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Print Number: 01 Print Year: 2021
Brief contents
Part 1 Foundations of Health Psychology

Chapter 1 Introducing Health Psychology 3
Chapter 2 Conducting Health Research 21
Chapter 3 Seeking and Receiving Health Care 43
Chapter 4 Adhering to Healthy Behavior 65
PART 2 Stress, Pain, and Coping

Chapter 5 Defining, Measuring, and Managing Stress 95
Chapter 6 Understanding Stress, Immunity, and Disease 129
Chapter 7 Understanding and Managing Pain 155
Chapter 8 Considering Alternative Approaches 187
PART 3 Behavior and Chronic Disease

Chapter 9 Behavioral Factors in Cardiovascular Disease 221
Chapter 10 Behavioral Factors in Cancer 251
Chapter 11 Living with Chronic Illness 275
PART 4 Behavioral Health

Chapter 12 Smoking Tobacco 305
Chapter 13 Using Alcohol and Other Drugs 335
Chapter 14 Eating and Weight 367
Chapter 15 Exercising 399
PART 5 Looking Toward the Future

Chapter 16 Future Challenges 427
Glossary 448
References 454
Name Index 523
Subject Index 565

iii
contents
Preface xiii Research and the Placebo 24
About the Authors xvii Would You BELIEVE...? Prescribing Placebos

May Be Considered Ethical 25
IN SUMMARY 26
2-2 Research Methods in Psychology 26
PART 1 Foundations of Health
Correlational Studies 26
Psychology Cross-Sectional and Longitudinal Studies 27
1 Introducing Health Psychology 3 Experimental Designs 28
Ex Post Facto Designs 29
1-1 The Changing Field of Health 3
CHAPTER
IN SUMMARY 29
Real-World Profile of COVID-19 Pandemic 4
Patterns of Disease and Death 6 2-3 Research Methods in Epidemiology 29
Observational Methods 30
Would You BELIEVE...? College is Good for
Your Health 8 Randomized Controlled Trials 30
Escalating Cost of Medical Care 10 Meta-Analysis 32
What is Health? 10 An Example of Epidemiological Research:
The Alameda County Study 32
Would You BELIEVE...? It Takes More Than a
Virus to Give You a Cold 11 Becoming an Informed Reader of
Health-Related Research on the Internet 33
IN SUMMARY 12
IN SUMMARY 34
1-2 Psychology’s Relevance for Health 13
The Contribution of Psychosomatic Medicine 13 2-4 Determining Causation 34
The Emergence of Behavioral Medicine 14 The Risk Factor Approach 34
The Emergence of Health Psychology 15 Cigarettes and Disease: Is There a Causal
Relationship? 35
IN SUMMARY 16
IN SUMMARY 36
1-3 The Profession of Health Psychology 16
2-5 Research Tools 37
The Training of Health Psychologists 16
The Work of Health Psychologists 16 The Role of Theory in Research 37
The Role of Psychometrics in Research 38
Real-World Profile of Angela Bryan 17
IN SUMMARY 39
IN SUMMARY 18
Questions 39
Questions 18
Suggested Readings 40
2 Conducting Health Research 21 3 Seeking and Receiving Health

Care 43
CHAPTER
CHAPTER
Check YOUR BELIEFS About Health Research 22

3-1 Seeking Medical Attention 43
2-1 The Placebo in Treatment and Research 22
Check YOUR BELIEFS Regarding Seeking and Receiving
Treatment and the Placebo 22
Health Care 44
Real-World Profile of Sylvester Colligan 23
iv
Real-World Profile of Lance Armstrong 45 IN SUMMARY 81
Illness Behavior 46 Stage Theories of Health Behavior 81
The Sick Role 51 IN SUMMARY 85
IN SUMMARY 52 4-4 The Intention–Behavior Gap 85
3-2 Seeking Medical Information from Behavioral Willingness 85
Nonmedical Sources 53 Implementational Intentions 86
The Internet 53 Would You BELIEVE...? Both Real and Online
Lay Referral Network 53 Social Networks Can Influence Health 86
Would You BELIEVE...? There is IN SUMMARY 87
Controversy about Childhood Vaccinations 54
4-5 Improving Adherence 88
3-3 Receiving Medical Care 55
IN SUMMARY 90
Limited Access to Medical Care 55
Choosing a Practitioner 56 BECOMING HEALTHIER 90
Being in the Hospital 58 Questions 91
Would You BELIEVE...? Hospitals May Suggested Readings 92
Be a Leading Cause of Death 59
IN SUMMARY 61
Questions 62 PART 2 Stress, Pain, and
Suggested Readings 63 Coping
4 Adhering to Healthy Behavior 65 5 Defining, Measuring, and
4-1 Issues in Adherence 65 Managing Stress 95
CHAPTER
CHAPTER
Check YOUR BELIEFS Regarding Adhering 5-1 The Nervous System and the
to Healthy Behavior 66 Physiology of Stress 95
What is Adherence? 66
Check HEALTH RISKS Life Events Scale for Students 96
How is Adherence Measured? 66
The Peripheral Nervous System 96
Real-World Profile of Rajiv Kumar 67
Real-World Profile of COVID-19
How Frequent is Nonadherence? 68
Pandemic 97
What are the Barriers to Adherence? 69
The Neuroendocrine System 98
IN SUMMARY 70 Physiology of the Stress Response 101
4-2 What Factors Predict Adherence? 70 IN SUMMARY 103
Disease Severity 70 5-2 Theories of Stress 103
Treatment Characteristics 70
Selye’s View 103
Personal Factors 71
Lazarus’s View 105
Environmental Factors 72
IN SUMMARY 106
Interaction of Factors 74
5-3 Sources of Stress 106
IN SUMMARY 75
Cataclysmic Events 106
4-3 Why and How Do People Adhere
Life Events 108
to Healthy Behaviors? 75
Daily Hassles 108
Continuum Theories of Health Behavior 76
Would You BELIEVE...? Vacations Relieve 6-3 Does Stress Cause Disease? 140
Work Stress . . . But Not for Long 111 The Diathesis–Stress Model 140
IN SUMMARY 112 Stress and Disease 141
5-4 Measurement of Stress 112 Would You BELIEVE...? Being a
Methods of Measurement 112 Sports Fan May Be a Danger to Your Health 145
Stress and Psychological Disorders 148
IN SUMMARY 114
In Summary 151
5-5 Coping with Stress 114
Personal Resources That Influence Coping 114 BECOMING HEALTHIER 152
Would You BELIEVE...? Pets May Be Better Questions 152

Support Providers Than People 117 Suggested Readings 152
Personal Coping Strategies 117
IN SUMMARY 119
7 Understanding and
Managing Pain 155
CHAPTER
5-6 Behavioral Interventions for
Managing Stress 119 7-1 Pain and the Nervous System 155
Relaxation Training 119 Check YOUR EXPERIENCES
Regarding Your Most Recent Episode of Pain 156
BECOMING HEALTHIER 120
Cognitive Behavioral Therapy 121
Real-World Profile of Pain 157
The Somatosensory System 157
Emotional Disclosure 122
The Spinal Cord 158
Mindfulness 124
The Brain 158
IN SUMMARY 125
Neurotransmitters and Pain 160
Questions 126 Would You BELIEVE...? Emotional
Suggested Readings 127 and Physical Pain are Mainly the Same
in the Brain 160
6 Understanding Stress, Immunity, The Modulation of Pain 161
and Disease 129
CHAPTER
IN SUMMARY 162
6-1 Physiology of the Immune System 129 7-2 The Meaning of Pain 162
Real-World Profile of Big City Taxi The Definition of Pain 163
Drivers 130 The Experience of Pain 163
Organs of the Immune System 130
7-3 Theories of Pain 166
Function of the Immune System 131
Immune System Disorders 133 IN SUMMARY 169
7-4 Pain Syndromes 169
In Summary 136
Headache Pain 170
6-2 Psychoneuroimmunology 136
Arthritis Pain 171
History of Psychoneuroimmunology 136
Cancer Pain 172
Research in Psychoneuroimmunology 137
Phantom Limb Pain 172
Would You BELIEVE...? Pictures
of Disease are Enough to Activate the IN SUMMARY 173
Immune System 137 7-5 The Measurement of Pain 174
Physical Mechanisms of Influence 139 Self-Reports 174
In Summary 140 Behavioral Assessments 176
Physiological Measures 176
vi
IN SUMMARY 177 Alternative Treatments for Pain 206
7-6 Managing Pain 177 Would You BELIEVE...? Humans are Not the
Medical Approaches to Managing Pain 177 Only Ones Who Benefit from Acupuncture 209
Behavioral Techniques for Managing Pain 180 Alternative Treatments for Other Conditions 210
Limitations of Alternative Therapies 215
IN SUMMARY 183
Integrative Medicine 216
Questions 184
IN SUMMARY 217
Questions 218
8 Considering Alternative Suggested Readings 219
Approaches 187
CHAPTER
Check Your HEALTH CARE PREFERENCES

