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It is health that is real wealth and not pieces of gold and silver. —Mahatma Gandhi
The media regularly inform us of problems within the health-care system: Many Americans have no health insurance; increasing obesity is creating record rates of diabetes; health-care costs are the leading cause of personal bankruptcy; and myriad factors are resulting in a national physician and nursing shortage. Indeed, our health-care system is in crisis, despite state-of-the-art medical technology and an increase in the average human life span. However, the media often fail to present the complete picture of health by overemphasizing high-tech biological and pharmaceutical treatments and often ignoring how behavior contributes to health problems. The medical system and consumers of health care often focus on “sick care” or “resurrection medicine” rather than on wellness and prevention.
Of course, many people think that an ER physician should treat the heart attack of an elderly grandmother. But, does knowledge of this woman’s affinity for fried foods, lifelong smoking habit, or development of obesity-related Type II diabetes sway opinions of how much money is spent to save her life or attempt to rehabilitate her back to health? These dilemmas force society to consider who is responsible for the state of this patient’s health and who will fund her care. The health-care crisis is complex and there are no easy solutions to it. Ethical issues concerning individual lifestyle behaviors, personal rights, or entitlement to health care frequently collide with health-care accessibility and affordability. The field of health psychology will likely play a role in any solution to current and future health care challenges.
Health psychology is a young field of psychology that integrates the scientific exploration and clinical applications of psychology, medicine, and public health disciplines such as health promotion, epidemiology, health education, and health policy. Western medicine typically focuses on diagnosing and treating the anatomical or physiological causes of disease. Epidemiology is a branch of public health that focuses on the distribution, related risk factors, and control of disease in a population. In addition, public health also includes health promotion, health communication, health education, and environmental health interventions to prevent illness and enhance individual and community health.
In 1978, the American Psychological Association (APA) formed Division 38, “Health Psychology,” to facilitate collaboration between psychologists and other health professionals interested in the psychological and behavioral aspects of mental and physical health. Health psychology is a specialization within psychology that adopts a biopsychosocial model of health and disease, and that utilizes information, methods, and interventions from other health-related disciplines to prevent and treat disease. The biopsychosocial model of health and disease is broader than the usual biomedical model practiced in Western medicine. The biopsychosocial model does not separate the mind from the rest of the body and considers the impact of behavior and the environment on health and disease. Health psychologists believe the holistic biopsychosocial model offers some optimism for improvements to personal and public health and to health-care systems.
The leading causes of death for Americans are heart disease, cancer, stroke, accidents, and lung disease. This pattern of disease is very different from the leading causes of death at the turn of the century in 1900: pneumonia/influenza, tuberculosis, and intestinal disease. The pattern of mortality changed from infectious disease, which was diminished through public sanitation and immunizations, to a pattern of chronic, lifestyle-driven diseases. People are now dying, at least in part, from the cumulative effects of their own behavior. In fact, half of all deaths in the United States each year are estimated to have preventable, behavioral causes. Behavior obviously counts. Health psychologists study the causes and methods of strategically decreasing unhealthful behaviors (e.g., smoking, dietary fat consumption, unsafe sex) and increasing healthful behaviors (e.g., regular exercise, practicing stress management) to prevent and treat disease. This chapter covers theories and models, research methods, and applications of health psychology. In addition, we compare health psychology to other health disciplines and discuss future directions in the field of health psychology.
The current Western model of health relies heavily on biomedical models and typically separates the mind from the body. Health psychology recognizes the importance of anatomy and physiology in the diagnosis, understanding, and intervention of disease. However, health psychologists focus on psychological and social variables and recognize the reciprocal relationship among biological, psychological, and social influences on health and illness. A health psychologist considers the interaction of biological variables such as genetic predisposition or immune system response; psychological and behavioral variables such as perceptions of stressors, coping strategies, and lifestyle; and social variables such as interpersonal relationships, culture, and environment in theorizing about causes of wellness versus illness and for developing interventions.
Social Cognitive Theory and Related Models
Better keep yourself clean and bright; you are the window through which you must see the world. —George Bernard Shaw
Albert Bandura’s (1977, 2004) social cognitive theory provides a broad and rich framework through which to understand health behaviors and provides a foundation for increasing positive health behaviors and decreasing health-compromising behaviors. In general, Bandura proposed that the environment, individual behaviors, and individual cognitions interact and impact one another, a concept known as reciprocal determinism. Social cognitive theory also emphasizes the importance of personal learning experiences (e.g., past attempts to quit smoking) and observations of others’ experiences (e.g., vicarious learning from watching a friend attempt to quit smoking) in understanding and changing behavior.
According to Bandura, there are five major determinants of behavior. The first is knowledge. For example, an individual would be more likely to decrease smoking if aware of the hazards of smoking. The second determinant of behavior is self-efficacy, which is an individual’s perceived confidence to perform a specific behavior in a specific situation. For example, an individual will likely be more successful at quitting smoking if he or she feels confident, rather than doubtful, in his or her ability not to smoke in a variety of situations (e.g., when experiencing stress, when socializing with friends). A third determinant of behavior includes positive and negative outcome expectancies. These are physical responses, social reactions, and self-evaluative consequences that an individual expects from his or her behaviors. For example, an individual will likely be more successful at quitting smoking if he or she anticipates breathing more easily, receiving support from friends for efforts at quitting, and envisioning feeling positive about quitting smoking.
