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Contents
Prefacexv
Acknowledgmentsxviii
About the Author xix
1. An Interdisciplinary View of Health 1

Chapter Outline 1
Chapter Objectives 1
Opening Story: How Would You Describe Winston’s Health? 1
Section I. A Brief History of Health 4
Health Practices in Early Civilizations 4
Health Practices in the United States 10
Summary10
Section II. Defining Health Today 11
Early Holistic Concepts 11
Models of Health and Well-Being 12
Section III. Current Views on Determinants of Health: A Health
Psychology Perspective 16
Individual/Demographic Influences 16
Family/Cultural Influences 18
Physical Environmental Influences on Health 19
Social Environmental Influences on Health 20
Health Systems/Health Policies Influences 20
Summary21
Personal Postscript 22
Questions to Consider 23
Important Terms 24
2. Research Methods 25
Chapter Outline 25
Opening Story: Healthy Volunteer Dies in Asthma Study 26
Section I. Measuring Health 27
Borrowing from Epidemiology 27
Summary32
viii Contents
Section II. Methodology 32

Qualitative Studies 32
Correlational Studies 35
Experimental Studies 36
Intervention Studies 42
Ethical Considerations in Experimental Design 42
Quasi-Experimental Intervention Studies 43
Summary44
Section III. Research Ethics and Policy 44
Reactions to the Word Research44
The Tuskegee Syphilis Study 45
The Nuremberg Code of 1947 47
Study of Interpersonal Dynamics (Stanford Prison Experiment) 49
Research without Informed Consent 52
Summary53
Important Terms 55
3. Global Communicable and Chronic Disease 57

Chapter Outline 57
Opening Story: Man with Drug-Resistant Tuberculosis Causes International
Health Scare 58
Section I. Global Health Problems 62
Communicable Diseases: Human-to-Human Transmission 62
Recurring Diseases 69
Chronic Diseases 74
Measures of Life Expectancy, Quality of Life, and Chronic Illnesses 81
Section II. Global Health Organizations 83
World Health Organization (WHO) 85
The Federation of Red Cross and Red Crescent Societies 86
Médecins Sans Frontières (Doctors Without Borders) 87
Section III. Health Policy 87
National Policy: Global Implications 87
Isolation and Containment for TB and HIV/AIDS 88
Section IV. The Economic Consequences of Poor Health 88
Who Is Affected? 88
Individual Health and Community Outcomes 89
Summary90
Important Terms 91
Contents ix
4. Theories and Models of Health Behavior Change 93

Chapter Outline 93
Opening Story: Eddie’s Dilemma 94
Section I. Theories and Models of Health Behavior Change 95
Expectancy Value Theory (EVT) 95
Social Cognitive Theory (SCT) 97
Theory of Planned Behavior (TPB) 99
Health Belief Model (HBM) 101
Transtheoretical Model of Behavioral Change (TTM) 105
Section II. Social Marketing: A Technique to Promote Behavior Change 108
The Four Ps 109
Blended Models 112
Section III. The Ecological Approach to Health: Factors That Influence Health Behaviors 115
Individual Factors 115
Cultural and Social Networks 118
Physical Environment 120
Health Systems 121
Health Policy 123
Section IV. Challenges to Sustaining Health Behavior Change 124
Short- versus Long-Term Adherence 124
The Appeal of Unhealthy Behaviors 125
Important Terms 126
5. Risky Health Behaviors 128

Chapter Outline 128
Opening Story: Distracted to Death 129
Section I. Unintentional Injury and Violence 133
Motor Vehicle Accidents 133
Violence135
Section II. Substance Use and Abuse: Influence of Culture, Age, and Gender 139
Cigarettes140
Alcohol144
Illegal and Prescription Drugs 149
Section III. Risky Sexual Behaviors 152
Defining Risk 152
Early Initiation Behaviors 153
HIV/AIDS154
HIV Origins, Transmission and Human Behavior 156
Human-to-Human Transmission 157
x Contents
Health-Protecting Behaviors 159

Substance Use and Sexual Behavior 159
Teenage Pregnancies 159
Section IV. Eating Disorders 160
Anorexia Nervosa 160
Bulimia162
Obesity162
Binge Eating 163
Eating Disorders in Context 164
Summary164
Important Terms 166
6. Emotional Health and Well-Being 168

Chapter Outline 168
Opening Story: Angelita 168
Section I. Four Models of Well-Being 171
Biomedical Model 171
Biopsychosocial Model 173
Wellness Model 179
Social Ecological Model 183
Summary187
Section II. Positive Psychology 187
Defining Positive Psychology 188
Positive versus Negative Psychology? 188
Positive Psychology and Health 189
Critiques of Positive Psychology 190
Section III. Traditional Medicines 192
Contributions of Traditional Medicine 193
Chinese Traditional Medicine (CTM) 194
Curanderismo197
Native American Health Practices 198
Important Terms 201
7. Stress and Coping 203

Chapter Outline 203
Opening Story: Sarah 203
Section I. Defining Stress 206
Three Theories of Stress 207
Contents xi
Section II. Stress and Illness 217

Chronic Illness and Stress 217
Can Stress Lead to Illness? 218
The Diathesis–Stress (D–S) Model of Disease 218
Personality Type, Stress, and Illness 219
Psychosocial Events and Stress 220
Daily Life Hassles and Stress 225
Catastrophic Events and Stress 226
Section III. Coping with Stress 227
Cognitive Coping 228
Behavioral Coping Strategies 229
High-Risk Behaviors and Stress 235
Stress, Sexual Behaviors, and Substance Abuse 236
Positive Affect and Stress 236
Important Terms 240
8. Psychoneuroimmunology 242
Chapter Outline 242
Opening Story: Earvin “Magic” Johnson 242
Section I. Natural, Acquired and Cell Mediated Immunity 244
The Human Immune System 244
Summary247
Section II. Psychological Health and the Immune System 247
Summary252
Individual Variability, Stress and Immune Function 252
Depression and the Immune System 253
Psychoneuroimmunology and Social Support Networks 254
Loneliness and Health 255
Rats!257
Summary257
Section III. Psychoneuroimmunology and Chronic Illnesses 258
Cancer and Immune Function 258
Heart Disease and Immune Function 260
Section IV. Psychoneuroimmunology, Environmental Factors and Health 260
Summary261
Important Terms 264
9. Cardiovascular Disease 266

Chapter Outline 266
xii Contents

Opening Story: Tim Russert 266
Section I. The Heart and Its Functions 268
Structure268
Function269
Summary270
Section II. Cardiovascular Disease 270
Coronary Artery Disease (CAD) 271
Cardiac Arrest 272
Stroke273
Hypertension273
Section III. Psychosocial Factors and Cardiovascular Disease 274
Stress274
Ethnicity275
Perceived Racism 275
Personality277
Summary277
Section IV. Cardiovascular Disease and Health Determinants 277
Individual Determinants 277
Community/Environment290
Health Systems and Access to Care 290
Important Terms 293
10. Chronic Pain Management and Arthritis 295

Chapter Outline 295
Opening Story: Juvenile Arthritis 295
Section I. “The Decade of Pain” 297
Defining Pain 298
Pain Perception 299
Individual Difference Factors and Pain 299
Changing Characteristics of Pain 303
Section II. Pain and Arthritis 305
Types of Arthritis 305
Measuring Pain 310
Pain Management versus Pain Elimination 312
Section III. Pharmacological and Psychotherapeutic Management of Pain 312
Medical Therapies for Arthritis 313
Alternative Therapies 315
Psychotherapeutic Treatments 316
Caregivers, Pain Management, and Psychological Distress 320
Contents xiii