About Health Research 188
PART 3 Behavior and Chronic
8-1 Alternative Medical Systems 188
Disease
Real-World Profile of T. R. Reid 189
Traditional Chinese Medicine 189 9 Behavioral Factors in Cardiovascular
Ayurvedic Medicine 190
CHAPTER Disease 221
IN SUMMARY 192 9-1 The Cardiovascular System 221
8-2 Alternative Products and Diets 192 Check Your HEALTH RISKS
Regarding Cardiovascular Disease 222
IN SUMMARY 193
8-3 Manipulative Practices 194 Real-World Profile of Emilia Clarke 223
Chiropractic Treatment 194 The Coronary Arteries 223
Massage 194 Coronary Artery Disease 224
Stroke 226
IN SUMMARY 196
Blood Pressure 227
8-4 Mind–Body Medicine 196
IN SUMMARY 228
Meditation and Yoga 196
9-2 The Changing Rates of Cardiovascular
BECOMING HEALTHIER 197 Disease 230
Qi Gong and Tai Chi 198 Reasons for the Decline in Death Rates 230
Biofeedback 199 Heart Disease Throughout the World 231
Hypnotic Treatment 200
IN SUMMARY 231
Physiology and Mind–Body Medicine 201
9-3 Risk Factors in Cardiovascular
IN SUMMARY 201
Disease 232
8-5 Who Uses Complementary and Inherent Risk Factors 232
Alternative Medicine? 202 Physiological Conditions 234
Culture, Ethnicity, and Gender 202 Behavioral Factors 236
Motivations for Seeking Alternative Treatment 203
Would You BELIEVE...? Chocolate May Help
IN SUMMARY 204 Prevent Heart Disease 237
8-6 How Effective are Alternative Would You BELIEVE...? Nearly All the Risk for
Treatments? 204 Stroke is Due to Modifiable Factors 238
Alternative Treatments for Anxiety, Stress, and Psychosocial Factors 239
Depression 205 IN SUMMARY 242
vii
9-4 Reducing Cardiovascular Risks 243 IN SUMMARY 271
Before Diagnosis: Preventing First Heart Questions 272
Attacks 243 Suggested Readings 272
After Diagnosis: Rehabilitating Cardiac Patients 246
11 Living with Chronic Illness 275
11-1 The Impact of Chronic Disease 275
CHAPTER
IN SUMMARY 248
Real-World Profile of Nick Jonas 276
Questions 248
Impact on the Patient 276
Suggested Readings 249 Impact on the Family 278
10 Behavioral Factors in Cancer 251 IN SUMMARY 279
10-1 What is Cancer? 251 11-2 Living with Alzheimer’s Disease 279
CHAPTER
Check Your Health Risks Regarding Cancer 252 Would You BELIEVE...? Using Your Mind May
Help Prevent Losing Your Mind 281
Real-World Profile of Steve Jobs 253
Helping the Patient 282
10-2 The Changing Rates of Cancer Deaths 253
Helping the Family 283
Cancers with Decreasing Death Rates 254
IN SUMMARY 284
Cancers with Increasing Incidence and Mortality
Rates 255 11-3 Adjusting to Diabetes 284
IN SUMMARY 256
The Physiology of Diabetes 284
The Impact of Diabetes 286
10-3 Cancer Risk Factors Beyond
Health Psychology’s Involvement with Diabetes 287
Personal Control 257
Inherent Risk Factors for Cancer 257 IN SUMMARY 288
Environmental Risk Factors for Cancer 258 11-4 The Impact of Asthma 289
IN SUMMARY 259 The Disease of Asthma 289
Managing Asthma 290
10-4 Behavioral Risk Factors for Cancer 259
Smoking 260 IN SUMMARY 291
Diet 262 11-5 Dealing with HIV and AIDS 292
Alcohol 264 Incidence and Mortality Rates for HIV/AIDS 292
Sedentary Lifestyle 264 Symptoms of HIV and AIDS 294
Ultraviolet Light Exposure 264 The Transmission of HIV 295
Would You BELIEVE...? Cancer Prevention Psychologists’ Role in the HIV Epidemic 296
Prevents More Than Cancer 266 BECOMING HEALTHIER 299
Sexual Behavior 266
IN SUMMARY 299
Psychosocial Risk Factors in Cancer 267
11-6 Facing Death 300
IN SUMMARY 267
Adjusting to Terminal Illness 300
10-5 Living with Cancer 268
Grieving 301
Problems with Medical Treatments for Cancer 268
IN SUMMARY 302
Adjusting to a Diagnosis of Cancer 269
Social Support for Cancer Patients 270 Questions 302
Psychological Interventions for Cancer Patients 270 Suggested Readings 303
viii
PART 4 Behavioral Health 13 Using Alcohol and Other Drugs 335
Alcohol Consumption—Yesterday
CHAPTER
and Today 335
12 Smoking Tobacco 305 13-1 A Brief History of Alcohol

Consumption 335
12-1 Smoking and the Respiratory System 305
CHAPTER
Check Your Health Risks Regarding Alcohol and

Check healtH Risks Regarding Tobacco Use 306 Drug Use 336
Real-World Profile of Famous Former Real-World Profile of Daniel Radcliffe 336

Smokers 306 13-2 The Prevalence of Alcohol Consumption
Functioning of the Respiratory System 306 Today 338
What Components in Smoke Are Dangerous? 309
IN SUMMARY 340
IN SUMMARY 309
13-3 The Effects of Alcohol 340
12-2 A Brief History of Tobacco Use 309
13-4 The Hazards of Alcohol 342
12-3 Choosing to Smoke 310
13-5 The Benefits of Alcohol 344
Who Smokes and Who Does Not? 311
Why Do People Smoke? 313 IN SUMMARY 346
13-6 Why Do People Drink? 347
IN SUMMARY 318
Disease Models 348
12-4 Health Consequences of Tobacco Use 318
Cognitive-Physiological Theories 349
Cigarette Smoking 318
The Social Learning Model 351
Would You BELIEVE...? Smoking is Related to
Mental Illness 320 IN SUMMARY 352
Cigar and Pipe Smoking 321 13-7 Changing Problem Drinking 352
E-cigarettes 321 Change Without Therapy 353
Passive Smoking 322 Treatments Oriented Toward Abstinence 353
Smokeless Tobacco 323 Controlled Drinking 354
The Problem of Relapse 355
IN SUMMARY 323
12-5 Interventions for Reducing IN SUMMARY 355
Smoking Rates 324 13-8 Other Drugs 356
Deterring Smoking 324 Health Effects 356
Quitting Smoking 324 Would You BELIEVE...?
Who Quits and Who Does Not? 326 Brain Damage is Not a Common Risk
Relapse Prevention 327 of Drug Use 357
IN SUMMARY 328 BECOMING HEALTHIER 360
12-6 Effects of Quitting 328 Drug Misuse and Abuse 361

Treatment for Drug Abuse 362
Preventing and Controlling
Quitting and Weight Gain 329 Drug Use 363
Health Benefits of Quitting 331
IN SUMMARY 364
IN SUMMARY 331
Questions 364
Questions 332
ix
14 Eating and Weight 367 IN SUMMARY 403
15-3 Physical Activity and
14-1 The Digestive System 367
CHAPTER
Cardiovascular Health 404

Check Your Health Risks Early Studies 404
Regarding Eating and Controlling
Later Studies 405
Your Weight 368
Do Women and Men Benefit Equally? 406
Real-World Profile of Danny Cahill 368 Physical Activity and Cholesterol Levels 406
14-2 Factors in Weight Maintenance 370
IN SUMMARY 407
Experimental Starvation 370
15-4 Other Health Benefits
Experimental Overeating 371
of Physical Activity 407
IN SUMMARY 372 Protection Against Cancer 407
14-3 Overeating and Obesity 372 Prevention of Bone Density Loss 408
What is Obesity? 373 Improved Sleep 408
Why are Some People Obese? 375 Control of Diabetes 408
Would You BELIEVE...? You May Need Psychological Benefits of Physical
to Nap Rather Than to Diet 377 Activity 409
How Unhealthy is Obesity? 379 Would You BELIEVE...?
IN SUMMARY 380
It’s Never Too Late—or Too Early 409
14-4 Dieting 382 IN SUMMARY 413
Approaches to Losing Weight 382 Would You BELIEVE...?

Is Dieting a Good Choice? 386 Exercise Can Help You Learn 413
15-5 Hazards of Physical Activity 414
IN SUMMARY 386
Exercise Addiction 414
14-5 Eating Disorders 387
Injuries from Physical Activity 417
Anorexia Nervosa 388
Death During Exercise 418
Bulimia 391
Reducing Exercise Injuries 418
Binge Eating Disorder 393
IN SUMMARY 419
15-6 How Much is Enough but Not Too
IN SUMMARY 396 Much? 419
Questions 396 15-7 Improving Adherence to Physical
Suggested Readings 397 Activity 420
15 Exercising 399 BECOMING HEALTHIER 421
15-1 Types of Physical Activity 399 IN SUMMARY 424

CHAPTER
Check Your Health Risks Regarding Exercise and

Questions 424
Physical Activity 400 Suggested Readings 425
Real-World Profile of Ricky Gervais 400
15-2 Reasons for Exercising 401
Physical Fitness 401
Weight Control 402
PART 5 Looking Toward the 16-3 Making Health Psychology Personal 442
Understanding Your Risks 442
Future
What Can You Do to Cultivate a Healthy
16 Future Challenges 427 Lifestyle? 445
16-1 Challenges for Healthier People 427 IN SUMMARY 446

