Manne et al., 2002;
Sieverding, Matterne, & Ciccarello, 2010). As is true
of many health behaviors, beliefs predict the intention
to participate in colorectal screening, whereas life dif-
ficulties (low SES, poor health status) interfere with
actually getting screened (Power et al., 2008).
Community-based programs that use the mass
media, community-based education, interventions
through social networks such as churches, health care
provider recommendations, and reminder notices pro-
mote participation in cancer screening programs and
can attract older adults (Campbell et al., 2004; Curbow
et al., 2004). T elephone-based interventions tailored

72 Part Two Health Behavior and Primary Prevention

needed (Buller, Buller, & Kane, 2005). Nonetheless,
even brief interventions directed to specific sun safety
practices, such as decreasing indoor tanning, can be
effective (Abar et al., 2010).

■ DEVELOPING A HEALTHY DIET

Diet is an important and controllable risk factor for
many of the leading causes of death and disease. For
example, diet is related to serum cholesterol level and
to lipid profiles. The dramatic rise in obesity in the
United States has added urgency to this issue. How-
ever, only about 13 percent of adults get the recom-
mended servings of fruit and only about 9 percent get
the recommended servings of vegetables each day
(Centers for Disease Control and Prevention, July
2015; Table 4.2). Experts estimate that unhealthful
eating contributes to more than 678,000 deaths per
year (U.S. Burden of Disease Collaborators, 2013).
Dietary change is critical for people at risk for or
already diagnosed with chronic diseases such as coro-
nary artery disease, hypertension, diabetes, and can-
cer (Center for the Advancement of Health, 2000f).
These are diseases for which people low in SES are
more at risk, and diet may explain some of the relation
between low SES and these disorders. For example,
supermarkets in high-SES neighborhoods carry more
health-oriented food products than do supermarkets in
low-income areas. Thus, even if the motivation to
change one’s diet is there, the food products may not
be (Conis, 2003, August 4).

Communications to adolescents and young adults
that stress the gains that sunscreen use will bring
them, such as freedom from concern about skin can-
cers or improvements in appearance, may be more
successful than those that emphasize the risks
(Detweiler, Bedell, Salovey, Pronin, & Rothman,
1999; Jackson & Aiken, 2006). When risks are em-
phasized, it is important to stress the immediate ad-
verse effects of rather than the long-term risks of
chronic illness, because adolescents and young adults
are especially influenced by immediate concerns.
In one clever investigation, one group of beachgo-
ers were exposed to a photo-aging intervention that
showed premature wrinkling and age spots; a second
group received a photo intervention that made the
negative appearance-related consequences of UV ex-
posure very salient; a third group received both inter-
ventions; and a fourth group was assigned to a control
condition. Those beachgoers who received the UV
photo information engaged in more sun protective be-
haviors, and the combination of the UV photo with the
photo-aging information led to substantially less
sunbathing over the long-term (Mahler, Kulik,
Gerrard, & Gibbons, 2007; Mahler, Kulik, Gibbons,
Gerrard, & Harrell, 2003). Similar interventions appear
to be effective in reducing the use of tanning salons
(Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005).
Health psychologists have explored Internet-
based strategies as a vehicle for distributing sun safety
materials. Responses have thus far been weak, suggesting
that more personal and aggressive approaches may be

Despite the risks of exposure to the sun, millions of people each year continue to

sunbathe.

Chapter 4 Health-Promoting Behaviors 73

Switching from trans fats (as are used for fried and
fast foods) and saturated fats (from meat and dairy
products) to polyunsaturated fats and monounsatu-
rated fats is a healthful change as well (Marsh, 2002,
September 10). Current U.S. government guidelines
for a balanced diet are described in Table 4.2.
Several specific diets, in addition to low-fat diets,
have health benefits. Healthy “Mediterranean” diets
are rich in vegetables, nuts, fruits, and fish and low in
red meat. Low-carbohydrate diets with vegetarian
sources of fat and protein and little bread and other
high-carbohydrate foods can have healthful effects.
Many people like these diets, and so they can be fairly
easily adopted and adhered to over time.

Resistance to Modifying Diet

It is difficult to get people to modify their diet, how-
ever, even when they are at high risk for CHD or when
their physician recommends it. The typical reason that
people switch to a diet low in cholesterol, fats, calo-
ries, and additives and high in fiber, fruits, and vege-
tables is to improve appearance, not to improve health.
Even so, fewer than half of U.S. adults meet the di-
etary recommendations for reducing fat levels and for
increasing fiber, fruit, and vegetable consumption
(Kumanyika et al., 2000).
Rates of adherence to a new diet may be high at first
but fall off over time. Some diets are restrictive, monot-
onous, expensive, and hard to implement. Changes in
shopping, meal planning, cooking methods, and eating
habits may be required. In addition, tastes are hard to
alter. Foods that are high in fat and sugars help turn off
stress hormones, such as cortisol, but they contribute to
an unhealthy diet (Dallman et al., 2003). A preference
for meat, a lack of health consciousness, a limited inter-
est in exploring new foods, and low awareness of the
link between eating habits and illness are all tied to poor
dietary habits.