A fourth determinant of behavior involves goal setting. Individuals will generally be more successful attaining goals when those goals are consistent with values (e.g., I value health and clean air), when goals are proximal or short-term (e.g., not smoking during breaks at work), and when there are rewards for reaching goals (e.g., money saved for a restaurant meal after a week of not smoking) rather than when goals are distal or long-term (e.g., quit smoking). The final determinant of behavior, according to Bandura’s social-cognitive theory, involves personal perception of environmental and social support for change. For example, a person may perceive himself or herself as having access to health services to assist with efforts to decrease smoking (e.g., counseling, prescription medication) or he or she may perceive barriers to health services as interfering with efforts to quit smoking (e.g., separate health insurance deductible for counseling services).
Self-efficacy is considered a primary determinant of behavior in social cognitive theory. Perceived confidence is proposed to be influenced by past personal experience, vicarious experience, verbal persuasion, and personal emotional reactions. Confidence for quitting smoking will be greater if the person has had past quitting successes, observed someone else as successful at quitting smoking, received verbal encouragement from others to quit smoking, and did not experience anxiety related to efforts to quit smoking. Self-efficacy directly impacts efforts toward health behaviors and indirectly influences goal setting (e.g., set more challenging goals when more confident), outcome expectancies (e.g., expect more positive outcomes from health-related behaviors when more efficacious), and perceptions of social and structural supports and barriers.
Theories are broad and are used to organize complex relationships between variables. Models typically utilize variables outlined in theories but are not as broad as theories and yield specific and testable hypotheses. A frequently utilized model in the field of health psychology that emphasizes personal perceptions outlined by Bandura’s social cognitive theory is Becker’s (1974) health beliefs model (HBM). In the HBM, beliefs about the threat of an illness relate to engagement in health-related behaviors. Beliefs about illness threat include both beliefs about personal susceptibility to illness (e.g., I have a family history of diabetes) and beliefs about the severity of consequences related to illness (e.g., diabetes can result in blindness). In addition, beliefs about the likelihood of particular health behaviors (e.g., increasing exercise or decreasing sugar intake) resulting in positive health outcomes (e.g., reduced risk of diabetes) and beliefs about barriers to initiating or maintaining particular health behaviors relate to actual health behaviors. The HBM is very popular in health education programs and has been applied to behaviors ranging from use of child safety restraints to cancer. Evaluations of the utility of the HBM suggest that elements of the model relate only modestly to health behavior change (Harrison, Mullen, & Green 1992; Janz & Becker, 1984). However, the model is rarely assessed in its entirety and is often tested using retrospective rather than prospective research designs (Harrison et al., 1992).
Another social cognitive model is the theory of planned behavior (TPB; Ajzen, 1991). The TPB focuses on the discrepancy between attitudes (e.g., I believe exercise is healthy) and behavior (e.g., I don’t exercise regularly). According to the TPB, behavior is a function of the intention to perform a specific behavior. Intention is related to outcomes expected from engagement in a specific behavior (e.g., regular exercise will lower my risk of Type II diabetes), perceptions of how others will view engagement in a specific behavior (e.g., friends will support efforts to exercise), and perception of perceived control over a specific behavior (e.g., I am capable of exercising three times a week). A comparison of the HBM and the TPB assessing a sample of male undergraduate college students found the two models were fairly similar in predicting past testicular self-examination. Moreover, and consistent with Bandura’s (2004) social cognitive theory, self-efficacy was the most powerful predictor of testicular self-examination in these men (McClenahan, Shevlin, Adamson, Bennett, & O’Neill, 2006).
Another frequently utilized model in health psychology is the transtheoretical model (TTM; Prochaska & DiClemente, 1982). As the name transtheoretical implies, this model draws from many theories and emphasizes similarities across theories rather than differences among them. The TTM is a model of change across time and was initially developed from studies of successful efforts to change smoking behavior. Prochaska and DiClemente noted that change is a process rather than a single event. The stages of change (SOC) describe readiness to change and are a primary component of the TTM.
The first SOC is the precontemplation stage, whereby an individual does not see him- or herself as needing to change and is not motivated to change. The second SOC is the contemplation stage, in which an individual weighs the pros and cons of changing his or her current behavior. For example, a person may acknowledge a number of positive outcomes associated with smoking (e.g., socialization) but also notes a number of negative outcomes associated with smoking (e.g., clothes smell). The individual is ambivalent about change during this stage.