Important Terms 322
11. Cancer 325

Chapter Outline 325
Opening Story: Can Cell Phones Cause Cancer? Consider the Case of Reginald Lewis 326
Section I. Defining Cancer 329
Tumors329
Categories of Cancer 330
Comparing Global and U.S. Incidences of Cancer 332
Section II. Risk Factors for Cancer 333
Cancer and Gender 333
Genetic Factors 336
Race/Ethnicity and Cancer 337
Environment and Cancer Mortality 339
Health Behaviors and Cancers 340
Section III. Cancer: Treatments and Preventions 344
Preventive Health Behaviors 345
Section IV. Medical and Psychological Treatments 349
The Diagnosis: A Psychological Process 350
Medical Therapies 350
Psychological Comorbidity 351
Psychotherapeutic Approaches 352
Summary357
Important Terms 358
12. Health Care Systems and Health Policy: Effects on Health Outcomes 359
Chapter Outline 359
Opening Story: Michelle’s Dilemma 359
Section I. Access to the Health Care System 362
Health Care: An Unnecessary Expense? 362
Health Care: An Unaffordable Expense? 363
Section II. Overview of Health Care Systems in the United States 364
In the Beginning 364
Health Plans: Gatekeepers to Health Care 365
Section III. Negotiating the System 378
Consumer Satisfaction 379
Consumer–Provider Communication 381
Trust383
Section IV. Challenges for Health Care Providers 384
xiv Contents
Physicians’ Three “Fatal” Communication Errors 385

Physician Miscommunication or Patient Inattentiveness 386
Nonverbal Communication Cues 386
Section V. Health Policy 388
Preventive Care 388
Single-Payer Health Care System 389
Important Terms 392
13. The Health Psychologist’s Role: Research, Application, and Advocacy 394
Chapter Outline 394
Opening Story: John and Ahmed: Aspiring Health Psychologists 395
Section I. Working with Individuals 396
Education396
Evaluation of Interventions 400
Promoting Individual Self-Advocacy 401
Section II. Working with Communities 409
Community Needs Assessment 409
Program Implementation 410
Selecting Populations within Communities 411
Promoting Community Advocates 412
Section III. Working with Health Care Systems 412
Assessing Access to Health Care 412
Promoting Access to Health Care through Advocacy 414
Section IV. Working in Health Policy 415
Smoking Bans as Health Policy 415
Workplace Safety 416
A Healthy Workplace 417
Advocating for New Health Policies 417
Health Psychologists as Health Advocates 419
Important Terms 421
References423
Index495