Stress and Diet Stress has a direct and negative
effect on diet. People under stress eat more fatty foods,
fewer fruits and vegetables, and are more likely to
snack and skip breakfast (O’Connor, Jones, Ferguson,
Conner, & McMillan, 2008). People with low status
jobs, high workloads, and little control at work also
have less healthy diets. When people are under stress,
they are distracted, may fail to practice self-control,
and may not pay much attention to what they are eat-
ing (Devine, Connors, Sobal, & Bisogni, 2003). Thus,
the sheer cognitive burden of daily life can interfere

Changing Diet
The good news is that changing one’s diet can im-
prove health. A diet high in fruits, vegetables, with
some whole grains, peas and beans, poultry, and fish
and low in refined grains, potatoes, and red and pro-
cessed meats lowers the risk of coronary heart disease
(Fung, Willett, Stampfer, Manson, & Hu, 2001).

TABLE 4.2 | Current USDA Recommendations for
a Balanced Diet

The United States Agriculture Department currently
recommends a 2,000-calorie-a-day diet made up of the
following components:

–Dairy (3 cups) –Fruits (2 cups)

–Vegetables (2.5 cups) –Grain (3 oz)

–Meat (6 oz) –Oil (6 tsp)

74 Part Two Health Behavior and Primary Prevention

shown to be helpful in getting people to increase their
fruit and vegetable intake and otherwise improve their
diets (Ahluwalia et al., 2007; Harris et al., 2014).
Training in self-regulation, including planning skills
and formation of explicit behavioral intentions (Stadler,
Oettingen, & Gollwitzer, 2010), can improve dietary
adherence. Implementation intentions regarding ex-
actly when, where, and what food will be consumed
can also help people bring snacking under intentional
control (Harris et al., 2014). However, much eating
and snacking occurs mindlessly, when people are ex-
erting little self-control. In such cases, simple environ-
mental interventions, such as a sign in a cafe promoting
healthy eating, can help people make good choices
(Allan, Johnston, & Campbell, 2015).
Recent efforts to change the dietary habits of high-
risk people have focused on the family (Gorin et al.,
2013). Eating meals together promotes better eating
habits. In family interventions, family members typi-
cally meet with a dietary counselor to discuss ways to
change the family diet. When all family members are
committed to and participate in dietary change, it is
easier for a target family member (such as a cardiac
patient) to do so as well (Wilson & Ampey-Thornhill,
2001). Children who are involved in these interventions
may practice better dietary habits into adolescence and
adulthood. An intervention with Latino mothers with
Type 2 diabetes and their overweight daughters made
use of this strong social tie to promote weight loss and
healthy eating (Sorkin et al., 2014).
Community interventions aimed at dietary change
have been undertaken. For example, nutrition education
campaigns in supermarkets have shown some success.
In one study, a computerized, interactive nutritional in-
formation system placed in supermarkets significantly
decreased high-fat purchases and somewhat increased
high-fiber purchases (Jeffery, Pirie, Rosenthal, Gerber,
& Murray, 1982; Winett et al., 1991).
Tailoring dietary interventions to ethnic identity
and making them culturally and linguistically appro-
priate may achieve particularly high rates of success
(Eakin et al., 2007; Martinez et al., 2008; Resnicow,
Davis, et al., 2008). In Latino populations, face-to-
face contact with a health adviser who goes through
the steps for successful diet modification may be es-
pecially important, due to the emphasis on personal
contact in Latino culture and communities (Elder
et al., 2005).
Researchers are moving toward interventions that
are cost-effective to alter behavior related to diet and

with the ability to control food consumption by
preventing people from monitoring their eating (Ward
& Mann, 2000).

Who Controls Their Diet? People who are high
in conscientiousness and intelligence do a better job
of adhering to a healthy diet. People who have high
self-control are better able to manage a healthy diet
than people without executive control skills (Hall,
2011). A strong sense of self-efficacy, knowledge
about dietary issues, family support, and the percep-
tion that dietary change has important health benefits
are also critical to developing a healthy diet (Steptoe,
Doherty, Kerry, Rink, & Hilton, 2000).
When people are informed about social norms
regarding diet, they are more likely to make a change
toward those norms (Robinson, Fleming, & Higgs,
2014). For example, if the people around you have
stopped drinking soda because they think it is un-
healthy, you are more likely to do so as well.