The third SOC is the preparation stage. In this stage, an individual is less ambivalent than individuals contemplating the need to change, but is not fully ready to change overt behavior. For example, a smoker in the preparation SOC may research options for quitting smoking but is not ready to act on them. The fourth SOC is the action stage, in which an individual actively changes behavior. For example, a smoker in this stage may seek treatment, join a self-help group, or announce to friends that he or she has quit smoking and thrown out his or her cigarettes. The final SOC is the maintenance stage, whereby an individual works actively to sustain changes already achieved. Relapse is unfortunately frequent in health behavior change, and people often cycle through stages rather than going through the five stages in a linear manner.
The TTM relates to the broader social cognitive theory. Movement through the stages of change is more likely when self-efficacy for change is high. In addition, movement through the stages is more likely when the pros of changing behavior exceed the cons of changing behavior (i.e., decisional balance). Finally, the TTM proposes that specific processes of change should be carefully matched with the individual’s SOC. Most interventions assume readiness to change and target individuals in the action stage, making these interventions potentially inappropriate for individuals in other stages of change. Information in the form of consciousness raising and self-evaluation may be most helpful in the early stages, whereas specific coping strategies such as contingency management and stimulus control may be most helpful in the later stages of change. Consistent with the TTM, across 12 health behaviors (e.g., quitting smoking, using sunscreen, using condoms) the pros of changing increased between precontemplation and contemplation and the cons of changing decreased between contemplation and action. Further, stage-matched smoking cessation interventions have been found to exceed non-stage-specific smoking cessation interventions (Prochaska & Velicer, 1997).
Science is the tool of the Western mind and with it more doors can be opened than with bare hands. —C. G. Jung
Health psychology research aims to understand the complexities of health-related behavior and how to act deliberately in changing behaviors, cognitions, and emotions to protect health and treat disease. Health psychology borrows empirical information and research methods from a variety of basic science and applied areas including social, developmental, learning, and personality psychology; human and animal anatomy; physiology; epidemiology; sociology; and marketing.
Epidemiological Research Designs
Health psychologists often use epidemiological designs in their research. Epidemiological research involves tracking samples of humans to identify risk factors (e.g., cigarette smoking) and protective factors (e.g., early screening for cancers) in relation to disease. Epidemiology provides unique statistics, such as prevalence and incidence rates. Prevalence rates indicate the proportion of the population with a disease at a specific time and can be used to reflect the impact of both preventative and treatment interventions. An incidence rate is the proportion of the population newly diagnosed with a disease within one year and is valuable for assessing preventative interventions. For example, if health psychologists target abstinence and safer sex programs for teens in one city and compare that city to a control city receiving no intervention, the incidence of teen pregnancy and sexually transmitted infection would be predicted to decrease in the first city and remain constant in the control city. Relative risk is the ratio of the incidence or prevalence of a disease for those with a risk factor to the incidence or prevalence of a disease for those without the risk factor. For example, according to statistics reported by the Centers for Disease Control and Prevention (CDC, 2005), female cigarette smokers have 13 times the risk of developing lung cancer compared to female nonsmokers.
Retrospective and prospective nonexperimental cohort designs are common in health psychology and other health fields. Retrospective cohort designs represent a starting point to understanding how risk factors and protective factors may influence disease. A retrospective epidemiological design begins with a group of people who have the disease of interest. For example, Sacco and colleagues in 2001 studied an ethnically diverse group of male New Yorkers who had survived a stroke. The researchers then created an artificial control group by finding an ethnically diverse group of male New Yorkers, as similar as possible on important variables like age and socioeconomic status, who did not have a positive stroke history. The protective factor of interest was high-density lipoprotein (HDL), the “good cholesterol,” which is a protein in the blood that tows the bad cholesterol (LDL, or low-density lipoprotein) out of the body. Sacco et al.’s findings suggest that HDL seems to protect against stroke. The “seems to” in the last sentence is an important critical note about the retrospective design. Although retrospective research is easier to conduct than other research because information is assessed at one point in time (i.e., cross-sectionally), it cannot provide evidence of causality because information is not assessed across time, and the researcher does not control the variable of interest (e.g., participants’ intake of HDL and LDL).
Prospective designs are longitudinal, whereby researchers study a representative population of people who are healthy and track variables of interest across time, during which some people become ill while others stay healthy. For example, the largest prospective cohort study about women’s health, the Nurses’ Health Study, began in 1976 under the direction of Dr. Frank Speizer (Belanger, Hennekens, Rosner, & Speizer, 1978) and has tracked 127,000 female nurses between the initial ages of 30 to 55. Every two years, participating nurses report their medical histories, daily diet habits, and critical life events. This prospective study has yielded over 260 scientific publications. Twenty years after the study started, polyunsaturated fat intake was found protective against coronary heart disease (CHD), the leading cause of death in women, whereas transfat intake was associated with elevated risk of CHD (Oh, Hu, Manson, Stampfer, & Willett, 2005). Dietary carbohydrate intake and fiber intake were both found unrelated to the risk of breast cancer in the participating nurses (Holmes et al., 2004).