PREFACE
Health psychologists have come to view health as a dynamic process that involves the interaction of
biology, human behavior, physical and social environments, health systems, and health policy. Perhaps the
best evidence for this claim is found in a number of recent events in the United States and in other countries
across the globe.
Consider, for example, Flint, Michigan. In 2014 local government officials decided to change the source
of the city’s drinking water from Lake Huron to the Flint River. But, the water from the Flint River was
not being treated with an anti-corrosive agent, as required by federal law. The result? The untreated water
caused lead to leach from the pipes into the water supply. Families in Flint who relied on this water were
ingesting lead with each glassful of water. Now, health care providers are carefully monitoring Flint’s
children for signs of lead poisoning that may have a lasting and irreversible impact on children including
impaired cognitive processes, behavioral disorders and developmental delays.
This example and scores of others illustrate the complex relationship between physical environments,
health policies and individual health outcomes. It illustrates also why, as health psychologists, we must look
at the role of external factors as well as individual determinants when attempting to explain and improve
health outcomes.
Health Psychology: An Interdisciplinary Approach to Health presents a social ecological perspective, an
approach consistent with the changes and developments in the field. Using this model, we now include, in
greater depth, a review and analysis of the impact of cultural, environmental, spiritual, and systems factors
on health and health outcomes. The expanded perspective encourages, and in fact requires, that we consider
the role of related disciplines such as anthropology, biology, economics, environmental studies, medicine,
public health, and sociology on health outcomes. Many health psychologists contend that it is only through
the lens of an interdisciplinary approach that we come to understand how health affects the individual on a
mental and emotional level, and how the individual responds to the challenges.
The expanded model of health evident in the social ecological model is also more consistent with the
new definition of health proposed by the American Psychological Association’s (APA) Division of Health
Psychology. Members of the Division, and an increasing number of health psychologists, believe that a
more comprehensive and integrated approach to health psychology will enable us to arrive at a better
understanding of the role of each factor in determining health outcomes.
Consistent with an interdisciplinary approach to health, one that gives equal weight to the physiological,
emotional, psychological, environmental, and systems contributions to overall individual well-being, we
introduce several topics in this text not typically covered in health psychology. For example, we introduce
and explore in greater detail than many texts the global nature of health. Comparing the health outcomes of
people with the same illness in different countries allows us to see the impact of different environments and
xvi PREFACE
health systems on health status. We also devote a section of Chapter 5, Risky Health Behaviors, to HIV/
AIDS, the pandemic of the twentieth century that cost over 35 million people their lives, to explore how
determinants such as individual behaviors and lifestyles, social environments, health systems, and health
policy promote or inhibit the spread of the disease. Finally, unlike other health psychology textbooks,
we devote a full chapter to psychoneuroimmunology, an integral component to our understanding of the
relationship between psychological, neurological and immunologic a health.
Departing from the format of some health psychology textbooks, this text does not include a separate
chapter on biological systems. Rather, we incorporate in each chapter a section on the physiological systems
relevant to that issue. For example, when discussing emotional health and well-being, we devote a section of
the chapter to a discussion of the biological systems and neurotransmitters that are essential to understand
the body’s response to emotions. Likewise in the chapter on cardiovascular health, we review the heart and
its components as well as the circulatory system prior to discussing specific cardiovascular diseases or their
treatments.
Several features are included in this text to underscore the point that health is an integral part of our
lives. First, each chapter begins with an Opening Story that poses a scenario or problem for consideration.
The stories highlight a central concept in the chapter and draws readers into the main topic of the chapter.
Stories summarize current events that pertain to or impact health and allow the reader to apply the
concepts in the chapter to real life situations. For example, the chapter on Cancer begins with a story on the
association between cell phone use and brain tumors.
Second, each chapter ends with a Personal Postscript that encourages students to reflect on the main
concepts of the chapter and to apply them to actual or likely life events. Personal postscripts are designed
especially for a college-aged audience. They propose situations and offer advice or solutions to situations
commonly encountered by college students that pertain to health. Finally, the postscripts bring the chapters
“full circle,” allowing students to reflect again on the applied aspects of the health issues presented in the
chapter.
Third, the chapters include special “boxes” that explore selected material in depth without disrupting
the flow of the text. It is ideal for students and instructors who seek more in-depth information on a topic
introduced in the text. At the same time, the information in boxes can be omitted by readers who are less
interested in the details.
Fourth, and central to the social ecological model, one chapter is dedicated to the role of health systems
that also identifies career opportunities in health policy. Students are presented with various ways in which
health psychologists can provide research and direct service to health policy institutions that affect the
health of individuals, communities, regions, and countries.
Finally, the chapters conclude with Important Terms, concepts, and procedures common in health and
health related fields. Terms are highlighted and defined in text and itemized at the end of each chapter to
remind students of the important concepts to remember in each chapter.
NEW TO THIS EDITION
New innovations in health seem like a daily occurrence. Along with these innovations come discoveries of
new factors that affect individual well-being and improved treatment regimens. In light of these changes
any textbook in the field of Health Psychology will need to be updated regularly. Health Psychology: An
Interdisciplinary Approach to Health is no exception. Several major changes and additions have been made
for the third edition based on feedback from adopters and reviewers.
PREFACE xvii
1. Two major changes were implemented in each chapter:
a. Updated statistics—Data on vital health statistics for the United States and globally have been
updated using data from the Centers for Disease Control and Prevention, World Health Organization,
and other expert national and global organizations.
b. Updated references—As noted previously, cutting-edge research in health is occurring daily. We
have updated the research findings throughout the text, paying particular attention to findings
that challenge previously held beliefs. We examine the implications of the new findings for health
psychologists.
2. In addition, significant changes were made to specific chapters. They include:
• Chapter 5—The significant improvements in testing for and treating HIV/AIDS lead us to reclassify
this health issue. Some health providers have even reclassified it as a chronic health issue rather
than a fatal health problem. While we hold to the view that HIV/AIDS remains a serious health
problem, we acknowledge the major accomplishments in HIV/AIDS education and treatment which
has significantly decreased the incidence and prevalence of this disease over the past 20 years.
Importantly, it has also significantly reduced the mortality rates due to AIDS. Consequently, in this
new edition, our discussion of HIV/AIDS has been updated and the topic included as a major section
in Chapter 5, Risky Health Behaviors.
• Chapter 8—Based on feedback from adopters we developed a new chapter entitled
Psychoneuroimmunology. This topic was originally introduced at the conclusion of
the old Chapter 8, HIV/AIDS. Many new developments in the field convinced us that
Psychoneuroimmunology deserved its own chapter. In this chapter we explore the complex but
riveting studies that attempt to explain the relationship between psychology and the immune
function. Specifically we delve into the debate on the possible effect of psychological stressors, like
anxiety, on immune response. We examine research that suggests that some cytokines including
interleukin-1B (IL-1B), interleukin-2 (IL-2), and interleukin-6 (IL-6) which play a vital role in
boosting the immune system, may be suppressed as a result of psychological stressors like anxiety.
We explore research that suggest that other cytokines, like interleukin-4 (IL-4) and interleukin-10
(IL-10), that suppress immune system response may be boosted by these same psychological factors.
We contrast these findings with a significant body of research that contradicts these findings. We
expand our discussion of the immune response system in two special Boxes in the chapter. We also
endeavor to explain the vital role of the research on rats that helps us to understand the human
immune system. Included also in Chapter 8 is an expanded discussion of a timely topic: the possible
relationship between cyber networks, psychological factors and immune response. Specifically we
explore the relationship between loneliness, cyber networks and immune response.
• Chapter 12—This third edition continues to update the changing landscape of the Affordable Care
Act, the most significant piece of legislation on health policy in the United States in over 60 years.
A discussion of the significant features of this Act, together with a brief review of the history of
attempted and realized health policy reforms in the U.S. over the century and challenges to this new
system, offers students an overview of the potential impact of the new policy on all U.S. citizens.
ACKNOWLEDGMENTS
If it takes a village to raise a child, it also takes one to create a textbook. The third edition of this text
involved a new village at Routledge who have been immensely helpful in the transition. A number of people
have given generously of their time, talents and knowledge, and evidenced great patience while I learned the
new system. I am particularly pleased to be working with an outstanding editorial staff at Routledge which
includes Christina Chronister, Julie Toich and Merrideth Miller, and the immensely helpful production staff,
including Joanna Hardern, Ross Armstrong and Jackie Dias.
I owe a great debt of gratitude to a number of research assistants who invested many hours searching for
and recommending new material, and updating statistics and references for this third edition. They include
Stephen Alvear, Yasmin Hussein, and Shakeera Walker. I could not have completed this work without you.
I wish to thank the adopters and reviewers of the first and second edition of this text for their suggested
improvements for this edition. Their comments contributed to an enhanced third edition and to significant
changes to several chapters. I particularly wish to thank Susan Johnson, University of North Carolina at
Charlotte; Kc Kalmbach, Texas A&M University San Antonio; Amy Peterman, University of North Carolina
at Charlotte; Victoria Kazmerski, Penn State University Behrend Campus; Sylvie Lombardo, Oakland
University; Mark Vosvick, Rutgers State University of New Jersey; and Ephrem Fernandez, University of
Texas-San Antonio.
I also wish to thank the many reviewers for their valuable comments and suggestions during the
preparation of the manuscript. Included in that list are Carole Baker, Todd Doyle, Karla Felix, Caren
Ferrante, Tamara Fish, Timothy Hedman, Dave Holson, Michelle Loudermilk, Rafaela Machado, Cruz
Medina, Meg Milligan, Christina J. Ragin, Luther M. Ragin, Jr., Renee Michelle Ragin, Sarah Riddick,
Sangeeta Singg, Guido G. Urizar, and Gary Winkel. A special thanks to Lynne D. Richardson, the late Shelly
Jacobson, and my colleagues at the Mount Sinai School of Medicine, Department of Emergency Medicine,
for their support and assistance in our research on health care, which shaped my current perspectives of
health.
Finally, my greatest debt is to my husband, Luther M. Ragin, Jr., and our two daughters, Renee Michelle
and Christina, without whose support and assistance I could not have written this text.
Deborah Fish Ragin
ABOUT THE AUTHOR
Deborah Fish Ragin is Professor of Psychology at Montclair State University. She is a graduate of Vassar
College, where she earned an A.B. in Psychology and Hispanic Studies in 1978. She continued her studies
of psychology at Harvard University, where she earned her M.A. in 1984 and her Ph.D. in Experimental
Psychology in 1985. Dr. Ragin served on the faculty of Hunter College at the City University of New York,
and on the faculty of the Mount Sinai School of Medicine’s Department of Emergency Medicine (now the
Icahn School of Medicine) (New York City).
Her professional service includes a five year appointment as an American Psychological Association (APA)
Representative to the United Nations, where she focused on global efforts to address the psychosocial
impact of HIV/AIDS. She completed a three-year term as President of the APA’s Society for the Study of
Peace, Conflict and Violence (Division 48 Peace Psychology) in 2009, and was a member of the American
Psychological Association’s Committee on Divisions and APA Relations. She currently serves as a
member of the Health Research Council of the Health Psychology Division (Division 38) of the American
Psychological Association.
Dr. Ragin’s research focuses on health systems and health policy, examining disparities in health care.
She is the author of numerous articles on HIV/AIDS, domestic violence, health care disparities, healthy
communities, and research ethics.
CHAPTER 1
An Interdisciplinary View
of Health
Chapter Outline
Opening Story: How Would You Describe Winston’s Health?
Section I: A Brief History of Health
Section II: Defining Health Today
Section III: Current Views on Determinants of Health: A Health Psychology Perspective
Personal Postscript
Questions to Consider
Important Terms
Chapter Objectives
After reading this chapter, you will be able to:
1. Identify three ancient cultures that contributed to our current concept of determinants of health.
2. Identify Hippocrates and explain the mind–body connection in health.
3. Identify the role of health policy as a determinant of health in three civilizations.
4. Describe how religion influenced beliefs about health and illness.
5. Identify the four domains of health as defined by the American Psychological Association Division of Health Psychology.
6. Identify and describe four current models of health.
OPENING STORY: HOW WOULD YOU DESCRIBE WINSTON’S HEALTH?
Winston describes himself as an “average high school senior.” He is the captain of his school’s
varsity baseball team, he helps coach his younger sister’s Little League softball team, he writes for
his school newspaper, and he is applying to college. Yet most people who know him think Winston
is exceptional. He performs all of his academic and extracurricular activities well while managing
health flare-ups caused by multiple sclerosis.
2 HEALTH PSYCHOLOGY
Multiple sclerosis (MS) is a persistent neurological disease with episodes that can last for long
periods of time. It is caused by damage to the nerve fibers in the body. The damage disrupts normal
neurological functions and can cause a variety of symptoms, including fatigue, headaches, light-
headedness, soreness on various parts of the body, and blurred vision (Kunz, 1982). Some people
with MS also report mental and emotional problems, including mood swings or depression.
Winston was diagnosed with MS at age 16, after numerous episodes of fatigue, blurred vision, and
weakness in his arms and fingers. Now, at age 18, Winston says he has learned to manage his disease.
He takes medication to control the symptoms but can have occasional flare-ups. Still, Winston does
not let his condition stop him from participating in the activities he enjoys. He attends every varsity
baseball practice and game. When he feels unable to play, he asks the team’s designated hitter to take
his place. And, when fatigued, he still cheers loudly from the dugout.
He even manages to maintain his sense of humor about his illness. Once, while warming up before
a game, Winston noticed his vision was blurry. His coach insisted he rest for the first several innings.
Eventually, Winston convinced the coach he was ready to return to the game. But, as he walked to
the plate, he turned and jokingly asked, “Coach, which pitcher should I focus on, the one on the left
or the one on the right?”
In spite of the difficulties, when asked about his health, Winston always responds the same: “I’m
great. I’m doing well, and my health is excellent.”
Would you agree? 
Not everyone would agree with Winston’s characterization of his health. For some, having a disease or
illness is, by definition, inconsistent with being in “excellent health.” Others might label Winston’s health
status as “fair” because he takes medicine for his illness and at times is unable to perform specific activities.
Finally, people who consider Winston to be in “good health” may contend that even though he has a
chronic illness, here meaning an illness that is persistent and that lasts over time (see Chapter 3, Global
Communicable and Chronic Disease), he appears to manage well with the help of medication. In addition,
he appears to be coping well emotionally. Winston’s positive attitude and his efforts to remain active would
suggest, to some people, overall good health.
What explains the diverse opinions about Winston’s health? Different theories about what constitutes
health, which are shaped in part by historical and cultural factors is one explanation. We introduce some
of these theories in this chapter and return to them throughout the book. Briefly, some people believe
that health is determined by a person’s physiological state, here meaning a person’s ability to physically
perform his or her daily functions without limitations, restrictions, or impediments. Such beliefs may derive
from theories that propose that an individual’s health is defined by the presence or absence of disease,
dysfunction, or other abnormal biological changes in the body (see Chapter 6, Emotional Health and
Well-Being) (Wade & Halligan, 2004). Others believe that health is defined not only by a person’s physical
functional status but also by that person’s attitude about the illness and his or her overall mental and
emotional state. For these people, health is a holistic concept. We define holistic health as a state of being
influenced by physiological, psychological, emotional, and social factors. Hippocrates, a Greek physician
A n I n t e r d i s cip l i n ar y V i e w o f H e a l t h 3
and philosopher, is often credited as the first to acknowledge the connection between emotions and health
(Salovey, Rothman, Detweiler, & Steward, 2000). Yet, we will see here and in Chapter 6 (Emotional
Health and Well-Being) that many other cultures also believed that physical health was integrally linked to
emotional and mental health. In fact, a review of the history of health will reveal that health is an evolving
concept that has been shaped over time by science, culture, and history (Boddington, 2009).
For the moment, Winston’s characterization of his own health appears to be consistent with the holistic
definition. When describing his health, he considers his physiological condition, including his ability to
perform tasks (especially favorite activities such as baseball), his psychological and emotional state and his
level of satisfaction with his life. Using this holistic definition, it may be easy to see why Winston describes
his health as excellent.
History shows that for centuries scholars have identified a host of different primary or contributing
factors that influence health outcomes. We call these factors determinants of health. We will see that some
determinants are universal, while others appear to be specific to a culture or time.
Psychologists who adhere to a holistic model identify four health determinants: physiological,
psychological, emotional and social. But we will also see in this chapter that the proponents of the social
ecological model contend that five determinants impact health. They include individual physiology and
behaviors (such as diet, exercise, and use of alcohol), family and cultural traditions (diet, social customs,
and belief systems), physical environmental conditions (such as clean water and safe neighborhoods), health
systems (health care delivery organizations), and health policies (regulations that promote or protect the
health of communities). Some even include a sixth determinant: spiritual well-being. Although we explore
the social ecological model later in the chapter, for the moment it is important to note that it is perhaps the
only model that specifically names health systems and health policy as health determinants, factors that
were also introduced by earlier civilizations as important to health outcomes.
Which model best characterizes Winston’s views? Recall that in the opening story, we noted that
Winston’s concept of health was consistent with a holistic health perspective. He assessed his physical,
psychological, emotional, and social well-being, all of which he believed were excellent.
In this chapter, we will begin our overview of health and well-being by exploring health determinants
identified in earlier civilizations, such as those in the Indus Valley and ancient China, Egypt, and Greece.
As we progress forward in time, we will compare these early beliefs with the healing practices of Native
American and southern African cultures in which botany, here meaning the study of plants and plant life,
were important to their health practices. We conclude the historical review by examining the impact of
spiritual beliefs on health in Western Europe during the Middle Ages and afterward during the Renaissance.
In Section II, we review three of the current models used by health psychologists: the biopsychosocial
model, the wellness model, and the social ecological model. All three and others are explored in greater
depth in Chapter 6, Emotional Health and Well-Being. Here, however, we focus on these three models to
complete the historical timeline of the definitions and determinants of health.
Finally, in Section III, we review current research that explores the role of biological (physiological),
social (including family and community), and environmental factors, as well as health systems and the
health policies on individual health outcomes. In other words, we review the research that lends credence
to the social ecological model. We then explore the contributions of health psychologists in explaining and
changing individual health outcomes.
After reading this chapter, you will be able to summarize the changes over time and across cultures in the
concepts and determinants of health. You will be able to compare and contrast the earlier views of health with
current and modern concepts and to describe the research that supports or refutes the current perspectives.
4 HEALTH PSYCHOLOGY
SECTION I. A BRIEF HISTORY OF HEALTH
It is tempting to think that our current beliefs about health reflect new knowledge, based partly on new
research findings. But history shows us that early civilizations, beginning in the third century bce (Before
Common Era), pioneered some of the “modern” concepts of health that we embrace today. From written
records, public works (infrastructure), and even art, we can glimpse the health beliefs and practices of these
civilizations and link them to the health outcomes of their populations.
Health Practices in Early Civilizations