Interventions to Modify Diet Recent efforts to
induce dietary change have focused heavily on reduc-
ing portion size, snacking, and sugary drink consump-
tion. Portion size has increased greatly over the past
decades, contributing to obesity. Snacking has also
been tied to obesity. Sugary drinks have been tied to
higher heart disease risk (de Koning et al., 2012) and
are suspected of contributing to the rising rates of type
2 diabetes. Accordingly, interventions have been di-
rected to these issues, as well as to reducing fat and in-
creasing vegetable and fruit consumption. Specific
health risks such as obesity, diabetes, or CHD often
lead people to change their diets, and physicians,
nurses, dieticians, and health psychologists work with
patients to develop an appropriate diet.
Most diet change is implemented through
cognitive-behavioral interventions. Efforts to change
diet begin with education and training in self-monitoring:
Most people are poorly informed about what a healthy
diet is and do not pay sufficient attention to what they
actually eat (O’Brien, Fries, & Bowen, 2000). Addi-
tional components are stimulus control, and contin-
gency contracting, coupled with relapse prevention
techniques for high-risk-for- relapse situations, such as
parties. Drawing on social support for making a dietary
change and increasing one’s sense of self-efficacy are
two critical factors for improving diet (Steptoe,
Perkins-Porras, Rink, Hilton, & Cappuccio, 2004).
Self affirmation and motivational interviewing have

Chapter 4 Health-Promoting Behaviors 75

sound. In stage 2, breathing and heart rates even out,
body temperature drops, and brain waves alternate be-
tween short bursts called sleep spindles and large K-
complex waves. Stages 3 and 4, deep sleep, are marked
by delta waves. These are the phases most important
for restoring energy, strengthening the immune sys-
tem, and prompting the body to release growth hor-
mone. During REM sleep, eyes dart back and forth,
breathing and heart rates flutter, and we often dream
vividly. This stage of sleep is marked by beta waves
and is important for consolidating memories, solving
problems from the previous day, and turning knowl-
edge into long-term memories (Irwin, 2015). All of
these phases of sleep are essential.

Sleep and Health
An estimated 50–70 million Americans suffer from
chronic sleep disorders—most commonly, insomnia
(Centers for Disease Control and Prevention, September
2015). Many other people, such as college students,
choose to deprive themselves of sleep in order to keep
up with all the demands on their time. But sleep is an
important restorative activity, and people who deny
themselves sleep may be doing more harm than they
realize.
Roughly 40 percent of adults sleep less than
7 hours a night on weeknights, one-third of adults

exercise, rather than large-scale CBT interventions.
For example, computer-tailored dietary fat intake in-
terventions can be effective both with adults and with
adolescents (Haerens et al., 2007). Telephone counsel-
ing can achieve beneficial effects (Madlensky et al.,
2008). Such interventions can reach many people at
relatively low cost.
Change is likely to come from social engineering
as well. When children have access to school snack
bars that include sodas, candy, and other unhealthy
foods, it undermines their consumption of healthier
foods (Cullen & Zakeri, 2004).
Some of these interventions may seem heavy-
handed. After all, most people eat what they want
based on their preferences or what is available. Nudg-
ing people in the right direction through subtle mes-
sages may work as well as, or better than, explicit
warnings (Wagner, Howland, & Mann, 2015). Elimi-
nating snack foods from schools, making school
lunch programs more nutritious, making snack foods
more expensive and healthy foods less so, and taxing
products high in sugar or fats (Brownell & Frieden,
2009) will make some inroads into promoting healthy
food choices.

■ SLEEP

Michael Foster, a trucker who carried produce, was
behind in his truck payments. To catch up, he needed
to make more runs each week. To do so, he began
cutting back from 6 hours of sleep a night to 3 or 4,
stretches that he grabbed in his truck between jobs.
On an early-morning run between Fresno and Los
Angeles, he fell asleep at the wheel and his truck
went out of control, hitting a car and killing a family.

What Is Sleep?
Sleep is a vital health habit. It has a powerful effect
on risk of infectious disease, risk of depression,
poor responses to vaccines, and the occurrence and
progression of several chronic disorders, including
cardiovascular disease and cancer (Irwin, 2015).
But sleep is often abused.
There are two broad types of sleep: non–rapid eye
movement (NREM) and rapid eye movement (REM).
NREM sleep consists of four stages. Stage 1, the light-
est and earliest stage of sleep, is marked by theta
waves, when we begin to tune out the sounds around
us, although we are easily awakened by any loud

Scientists have begun to identify the health risks associated

with little or poor-quality sleep.