Randomized Controlled Trials
Another research design in health psychology is the randomized controlled trial (RCT), which is the classic experimental design frequently used in psychology. In a RCT, the researcher controls the independent variable (e.g., an intervention) to examine any differences on disease-relevant dependent variables (e.g., cholesterol levels). This design has several important features. First, the experimenter randomly assigns human participants to conditions. Imagine conducting a RCT to study the effects of yoga on heart health. The independent variable, or experimenter-controlled variable, would be yoga training (versus no yoga training) for participants. The dependent variables, or those variables expected to change as a result of the independent variable, would include physiological variables of heart fitness and stress. If participants were allowed to self-select their experimental condition, fans of yoga would likely pick the experimental condition and participants unfamiliar with yoga, or those holding negative opinions of yoga, would likely choose the control group. Thus, to participate in a RCT, individuals must consent to be randomly assigned by the experimenter to one of these groups. Randomization ensures group similarity at the beginning of the study so any differences on the dependent variable after participation in the study can be attributed only to the experimental manipulation of the independent variable. Thus, RCTs provide valuable information concerning what causes disease and what protects from disease. However, RCTs are costly and time consuming and researchers need detailed information gleaned from retrospective, prospective, and other basic science research before they can carefully design a useful RCT.
The placebo effect is a change created by a person’s belief in a treatment, rather than a change created by the actual treatment. The placebo effect, in and of itself, is an interesting mind/body response that deserves to be understood and harnessed in health care. However, health psychology RCTs are potentially negatively impacted by the placebo effect. For example, approximately 50 percent of the effect of antidepressant medications is estimated to result from positive patient expectations about the effectiveness of the medications (Kirsch & Sapirstein, 1998). Therefore, for the sake of scientific integrity, the placebo effect in RCTs is considered a variable that should be controlled. Such control is normally accomplished through “blinding.” For example, in a double-blinded design, neither the participants nor the research assistants know the participants’ experimental condition. A double-blinded RCT could be used to investigate a new medication to treat irritable bowel syndrome (IBS), a disorder that creates pain, alternating bowel patterns between diarrhea and constipation, and lifestyle restriction for its victims. Participants with IBS would agree to random assignment to receive the active medication or the inactive placebo medication, or “sugar pill.” The pills look identical, thereby blinding the participants, but both groups of participants would expect the medication potentially to help their IBS symptoms. The research assistants handing out the pills to participants also are blinded to prevent any communication of condition information to the participants.
Unfortunately, most behavioral interventions are difficult to conduct using blinded conditions because participants are often active participants in the therapies. An exercise intervention to promote weight loss for diabetes patients will be clearly evident to participants in the experimental group because they know they are using behavioral strategies to exercise regularly. Participants in the control group would know they are not being taught exercise promotion strategies. However, behavioral researchers attempt to manipulate expectations to control for the placebo effect. For example, individuals not assigned to the exercise group might be assigned to an active control condition (e.g., reading) and be told by the experimenter that reading is expected to promote weight loss. In addition, research assistants who do not know a participant’s randomized condition could assess the dependent variables (e.g., blood sugar levels).
The media often report conflicting information about health topics and, indeed, individual studies may differ if reviewed in isolation. Replication of research findings, therefore, is an important aspect of scientific discovery. A meta-analysis of a health psychology area is one way of reviewing findings across studies and identifying consistency of findings. A meta-analysis is a study of studies, typically a systematic quantitative review of RCTs that summarizes the effectiveness of a particular intervention for a particular illness or population. In some cases, a meta-analysis is fairly conclusive, leading to an end of future replication studies and suggesting new directions for investigation. For instance, Dusseldorp, van Elderen, Maes, Meulman, and Kraaij (1999) published a meta-analysis of 37 studies examining the effectiveness of health education and stress management programs for individuals who experienced cardiac events, typically heart attacks. They concluded that these cardiac rehabilitation programs reduced patient death from heart problems by 34 percent, and reduced the reoccurrence of a heart attack by 29 percent compared to patients not randomly assigned to cardiac rehabilitation programs. Studies such as this one may be used by the Agency for Health Care Policy and Research, an agency that relies on multidisciplinary panels to make recommendations based on scientific evidence to develop and refine guidelines for cardiovascular disease rehabilitation (Gaus, 1995).
In some cases, however, meta-analyses do not provide conclusive findings. For example, experts continue to debate the usefulness of psychological interventions for cancer patients. In 1989, Spiegel, Bloom, Kraemer, and Gottheil published an original study in which 86 female patients with metastatic breast cancer were randomly assigned to a support group or a control group. All participants received continued medical care. Participants assigned to the support group lived 35.6 more months, whereas participants in the control condition lived only 18.9 months after the start of the study. This research suggested that supportive group psychotherapy extended the life of a breast cancer patient and was featured in the Emmy-award-winning program Healing and the Mind (Davidson-Moyers, Grubin, Markowitz, & Moyers, 1993). The finding, however, was not consistently replicated in other studies. In fact, the journal Annals of Behavioral Medicine recently featured a debate of the utility of psychological interventions for cancer patients. Lepore and Coyne (2006) interpreted the literature and meta-analyses as refuting the value of psychological interventions for the typical cancer patient. On the other hand, Andrykowski and Manne (2006) interpreted the literature and meta-analyses as supporting psychological interventions as effective in managing distress in some cancer patients. Hence, even meta-analyses do not always secure definitive scientific truth.