UNDERSTANDING HEALTH THROUGH HEALTH POLICY There are many health behaviors that we
take for granted. For example, most people today accept that clean water and sanitation are essential to
prevent illness and to maintain good physiological health. But did you know that the Egyptian and Indian
civilizations also considered clean water and sanitation important health determinants? The notions of
health in these civilizations may differ, but both cultures established and maintained public water delivery
systems that enhanced the health of their populations.
For example, archeological records from the Indus Valley region in the second millennium before the
Common Era (2000 bce) revealed evidence of bathrooms and sophisticated public and private drainage
systems, as shown in Figure 1.1. Located in an area known presently as Pakistan, the Indus Valley
civilization consisted of more than 100 well-ordered and structured towns and villages that appeared
to be administered by a centralized form of government. The ruins from the largest cities in the Indus
Valley, Harappa and Mohenjo-Daro, also revealed large water reservoirs constructed on the outskirts of
the communities to collect and store clean water for personal consumption (Misra, 2001). Ancient Greek
aqueducts that transported water show that this culture also understood the health implications of clean
water. What is more, similar aqueducts were also discovered in Jerusalem and Bethlehem in the second and
first centuries bce, as well as throughout the Roman Empire (Franco & Williams, 2000).
Water, drainage, and sewer systems are examples of infrastructure constructed usually as a result of
policies issued by a ruler or other governing authorities charged with protecting the water supply for its
citizens. For example, health policies that provided access to clean water ensured that civilizations as diverse
as the Indus Valley and ancient Greece and Rome would have less exposure to contaminants that could
cause illnesses. The policies were a determinant of health in these civilizations.
To put the early policy works into perspective, consider this: The aqueducts and drainage systems of
earlier civilizations are similar to the extensive sewer, drainage, and water supply systems we find in many
modern cities today. Centuries from now, the remnants of our current systems may be interpreted by later
civilizations as evidence of our belief that the structures and policies that provide access to clean water to
inhabitants are two important determinants of health.
In essence, artifacts such as the ruins of earlier civilizations are one way we learn about health beliefs
and practices that predate modern views.
UNDERSTANDING HEALTH THROUGH PHILOSOPHY AND MEDICINE Many people credit