CHAPTER
Real-World Profile of Dwayne and Robyn 428 Questions 447

Increasing the Span of Healthy Life 430 Suggested Readings 447
Reducing Health Disparities 431
Would You BELIEVE...? Health Literacy Can Glossary 448
Improve by “Thinking Outside the Box” 433
References 454
IN SUMMARY 435
16-2 Outlook for Health Psychology 436 Name Index 523
Progress in Health Psychology 436 Subject Index 565
Future Challenges for Health
Care 436
Will Health Psychology Continue to Grow? 441
IN SUMMARY 442
xi
Preface
H
ealth is a far different phenomenon today than What’s New?
it was just a century ago. Most serious diseases
The tenth edition reorganizes several chapters to bet-
and disorders now result from people’s behavior.
ter emphasize the theoretical underpinnings of health
People smoke, eat unhealthily, do not exercise, or cope
behavior. For example, Chapter 4 focuses on adherence
ineffectively with the stresses of modern life. As you will
to healthy behavior and presents both classic and con-
learn in this book, psychology—the science of behav-
temporary theories of health behavior, including recent
ior—is increasingly relevant to understanding phys-
research on the “intention–behavior gap.” Readers of
ical health. Health psychology is the scientific study of
the tenth edition will benefit from the most up-to-date
behaviors relating to health enhancement, disease pre-
review of health behavior theories—and their applica-
vention, safety, and rehabilitation.
tions—on the market. They will also be able to hone in
The first edition of this book, published in the
on key concepts and topics highlighted in the Learning
1980s, was one of the first undergraduate texts to cover
Objectives placed at the beginning of each chapter.
the then-emerging field of health psychology. Now, in
The tenth edition also features new boxes on
this tenth edition, Health Psychology: An Introduction to
important and timely topics such as
Behavior and Health remains a preeminent undergradu-
ate textbook in health psychology. • The Covid-19 Pandemic
• Why is there a controversy about childhood
vaccinations?
The Tenth Edition • Do online social networks influence your health?
• How much of your risk for stroke is due to
This tenth edition retains the core aspects that have behavior? (Answer: nearly all)
kept this book a leader throughout the decades: (1) a • Does drug use cause brain damage?
balance between the science and applications of the • Can sleep deprivation lead to obesity?
field of health psychology and (2) a clear and engaging • Can exercise help you learn?
review of classic and cutting-edge research on behavior
Other new or reorganized topics within the
and health.
chapters include:
The tenth edition of Health Psychology: An Intro-
duction to Behavior and Health has five parts. Part • Several Real-World Profiles, including the
1, which includes the first four chapters, lays a solid COVID-19 pandemic, pain patients, T. R. Reid,
foundation in research and theory for understanding Emilia Clarke, and Nick Jonas.
subsequent chapters and approaches the field by con- • Illustration of the evolving nature of health research
sidering the overarching issues involved in seeking in Chapter 2, through examples of studies on the
medical care and adhering to health care regimens. link between diet and colon cancer.
Part 2 deals with stress, pain, and managing these • New research on the role of stigma in influencing
conditions through conventional and alternative people’s decision to seek medical care, in Chapter 3.
medicine. Part 3 discusses heart disease, cancer, and • The role of optimism and positive mood in coping
other chronic diseases. Part 4 includes chapters on with stress, in Chapter 5.
tobacco use, alcohol, eating and weight, and physi- • Mindfulness as a useful technique for managing
cal activity. Part 5 looks toward future challenges in stress (Chapter 5), managing pain (Chapter 7), and
health psychology and addresses how to apply health as a promising therapy for binge eating disorder
knowledge to one’s life to become healthier. (Chapter 14).
xiii
xiv PREFACE
• Stress and its influence on the length of telomeres, from many opportunities to engage with the material
in Chapter 6. throughout each chapter.
• Marriage as a key factor in predicting survival fol-
lowing cancer diagnosis, in Chapter 10. Check Your Health Risks At the beginning of most
• The use of dignity therapy to address psychosocial chapters, a “Check Your Health Risks” box person-
issues faced by terminal patients, in Chapter 11. alizes material in each chapter. Each box consists of
• The use of smartphone “apps” and fitness trackers several health-related behaviors or attitudes that readers
in promoting physical activity, in Chapter 15. should check before looking at the rest of the chapter.
After checking the items that apply to them and then
becoming familiar with the chapter’s material, readers
What Has Been Retained? will develop a more research-based understanding of
their health risks. A special “Check Your Health Risks”
In this revision, we retained the most popular features
appears inside the front cover of the book. Students
that made this text a leader over the past two dec-
should complete this exercise before they read the
ades. These features include (1) “Real-World Profiles”
book and look for answers as they proceed through the
for each chapter, (2) chapter-opening questions; (3) a
chapters (or check the website for the answers).
“Check Your Health Risks” box in most chapters; (4)
one or more “Would You Believe . . .?” boxes in each Would You Believe . . .? Boxes We keep the popular
chapter; and (5) a “Becoming Healthier” feature in “Would You Believe . . .?” boxes, adding many new ones
many chapters. These features stimulate critical think- and updating those we retained. Each box highlights a
ing, engage readers in the topic, and provide valuable particularly intriguing finding in health research. These
tips to enhance personal well-being. boxes explode preconceived notions, present unusual
findings, and challenge students to take an objective
Real-World Profiles Millions of people—including
look at issues that they may not have evaluated carefully.
celebrities—deal with the issues we describe in this
book. To highlight the human side of health psychology, Becoming Healthier Embedded in most chapters
we open each chapter with a profile of a person in the is a “Becoming Healthier” box with advice on how to
real world. Many of these profiles are of famous peo- use the information in the chapter to enact a healthier
ple, whose health issues may not always be well known. lifestyle. Although some people may not agree with
Their cases provide intriguing examples, such as Barack all these recommendations, each is based on the most
Obama’s attempt to quit smoking, Lance Armstrong’s current research findings. We believe that if you follow
delays in seeking treatment for cancer, Steve Jobs’s fight these guidelines, you will increase your chances of a
with cancer, Halle Berry’s diabetes, Daniel Radcliffe’s long and healthy life.
alcohol abuse, and Ricky Gervais’s efforts to increase
physical activity. We also include a profile of “celebri-
ties” in the world of health psychology, including Dr. Other Changes and Additions
Angela Bryan, Dr. Norman Cousins, and Dr. Rajiv We have made several subtle changes in this edition that
Kumar, to give readers a better sense of the personal we believe make it an even stronger book than its pre-
motivation and activities of those in the health psychol- decessors. More specifically, we
ogy and medical fields. • Replaced old references with more recent ones
Questions and Answers In this text, we adopt a pre- • Reorganized many sections of chapters to improve
view, read, and review method to facilitate student’s the flow of information
learning and recall. Each chapter begins with a series • Added several new tables and figures to aid stu-
of Questions that organize the chapter, preview the dents’ understanding of difficult concepts
material, and enhance active learning. As each chapter • Highlighted the biopsychosocial approach to
unfolds, we reveal the answers through a discussion health psychology, examining issues and data from
of relevant research findings. At the end of each major biological, psychological, and social viewpoints
topic, an In Summary statement recaps the topic. Then, • Drew from the growing body of research from
at the end of the chapter, Answers to the chapter-open- around the world on health to give the book a more
ing questions appear. In this manner, students benefit international perspective
PREFACE xv
• Recognized and emphasized gender issues when- suggested readings are quite recent, but we also selected
ever appropriate several that have lasting interest. We include only read-
• Retained our emphasis on theories and models ings that are intelligible to the average college student
that strive to explain and predict health-related and that are accessible in most college and university
behaviors libraries.
MindTap® Psychology: We now provide MindTap®
in the tenth edition. MindTap for Health Psychology
Writing Style 10th Edition is the digital learning solution that helps
instructors engage and transform today’s students into
With each edition, we work to improve our connec- critical thinkers. Through paths of dynamic assign-
tion with readers. Although this book explores comments and applications that you can personalize, real-
plex issues and difficult topics, we use clear, concise, time course analytics, and an accessible reader, MindTap
and comprehensible language and an informal, lively helps you turn cookie cutter into cutting edge, apathy
writing style. We write this book for an upper-divi- into engagement, and memorizers into higher-level
sion undergraduate audience, and it should be easily thinkers. As an instructor using MindTap you have at
understood by students with a minimal background in your fingertips the right content and unique set of tools
psychology and biology. Health psychology courses typ- curated specifically for your course all in an interface
ically draw students from a variety of college majors, so designed to improve workflow and save time when
some elementary material in our book may be repeti- planning lessons and course structures. The control to
tive for some students. For other students, this material build and personalize your course is all yours, focusing
will fill in the background they need to comprehend the on the most relevant material while also lowering costs
information within the field of health psychology. for your students. Stay connected and informed in your
Technical terms appear in boldface type, and a course through real-time student tracking that provides
definition usually appears at that point in the text. These the opportunity to adjust the course as needed based on
terms also appear in an end-of-the-book glossary. analytics of interactivity in the course.
Online Instructor’s Manual: We provide an online
instructor’s manual, complete with lecture outlines, dis-
Instructional Aids cussion topics, suggested activities, media tools, and
Besides the glossary at the end of the book, we supply video recommendations.
several other features to help both students and instruc- Online PowerPoints: Microsoft PowerPoint® slides
tors. These include stories of people whose behavior are provided to help you make your lectures more
typifies the topic, frequent summaries within each engaging while effectively reaching your visually ori-
chapter, and annotated suggested readings. ented students. The PowerPoint® slides are updated to
reflect the content and organization of the new edition
of the text.
Within-Chapter Summaries Cengage Learning Testing, powered by Cognero®:
Rather than wait until the end of each chapter to pres- Cengage Learning Testing, Powered by Cognero®, is a
ent a lengthy chapter summary, we place shorter sum- flexible online system that allows you to author, edit,
maries at key points within each chapter. In general, and manage test bank content. You can create multiple
these summaries correspond to each major topic in a test versions in an instant and deliver tests from your
chapter. We believe these shorter, frequent summaries LMS in your classroom.
keep readers on track and promote a better understand-
ing of the chapter’s content.
Acknowledgments
Annotated Suggested Readings We would like to thank the people at Cengage for their
At the end of each chapter are three or four annotated assistance: Laura Ross, Product Director, Cazzie Reyes,
suggested readings that students may wish to examine. Product Team Manager, Jessica Witzcak, Product Assis-
We chose these readings for their capacity to shed addi- tant, and Deanna Ettinger, Intellectual Property Man-
tional light on major topics in a chapter. Most of these ager. Special thanks go to Jacqueline Czel our Content
xvi PREFACE
Manager and to Sangeetha Vijayanand who led us He made contributions that helped to shape the book
through the production at Lumina. and provided generous, patient, live-in, expert com-
We are also indebted to several reviewers who read puter consultation and tech support that proved essen-
all or parts of the manuscript for this and earlier edi- tial in the preparation of the manuscript.
tions. We are grateful for the valuable comments of the Linda also acknowledges the huge debt to Jess Feist
following reviewers: and his contributions to this book. Jess was last able to
work on the sixth edition, and he died in February 2015.
Sangeeta Singg, Angelo State University
His work and words remain as a guide and inspiration
Edward Fernandes, Barton College for her and for John; this book would not have existed
Ryan May, Marietta College without him.
Erin Wood, Catawba College John thanks all his past undergraduate students for
making health psychology such a thrill to teach. This
Linda notes that authors typically thank their book is dedicated to them and to the future generation
spouses for being understanding, supportive, and sacri- of health psychology students.
ficing, and her spouse, Barry Humphus, is no exception.
ABOUT THE AUTHORS
L
inda Brannon is a pro- interest in personality theory to his authorship of The-
fessor in the Depar t- ories of Personality, coauthored with his son Greg Feist.
ment of Psychology at Linda’s interest in gender and gender issues led her to
McNeese State University in publish Gender: Psychological Perspectives, which is in
Lake Charles, Louisiana. Linda its seventh edition.
joined the faculty at McNeese
J
after receiving her doctorate ohn A. Updegraff is a pro-
in human experimental psy- fessor of social and health
chology from the University of psychology in the Depart-
Texas at Austin. ment of Psychological Sciences
at Kent State University in
J
ess Feist was Professor Kent, Ohio. John received his
Emeritus at McNeese State PhD in social psychology at
University. He joined the University of California, Los
faculty after receiving his doc- Angeles, under the mentorship
torate in counseling from the of pioneering health psycholo-
University of Kansas and stayed gist Shelley Taylor. John then
at McNeese until he retired in completed a postdoctoral fellowship at University of
2005. He died in 2015. California, Irvine, prior to joining the faculty at Kent
In the early 1980s, Linda State.
and Jess became interested in John is an expert in the areas of health behavior,
the developing field of health health communication, stress, and coping, and is the
psychology, which led to their coauthoring the first edi- recipient of multiple research grants from the National
tion of this book. They watched the field of health psy- Institutes of Health. His research appears in the field’s
chology emerge and grow, and the subsequent editions top journals.
of the book reflect that growth and development. John stays healthy by running the roads and trails
Their interests converge in health psychology but near his home. John is also known for subjecting stu-
diverge in other areas of psychology. Jess carried his dents and colleagues to his singing and guitar playing
(go ahead, look him up on YouTube).
xvii
pogonici/Shutterstock.com
LEARNING OBJECTIVES
After studying this chapter, you will be able to…
1-1 Recognize how the major causes of 1-4 Trace the expanding role of psychology
death have changed over the last in understanding physical health, from
century its roots in psychosomatic medicine and
behavioral medicine to its current role in
1-2 Understand how factors such as age, the field of health psychology
ethnicity, and income relate now to the
risk of disease and death 1-5 Familiarize yourself with the profession
of health psychology, including how
1-3 Contrast the biomedical model with the health psychologists are trained and the
biopsychosocial model of health varied types of work that they do
CHAPTER 1
CHAPTER OUTLINE Introducing
Real-World Profile of the COVID-19
Pandemic Health
Psychology
Real-World Profile of Angela Bryan
●● The Changing Field of Health
●● Psychology’s Relevance for