Experimental health psychologists often have a background in social psychology or developmental psychology and typically work in academic or research settings.
However, most health psychologists are also trained in applied clinical or counseling psychology. Applied health psychologists work in a number of different settings including medical centers and medical schools, rehabilitation centers, and private practices, as well as in academic and research institutions. The number of these professionals has increased substantially in recent history (Enright, Resnick, DeLeon, Sciara, & Tanney, 1990).
Half the costs of illness are wasted on conditions that could be prevented. —Dr. Joseph Pizzorno
One application of health psychology is health promotion and disease prevention. Prevention efforts can be primary, secondary, or tertiary in focus. Primary prevention programs target healthy people before the onset of symptoms or illness with the goal of keeping them well (e.g., water fluoridation for the prevention of dental cavities). Secondary prevention programs target people considered to be at risk for a particular illness or an expansion of a problem (e.g., a low-fat diet for someone with high cholesterol). Finally, tertiary prevention programs target individuals who suffer from the target illness to limit disability or prevent death (e.g., behavioral strategies to increase compliance with insulin regimen and diet for diabetic individuals).
Biopsychosocial Pathways to Health
A sad soul can kill you quicker, far quicker, than a germ. —John Steinbeck
Applied health psychology involves the complex relationship between traditional medical interventions and psychological and social interventions. Friedman, Sobel, Myers, Caudill, and Benson (1995) reviewed the psychological and social variables associated with the demand for and use of medical services. Friedman et al. discussed six interacting pathways through which behavioral interventions may improve health care and patient quality of life while decreasing overall costs.
The first pathway concerns the role of information and self-help to assist in decisions to access professional medical care. For example, researchers at Stanford University developed the Arthritis Self-Management course (Lorig, Mazonson, & Holman, 1993) to teach people with arthritis about their disease, to cope with pain, use appropriate exercise and medications, communicate about their disease, promote healthful eating and sleep habits, and make informed decisions about accessing professional health care. The course intended to increase personal self-efficacy for coping with arthritis. In controlled randomized studies, participation in the Arthritis Self-Management course related to decreased self-reported pain, increased quality of life, and decreased physician visits (e.g., Lorig et al.). The course is now recommended by the Centers for Disease Control and Prevention, the Arthritis Foundation, and the American College of Rheumatology.
The second pathway identified by Friedman and colleagues concerns the negative physiological effects of psychological stress. When faced with danger, the sympathetic nervous system adaptively activates to prepare the body to fight or flee. Psychological stress can also activate an emergency physiological fight-or-flight response, and repeated stressors and activation of this system may negatively impact health and immune system responses. Hence, psychological “dis-ease” from prolonged stress can result in chronic sympathetic activation and can cause physical disease.
On the other hand, activation of the parasympathetic nervous system, a system that relaxes the sympathetic nervous system, may relate to positive health outcomes. Grossman, Niemann, Schmidt, and Walach (2004) conducted a meta-analysis of the effectiveness of mindfulness-based stress reduction group interventions on physical and mental health outcomes. Studies analyzed included group interventions that involved daily practice of meditation and nonjudgmental awareness of everyday experiences. Although only 20 studies met all inclusion criteria for this meta-analysis, the results suggested that mindfulness-based stress reduction relates reliably with physical and mental health benefits.
Stress reduction interventions seem to impact the mind and body through multiple pathways to improve overall health. Hiroko and colleagues (2005) found reduced self-reported stress levels and increased natural killer cells (related to proper immune system activity) in blood samples after regular practitioners participated in a Nishino breathing class (a Japanese practice similar to the Chinese qigong practice). Although this study was flawed due to the inclusion of highly practiced individuals as participants and the exclusion of a control group, it offers some insight into the potential for relaxation techniques having a positive impact on biological health indicators.
As noted earlier, the leading causes of death relate to lifestyle behaviors such as tobacco use, diet, and activity level. Hence, the third pathway identified concerns targeting behaviors related to health. The management of many physical illnesses depends on specific behaviors. For example, a health psychologist may work with a diabetic patient to increase compliance with blood sugar testing and insulin injections, as well as exercise and weight loss. Chodosh and colleagues (2005) published a meta-analysis evaluating the impact of programs designed to help older adults monitor and self-manage diabetes, hypertension, or osteoarthritis. They noted clinically and statistically significant benefits related to self-management programs for diabetes and hypertension, as noted by physiological improvements in blood markers and blood pressure as well as limited improvements in pain and functioning relative to osteoarthritis. In a seminal study, Ornish and colleagues (1998) randomly assigned patients with substantial coronary artery blockages either to traditional medical care, such as bypass surgery, or a comprehensive lifestyle change program that included exercise, a very low-fat diet, smoking cessation (if applicable), stress reduction, and social support. They found that patients in the lifestyle program showed a reversal of heart disease, whereas patients in the traditional medical care condition did not. The findings suggest that medical intervention remedies the immediate problem (i.e., lack of blood flow to the heart), but that extensive lifestyle change may treat the underlying causes and actually reverse the symptoms of heart disease.