76 Part Two Health Behavior and Primary Prevention

adversity (Jarrin, McGrath, & Quon, 2014), who have
high levels of hostility or arousal (Fernández- Mendoza
et al., 2010; Granö, Vahtera, Virtanen, Keltikangas-
Järvinen, & Kivimäki, 2008), who use maladaptive
coping strategies to cope with stress (Fernández-
Mendoza et al., 2010), and who ruminate on the
causes of their stress (Zawadzki, Graham, & Gerin,
2012) have poor sleep quality and report sleep distur-
bances. Stressful events regarded as uncontrollable
can produce insomnia (Morin, Rodrigue, & Ivers,
2003). People who deal with stressful events by rumi-
nating or focusing on them are more prone to insom-
nia than are those who deal with stressful events by
blunting their impact or distracting themselves
(Fernández-Mendoza et al., 2010; Voss, Kolling, &
Heidenreich, 2006; Zoccola, Dickerson, & Lam,
2009). Sleep may have particular significance for peo-
ple low in SES, as low SES is linked to poor subjec-
tive and objective sleep quality (Friedman et al., 2007;
Mezick et al., 2008). Abuse of alcohol is also related
to poor sleep quality (Irwin, Cole, & Nicassio, 2006).
Although the health risks of insufficient sleep are
now well known, less well known is the fact that peo-
ple who habitually sleep more than 7 hours every
night also incur health risks (van den Berg et al.,
2008a). Long sleepers, like short sleepers, also have
more symptoms of psychopathology, including
chronic worrying (Grandner & Kripke, 2004).
Behavioral interventions have been undertaken
for the treatment of insomnia, including mindfulness-
based interventions (Britton, Haynes, Fridel, &
Bootzin, 2010), relaxation therapy, control of sleep-
related behaviors (such as the routine a person engages
in before going to sleep), and cognitive-behavioral
interventions. All these treatments show success in
treating insomnia (Irwin et al., 2006). Table 4.3 lists
some of the recommendations used in interventions to
promote better sleep.

■ REST, RENEWAL, SAVORING

An important set of health behaviors that is only be-
ginning to be understood involves relaxation and re-
newal, the restorative activities that help people
savor the positive aspects of life, reduce stress, and
restore emotional balance (Pressman et al., 2009).
For example, simply not taking a vacation is a risk
factor for heart attack among people with heart dis-
ease (Gump & Matthews, 1998; Steptoe, Roy, &
Evans, 1996). Participating in enjoyable leisure time

experience sleep problems (Stein, Belik, Jacobi, &
Sareen, 2008), and 54 percent of people over age 55
report insomnia at least once a week (Weintraub,
2004). For women, sleep disorders may be tied to hor-
monal levels related to menopause (Manber, Kuo,
Cataldo, & Colrain, 2003). Even children who sleep
too little or too much incur health risks, including risk
of early death (Duggan, Reynolds, Kern, & Friedman,
2014); low socioeconomic status contributes to poor
sleep among children (El-Sheikh et al., 2013).
Insufficient sleep (less than 7 hours a night) af-
fects cognitive functioning, mood, job performance,
and quality of life (Karlson, Gallagher, Olson, &
Hamilton, 2012; Pressman & Orr, 1997). Any of us
who has spent a sleepless night tossing and turning
over some problem knows how unpleasant the follow-
ing day can be. Insomnia compromises well-being on
the short term and quality of life on the long term
(Karlson, Gallagher, Olson, & Hamilton, 2013). Poor
sleep can be a particular problem in certain high-risk
occupations, such as police work, in which officers
are exposed to traumatic events (Irish, Dougall,
Delahanty, & Hall, 2013).
As noted, there are health risks of inadequate
sleep (Leger, Scheuermaier, Phillip, Paillard, &
Guilleminault, 2001). Chronic insomnia can com-
promise the ability to secrete and respond to insulin
(suggesting a link between sleep and diabetes); it in-
creases the risk of coronary heart disease (Ekstedt,
Åkerstedt, & Söderström, 2004); it increases blood
pressure and dysregulates stress physiology (Franzen
et al., 2011); it can affect weight gain (Motivala,
Tomiyama, Ziegler, Khandrika, & Irwin, 2009); it
can reduce the efficacy of flu shots; and it is tied to
adverse immune changes including chronic inflam-
mation (Motivala, 2011). More than 70,000 of the
nation’s annual automobile crashes are accounted for
by sleepy drivers, and 1,550 of these are fatal each
year. In one study of healthy older adults, sleep dis-
turbances predicted all-cause mortality over the next
4–19 years of follow-up (Dew et al., 2003). Children
who do not get enough sleep may show behavioral
problems (Pesonen et al., 2009). By contrast, good
sleep quality can act as a stress buffer (Hamilton,
Catley, & Karlson, 2007).
Who can’t sleep? People who are going through
major stressful life events or traumas, who are suffer-
ing from major depression (Sivertsen et al., 2012),
who are experiencing stress at work (Burgard &
Ailshire, 2009), who are experiencing socioeconomic