Health
●● The Profession of Health 1-1 The Changing Field of
Psychology Health
QUESTIONS LEARNING OBJECTIVES
This chapter focuses on three basic
1-1 Recognize how the major causes of death have
changed over the last century
questions:
1. How have views of health 1-2 Understand how factors such as age, ethnicity, and
income relate now to the risk of disease and death
changed?
2. How did psychology become 1-3 Contrast the biomedical model with the biopsy-
chosocial model of health
involved in health care?
“W
3. What type of training do health e are now living well enough and long enough
psychologists receive, and what to slowly fall apart” (Sapolsky, 1998, p. 2).
kinds of work do they do? The field of health psychology developed
relatively recently—the 1970s, to be exact—to address the chal-
lenges presented by the changing field of health and health care.
A century ago, the average life expectancy in the United States
was approximately 50 years of age, far shorter than it is now.
When people in the United States died, they died largely from
infectious diseases such as pneumonia, tuberculosis, diarrhea,
and enteritis (see Figure 1.1). These conditions resulted from
contact with impure drinking water, contaminated foods, or
sick people. People might seek medical care only after they
became ill, but medicine had few cures to offer. The duration
of most diseases—such as typhoid fever, pneumonia, and diph-
theria—was short; a person either died or got well in a matter of
weeks. People felt limited responsibility for contracting a conta-
gious disease because such a disease was not controllable.
Life and death are now dramatically different than they
were a century ago. Life expectancy in the United States is
nearly 80 years of age, with more Americans now than ever liv-
ing past their 100th birthday. Over 30 countries boast even lon-
ger life expectancies than the United States, with Japan boasting
the longest at 84 years of age. Public sanitation for most citizens
4 PART 1 ■ Foundations of Health Psychology
Real-World Profile of COVID-19 Pandemic

This is an image of a SARS-CoV-2 virus. It is tiny, only 100 nanometers in diameter.
Alissa Eckert, MS; Dan Higgins, MAMS/CDC

(Centers for Disease Control and Prevention)
It would take 1,000 of these, lined up side to side, to make a speck that could be
seen by even the sharpest of human eyes.
Yet this virus was the cause of the global COVID-19 pandemic, an unprece-
dented public health crisis. In the first year of its emergence, COVID-19 resulted
in over nearly 2 million deaths, economic collapses, school and business clo-
sures, unemployment, and a fundamental shift in how humans interact with one
another. How could a virus so small have such a devastating impact?
The SARS-CoV-2 virus cannot reproduce on its own; it requires a host, such
as a human, to spread. As such, the SARS-CoV-2 virus is a biological disease-
causing agent, but its spread is due to human behavior. It is passed from person to person mainly through
close, interpersonal contact with an infected person. People’s behavior, in turn, is shaped by psychological,
social, and cultural factors, including their beliefs about risk and severity of infection, adherence to preven-
tive measures, their perceptions of what others around them do, and the cultural environment in which they
live. For example, some countries such as Singapore, Taiwan, and South Korea endorsed immediate and strict
social policies to contain the potential spread of the virus. Other countries such as Sweden did not, at least
immediately. Even within countries such as the United States, people’s behaviors varied widely from state to
state, as did the infection rates between communities.
Among those infected by SARS-CoV-2, the potential for severe illness or death also depends on factors
influenced by behavior. Older adults are at greatest risk, as well as people with underlying chronic conditions
such as diabetes, cancer, chronic obstructive pulmonary disease, and obesity. As you will learn in this book, the
development and management of these medical conditions are influenced, to some degree, by people’s past
and current behavior. The immune system’s ability to fight off an infection, too, can be diminished due to stress,
sleep loss, depression, and loneliness; rates of such experiences and conditions increased during the COVID-19
pandemic. Some ethnic groups were at greater risk of illness than others, with these disparities due likely to a
combination of environmental, economic, behavioral, and social factors.
When vaccines and cures are available for COVID-19, behavior remains important. People will need to choose
to obtain vaccinations or adhere to treatments. These behaviors, again, are shaped by psychological, social, and
cultural factors, including beliefs about effectiveness or support from health care providers and family.
The COVID-19 pandemic, like many other health issues we will review in this book, is more than simply a
matter of biology, but a matter of behavior as well. For this reason, the field of health psychology emerged and has
adopted a biopsychosocial model of health, which we introduce in this chapter. The biopsychosocial model
accounts for the complex ways that biology, behavior, beliefs, emotions, the social environment, and culture all
interact to either increase our risk of illness or help us remain healthy. The rest of this book will cover many issues
that are relevant to the COVID-19 pandemic, including how research contributes to our knowledge of behavioral
factors in health (Chapter 2), when and why people seek medical care (Chapter 3), why people do not always
engage in healthy behaviors (Chapter 4), stress and its role in disease (Chapters 5 and 6), and how behavior relates
to health and chronic illness (Chapters 9 through 15). As you read the pages ahead, you will see many examples of
the central premise of health psychology: While illness is based in biology, our behavior matters.
CHAPTER 1 ■ Introducing Health Psychology 5
Leading causes of death, 1900
Pneumonia 11.8%
Tuberculosis 11.3%
Diarrhea and
8.3%
enteritis
Heart disease 6.2%
Liver disease 5.2%
Injuries 4.2%
Cancer 3.7%
Senility 2.9%
Diphtheria 2.3%
0 5 10 15 20 25 30 35 40 45
1900 Percentage of deaths
Leading causes of death, 2017

Heart disease 23%
Cancer 21.3%
Unintentional
injuries 6.0%
Chronic lower
5.7%
respiratory disease
Stroke 5.2%
Alzheimer’s
disease 4.3%
Diabetes mellitus 3.0%