The fourth identified pathway involves provision of social support. A quality social support network correlates positively with physical and mental health (Cohen, 1988), whereas a strained marital relationship, for instance, relates to impaired cardiovascular, endocrine, and immune functioning (Robles & Kiecolt-Glaser, 2003). Social support has many potential positive influences on health, including social pressure for positive social behaviors, provision of resources, and support of positive emotional states. In an interesting study, Pressman and colleagues (2005) found that college freshmen reporting high levels of loneliness and small social support networks had the lowest antibody response to an influenza vaccination compared to other college freshmen. Thus, although it is not well understood, social support may relate to physiological indices that, in turn, relate directly to disease processes.
Social support interventions also relate to positive health outcomes. For example, a doula is a paraprofessional who provides emotional support, companionship, physical comfort (e.g., massage) and information to a woman during labor and delivery. Women randomly assigned a doula during labor and delivery had fewer Cesarean section surgeries, shorter labor time, and lower rates of newborn babies’ requiring hospitalization on average than those who were not provided a doula (e.g., Klaus, Kennell, Berkowitz, & Klaus, 1992).
A fifth pathway through which psychological and social variables may impact seeking of medical intervention is undiagnosed psychiatric disorders. Indeed, Ford and colleagues (2004) found that heavy users of costly emergency medical care also experience high levels of depressive and anxiety symptoms. Patient reports of negative emotions such as depression, anxiety, and anger reliably associate with morbidity and mortality from chronic illnesses, including cardiovascular disease (Barefoot et al., 2000) and diabetes (Lustman, Frank, & McGill, 1991). On the other hand, Richman and colleagues (2005) explored the longitudinal relationship between the positive emotions of hope and curiosity and hypertension, diabetes, and respiratory tract infections. They found that higher levels of hope were associated with a decreased likelihood of having or developing the three illnesses. In addition, they found that higher levels of curiosity related to a decreased likelihood of hypertension and diabetes. Although patient outcomes are best when comorbid psychiatric symptoms and disorders are recognized and addressed in the context of emergency medicine, a recent study found that emergency department physicians often fail to recognize classic symptoms of depression and panic disorder (Gerard, Michael, & Gerard, 2005).
A final pathway proposed by Friedman and colleagues (1995) involves the possibility that some people express psychological distress through physical symptoms and therefore access traditional biomedical services. In fact, a group of disorders known as somatoform disorders involve the presentation of physical symptoms that are at least partially accounted for by psychological variables. For example, somatization disorder is a rare psychological disorder in which people present with numerous physical symptoms across a period of years that result in excessive spending of health-care dollars. Traditional biomedical health care does not improve the physical symptoms of an individual with somatization disorder because the driving force of the disease is psychological rather than biological. It is important to individual health—and it is economically feasible—to address the psychological distress experienced by patients seeking medical services.
In another applied arena, health psychologists may play a role in creating and changing public health policies. According to the National Center for Health Statistics (CDC, n.d.), rates of obesity have increased across the last two decades, with over 60 percent of the United States population being overweight or obese and over 30 percent of the population meeting criteria for obesity. Many variables likely contribute to increased rates of obesity and associated health risks including sedentary lifestyles and diet. However, despite increased awareness of the health dangers associated with high-fat diets and trans fat intake in particular, many restaurants rely heavily on trans fats for food preparation. Knowledge is necessary—but not always sufficient—in supporting health behavior change.
Oftentimes health psychologists focus on individual behavior change; however, psychologists also recognize the influence of the environment on personal health behaviors. For example, Dr. Kelly Brownell, a health psychologist at Yale University, has likened the fast-food industry to “Big Tobacco” in terms of marketing a known dangerous substance to the public. Brownell was recognized in 2006 by Time magazine (Huckabee, 2006) as one of the 100 most influential people for his work in the area of nutrition, obesity, and public policy. He proposed the “Twinkie tax” as a tax on junk food and has taken a strong stance on the importance of protecting the public from harmful food despite the threat to individual liberties, the political ramifications, and the financial risks to big business. Consistent with Brownell’s stance on the need for greater societal controls, New York City recently passed legislation banning the use of trans fats in area restaurants that will go into full effect in 2008. Brownell was called on as an expert witness for the passing of this historical legislation intended to protect the public from this known dietary risk factor.