Chapter 4 Health-Promoting Behaviors 77

TABLE 4.3 | A Good Night’s Sleep

• Get regular exercise, at least three times a week.
• Keep the bedroom cool at night.
• Sleep in a comfortable bed that is big enough.
• Establish a regular schedule for awakening and going

to bed.
• Develop nightly rituals that can get you ready for bed,

such as taking a shower.
• Use a fan or other noise generator to mask background

sound.
• Don’t consume too much alcohol and don’t smoke.
• Don’t eat too much or too little at night.
• Don’t have strong smells in the room, such as from

incense, candles, or lotions.
• Don’t nap after 3 p.m.
• Cut back on caffeine, especially in the afternoon or

evening.
• If awakened, get up and read quietly in another place,

so that bed is associated with sleep, not sleeplessness.

Sources: Gorman, 1999; S. L. Murphy, 2000.

activities, such as hobbies, sports, socializing, or
spending time in nature, has been tied to lower blood
pressure, lower cortisol, lower weight, and better
physical functioning. Satisfaction with leisure activi-
ties can improve cognitive functioning among the el-
derly (Singh-Manoux, Richards, & Marmot, 2003)
and promote good health behaviors (Kim, Kubzansky,
& Smith, 2015).
Unfortunately, little other than intuition currently
guides our thinking about restorative processes. None-
theless, health psychologists suspect that rest, re-
newal, and savoring—involving activities such as
going home for the holidays, relaxing after exams, and
enjoying a walk or a sunset—have health benefits. ∙

78 Part Two Health Behavior and Primary Prevention

minority and older women, undergo them
because of lack of information, unrealistic fears,
and the high cost and lack of availability of
mammograms. Colorectal screening is also an
important cancer-related health behavior.

7. Dietary interventions involving reductions in
cholesterol, fats, calories, and additives and
increases in fiber, fruits, and vegetables are
widely recommended. Yet long-term adherence
to such diets is limited for many reasons:
Recommended diets are sometimes boring; tastes
are hard to change; and behavior change often
falls off over time.

8. Dietary interventions through the mass media and
community resources have promise. Intervening
with the family is also helpful in promoting and
maintaining dietary change. Cognitive behavioral
therapeutic interventions (CBT) have been
successfully employed to alter diet, although
recent interventions have moved to less costly
formats, such as telephone interventions.

9. Sufficient sleep, rest renewal, and relaxation are
also important health behaviors. Many people
abuse their sleep intentionally or suffer from
insomnia. A variety of behavioral methods that
promote relaxation can offset these risks. In
addition, setting aside time to savor the pleasant
aspects of life and simply taking a vacation may
have health benefits.

1. Health-enhancing behaviors are practiced by
people to improve their current and future health.
Such behaviors include exercise, accident
prevention measures, cancer detection processes,
consumption of a healthy diet, 7–8 hours of sleep
each night, and opportunities for rest and renewal.

2. Exercise reduces risk for heart attack and
improves other aspects of bodily functioning.
Exercise also improves mood and reduces stress.

3. Few people adhere regularly to the standard
exercise prescription of at least 30 minutes at
least three times a week. People are more likely
to exercise when the form of exercise is
convenient and they like it, if their attitudes favor
exercise, and if they come from families in
which exercise is practiced.

4. Cognitive-behavioral interventions, including
relapse prevention components, have been
moderately successful in helping people adhere
to regular exercise programs.

5. Accidents are a major cause of preventable
death, especially among children and
adolescents. Publicity in the mass media,
legislation promoting accident prevention
measures, training of parents by health
practitioners, and interventions to promote safety
measures for children have reduced these risks.

6. Mammograms are recommended for women
over age 50, yet not enough women, especially

S U M M A R Y

K E Y T E R M

aerobic exercise

C H A P T E R 5
SES, Culture, and Obesity

Obesity and Dieting as Risk Factors for Obesity

Stress and Eating

Interventions

Cognitive Behavioral Therapy (CBT)

Evaluation of Cognitive-Behavioral Weight-Loss
Techniques

Taking a Public Health Approach

Eating Disorders
Anorexia Nervosa

Bulimia

Alcoholism and Problem Drinking
The Scope of the Problem

What Is Substance Dependence?

Alcoholism and Problem Drinking

Origins of Alcoholism and Problem Drinking

Treatment of Alcohol Abuse

Treatment Programs

Evaluation of Alcohol Treatment Programs

Preventive Approaches to Alcohol Abuse

Drinking and Driving

Is Modest Alcohol Consumption a Health Behavior?

Smoking
Synergistic Effects of Smoking

A Brief History of the Smoking Problem

Why Do People Smoke?