Influenza and
2.0%
pneumonia
Kidney disease 1.8%
Suicide 1.7%
0 5 10 15 20 25 30 35 40 45
2017 Percentage of deaths
FIGURE 1.1 Leading causes of death, United States, 1900 and 2013.
Source: Healthy people, 2010, 2000, by U.S. Department of Health and Human Services, Washington, DC: U.S. Government
Printing Office; “Deaths: Final Data for 2017,” 2019, by Heron, M., National Vital Statistics Reports, 68(6), Table C.
of industrialized nations is vastly better than it was a cen- United States and account for a greater proportion of
tury ago. Vaccines and treatments exist for many infec- deaths than infectious diseases ever did. Chronic diseases
tious diseases. However, improvements in the prevention develop and then persist or recur, affecting people over
and treatment of infectious diseases allowed for a differ- long periods of time. Every year, over 2 million people in
ent class of disease to emerge as today’s killers: chronic the United States die from chronic diseases, but over 130
diseases. Heart disease, cancer, and stroke—all chronic million people—almost one out of every two adults—live
diseases—are now the leading causes of mortality in the with at least one chronic disease.
Furthermore, most deaths today are attributable kidney disease, septicemia (blood infection), liver dis-
to diseases associated with lifestyle and behavior. Heart ease, hypertension, and Parkinson’s disease. For many
disease, cancer, stroke, chronic lower respiratory dis- of these recently increasing causes, behavior is a less
eases (including emphysema and chronic bronchitis), important component than for those causes that have
unintentional injuries, and diabetes are all due in part decreased. However, the rising death rates due to Alzhei-
to cigarette smoking, alcohol abuse, unhealthy eating, mer’s and Parkinson’s reflect another important trend in
stress, and a sedentary lifestyle. Because today’s major health and health care: an increasingly older population.
killers arise in part due to lifestyle and behavior, peo-
ple have a great deal more control over their health than Age Obviously, older people are more likely to die than
they did in the past. However, many people do not exer- younger ones, but the causes of death vary among age
cise this control, so unhealthy behavior is an important groups. Thus, the ranking of causes of death for the entire
public health problem. Indeed, unhealthy behavior con- population may not reflect any specific age group and
tributes to the escalating costs of health care. may lead people to misperceive the risk for some ages. For
In this chapter, we describe the changing patterns of example, cardiovascular disease (which includes heart
disease and disability and the increasing costs of health disease and stroke) and cancer account for over 50% of
care. We also discuss how these trends change the very all deaths in the United States, but they are not the leading
definition of health and require a broader view of health cause of death for young people. For individuals between
than in the past. This broad view of health is the biopsy- 1 and 24 years of age, unintentional injuries are the lead-
chosocial model, a view adopted by health psychologists. ing cause of death, and violent deaths from suicide and
homicide rank high on the list as well (National Center
for Health Statistics [NCHS], 2018). Taken together,
Patterns of Disease and Death injuries, suicides, and homicide account for over half of
The 20th century brought about major changes in the deaths during these younger years. As Figure 1.2 reveals,
patterns of disease and death in the United States, includ- other causes of death account for much smaller percent-
ing a shift in the leading causes of death. Infectious dis- ages of deaths among adolescents and young adults than
eases were the leading causes of death in 1900, but over unintentional injuries, homicide, and suicide.
the next several decades, chronic diseases—such as heart For adults 45 and older, the picture is quite dif-
disease, cancer, and stroke—became the leading killers. ferent. Cardiovascular disease and cancer become the
Only with the COVID-19 pandemic beginning in 2020 leading causes of death, accounting for nearly half of
has an infectious disease been a leading cause of death deaths. As people age, they become more likely to die,
in this century. In 2020, COVID-19 was the third most so the causes of death for older people dominate the
common cause of death in the United States, after heart overall figures. However, younger people show very dif-
disease and cancer. When the COVID-19 pandemic sub- ferent patterns of mortality.
sides, chronic diseases will remain as the leading causes
of mortality in the United States. Ethnicity, Income, and Disease Question 2 from the
During the first few years of the 21st century, deaths quiz inside the front cover asks if the United States is
from some chronic diseases—those related to unhealthy among the top 10 nations in the world in terms of life
lifestyles and behaviors—began to decrease. These include expectancy. It is not even close. It ranks 34th among all
heart disease, cancer, and stroke, which all were respon- nations (World Health Organization [WHO], 2018c).
sible for a smaller proportion of deaths in 2010 than in Within the United States, ethnicity is also a factor in life
1990. Why have deaths from these diseases decreased in expectancy, and the leading causes of death also vary
the last few decades? We will discuss this in greater detail among ethnic groups. Table 1.1 shows the ranking of
in Chapter 9, but one major reason is that fewer people the leading causes of death for four ethnic groups in the
in the United States now smoke cigarettes than in the United States. No two groups have identical profiles of
past. This change in behavior contributed to some of the causes, and some causes do not appear on the list for
decline in deaths due to heart disease; improvements in each group, highlighting the influence of ethnicity on
health care also contributed to this decline. mortality.
Death rates due to unintentional injuries, suicide, If African Americans and European Americans
and homicide have increased in recent years. Signif- in the United States were considered to be different
icant increases also occurred in Alzheimer’s disease, nations, European America would rank higher in life
25.1%
Ages 65 and over 20.7%
2.7%
20.8% Unintentional
28.4% injury (accident)
45–64 years old
3.1% Suicide
8.8% Homicide
10.1% Cancer
10.4%
Heart disease
25–44 years old 6.3%
10.9%
34.6%
2.9%
5.1%
10–24 years old 14.4%
19.2%
40.6%
0 5 10 15 20 25 30 35 40 45 50
Percentage of deaths
FIGURE 1.2 Leading causes of death among individuals aged 10–24, 25–44,
45–64, and 65+, United States, 2017.
Source: “Deaths: Final Data for 2017,” 2019, by Heron, M., National Vital Statistics Reports, 68(6), Figure 2.
TABLE 1.1 Leading Causes of Death for Four Ethnic Groups in the United States, 2017
European Hispanic African Asian

Americans Americans Americans Americans
Heart disease 1 2 1 2
Cancer 2 1 2 1
Chronic lower respiratory disease 3 8 6 8
Unintentional injuries 4 3 3 4
Stroke 5 4 4 3
Alzheimer’s disease 6 6 9 6
Diabetes 7 5 5 5
Pneumonia & influenza 8 11 12 7
Suicide 9 9 16 11
Kidney disease 10 10 8 9
Chronic liver disease 11 7 14 14
Septicemia 12 13 10 12
Hypertension 14 14 11 10
Homicide 20 12 7 18
Source: “Deaths: Leading Causes for 2017,” 2019, by M. Heron, National Vital Statistics Reports, 68(6), Table D.
expectancy than African America—38th place and 80th The association between income level and health
place, respectively (NCHS, 2021; WHO, 2018c). Thus, is so strong that it appears not only at the poverty level
European Americans have a longer life expectancy than but also at higher income levels. That is, very wealthy
African Americans, but neither should expect to live as people have better health than people who are just,
long as people in Japan, Canada, Iceland, Australia, the well, wealthy. Why should very wealthy people be
United Kingdom, Italy, France, Hong Kong, Israel, and healthier than other wealthy people? One possibil-
many other countries. ity comes from the relation of income to educational
Hispanics have socioeconomic disadvantages level, which, in turn, relates to occupation, social class,
like those of African Americans (U.S. Census Bureau and ethnicity. The higher the educational level, the less
[USCB], 2011), including poverty and low educational likely people are to engage in unhealthy behaviors such
level. About 10% of European Americans live below the as smoking, eating high-fat foods, and maintaining a
poverty level, whereas 32% of African Americans and sedentary lifestyle (see Would You Believe . . .? box).
26% of Hispanic Americans do (USCB, 2011). Euro- Another possibility is the perception of social status.
pean Americans also have educational advantages: 86% People’s perception of their social standing may differ
receive high school diplomas, compared with only 81% from their status as indexed by educational, occupa-
of African Americans and 59% of Hispanic Ameri- tional, and income level; remarkably, this perception
cans. These socioeconomic disadvantages translate into relates to health status more strongly than objective
health disadvantages (Crimmins et al., 2007; Smith & measures (Operario, Adler, & Williams, 2004). Thus,
Bradshaw, 2006). That is, poverty and low educational the relationships between health and ethnicity are
level both relate to health problems and lower life intertwined with the relationships between health,
expectancies. Thus, some of the ethnic differences in income, education, and social class.
health are due to socioeconomic differences.
Access to health insurance and medical care is not Changes in Life Expectancy During the 20th century,
the only factor that makes poverty a health risk. Indeed, life expectancy rose dramatically in the United States
the health risks associated with poverty begin before birth. and other industrialized nations. In 1900, life expec-
Even with the expansion of prenatal care by Medicaid, tancy was 47.3 years, whereas today it is almost 78 years
poor mothers, especially teen mothers, are more likely to (NCHS, 2021). In other words, infants born today can
deliver low-birth-weight babies, who are more likely than expect, on average, to live more than a generation longer
normal-birth-weight infants to die (NCHS, 2021). Also, than their great-great-grandparents born at the begin-
pregnant women living below the poverty line are more ning of the 20th century.
likely than other pregnant women to be physically abused What accounts for the 30-year increase in life expec-
and to deliver babies who suffer the consequences of pre- tancy during the 20th century? Question 3 from the quiz
natal child abuse (Zelenko et al., 2000). inside the front cover asks if advances in medical care
Would You
College Is Good for Your Health
BELIEVE...?
Would you believe that attend- have been to college have lower death to college offers much more protec-
ing college could be good for your rates than those who have not. This tion. For example, people with less
health? You may find that difficult advantage applies to both women and than a high school education die at
to believe, as college seems to add men and to infectious diseases, chronic a rate of 575 per 100,000; those with
stress, exposure to alcohol or drugs, diseases, and unintentional injuries a high school degree die at a rate
and demands that make it difficult to (NCHS, 2015). Better-educated people of 509 per 100,000; but people who
maintain a healthy diet, exercise, and report fewer daily symptoms and less attend college have a death rate of
sleep. How could going to college stress than less educated people (Grzy- only 214 per 100,000 (Miniño et al.,
possibly be healthy? wacz et al., 2004). 2011). The benefits of education for
The health benefits of college Even a high school education health and longevity apply to peo-
appear after graduation. People who provides health benefits; but going ple around the world. For example,
a study of older people in Japan with similar education, providing good health and long life. For exam-
(Fujino et al., 2005) found that low an environment with good health- ple, people with a college education
educational level increased the risk related knowledge and attitudes are less likely than others to smoke
of dying. A large-scale study of the (Øystein, 2008). Income and occu- or use illicit drugs (Johnston et al.,
Dutch population (Hoeymans, van pation may also contribute (Batty 2007), and they are more likely to eat
Lindert, & Westert, 2005) also found et al., 2008); people who attend col- a low-fat diet and to exercise.
that education was related to a lege, especially those who graduate, Thus, people who attend col-
wide range of health measures and have better jobs and higher average lege acquire many resources that are
health-related behaviors. incomes than those who do not and reflected in their lower death rate—
What factors contribute to this thus are more likely to have better income potential, health knowledge,
health advantage for people with access to health care. In addition, more health-conscious spouses and
more education? Part of that advan- educated people are more likely to friends, attitudes about the impor-
tage may be intelligence, which be informed consumers of health tance of health, and positive health
predicts both health and longevity care, gathering information on their habits. This strong link between edu-
(Gottfredson & Deary, 2004). In addi- diseases and potential treatments. cation and health is one clear exam-
tion, people who are well educated Education is also associated with a ple of how good health is more than
tend to live with and around people variety of habits that contribute to simply a matter of biology.
were responsible for this increase. The answer is “False”; birthday, these deaths lower the population’s average life
other factors have been more important than medical expectancy much more than do the deaths of middle-
care of sick people. The single most important contrib- aged or older people. As Figure 1.3 shows, infant death
utor to the increase in life expectancy is the lowering rates declined dramatically between 1900 and 1990, but
of infant mortality. When infants die before their first little decrease has occurred since that time.
170
160 162
150
140
Infant mortality (deaths per 1000)
130 132
120
110
100
90 92
80
70 69
60
55
50
40 33
30 26
20
20 12.6 9.2
10 6.9 6.15 5.79
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2017
Year
FIGURE 1.3 Decline in infant mortality in the United States, 1900–2013.