Most practicing health psychologists are clinical psychologists who have specialized training in prevention and treatment of medical disease. Minimally, individuals practicing health psychology have a master’s degree. However, more typically, health psychologists have a doctoral degree, typically the PhD (doctorate of philosophy). Doctoral programs in health psychology are competitive, requiring above-average college grades and competitive GRE scores. A master’s degree takes two to three years of full-time post-bachelor’s degree training and a doctoral program requires a minimum of five years of post-undergraduate education including a yearlong applied internship, often at a medical school. Many health psychologists also spend one to three years after they earn a doctoral degree in post-doctoral training, further specializing in the field, gaining more clinical experience, achieving licensure, and sharpening research skills. Although the title “psychologist” is strictly reserved for doctoral-trained psychologists, master’s-level health psychology graduates can function as psychological associates or counselors in many states.
Similar to traditional clinical and counseling psychologists, applied health psychologists are skilled in assessment and treatment of psychological disorders like anxiety and depression, but receive additional training in biology, epidemiology, behavioral medicine, and health psychology. Thus, applied health psychology is frequently an area of specialization within clinical or counseling psychology. Health psychologists can also be experimental in their focus, specializing in basic health psychology research (e.g., relation between behavior and immune system functioning), serving as consultants, or promoting environmental change rather than directly caring for patients.
Clinical health psychologists also share important similarities and differences with other health-care providers like physicians, nurses, dieticians, and physical therapists. Although health psychologists receive supplemental training in the medical field (i.e., anatomy, physiology, and medicine), they are not medical doctors, are not typically trained to prescribe medications, and are never permitted to perform medical procedures. Health psychologists are similar to physicians who practice integrative medicine, adhering more to the biopsychosocial model than to the biomedical model of health and disease. In their practice, clinical health psychologists are also similar to professional registered nurses in that they employ a client-centered and humanistic style of interaction and often work to prevent illnesses. In addition, health psychologists are similar to other health professionals. Like dieticians, health psychologists recognize the benefits of positive nutrition on health, but health psychologists focus on the behavioral, emotional, cognitive, and environmental aspects of achieving healthful eating habits rather than prescribing specific dietary recommendations. Like physical therapists, health psychologists accept that a fit body relates to health and overall functioning in life, and like public health professionals, health psychologists understand how environment, culture, social institutions, and public policy impact individual and community-level health.
The labels “medical psychology” and “behavioral medicine” are often used interchangeably with “health psychology.” The field of health psychology, although integrative, is reserved for psychologists, whereas behavioral medicine is practiced by health professionals who are not psychologists. Information about training programs can be found online at the Health Psychology Division 38 Web site (http://www.health-psych.org/education.php) and the Web site for the Society for Behavioral Medicine (http://www.sbm.org/careers).
The field of health care is increasingly concerned with the economic “bottom line.” Friedman et al.’s (1995) review noted numerous examples of cost reduction associated with the use of psychosocial interventions in the context of medical interventions. Traditionally, insurance companies distinguish between physical health and mental health. For example, insurance companies generally require patients to pay a separate deductible for physical and mental health coverage, and there are often different levels of reimbursement for physical and mental health care. Health psychologists and other professionals who ascribe to the biopsychosocial model of health and disease argue for removal of the mind/body dichotomy in health care and equal coverage of behavioral and traditional medical services, and will likely continue to advocate for such policy change in the future (i.e., parity laws). Continued examination of the relationship between psychological, social, and more traditional biological variables associated with health and illness will be crucial to broadening the health-care system and changing financial reimbursement of healthcare services.
Quality Versus Quantity of Life
———————Death is not the greatest loss in life. The greatest loss is what dies inside us while we live. —Norman Cousins
It is likely that health psychologists will increase their roles in political and public health realms. Dr. Robert M. Kaplan, Chair of the Department of Health Services at the UCLA School of Public Health, has spent a career advocating for changes in health-care research and policy. Historically, the American health-care system has valued the effects of treatments on disease or specific disease symptoms (e.g., does a medication for hypertension reduce blood pressure?). In 1994, Kaplan provided the health psychologist’s answer to the question of the meaning of life by using a cartoon. The character “Ziggy” asks the wise man on the mountain top, “What is the meaning of life?” and receives the response that the meaning of life is “doin’ stuff.” Chronic illnesses like diabetes and lung cancer cause people to “do less stuff.” Kaplan (2003) recommended that health-care practice and research focus on quality of life as well as length of life. In addition, Kaplan argued that medical decision making is often uncertain and ambiguous and should involve shared patient-doctor decisions. For example, men with prostate cancer can confer with their urologist about multiple treatment options, including surgery or radiation (i.e., with risk of incontinence and impotence) versus continued assessment (i.e., “watch and wait,” which has the risk for potential spread of the cancer to areas outside the prostate). The first treatment option aggressively removes the disease, yet has quality-of-life ramifications. The latter treatment option maintains quality of life, but may allow for worsening of the disease.
As discussed earlier, over the course of the last century, the pattern of health problems in the United States has changed from acute infectious diseases to chronic illnesses. Management of acute infectious diseases appropriately focuses on disease-specific symptom outcomes (e.g., presence of bacteria). However, according to Kaplan and other health psychologists, management of chronic illnesses warrants a change in how health-care outcomes are assessed. When determining treatment success of patients suffering from chronic illnesses, self-reports of functioning and quality of life are essential.