Nicotine Addiction and Smoking

Interventions to Reduce Smoking

Smoking Prevention Programs

Health-Compromising Behaviors

C H A P T E R O U T L I N E

Characteristics of Health-Compromising Behaviors
Obesity

What Is Obesity?

Obesity in Childhood

80 Part Two Health Behavior and Primary Prevention

Some years back, my father went for his annual physical, and his doctor told him, as the doctor did
each year, that he had to stop smoking. As usual, my
father told his doctor that he would stop when he was
ready. He had already tried several times and had been
unsuccessful. My father had begun smoking at age 14,
long before the health risks of smoking were known,
and it was now an integrated part of his lifestyle,
which included a couple of cocktails before a dinner
high in fat and cholesterol and a hectic life that pro-
vided few opportunities for regular exercise. Smoking
was part of who he was. His doctor then said, “Let me
put it this way. If you expect to see your daughter
graduate from college, stop smoking now.”
That warning did the trick. My father threw his
cigarettes in the wastebasket and never had another
one. Over the years, as he read more about health, he
began to change his lifestyle in other ways. He began to
swim regularly for exercise, and he pared down his diet
to one of mostly fish, chicken, vegetables, fruit, and
cereal. Despite the fact that he once had many of the
risk factors for early heart disease, he lived to age 83.

■ CHARACTERISTICS OF
HEALTH-COMPROMISING
BEHAVIORS

In this chapter, we address health-compromising
behaviors—behaviors practiced by people that under-
mine or harm their current or future health. My
father’s problems with stopping smoking illustrate
several important points about these behaviors. Many
health-compromising behaviors are habitual, and sev-
eral, including smoking, are addictive, making them
very difficult habits to break. On the other hand, with
proper interventions, even the most intractable health
habit can be modified. When a person succeeds in
changing a poor health behavior, often he or she will
make other healthy lifestyle changes. The end result is
that risk declines, and a disease-free middle and old
age becomes a possibility.
Many health-compromising behaviors share sev-
eral additional important characteristics. First, there
is a window of vulnerability in adolescence. Behav-
iors such as drinking to excess, smoking, using illicit
drugs, practicing unsafe sex, and taking risks that
can lead to accidents or early death all begin in early
adolescence and sometimes cluster together as
part of a problem behavior syndrome (Donovan &
Jessor, 1985; Lam, Stewart, & Ho, 2001). In the past,

adolescent boys were more at risk of falling into
these patterns, but girls are catching up (Mahalik et
al., 2013). Not all health-compromising behaviors
develop during adolescence; obesity, for example,
can begin early in childhood. Nonetheless, there is
an unnerving similarity in the factors that elicit and
maintain many health-compromising behaviors.
Many of these behaviors are tied to the peer cul-
ture, as children learn from and imitate their peers, es-
pecially the male peers they like and admire (Bricker
et al., 2009; Gaughan, 2006). Wanting to be attractive
to others becomes very important in adolescence, and
this factor is significant in the development of eating
disorders, alcohol consumption, tobacco and drug use,
tanning, unsafe sexual encounters, and vulnerability to
injury (Shadel, Niaura, & Abrams, 2004). Exposure to
peers’ risky behavior, such as unsafe driving, increases
risk-taking (Simons-Morton et al., 2014).
Many of these behaviors are pleasurable, enhanc-
ing the adolescent’s ability to cope with stressful situa-
tions, and some represent thrill seeking, which can be
rewarding in its own right. However, each of these be-
haviors is also dangerous. Each has been tied to at least
one major cause of death, and several, especially smok-
ing and obesity, are risk factors for more than one major
chronic disease. Adolescents who slip into these pat-
terns are less likely to practice good health habits and
use leisure time for exercise in midlife, setting the stage
for an unhealthy middle and older age (Wichstrøm, von
Soest, & Kvalem, 2013).
Third, these behaviors develop gradually, as the
person is exposed to the behavior, experiments with it,
and later engages in it regularly. As such, many health-
compromising behaviors are acquired through a pro-
cess that makes different interventions important at
the different stages of vulnerability, experimentation,
and regular use.
Fourth, substance abuse of all kinds, whether ciga-
rettes, food, alcohol, drugs, or health-compromising
sexual behavior, are predicted by some of the same
factors (Peltzer, 2010). Adolescents who get involved
in risky behaviors often have conflict with their parents
(Cooper, Wood, Orcutt, & Albino, 2003). Adolescents
with a penchant for deviant behavior and with low self-
esteem also show these behaviors (Duncan, Duncan,
Strycker, & Chaumeton, 2002). Adolescents who try to
combine long hours of employment with school have
an increased risk of alcohol, cigarette, and marijuana
abuse (Johnson, 2004). Adolescents who abuse sub-
stances typically do poorly in school; family problems,