Source: Data from Historical statistics of the United States: Colonial times to 1970, 1975 by U.S. Bureau of the Census,
Washington, DC: U.S. Government Printing Office, p. 60; “Deaths: Final Data for 2013,” 2016, by Xu, J., Murphy, S. L.,
Kochanek, K. D., & Bastian, B. A., National Vital Statistics Reports, 64(2), Table B; “Recent Declines in Infant Mortality in
the United States, 2005–2011,” National Center for Health Statistics, Number 120, 2013.
The prevention of disease also contributes to the condition, and they account for 86% of the dollars spent
recent increase in life expectancy. Widespread vaccination on health care (Gerteis et al., 2014). People with chronic
and safer drinking water and milk supplies all reduce infec- conditions account for 88% of prescriptions written,
tious disease, which increases life expectancy. A healthier 72% of physician visits, and 76% of hospital stays. Even
lifestyle also contributes to increased life expectancy, as though today’s aging population is experiencing better
does more efficient disposal of sewage and better nutrition. health than past generations, their increasing numbers
In contrast, advances in medical care—such as antibiotics will continue to increase medical costs.
and new surgical technology, efficient paramedic teams, One strategy for curbing mounting medical costs is
and more skilled intensive care personnel—play a surpris- to limit services, but another approach requires a greater
ingly minor role in increasing adults’ life expectancy. emphasis on the early detection of disease, changes to a
healthier lifestyle, and behaviors that help prevent disease.
For example, early detection of high blood pressure, high
Escalating Cost of Medical Care serum cholesterol, and other precursors of heart disease
The second major change within the field of health is allow these conditions to be controlled, thereby decreas-
the escalating cost of medical care. In the United States, ing the risk of serious disease or death. Screening peo-
medical costs have increased at a much faster rate than ple for risks is preferable to remedial treatment because
inflation, and currently the United States spends the most chronic diseases are quite difficult to cure and living with
of all countries on health care. Between 1960 and 2008, chronic disease decreases quality of life. Avoiding disease
medical costs in the United States represented an increas- by adopting a healthy lifestyle is even more preferable to
ingly larger proportion of the gross domestic product treating diseases or screening for risks. Staying healthy is
(GDP). Since 1995, the increases have slowed, but med- typically less costly than becoming sick and then getting
ical care costs as a percentage of the GDP are over 16% well. Thus, preventing diseases through a healthy lifestyle,
(Organisation for Economic Co-operation and Develop- detecting symptoms early, and reducing health risks are
ment [OECD], 2019). Considered on a per person basis, all part of a changing philosophy within the health care
the total yearly cost of health care in the United States field. As you will learn in this book, health psychologists
increased from $1,067 per person in 1970 to $9,105 in contribute to each of these aims.
2017 (NCHS, 2019), which is a jump of more than 850%!
These costs, of course, have some relationship to
increased life expectancy: As people live to middle and What is Health?
old age, they tend to develop chronic diseases that require “Once again, the patient as a human being with worries,
extended (and often expensive) medical treatment. fears, hopes, and despairs, as an indivisible whole and
Nearly half of people in the United States have a chronic not merely the bearer of organs—of a diseased liver or
kali9/E+/Getty Images
Technology in medicine is one reason for escalating medical costs.
stomach—is becoming the legitimate object of medical biopsychosocial model has at least two advantages over
interest,” says Franz Alexander (1950, p. 17), one of the the older biomedical model. First, it incorporates not
founders of the field of psychosomatic medicine. only biological conditions but also psychological and
What does it mean to be “healthy”? Question 1 from social factors. Second, it views health as a positive con-
the quiz at the beginning of the book asks if health is dition. The biopsychosocial model can also account for
merely the absence of disease. But is health more complex? some surprising findings about who gets sick and who
Is health the presence of some positive condition rather stays healthy (see the Would You Believe . . .? box). Thus,
than merely the absence of a negative one? Is health simply the biopsychosocial model has not only all the power of
a state of the physical body, or should health also consider the older biomedical model but also the ability to address
one’s beliefs, environment, and behaviors as well? problems that the biomedical model has failed to solve.
The biomedical model, which defines health as the According to the biopsychosocial view, health is
absence of disease, has been the traditional view of West- much more than the absence of disease. A person who
ern medicine (Papas, Belar, & Rozensky, 2004). This view has no disease condition is not sick; but this person may
conceptualizes disease solely as a biological process that not be healthy either. A person may have unhealthy
is a result of exposure to a specific pathogen, a disease- lifestyle habits or poor social support, cope poorly with
causing organism. This view spurred the development of high amounts of stress, or avoid medical care when it is
drugs and medical technology oriented toward removing warranted; all of these factors increase the risk of future
the pathogens and curing disease. The focus is on dis- disease. Because health is multidimensional, all aspects
ease, which is traceable to a specific agent. Removing the of living—biological, psychological, and social—must
pathogen restores health. be considered. This view diverges from the traditional
The biomedical model of disease is compatible with Western conceptualization, but as Table 1.2 shows,
infectious diseases that were the leading causes of death other cultures have held different views.
100 years ago. Throughout the 20th century, adherence Consistent with this broader view, the World Health
to the biomedical model allowed medicine to conquer or Organization (WHO) wrote into the preamble of its con-
control many of the diseases that once ravaged humanity. stitution a modern, Western definition: “Health is a state
However, when chronic illnesses began to replace infec- of complete physical, mental, and social well-being, and
tious diseases as the leading causes of death, the biomedi- not merely the absence of disease or infirmity.” This defi-
cal model became insufficient (Stone, 1987). nition clearly affirms that health is a positive state and
An alternative model of health exists now, one that not just the absence of pathogens. Feeling good is differ-
advocates a more comprehensive approach to medicine. ent from not feeling bad, and research in neuroscience
This alternative model is the biopsychosocial model, has confirmed the difference (Zautra, 2003). The human
which includes biological, psychological, and social brain responds in distinctly different patterns to positive
influences. This model holds that many diseases result feelings and negative feelings. Furthermore, this broader
from a combination of factors such as genetics, physiol- definition of health can account for the importance of
ogy, social support, personal control, stress, compliance, preventive behavior in physical health. For example, a
personality, poverty, ethnic background, and cultural healthy person is not merely somebody without a disease
beliefs. We discuss each of these factors in subsequent or a disability but also somebody who behaves in a way
chapters. For now, it is important to recognize that the that is likely to maintain that state in the future.
Would You
It Takes More Than a Virus to Give You a Cold
BELIEVE...?
One of the dirtiest jobs that an aspir- search of used, mucous-filled tissues. to rummage for snot—they want an
ing health psychologist could have When such tissues are found, the objective measure of how severely
is as a research assistant in Sheldon assistants unfold them, locate the their participants caught the com-
Cohen’s laboratory at Carnegie Mel- gooey treasures within, and pains- mon cold.
lon University. Cohen’s assistants sift takingly weigh their discoveries. Sheldon Cohen and his research
through study participants’ trash in These assistants have good reason team investigate the psychological
and social factors that predict the to predict who gets the cold and who experiences (Cohen, Tyrrell, & Smith,
likelihood that a person will suc- remains healthy. 1991), have better sleep habits (Cohen
cumb to infection. Healthy partic- Cohen’s findings expose the inad- et al., 2009), typically experience more
ipants in Cohen’s studies receive a equacy of the biomedical approach to positive emotion (Cohen et al., 2006),
virus through a nasal squirt and are understanding infection. Even though are more sociable (Cohen et al., 2003),
then quarantined in a “cold research everybody in his studies gets exposed and have more diverse social net-
laboratory”—actually, a hotel room— to the same pathogen in exactly the works (Cohen et al., 1997).
for one week. Participants also answer same manner, only some participants Thus, it takes more than just
several questionnaires about psy- get sick. Importantly, the people who exposure to a virus to succumb to
chological and social factors such resist infection share similar psycho- a cold or flu bug; exposure to the
as recent stress, typical positive and logical and social characteristics. Com- pathogen interacts with psycholog-
negative emotions, and the size and pared with people who get sick, those ical and social factors to produce ill-
quality of their social networks. Cohen who remain healthy are less likely ness. Only the biopsychosocial model
and his team use these questionnaires to have dealt with recent stressful can account for these influences.
TABLE 1.2 Definitions of Health Held by Various Cultures
Culture Time Period Health Is . . .

Prehistoric 10,000 bce Endangered by spirits that enter the body from outside
Babylonians and Assyrians 1800–700 bce Endangered by the gods, who send disease as a
punishment
Ancient Hebrews 1000–300 bce A gift from God; disease is a punishment from God
Ancient Greeks 500 bce A holistic unity of body and spirit
Ancient China Between 800 and A state of physical and spiritual harmony with nature
200 bce
Native Americans 1000 bce–present Total harmony with nature and the ability to survive under
difficult conditions
Galen in ancient Rome 130–200 ce The absence of pathogens, such as bad air or body fluids,
that cause disease
Early Christians 300–600 ce Not as important as disease, which is a sign that one is
chosen by God
Descartes in France 1596–1650 A condition of the mechanical body, which is separate from
the mind
Western Africans 1600–1800 Harmony achieved through interactions with other people
and objects in the world
Virchow in Germany Late 1800s Endangered by microscopic organisms that invade cells,
producing disease
Freud in Austria Late 1800s Influenced by emotions and the mind
World Health Organization 1946 “A state of complete physical, mental, and social
well-being”
diseases as the leading causes of death and disability.