Hippocrates, a Greek physician, with proposing an association between the mind and the body that affects
health. His views about the mind–body connection are represented in his humoral theory, a topic we discuss
more fully in Chapter 6, Emotional Health and Well-Being.
But Hippocrates was not the first to link emotional and physiological health. For example, researchers
have often noted that the mummification process and rituals used by the Egyptians in the third millennium
bce revealed a sophisticated knowledge of the body and the circulatory system (Nunn, 1996). In Egyptian
FIGURE 1.1 Indus River Valley Civilization Drainage System. An example of drainage systems from private homes in the
Indus River Valley.
Robert Harding Picture Library Ltd/Alamy
culture, a person’s health was influenced not only by anatomical systems but by scientific and spiritual
beliefs as well. And Daoist philosophy (developed by ancient Chinese civilizations) determined that the
harmonic balance of yin and yang, the environment, and the energy or life force, called Qi (pronounced
“chi”), were essential determinants of health. As we will see in Chapter 6, Emotional Health and Well-
Being, Daoist philosophy greatly influenced Chinese traditional medicine, a form of medicine that is
practiced by many today as complementary to or in lieu of Western medicine.
Hippocrates’ theory of a mind–body connection that influenced health was challenged by other Greek
philosophers. For example, in 500 bce, some Greek philosophers proposed the Aesculapian theory, which
held that illnesses had spiritual origins and required spiritual intervention, ritual cures, and mediation by
6 HEALTH PSYCHOLOGY
priests. Still others supported the Cnidian theory, which stated that illnesses were associated with physical
diseases and were unrelated to mental, spiritual, or emotional well-being (Chambers, 2001; Metzer, 1989).
Table 1.1 provides a brief timeline of these and other changing concepts of health.
What is interesting is that concepts of health like the three proposed by Greek philosophers reappear
over time and in other cultures. For example, like the Cnidians, Galen, a noted philosopher and physician
in Rome in 200 ce, and Descartes, a philosopher and mathematician in France in 1600 ce, proposed
that health is a disease that affected only the body, disassociating the body from influences of the mind or
emotion. But, like Hippocrates, Galen also believed that humors could cause illnesses. According to Galen,
the diseases that caused imbalance were located in the organs and not, as Hippocrates suggested, in the body
fluids. Clearly, Galen’s view was more consistent with a physiologically based concept of health and illness.
In comparison, other civilizations, such as the pre-Columbian cultures that include the Mayans and Aztecs
(1400 ce), the more than 1,000 Native American cultures in North America (1300 ce), and African cultures
such as the Khoisan (southern Africa) and the Yoruba and Dahomey (western Africa, 1500–1600 ce)
linked the spiritual health of individuals with their physiological health. These cultures treated both with
natural herbs and plants from their environments (Bucko & Cloud, 2008; De Smet, 1998).
We explore Native American, southern and western African, and other traditional health practices in
Chapter 6, Emotional Health and Well-Being. The important point here is that prior to the 16th century
TABLE 1.1 Concepts of Health
Era Year Culture Concept of Health
Before 2600 Egypt, Old Kingdom Health influenced by anatomical, scientific, and spiritual
Common beliefs. Sophisticated knowledge of body’s circulatory
Era (bce) system.
500 Greece Three views of health:

1. Aesculapian theory: Illness required spiritual intervention
and ritual cures.
2. Cnidian theory: Illness linked to physical disease.
3. Hippocrates’ humoral theory: Connection between mind
and body shapes health.
250 Ancient China Three determinants work together:

1. harmonic balance of forces
2. nature’s five elements
3. an energy or life force
Common 200 Rome (Galen) Health rooted in diseases caused by bad air or body fluids
Era (ce) that impair bodily activities.
500–1400 Middle Ages, Europe Disease as God’s punishment.
750–1260 Islamic cultures Holistic approach to health integrating anatomy, spirituality,
and culture.
1400 Pre-Columbian civilizations Heath determined by spiritual forces, but could be remedied
by herbal or physical treatments.
1600 Descartes (France) Separation of mind and body: diseases affected body.
1880 Koch (Germany) Bacteria cause disease.
1890 Freud Health influenced by emotions and mind.
1930s Flanders and Dunbar Psychosomatic medicine linking biological, behavioral,
psychological, and social contributors to health.
1948 World Health Organization A state of complete physical, mental, and social well-being
(WHO) and not merely the absence of diseases or infirmity.
there were a variety of concepts about health. Some, like Galen, believed health to be affected largely by
physiological states. Others, like the ancient Egyptian, Indian, Chinese, Native American, and African
cultures, examined the roles of emotional, spiritual, or environmental determinants as contributors to
individual health status. We will see shortly that some Western concepts of health include many of the same
determinants.
UNDERSTANDING HEALTH THROUGH PHARMACOLOGY Early and later civilizations also