Finally, it is likely that the subfield of psychoneuroimmunology will play a substantial role in the future of health psychology and health care in general. Psychoneuroimmunology is the interdisciplinary study of the reciprocal relationships among the brain, psychosocial variables such as cognitions and behaviors, immune and endocrine system functioning, and disease development and course. Advances in measurement of brain structure and function and advances in measurement of immune system responses (e.g., cytokines) will likely allow scientists to document mind/body interactions. Examples of psychoneuroimmunology research include the role of psychological stress in wound healing, disease development, and immunization responses, as well as the role of optimism and perceptions of control in endocrine responses and disease development.
Health psychology is a relatively young field that is primarily concerned with the relationship between psychosocial variables (i.e., behavior, cognitions, emotions, social support) and traditional health variables (i.e., disease development, health-care utilization). Although health psychology is a specialization within psychology, the field draws from other health fields such as epidemiology and health promotion. Health psychologists ascribe to a biopsychosocial model of health and disease and often collaborate with other health researchers and practitioners; thus, this field of psychology is an interdisciplinary specialization.
Recall the earlier example of an elderly grandmother who presents to the emergency department of her local hospital with a myocardial infarction (heart attack). Biologically, a heart attack occurs when one or more of the arteries that supply blood to the heart become clogged. This blood flow occlusion could result in heart tissue death, potentially damaging her heart and then possibly killing her. This woman’s presenting symptoms may have included chest pain and pressure, perhaps nausea and dizziness, and she would likely have been terrified.
In a primarily biomedical health-care system, she would be treated with fairly expensive procedures such as angioplasty (inserting a balloon that opens a clogged coronary artery and replacing the affected area with a stent within the artery) or bypass surgery, whereby a healthier artery would be removed from her leg and then attached to the heart to reroute blood flow to the affected area. Unfortunately, unless she was referred to a cardiac rehabilitation program or she made significant lifestyle changes on her own, she would likely continue to have future health problems related to her cardiovascular disease. This expensive and potentially pessimistic ending is a relative shortcoming of a biomedically-focused system of health care.
However, if the health-care system adhered to the biopsychosocial model today, this grandmother would be cared for by an interdisciplinary team of professionals including a health psychologist, a cardiologist, a dietician, a social worker, an exercise physiologist, and perhaps a chaplain in a comprehensive cardiac rehabilitation program. The treatment team would encourage the social support of her family. The chaplain would likely pray with her and help her see the meaning of this death-defying event in her life. The treating professionals would initially supervise an exercise program starting with small increments of aerobic exercise while she was medically monitored. The heart is like any muscle in the body: If it is unused, it becomes weak. If it is used in exercise, it heals and becomes stronger and can more efficiently pump blood through the circulatory system. The psychologist would use a noncoercive and motivational style of interviewing as well as cognitive behavioral techniques to address her smoking habit, to encourage exercise and dietary changes, and to assist her in stress management and accessing social support. The dietician would work with her and her family to decrease intake of fried foods and increase intake of fruits, vegetables, and whole-grain products. Through the education, social support, and behavior changes made in
the program, she would develop positive self-efficacy for daily health behaviors along with positive outcome expectancies that her health behaviors could have a positive impact on her physical and emotional health.
Furthermore, a biopsychosocial health-care system across her lifetime could have prevented this grandmother’s heart attack. For example, although she may have smoked during her teen years, she might have been counseled during her first pregnancy and quit, thereby improving her baby’s health and decreasing her personal risk for cardiovascular problems. Moreover, public education and her health-care provider could have provided her with knowledge and strategies for regular exercise and healthful eating so that she and her family developed a heart-healthy lifestyle. As a part of her religious practice, this woman could have had support services for healthy living within her place of worship. In this scenario she could have maintained a healthy weight and never developed Type II diabetes. Because she would not be plagued by heart disease in her elderly years, she could continue to be physically, emotionally, and intellectually active. Although this woman would die eventually, she would not die prematurely from chronic lifestyle-related disease.
Of course, the above depiction is idealistic. Knowledge concerning the dangers associated with smoking and high-fat diets has changed and developed across time. In addition, behavior change can be very difficult, and health psychologists are dedicated to understanding ways to promote health behaviors while maximizing quality of life. Health psychologists and other biopsychosocial health investigators and practitioners continue to research the complicated, yet real, relationships among biological, psychological, and social health variables and will continue to advocate for the use of research findings to improve individual and community health.
This chapter began by listing a multitude of problems within the American health-care system. The integration of health psychology and other health promotion disciplines into mainstream health care could positively impact some systemic health-care problems. For example, with access to health psychology services, Americans may lead healthier lives, thereby reducing obesity, which could, in turn, reduce diabetes and premature death. There could be less demand for expensive medical care because Americans would be healthier, thereby reducing costs of insurance and allowing more Americans to afford health insurance. Healthier bodies could limit the need for medications substituting for health behaviors (e.g., less cholesterol or blood pressure medication). Behavior counts, not only for personal health, but also for community health and healthcare systems.
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