IN SUMMARY These chronic diseases include heart disease, stroke,
In the past century, four major trends changed the field cancer, emphysema, and adult-onset diabetes, all of
of health care. One trend is the changing pattern of dis- which have causes that include individual behavior.
ease and death in industrialized nations, including the The increase in chronic disease contributed to
United States. Chronic diseases now replace infectious a second trend: the escalating cost of medical care.
Costs for medical care steadily increased from 1970 It took many years, however, for psychology to gain
to 2013. Much of this cost increase is due to a grow- acceptance by the medical field. In 1911, the American
ing elderly population, innovative but expensive Psychological Association (APA) recommended that
medical technology, and inflation. psychology be part of the medical school curriculum,
A third trend is the changing definition of but most medical schools did not follow this recom-
health. Many people continue to view health as the mendation. During the 1940s, the medical specialty
absence of disease, but a growing number of health of psychiatry incorporated the study of psychologi-
care professionals view health as a state of positive cal factors related to disease into its training, but only
well-being. To accept this definition of health, one a few psychologists were involved in health research
must reconsider the biomedical model that has (Matarazzo, 1994). During the 1960s, psychology’s role
dominated the health care field. in medicine began to expand with the creation of new
The fourth trend, the emergence of the biopsy- medical schools; the number of psychologists who held
chosocial model of health, relates to the changing academic appointments on medical school faculties
definition of health. Rather than define “disease” as nearly tripled from 1969 to 1993 (Matarazzo, 1994).
simply the presence of pathogens, the biopsycho- In the past several decades, psychologists have
social model emphasizes positive health and sees gained greater acceptance by the medical profession
disease, particularly chronic disease, as resulting (Pingitore et al., 2001). In 2002, the American Medical
from the interaction of biological, psychological, Association (AMA) accepted several new categories
and social conditions. for health and behavior that permit psychologists to
bill for services to patients with physical diseases. Also,
Medicare’s Graduate Medical Education program now
Apply What You’ve Learned accepts psychology internships, and the APA worked
with the WHO to formulate a diagnostic system for bio-
1. Consider an illness that you have learned about from psychosocial disorders, the International Classification
the media or your own personal experiences. What is of Functioning, Disability, and Health (Reed & Schelde-
the biological basis of the illness? What are some of
man, 2004). Thus, the role of psychologists in medical
the behaviors, beliefs, and aspects of a person’s social
and cultural environment that you believe contribute settings has expanded beyond traditional mental health
to risk for the illness? Does the biopsychosocial model problems to include programs to help people stop
help broaden your understanding of the condition, smoking, eat a healthy diet, exercise, adhere to medical
compared to the biomedical model? advice, reduce stress, control pain, live with chronic dis-
ease, and avoid unintentional injuries.
1-2 Psychology’s Relevance The Contribution of

for Health Psychosomatic Medicine
The biopsychosocial model recognizes that psycholog-
ical and emotional factors contribute to physical health
LEARNING OBJECTIVES problems. This notion is not new, as Socrates and Hip-
1-4 Trace the expanding role of psychology pocrates proposed similar ideas centuries ago. Further-
more, Sigmund Freud also proposed that unconscious
in understanding physical health, from
psychological factors could contribute to physical
its roots in psychosomatic medicine and symptoms, but Freud’s approach was not based on sys-
behavioral medicine to its current role in tematic scientific research.
the field of health psychology In 1932, Walter Cannon observed that emotions
are accompanied by physiological changes, a discov-
Although chronic diseases have biological causes, indi- ery that started a search to tie emotional causes to ill-
vidual behaviors and lifestyle also contribute to their ness (Kimball, 1981). Cannon’s research demonstrated
development. Because behavior is so important for that emotions could cause physiological changes capa-
chronic disease, psychology—the science of behavior— ble of causing disease. From this finding, Helen Flan-
is now more relevant to health care than ever before. ders Dunbar (1943) developed the notion that habitual
Will & Deni McIntyre/Science Source

The role of the psychologist in health care settings has expanded beyond traditional mental
health problems to include procedures such as biofeedback.
responses, which people exhibit as part of their person- The Emergence of Behavioral
alities, could relate to specific diseases. In other words,
Dunbar hypothesized a relationship between person- Medicine
ality type and disease. A little later, Franz Alexander From the psychosomatic medicine movement, two
(1950), a onetime follower of Freud, began to see emo- interrelated disciplines emerged: behavioral medicine
tional conflicts as a precursor to certain diseases. and health psychology.
These views led others to see a range of specific Behavioral medicine is “the interdisciplinary
illnesses as “psychosomatic.” These illnesses included field concerned with the development and integra-
such disorders as peptic ulcer, rheumatoid arthritis, tion of behavioral and biomedical science knowledge
hypertension, asthma, hyperthyroidism, and ulcerative and techniques relevant to health and illness and the
colitis. However, the widespread belief at the time in the application of this knowledge and these techniques to
separation of mind and body—a belief that originated prevention, diagnosis, treatment and rehabilitation”
with Descartes (Papas et al., 2004)—led many laypeople (Schwartz & Weiss, 1978, p. 250). A key component of
to regard these psychosomatic disorders as not being this definition is the integration of biomedical science
“real,” but rather “all in the head.” Thus, psychosomatic with behavioral sciences, especially psychology. The
medicine exerted a mixed impact on the acceptance of goals of behavioral medicine are like those in other
psychology within medicine; it benefited by connect- areas of health care: improved prevention, diagnosis,
ing emotional and physical conditions, but it may have treatment, and rehabilitation. Behavioral medicine,
harmed by belittling the psychological components however, attempts to use psychology and the behav-
of illness. Psychosomatic medicine, however, laid the ioral sciences in conjunction with medicine to achieve
foundation for the transition to the biopsychosocial these goals. Chapters 3 through 11 cover topics in
model of health and disease (Novack et al., 2007). behavioral medicine.
The Emergence of Health behaviors, as well as encouraging regular exercise,

medical and dental checkups, and safer behaviors. In
Psychology addition, health psychology helps identify conditions
At about the same time that behavioral medicine that affect health, diagnose and treat certain chronic
appeared, a task force of the American Psychological diseases, and modify the behavioral factors involved
Association revealed that few psychologists conducted in physiological and psychological rehabilitation. As
health research (APA Task Force, 1976). The report such, health psychology interacts with both biology
envisioned a future in which psychologists would con- and sociology to produce health- and disease-related
tribute to the enhancement of health and prevention of outcomes (see Figure 1.4). Note that neither psychol-
disease. ogy nor sociology contributes directly to outcomes;
In 1978, with the establishment of Division 38 of only biological factors contribute directly to physical
the American Psychological Association, the field of health and disease. Thus, the psychological and socio-
health psychology officially began. Health psychology logical factors that affect health must “get under the
is the branch of psychology that considers how indi- skin” in some way to affect biological processes. One
vidual behaviors and lifestyles affect a person’s physical of the goals of health psychology is to identify those
health. Health psychology also includes psychology’s pathways.
contributions to the enhancement of health, the pre- With its promotion of the biopsychosocial model, the
vention and treatment of disease, the identification of field of health psychology continues to grow. One branch
health risk factors, the improvement of the health care of this field—that is, clinical health psychology—continues
system, and the shaping of public opinion regarding to gain recognition in providing health care as part of
health. More specifically, it involves the application of multidisciplinary teams. Health psychology researchers
psychological principles to physical health areas such continue to build a knowledge base that will furnish infor-
as controlling cholesterol, managing stress, alleviating mation about the interconnections among psychological,
pain, stopping smoking, and moderating other risky social, and biological factors that relate to health.
Psychology Sociology
Personality Poverty
Self-efficacy Biology Ethnic background
Personal control Cultural beliefs
Genetics
Optimistic bias Racism
Physiology
Social support Living with chronic
Gender
Stress illness
Age
Coping skills
Vulnerability
Diet to stress
Risky behaviors Immune system
Adherence to Nutrition
medical advice
Medications
Outcomes
Health Disease
FIGURE 1.4 The biopsychosocial model: Biological, psychological, and sociologi-

cal factors interact to produce health or disease.
associations, publish their research in journals devoted

IN SUMMARY to health psychology (Health Psychology and Annals of
The involvement of psychology in health dates to the Behavioral Medicine, among others), and acquire train-
beginning of the 20th century, but at that time, few ing in unique doctoral and postdoctoral programs. In
psychologists were involved in medicine. The psy- addition, health psychology is recognized within med-
chosomatic medicine movement brought psycho- ical schools, schools of public health, universities, and
logical factors into the understanding of disease, and hospitals; health psychologists work within all these set-
that view gave way to the biopsychosocial approach tings. However, their training occurs within psychology.
to health and disease. By the 1970s, psychologists
had begun to develop research and treatment
aimed at chronic disease and health promotion; this
The Training of Health
research and treatment led to the founding of two Psychologists
fields: behavioral medicine and health psychology. Health psychologists are psychologists first and specialists
Behavioral medicine applies the knowledge in health second, but the training in health is extensive.
and techniques of behavioral research to physical People who pursue research in health psychology must
health, including prevention, diagnosis, treatment, learn the topics, theories, and methods of health psychol-
and rehabilitation. Health psychology overlaps with ogy research. Health psychologists who provide clinical
behavioral medicine, and the two professions have care, known as clinical health psychologists, must learn
many common goals. However, behavioral med- clinical skills and how to practice as part of a health care
icine is an interdisciplinary field, whereas health team. Some health psychologists also seek out training in
psychology is a specialty within the discipline of medical subspecialties, such as neurology, endocrinology,
psychology. Health psychology strives to enhance immunology, and epidemiology. This training may occur
health, prevent and treat disease, identify risk fac- in a doctoral program (Baum, Perry, & Tarbell, 2004), but
tors, improve the health care system, and shape many health psychologists also obtain postdoctoral train-
public opinion regarding health issues. ing, with at least two years of specialized training in health
psychology to follow a PhD or PsyD in psychology (Belar,
1997; Matarazzo, 1987). Practicums and internships in
Apply What You’ve Learned health care settings in hospitals and clinics are common
components of training in clinical health psychology
1. Select a health condition that is personally relevant (Nicassio, Meyerowitz, & Kerns, 2004).
and conduct an internet search of recent research
or news reports about the condition. Does current
research examine the role of psychological factors
in the prevention or development of the condition?
The Work of Health Psychologists
If so, how? Health psychologists work in a variety of settings, and
their work setting varies according to their specialty.
Angela Bryan is one of these health psychologists, and
1-3 The Profession of her work is described in this Real-World Profile. Some
health psychologists, such as Angela Bryan, are primar-
Health Psychology ily researchers, who work in universities or government
agencies, such as the National Institutes of Health and the
CDC, that conduct research. Health psychology research
LEARNING OBJECTIVES encompasses many topics; it may focus on behaviors
related to the development of disease or on evaluation
1-5 Familiarize yourself with the profession of of the effectiveness of new interventions and treatments.
health psychology, including how health Clinical health psychologists are often employed in hos-
psychologists are trained and the varied pitals, pain clinics, or community clinics. Other settings
types of work that they do for clinical health psychologists include health mainte-
nance organizations (HMOs) and private practice.
Health psychology now stands as a unique field and As Angela Bryan’s work shows, health psycholo-
profession. Health psychologists have their own gists engage in a variety of activities. Much of their work
Real-World Profile of ANGELA Bryan
Health psychology is a relatively new and fascinating field of psychology. Health