demonstrated knowledge of health through botany, the study of plants and plant life. For example, artifacts
from the Zulu and the Khoisan of southern Africa (van Wyk, 2008) and the Chinese and Indian cultures in
Asia, as well as the Native American and pre-Columbian cultures we referred to previously, demonstrate
extensive knowledge of the materia medica, the medicinal properties of plants. Plants provided the tools to
address the physical, mental, emotional, and spiritual health of members of these cultures. Consider this:
Moerman (1998), studying the medical practices of Native American cultures, found that many tribes used
over 4,000 plants to treat in excess of 25,000 different medical—here meaning physiological—illnesses. Yet,
the same plants were used to address over 15,000 spiritual and emotional health ailments as well. Similar
discoveries of the use of materia medica were found in Mesoamerican cultures, including the Mayan and
Aztec cultures (Cruz-Coke, 2007).
How do we know that plants were used as health aids? You may remember that at the beginning of
the section we stated that some cultures maintained written records of their health beliefs and practices
while others recorded their practices in art or other artifacts. Specifically, some accounts of the use of
medicinal herbs have been maintained in written records in China and India (De Smet, 1998). But, the
use of medicinal herbs in other cultures is documented in artwork, such as sculptures, paintings, and
other artifacts (See Box 1.1 and Figure 1.2). For example, historians have identified and decoded many
depictions of medical practices and health remedies in sub-Saharan African art found in Ghana, Nigeria, the
Republic of Congo, and Burkina Faso, to name a few (De Smet, 1998). In some cases, the art depicts health
procedures such as craniotomies (a cut into the skull, usually to gain access to the brain). In others, the
works depict a process such as extracting bark from a tree. In some cultures, tree bark is used to prevent the
growth of bacteria or to ease pain.
UNDERSTANDING HEALTH THROUGH RELIGION Over the centuries, spirituality has been included as
one of several factors that contribute to health (Chambers, 2001; Cruz-Coke, 2007; Falagas, Zarkadoulia, &
Samonis, 2006; Yeo, 2003; Zuskin et al., 2008). Beliefs about spirituality, religion, and their impact on health
are well documented in Egyptian, Islamic, pre-Columbian, African, and North American cultures.
It should not be surprising, therefore, that religion also shaped the concept of health in Western
European cultures, especially during the Middle Ages (500–1500 ce). Briefly, approximately 500 ce marked
the beginning of the decline of the Roman Empire. We must note that, prior to the Middle Ages, the Roman
Empire actively participated in extensive trade with other civilizations in Northern Africa (including
Egypt), India, and China. Through trade, these cultures shared goods and knowledge. At about 500 ce, the
peoples of Western Europe reduced their trade, exchange, and contact with other civilizations and suffered
deterioration in their infrastructure and a weakened economy. The self-imposed isolation from other
cultures led to what some historians characterize as a cultural decline (once referred to as the “Dark Ages”)
that lasted approximately 1,000 years.
During the Middle Ages, Rome also experienced a significant loss of population. One reason for the
population decline was a successive wave of pandemics, communicable diseases that affected large numbers
of people across a geographic region (see Chapter 3, Global Communicable and Chronic Disease). Two
8 HEALTH PSYCHOLOGY
pandemics in particular, the first and second plagues of Justinian (541–542 ce and 588 ce, respectively),
resulted in the death of millions of inhabitants.
What caused the plagues? We now attribute them to a recurrent bacterial infection that remained in the
population for over 200 years (Little, 2007; Walloe, 2008). Influenced by the religious doctrine of the time,
however, many people embraced the view that the plagues and other diseases were caused by demons. In
essence, sickness was a sign of God’s punishment for the sins committed by the sufferers (Orent, 2013).
Consistent with these beliefs, the Church—specifically, the priests—became responsible for healing the
spiritual afflictions that were thought to be the source of the disease.
It is important to point out that the belief that illnesses were caused by spiritual ill health is not
uncommon. Many of the cultures described earlier in this chapter held similar beliefs. In Europe, however,
the religious beliefs of the time stressed that diseases were punishments from God.
Near the end of the Middle Ages (approximately 1347–1350 ce), Europe experienced a third major
pandemic, the haemorrhagic plague, also referred to as the “Black Death.” This plague was, by far, the
most deadly. It accounted for more than 25 million deaths across the continent. To put the number into
perspective, the Black Death is believed to have killed approximately one-third of the population of Western
Europe in just two years, from 1348–1350 ce (Gowland & Chamberlain, 2005).
Any illness responsible for at least 25 million deaths is an important event when examining historical
health records. Yet the haemorrhagic plague is also significant because of the change in health beliefs
that occurred at approximately the same time. The plague struck just as Western Europe was about to
experience a Renaissance, a cultural rebirth. The Renaissance prompted a move away from the belief that
illnesses were a punishment for evil. It marked a return to the scientific exploration of the human body.
Consistent with the revised theory, scholars and physicians during the Renaissance suggested that some
diseases were the result of environmental, not spiritual, factors. Thus, to help control the haemorrhagic plague,
local municipalities in Western Europe instituted a number of policies to stem the outbreak. For example, local
administrators isolated and quarantined many people diagnosed with the disease. In addition, buildings and
houses were fumigated, and entire towns were burned in an effort to kill the germs and the animals, especially
rodents, assumed to carry the disease (Christensen, 2003; Duncan & Scott, 2005; Slack, 1989).
BOX 1.1 Artifacts: A Roadmap to Health Practices When Written Records

Are Not Available
What happens to the knowledge possessed by earlier cultures when there are no written records?
Fortunately, historians interested in the health practices and behaviors of earlier civilizations have
found a way to extract information about the health beliefs in such cultures through art.
Take, for example, African art objects. Carvings and other works of art produced by some African
cultures are interesting because of the level of detail depicted in the work, the artist’s skill in
reproducing images or people, and the material used to create the piece. Over the past 40 years,
ethnopharmacologists, researchers who study the medicinal practices of different cultures, have
discovered an added benefit of the works. The artwork also contains a wealth of information about
health practices and medicines used at the time. The discovery helps health researchers expand their
understanding of the concepts of health in different cultures.
FIGURE 1.2 Pendant: Decorative and Purposeful Ear Cleaners.
This pendant serves two purposes: decorative jewelry and practical medicinal use.
Pendant Cross, Amhara (silver), Ethiopian/Brooklyn Museum of Art, New York, USA/Gift of George V. Corinaldi Jr./The Bridgeman Art Library
10 HEALTH PSYCHOLOGY
One example of the health practices evident in art is seen in the pendant displayed in Figure 1.2. At
first, the pendant appears to be an ornamental piece of jewelry. But ethnopharmacologists discovered
the pendant serves two purposes. True, they are decorative and ornamental pieces, but in certain African
societies, they are also functional: They are ear cleaners! Without knowledge of a culture or its past
medical practices, it is easy to mistake the pendant as ornamental jewelry with little functional value.
Current research also suggests that some African art depicts procedures such as extraction of teeth,
caesarean sections, or craniotomies. Others depict activities such as removal of tree bark or cassava root:
two ingredients used in some medicines.
Through research, we are learning that the artistic record is yet another way that earlier civilizations
recorded health practices and reflected their concept of health.
Isolations, quarantines, fumigation of communities, and sophisticated water disposal and water
collection systems show, once again, the role of health policies, regulations designed to protect the health of
the community and thereby of individuals, in improving outcomes.
Sometimes the policies protect individuals from initial contact with the diseases. Other times, the
policies that helped contain diseases minimize their impact on the population. Using health policy and
environmental controls to reduce health risks is evidence that by the early 1500s ce, Western Europe
embraced the belief that better controls on environmental conditions and the enforcement of health policy
would have a positive impact on health outcomes.
Health Practices in the United States

The Renaissance also introduced a period of maritime exploration. Voyagers set out from Europe to
discover and colonize “new worlds.” In the process, however, they brought with them contagious diseases
that had deadly consequences for both the carriers and those who came in contact with them.
As in the case of the pandemics in Europe, some contagious diseases could decimate the entire
population of a region. For the colonizers of new territories like the Americas, outbreaks of yellow fever,
smallpox, and other contagious ailments were particularly problematic because they could threaten the
viability of new colonies. For this reason, by the early 1800s, shortly after the founding of the new United
States of America, major cities such as Philadelphia, New York, Boston, and Washington adopted public
health policies to protect their citizens and the new nation (Harvard University Library Open Collections
Program, 2008; Means, 1975). Once again, health policies became important determinants of health
outcomes for individuals as well as entire communities.
Summary
What can we learn about health from a brief review of ancient concepts and history of health practices? We
realize that many cultures established systems, built infrastructures, and made use of their natural resources,
such as herbs and plants, to protect and preserve the health of their citizens. By examining diverse cultures, we
also see the range of beliefs about health. While some cultures treated health holistically or ecologically, others
chose to focus almost exclusively on only one or two factors. We see that discoveries in the medical sciences,
specifically anatomy and biology, advanced our understanding of epidemiology, the study of the origins and
spread of disease. Such discoveries contributed to the development of the health models that are used by
psychologists today.
Finally, we learned that throughout history, health policies have played a critical role in changing the
environmental conditions that affect individual health status. By reviewing history, we see that the five
determinants of health as identified in the social ecological model—individual physiology and behaviors,
social environments (family, communities, and cultures), physical environments, health systems, and health
policies—have defined health throughout the centuries.
SECTION II. DEFINING HEALTH TODAY
Early Holistic Concepts