Chapter 5 Health-Compromising Behaviors 81

deviance, and low self-esteem appear to explain this
relationship (Andrews & Duncan, 1997). Reaching pu-
berty early (van Jaarsveld, Fidler, Simon, & Wardle,
2007), and having a low IQ, a difficult temperament,
and deviance-tolerant attitudes predict poor health be-
haviors (Repetti, Taylor, & Seeman, 2002). Good self
control diminishes and poor self-regulation facilitates
vulnerability to substance use (Wills et al., 2013). But
co-occurring mental health disorders, such as depres-
sion or anxiety, may fuel these problem behaviors and
make them harder to treat (Vannucci et al., 2014).
A particular dilemma is that many of these behav-
iors—drinking or cigarette smoking, for example—
may start out as experiments but smoking, drugs,
excessive alcohol consumption, and compulsive eat-
ing can become addictions. There may be common
brain circuitry for all these seemingly different behav-
iors, especially the circuitry that controls reward and
pleasure/pain (Salamone & Correa, 2013; Smith &
Robbins, 2013; Stice, Yokum, & Burger, 2013).
Finally, problem behaviors, including obesity,
smoking, and alcoholism, are more common in the
lower social classes (Fradklin et al., 2015). Lower-
class children and adolescents are exposed more to
problem behaviors and may use these behaviors to
cope with the stressors of low social class (Novak,
Ahlgren, & Hammarstrom, 2007). Practice of these
health- compromising behaviors are one reason that so-
cial class is so strongly related to most causes of dis-
ease and death (Adler & Stewart, 2010).

■ OBESITY

What Is Obesity?
Obesity is an excessive accumulation of body fat.
Generally, fat should constitute about 20–27 percent
of body tissue in women and about 15–22 percent in
men. Table 5.1 presents guidelines from the National
Institutes of Health for calculating your body mass
index and determining whether you are overweight or
obese.
The World Health Organization estimates that
600 million people worldwide are obese and 1.9 bil-
lion are overweight, including 42 million children un-
der age 5 (World Health Organization, January 2015).
Obesity is now so common that it has replaced malnu-
trition as the most prevalent dietary contributor to
poor health worldwide (Kopelman, 2000), and it will
soon account for more diseases and deaths in the
United States than smoking.

The obesity problem is most severe in the United
States. Americans are the fattest people in the world.
At present, 68 percent of the adult U.S. population is
overweight, and about 34 percent is obese (Ogden,
Carroll, Kit, & Flegal, 2012), with women and older
adults somewhat more likely to be overweight or obese
than men and younger adults (Fakhouri, Ogden, Carroll,
Kit, & Flegal, 2012) (Figure 5.1). Although obesity
levels have begun to level off, the trend has not yet
reversed (Kaplan, 2014).
There is no mystery why people in the United
States have become so heavy. The average American’s
food intake rose from 1,826 calories a day in the 1970s
to more than 2,000 by the mid-1990s (O’Connor,
2004, February 6). Soda consumption has skyrock-
eted from 22.2 gallons to 56 gallons per person per
year (Ervin, Kit, Carroll, & Ogden, 2012). Portion
sizes at meals have increased substantially over the
past 20 years (Nielsen & Popkin, 2003). Muffins that
weighed 1.5 ounces in 1957 now average half a pound
each (Raeburn, Forster, Foust, & Brady, 2002, Octo-
ber 21). Snacking has increased more than 60 percent
over the last three decades (Critser, 2003), and easy
access to food through microwave ovens and fast food
restaurants contributes to the increase. The average
American weight gain over the past 20 years is the ca-
loric equivalent of only three Oreo cookies or one can
of soda a day (Critser, 2003), so it does not take vast
quantities of food or sugary drinks to gain weight.

Risks of Obesity Obesity is a risk factor for
many disorders. It contributes to death rates for all
cancers and for the specific cancers of the colon, rec-
tum, liver, gallbladder, pancreas, kidney, and esopha-
gus, as well as non-Hodgkin’s lymphoma and multiple
myeloma. Estimates are that excess weight may ac-
count for 14 percent of all deaths from cancer in men
and 20 percent of all deaths from cancer in women
(Calle, Rodriguez, Walker-Thurmond, & Thun,
2003). Obesity also contributes substantially to
deaths from cardiovascular disease (Flegal, Grau-
bard, Williamson, & Gail, 2007), and it is tied to ath-
erosclerosis, hypertension, Type II diabetes, and
heart failure (Kerns, Rosenberg, & Otis, 2002). Obe-
sity increases risks in surgery, anesthesia administra-
tion, and childbearing (Brownell & Wadden, 1992). It
has been tied to poorer cognitive skills as early as
adolescence, well in advance of any diagnosable
chronic health condition (Hawkins, Gunstad, Calvo,
& Spitznagel, 2016).