MIND–BODY CONNECTION AND HEALTH Current concepts of health appear to have much in
common with the holistic perspectives suggested by earlier cultures. Not surprisingly, psychologists have
contributed to the current evolution in the definition of health. One well-known contributor is Sigmund
Freud, the “father of psychoanalytic psychology.”
Some may think it odd to see a reference to Freud in a book on health psychology. But when Freud
proposed that physiological illnesses can have psychological causes, he reintroduced the relationship
between the mind and body and its effects on health outcomes. This time, however, research on the mind–
body association and health resulted in the development of a new field: psychosomatic medicine. Much
like the concepts of health espoused centuries before, psychosomatic medicine examines the relationships
among the physiological, psychological, social, and behavioral influences on an individual’s health status.
In essence, the determinants of health that define psychosomatic medicine include all but two of the factors
thought to be influential centuries ago: environment and spiritual forces.
Freud’s research on psychosomatic causes of illnesses was largely nonreplicable because he based his
theories on his clinical work and intuitions. Fortunately, empirical studies by other pioneers in the field,
including Cannon and Washburn as well as Dunbar (Dunbar, 1943; Kimball, 1981), which suggested an
association between personality types and disease, supported the link between the mind–body connection
and health (Kimball, 1981).
In spite of some empirical support, psychosomatic diseases increasingly were viewed as invalid or false.
They became associated with chronic complaints that were more psychological than physiological. The
increasing emphasis on physiological causes of illness in the 20th century, together with the prevailing
popular view that psychosomatic illnesses were contrived, led to a decline in support for the mind–body
connection and health.
WORLD HEALTH ORGANIZATION MODEL OF HEALTH In 1948, the World Health Organization
(WHO) introduced another definition of health, one that integrates the physical, emotional, psychological,
and social determinants. According to WHO (Basic Documents, 2006), health is “a state of complete,
physical, mental and social well-being and not merely the absence of disease and infirmity” (pg. 1). In other
words, health is more than just a disease. It includes a person’s functional ability, psychological well-being,
physiological status, and social health. Does this sound familiar? Although not identical to the concepts
of health espoused by the earlier civilizations, WHO’s definition includes emotional and mental health as
factors in overall well-being. Some of these determinants were noted in the opening story as well.
Building on WHO’s definition are three additional models that also explore the physiological,
psychological, sociological, and, for some, environmental determinants of health. They include the
biopsychosocial model, the wellness model, and the social ecological model (sometimes referred to
simply as the ecological model) of health. We briefly review each model to provide the foundation for the
theoretical framework of the field of health psychology.
We begin, however, with the biomedical model, a model that is central to the practice of medicine in
Western cultures and, according to some, a core component of some holistic health models as well.
Models of Health and Well-Being

BIOMEDICAL MODEL The late 19th century (1880s) marked a return to the theory that germs, rather
than sins or spiritual forces, caused diseases. The renewed belief was supported by research by Robert Koch,
a German scientist who was the first person credited with discovering that specific bacteria can be linked to
specific diseases. Koch’s work led to the development of the biomedical model of health, which purported that
illness is defined as a dysfunction of the body caused by microorganisms that results in illness or disability
(Engel, 1977). The clear association between bacteria and disease once again placed a greater emphasis
on physiological factors as the principal determinant of health. While few would challenge the theory that
microorganisms can cause diseases, the more relevant question is whether microorganisms can also explain non-
physiological causes of illnesses. Most health researchers now agree that the biomedical model’s emphasis on
physical causes of illnesses overlooks the critical contributions of emotional, social, and environmental factors
on health. As we will see in later chapters, newer health theories account for some if not all of these factors.
BIOPSYCHOSOCIAL MODEL An odd-sounding name to be sure, the biopsychosocial model was one of
the first 20th-century models to reintroduce a holistic theory of health in which multiple factors, not just
physiology, explained health outcomes.
Engel (1977) proposed the biopsychosocial model in 1972 to explain outcomes not adequately
accounted for by biological factors alone. Engel suggests that biological factors (bio) in addition to
psychological influences (psycho), including emotions and personality traits (Folkman & Greer, 2002;
Ryan & Deci, 2000), as well as sociological (social) factors, such as family, culture, community and social
support, also strongly affect overall well-being and health outcomes.
Can emotions really affect our physical health? Research on the relationship between stress and illness
offers some of the clearest evidence of the association between emotional (stress) factors and adverse
physiological outcomes. For example, research by Rabin and colleagues (1989) suggests that emotions such
as stress have an impact on physiological health by affecting the immune system and by influencing health
behaviors. Recent studies also report an association between other emotions, such as depression, and heart
disease. Interestingly, some researchers even draw connections among depression, heart disease, and death
(Glassman & Shapiro, 1998; Schulz, Martire, Beach, & Scheier, 2005). We explore the relationship between
stress and physical health in greater depth in Chapter 7, Stress and Coping. Additionally, we examine
in greater detail the association between physiological health, psychological states and immune system
response in Chapter 8, Psychoneuroimmunology. For now, it is only important to note that current research
supports the link between the mind (emotions) and body that was suggested by earlier civilizations and by
individuals such as Hippocrates and Freud. Yet we know, even from our limited review thus far, that health
is a complex state influenced by more than just the mind and the body. The biopsychosocial model was the
first modern model to examine the psychological and social determinants of health.
CHALLENGES TO THE BIOPSYCHOSOCIAL MODEL In spite of its broader focus, some health
psychologists criticize the biopsychosocial model for being too “bio-centered.” According to these critics,
the model places biological determinants at the core of the concept of health. Specifically, Armstrong (2002)
notes that in this model, psychological and sociological factors are “add-ons” to explain outcomes that
cannot be explained using physiological factors alone. Thus, rather than offering a balanced perspective
that gives equal weight to biological, psychological, and sociological determinants of health, the
biopsychosocial model is criticized for being at its core a biological model.
A second critique suggests that the model overlooks environmental factors known to influence well-
being. Part of the problem here may be the definition of environmental. For some, social environmental
variables such as family, community, and culture represent environmental determinants of health. For
others, however, they do not. For example, some researchers who study the effects of environments on
health focus on air and water quality, toxic waste sites, or other pollutants as the principal physical
environmental determinants of health status. Indeed, many would agree that poor air quality can cause
breathing and other respiratory problems that may result in adverse health outcomes (see Chapter 4,
Theories and Models of Health Behavior Change). The point here is that for many researchers,
environmental determinants of health refer to the physical not social environment, and the biopsychosocial
model does not address physical environmental determinants.
Finally, the biopsychosocial model does not account for the effects of perceived quality of life or
spirituality on health status. (In truth, very few models include these factors). As we will see in the following
section on the wellness model, some research suggests that quality of life and spirituality are important
psychological and emotional factors that also affect health outcomes for some.
WELLNESS MODEL Not to be confused with well-being, which is defined as one’s overall state of health,
the wellness model adds two health determinants not commonly found in other models: spirituality and
quality of life. Recall the concepts of health in earlier civilizations that included spirituality as a core
determinant. In some respects, the wellness model is suggestive of those earlier beliefs with one caveat. In
the wellness model, spirituality refers to an individual’s perspective on the meaning of life and the impact of
their values on their overall well-being (Mullen, McDermott, Gold, & Belcastro, 1996). It is not intended to
have religious connotations.
An example of spirituality’s contribution to health and well-being in the wellness model is evident in
research that suggests that spirituality may enable one to experience peace and tranquility even during
stressful events. In other words, it helps to abate stress. Consider this: Research suggests that reducing stress
is important for maintaining good physiological health. If spirituality serves to reduce stress and create
peaceful environments for some, then we may reason that spirituality abates stress for those individuals,
thereby directly contributing to their overall well-being (Bosswell, Kahana, & Dilworth-Anderson, 2006;
Poage, Kitzenberger, & Olsen, 2004; Reid & Smalls, 2004).
One additional point should be made regarding spirituality and stress. Some spiritual beliefs encourage
individuals to adopt behaviors that lead to healthier outcomes. For example, an individual may refrain
from drinking alcohol or smoking cigarettes because of spiritual beliefs. Avoiding alcohol and cigarettes
are, themselves, health-enhancing behaviors, that is, behaviors that will increase one’s positive health status
(Poage, Kitzenberger, & Olsen, 2004; Reid & Smalls, 2004). Thus, in this way spirituality can be a health-
enhancing behavior because of its regulatory effects on behaviors that negatively affect health. We explore
the role of health-enhancing behaviors more fully in Chapter 5, Risky Health Behaviors.
Other contemporary examples of spiritual beliefs that are integral to health are found in the traditional
medical practices of many Native American tribes, in curanderismo—a religious and cultural belief system that
informs health and wellness among many Central and South American cultures, and also among the Suku, a
group in the Republic of the Congo in Africa. When addressing a physiological health concern, it would not
be uncommon in these cultures for the healer to attend to the emotional and spiritual health of his or her
“patient.” All three cultures consider spirituality to be a core component of health (Avery, 1991; Bourgeois,
1980; De Smet, 1998). We review this concept more fully in Chapter 6, Emotional Health and Well-Being.
Finally, the wellness model is the only model that includes the psychological concept of quality of life
as a determinant of health. In the wellness approach, an individual’s perceived satisfaction with life will
affect his or her overall well-being. Satisfaction is influenced by psychological as well as physiological states.
Remember Winston from our opening story? Most likely, Winston believes he has a very good quality
of life. Although he has MS, Winston’s positive psychological state undoubtedly helps him cope with his
physical limitations.
Not everyone enjoys a good quality of life, however. Consider a different scenario. A young man has
been a star athlete in basketball since his junior varsity days in middle school. As a college student, he was
widely recognized as an outstanding player who was destined for a career as a professional basketball
player. A sudden accident permanently damaged his spinal column, paralyzing him from the hips down.
The accident ended his dreams of playing professional basketball, confining him to a wheelchair. For weeks
after the accident, he was depressed and despondent. While he has learned to be largely self-reliant with
respect to his daily functions, he never speaks of basketball and forbids others to raise the subject with him.
How would you rate this former athlete’s quality of life?
The biopsychosocial model and the wellness model identify specific psychological, sociological, and for
the wellness model, spiritual factors that, researchers suggest, influence health outcomes. Yet according to
some researchers, there are still other critical determinants of health.
SOCIAL ECOLOGICAL MODEL We traced the evolution of the definition of health through three
models. In the process, we found that, with the exception of the biomedical model, most definitions of
health included both physiological and non-physiological determinants, including biology, emotions,
psychological states, social factors, quality of life, and spirituality. Can there be anything else? There is,
according to the social ecological or ecological model.
As depicted in Figure 1.3, the ecological model includes five major determinants of health. The individual
(biology and behavior) and the social environment created by family, community, and cultural practices
comprise the first two. Uniquely, the ecological model includes three new dimensions. First is the physical
environment, which includes factors such as housing conditions, neighborhood sanitation, cleanliness,
safety, and a physical space free of toxicity or pollutants. Second is health systems, defined here as the health
care delivery organizations that provide access to care. Last is health policy, which, as we saw earlier in the
chapter, is made up of the regulations that promote or protect the health of individuals in the community.
The ecological model suggests that an individual’s physical setting can contribute to or inhibit good
health outcomes. For example, waste products from manufacturing plants and automobile exhaust
can affect a community’s air and water quality, essential elements for life. The role of the physical
environment on health may be easy to grasp when considering environmental pollutants. But the model
also addresses the physiological and psychological consequences of negative environmental factors such
as crime and violence. Consider this: Is there a relationship between a neighborhood’s high rates of crime
and childhood obesity? Researchers seem to think so. Several studies have shown that children raised in
neighborhoods perceived to be unsafe due to crime and violence are at greater risk for obesity than those
in “safer” environments (Boehmer, Lovegreen, Haire-Joshu, & Brownson, 2006; Regan, Lee, Booth, &
Reese-Smith, 2006; Weir, Elelson, & Brand, 2006). The cause? Safety concerns make parents or other
caregivers less likely to allow children out of doors, limiting opportunities for physical activity. What is
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Health Psychology: An Interdisciplinary

Approach 3rd Edition, (Ebook PDF)

1. An Interdisciplinary View of Health 1

Section II. Methodology 32

3. Global Communicable and Chronic Disease 57

4. Theories and Models of Health Behavior Change 93

5. Risky Health Behaviors 128

Health-Protecting Behaviors 159

6. Emotional Health and Well-Being 168

7. Stress and Coping 203

Section II. Stress and Illness 217

9. Cardiovascular Disease 266

Chapter Objectives 266

10. Chronic Pain Management and Arthritis 295

Questions to Consider 322

11. Cancer 325

Physicians’ Three “Fatal” Communication Errors 385

NEW TO THIS EDITION

1. Two major changes were implemented in each chapter:

2. In addition, significant changes were made to specific chapters. They include:

OPENING STORY: HOW WOULD YOU DESCRIBE WINSTON’S HEALTH?

Would you agree? 

SECTION I. A BRIEF HISTORY OF HEALTH

Health Practices in Early Civilizations

UNDERSTANDING HEALTH THROUGH PHILOSOPHY AND MEDICINE Many people credit

Robert Harding Picture Library Ltd/Alamy

TABLE 1.1 Concepts of Health

Era Year Culture Concept of Health

500 Greece Three views of health:

250 Ancient China Three determinants work together:

UNDERSTANDING HEALTH THROUGH PHARMACOLOGY Early and later civilizations also

BOX 1.1 Artifacts: A Roadmap to Health Practices When Written Records

FIGURE 1.2 Pendant: Decorative and Purposeful Ear Cleaners.

Health Practices in the United States

SECTION II. DEFINING HEALTH TODAY

Early Holistic Concepts

Models of Health and Well-Being

Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

You might also like

1. An Interdisciplinary View of Health 1

Section II. Methodology 32

3. Global Communicable and Chronic Disease 57

4. Theories and Models of Health Behavior Change 93

5. Risky Health Behaviors 128

Health-Protecting Behaviors 159

6. Emotional Health and Well-Being 168

7. Stress and Coping 203

Section II. Stress and Illness 217

9. Cardiovascular Disease 266

Chapter Objectives 266

10. Chronic Pain Management and Arthritis 295

Questions to Consider 322

11. Cancer 325

Physicians’ Three “Fatal” Communication Errors 385

Would you agree? 