82 Part Two Health Behavior and Primary Prevention

Obesity is a chief cause of disability. The number
of people age 30–49 who are too heavy to care for
themselves or perform routine household tasks has
jumped by 50 percent. This increase bodes poorly for
the future. People who are disabled in their 30s and 40s
are more likely to have health care expenses and to
need nursing home care in older age, if they live that
long (Richardson, 2004, January 9). Being obese also
reduces the likelihood that a person will exercise, and
lack of exercise increases obesity; yet obesity and lack
of exercise appear to exert independent adverse effects
on health, leading to greater risks than either risk fac-
tor alone (Hu et al., 2004). One in four people over 50
is obese, and as the population ages, the numbers of
people who will have difficulty performing the basic
tasks of daily living, such as bathing, dressing, or even
walking, will be substantial (Facts of Life, December,
2004). Obesity is tied to poor cognitive functioning as
well (Verstynen et al., 2012).
Obesity is associated with early mortality (Adams
et al., 2006). People who are overweight at age 40 die,
on average, 3 years earlier than people who are thin
(Peeters et al., 2003). Abdominally localized fat, as

opposed to excessive fat in the hips, buttocks, or
thighs, is an especially potent risk factor for cardiovas-
cular disease, diabetes, hypertension, cancer, and de-
cline in cognitive function (Dore, Elias, Robbins,
Budge, & Elias, 2008). People with excessive abdomi-
nal weight (sometimes called “apples,” in contrast to
“pears,” who carry their weight on their hips) are more
psychologically and physiologically reactive to stress
(Epel et al., 2000). Fat tissue produces proinflamma-
tory cytokines, which may exacerbate diseases related to
inflammatory processes (see Chapter 2). Box 5.1 ex-
plores the biological regulation more fully.
Often ignored among the risks of obesity is the
psychological distress that can result. Although there
is a robust stereotype of overweight people as “jolly,”
studies suggest that the obese are prone to neuroticism
and psychiatric conditions, especially depression
(Sutin et al., 2013; Toups et al., 2013).
There are social and economic consequences of
obesity as well. An obese person may have to pay for
two seats on an airplane, have difficulty finding
clothes, endure derision and rude comments, and ex-
perience other reminders that the obese, quite literally,

TABLE 5.1 | Body Mass Index Table

Normal Overweight Obese Obese Extreme Obesity

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Height
(inches) Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

Source: National Heart, Lung & Blood Institute, 2004.

Chapter 5 Health-Compromising Behaviors 83

do not fit. Obesity is stigmatized as a disability whose
fault lies squarely with the obese person (Puhl,
Schwartz, & Brownell, 2005; Wang, Houshyar, &
Prinstein, 2006). Even health care providers may hold
these stereotypes. One woman reported that her phy-
sician told her “I was too fat for a proper exam and to
come back when I’d lost 50 pounds” (Center for the
Advancement of Health, 2008). The resulting effect
of repeated exposure to others’ judgments about their
weight can be heightened biological responses to
stress (Tomiyama et al., 2014), social alienation, and
low self-esteem. As a result, obese people sometimes
become reclusive, and one consequence is that diabe-
tes, heart disease, and other complications of obesity
may be far advanced by the time they seek a physi-
cian. Positive media portrayals of overweight and
obese people can go some distance to mitigate the
stigma (Brochu, Pearl, Puhl, & Brownell, 2014).

Obesity in Childhood

In the United States, approximately 42 million chil-
dren under 5 are overweight or obese (World Health

Organization, 2016). Nearly two-thirds of overweight
and obese children already have risk factors for
cardiovascular disease, such as elevated blood pres-
sure, elevated lipid levels, or hyperinsulemia (Sinha
et al., 2002). African American and Hispanic children
and adolescents are at particular risk. For the first time
in over 200 years, the current generation of children
has a shorter life expectancy than their parents due to
high rates of obesity (Belluck, 2005, March 17).
What causes the high rates of obesity in childhood?
There are genetic contributors to obesity, which com-
bine with risks conferred by low SES, increasing overall
risk to be obese (Dinescu, Horn, Duncan, & Turkheimer,
2016). The impact of genetics on weight may be exerted
in part by a vigorous feeding style that is evident early in
life. There are also genetically based tendencies to store
energy as fat rather than lean tissue. Another important
factor is sedentary lifestyles, involving television, video
games, and the Internet. Consumption of snacks and
sugary drinks during the sedentary activities greatly in-
crease the risks associated with obesity (Ervin & Ogden,
2013). Sugary drinks alone have been tied to 25,000
deaths per year in the U.S. and 180,000 worldwide in

TABLE 5.1 | Body Mass Index Table

Normal Overweight Obese Obese Extreme Obesity

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Height
(inches) Body Weight (pounds) Body Weight (pounds)