psychologists examine how people’s lifestyles influence their physical health. In
this book, you will learn about the diverse topics, findings, and people that make
up this field.
First, let’s introduce you to Angela Bryan, a health psychologist from the Uni-
versity of Colorado Boulder. Angela develops interventions that promote healthy
behavior, such as safe sex and physical activity. Angela has won several awards
Courtesy of Angela Bryan
for her work, including recognition that one of her interventions is among the
few that work in reducing risky sexual behavior among adolescents (“Safe on the
Outs”; Centers for Disease Control and Prevention [CDC], 2011b).
As an adolescent, Angela thought of herself as a “rebel” (Aiken, 2006), perhaps
an unlikely start for someone who now develops ways to help people to maintain
a healthy lifestyle. It was not until college that Angela discovered her passion for health psychology. She took
a course in social psychology that explored how people judge others. Angela quickly saw the relevance for
understanding safe sex behavior. At this time, the HIV/AIDS epidemic was peaking in the United States, and
condom use was one action people could take to prevent the spread of HIV. Yet people often resisted propos-
ing condoms to a partner due to concerns such as, “What will a partner think of me if I say that a condom is
needed?” Angela sought out a professor to supervise a research project on perceptions of condom use in an
initial sexual encounter.
Angela continued this work as a PhD student and developed a program to promote condom use among
college women. In this program, Angela taught women skills for proposing and using condoms. This work
was not always easy. She recalls, “I would walk through the residence halls on my way to deliver my interven-
tion, with a basket of condoms in one arm and a basket of zucchinis in the other. I can’t imagine what others
thought I was doing!”
Later, she expanded her work to populations at greater risk for HIV, including incarcerated adolescents,
intravenous drug users, HIV+ individuals, and truck drivers in India. She also developed an interest in promoting
physical activity.
In all her work, Angela uses the biopsychosocial model, which you will learn about in this chapter. Spe-
cifically, she identifies the biological, psychological, and social factors that influence health behaviors such as
condom use. Angela’s interventions address each of these factors.
Angela’s work is both challenging and rewarding; she works daily with community agencies, clinical psy-
chologists, neuroscientists, and exercise physiologists. She uses solid research methods to evaluate the success
of her interventions. More recently, she has started to examine the genetic factors that determine whether a
person will respond to a physical activity intervention.
Although she views many aspects of her work as rewarding, one aspect is especially worthwhile: “When
the interventions work!” she says. “If we can get one kid to use a condom or one person with a chronic illness to
exercise, that is meaningful.”
In this book, you will learn about the theories, methods, and discoveries of health psychologists such as
Angela Bryan. As you read, keep in mind this piece of advice from Angela: “Think broadly and optimistically
about health. A health psychologist’s work is difficult, but it can make a difference.”
is collaborative in nature; health psychologists engaged menus. Thus, the health psychologists contribute to the
in either research or practice may work with a team of promotion of health in a wide variety of manners.
health professionals, including physicians, nurses, phys-
ical therapists, and counselors.
The services provided by health psychologists work-
IN SUMMARY
ing in clinics and hospitals fit into several categories. One To maximize their contributions to health care,
type of service offers alternatives to pharmacological health psychologists must be both broadly trained
treatment; for example, biofeedback might be an alter- in the science of psychology and specifically trained
native to painkillers for headache patients. Another type in the knowledge and skills of areas such as neurol-
of service is providing behavioral interventions to treat ogy, endocrinology, immunology, epidemiology,
physical disorders such as chronic pain and some gas- and other medical subspecialties. Health psycholo-
trointestinal problems or to improve the rate of patient gists work in a variety of settings, including univer-
compliance with medical regimens. Other clinical health sities, hospitals, clinics, private practice, and HMOs.
psychologists may provide assessments using psycho- They typically collaborate with other health care
logical and neuropsychological tests or provide psycho- professionals in providing services for physical dis-
logical treatment for patients coping with disease. Those orders rather than for traditional areas of mental
who concentrate on prevention and behavior changes are health care. Research in health psychology is also
more likely to be employed in HMOs, school-based pre- likely to be a collaborative effort that may include
vention programs, or worksite wellness programs. the professions of medicine, epidemiology, nursing,
Like Angela Bryan, many health psychologists pharmacology, nutrition, and exercise physiology.
engage in both teaching and research. Those who work
exclusively in service-delivery settings are much less
likely to teach and do research and are more likely to Apply What You’ve Learned
spend time providing diagnoses and interventions for
people with health problems. Some health psychology 1. The Society for Health Psychology is the division
students go into allied health profession fields, such as of the American Psychological Association (APA)
social work, occupational therapy, dietetics, or pub- that represents the field of health psychology.
lic health. Those who go into public health often work Their website (societyforhealthpsychology.org) is
an excellent resource and includes short profiles of
in academic settings or government agencies and may health psychologists who have made outstanding
monitor trends in health issues or develop and evalu- contributions to the field. Read through some of
ate educational interventions and health awareness these profiles and answer these questions:
campaigns. Health psychologists also contribute to the (1) Where did they get their training, and do they
development and evaluation of widescale public health work in a university or hospital? (2) What health
decisions, including taxes and warning labels placed issues do they focus on and what are some of their
upon healthy products such as cigarettes, and the inclu- major discoveries? (3) How do you see their work
utilizing the biopsychosocial model of health?
sion of nutrition information on food products and
Questions to chronic diseases, (2) the increase in medical

costs, (3) the growing acceptance of a view of
This chapter has addressed three basic questions: health that includes not only the absence of dis-
1. How have views of health changed? ease but also the presence of positive well-being,
Views of health are changing, both among health and (4) the biopsychosocial model of health that
care professionals and among the general pub- departs from the traditional biomedical and psy-
lic. Several trends have prompted these changes, chosomatic models by including not only bio-
including (1) the changing pattern of disease and chemical abnormalities but also psychological and
death in the United States from infectious diseases social conditions.
2. How did psychology become involved in health organizations. Clinical health psychologists
provide services, often as part of a health care
care?
Psychology has been involved in health almost team. Health psychologists who are research-
from the beginning of the 20th century. During ers typically collaborate with others, sometimes
those early years, however, only a few psycholo- as part of a multidisciplinary team, to conduct
gists worked in medical settings, and most were not research on behaviors related to the development
considered full partners with physicians. Psychoso- of disease or to evaluate the effectiveness of new
matic medicine highlighted psychological explana- treatments.
tions of certain somatic diseases, emphasizing the
role of emotions in the development of disease. By
the early 1970s, psychology and other behavioral Suggested Readings
sciences began to play a role in the prevention and
Baum, A., Perry, N. W., Jr., & Tarbell, S. (2004). The
treatment of chronic diseases and in the promotion
development of psychology as a health science.
of positive health, giving rise to two new fields:
In R. G. Frank, A. Baum, & J. L. Wallander
behavioral medicine and health psychology.
(Eds.), Handbook of clinical health psychology
Behavioral medicine is an interdisciplinary
(Vol. 3, pp. 9–28). Washington, DC: American
field concerned with applying the knowledge and
Psychological Association. This recent review of
techniques of behavioral science to the mainte-
the development of health psychology describes
nance of physical health and to prevention, diag-
the background and current status of the field of
nosis, treatment, and rehabilitation. Behavioral
health psychology.
medicine, which is not a branch of psychology,
Belar, C. D. (2008). Clinical health psychology: A
overlaps with health psychology, a division within
health care specialty in professional psychology.
the field of psychology. Health psychology uses
Professional Psychology: Research and Practice, 39,
the science of psychology to enhance health, pre-
229–233. Clinical health psychology is the applied
vent and treat disease, identify risk factors, improve
branch of health psychology. Cynthia Belar traces
the health care system, and shape public opinion
the development of this field from the beginning,
regarding health.
pointing out the widespread influence of health
3. What type of training do health psychologists psychology on research and practice in clinical
receive, and what kinds of work do they do? psychology.
Health psychologists receive doctoral-level training Leventhal, H., Weinman, J., Leventhal, E. A., & Phil-
in psychology and often receive at least two years lips, L. A. (2008). Health psychology: The search
of postdoctoral work in a specialized area of health for pathways between behavior and health. Annual
psychology. Review of Psychology, 59, 477–505. This article
Health psychologists are employed in a vari- details how psychological theory and research can
ety of settings, including universities, hospitals, improve the effectiveness of interventions for man-
clinics, private practice, and health maintenance aging chronic illness.
iStock.com/gorodenkoff
LEARNING OBJECTIVES
After studying this chapter, you will be able to…
2-1 Understand the placebo effect and how 2-5 Identify the strengths and limitations
it demonstrates a role of psychological of observational methods, randomized
beliefs in health controlled trials, and meta-analyses
2-2 Contrast single-blind and double-blind 2-6 Understand the difference between
research designs in their ability to con- absolute risk and relative risk
trol for placebo effects 2-7 Identify the seven criteria that can help
2-3 Identify the strengths and limitations of researchers infer a causal relationship
correlational, cross-sectional, longitu- from non-experimental studies
dinal, experimental, and ex post facto 2-8 Recognize the important role of theory
research designs in guiding health research
2-4 Understand the difference between dis- 2-9 Understand how reliability and validity
ease prevalence and disease incidence improve measurement in health research
CHAPTER 2
CHAPTER OUTLINE Conducting
Real-World Profile of Sylvester
Colligan
The Placebo in Treatment and
Health Research
W
Research
hy did Sylvester Colligan get better? Was Moseley
●● Treatment and the Placebo
negligent in performing a fake surgery on Colligan?
●● Research and the Placebo
Surprisingly, many people do not view Moseley’s
Research Methods in Psychology treatment as negligent. Moseley and his colleagues (2002)
●● Correlational Studies were conducting a study of the effectiveness of arthroscopic
●● Cross-Sectional and knee surgery. This type of procedure is widely performed, but
Longitudinal Studies it is very expensive, and Moseley had doubts about its effec-
●● Experimental Designs tiveness (Talbot, 2000). So Moseley decided to perform an
●● Ex Post Facto Designs experimental study that included a placebo as well as a real
Research Methods in Epidemiology arthroscopic surgery. A placebo is an inactive substance or
●● Observational Methods condition that has the appearance of an active treatment and
●● Randomized Controlled Trials that may cause participants to improve or change because of
●● Meta-Analysis
their belief in the placebo’s efficacy.
Moseley suspected that this type of belief, and not the
●● An Example of Epidemiological
surgery, was producing improvements, so he designed a
Research: The Alameda County study in which half of the participants received sham—that is,
Study fake—knee surgery. Participants in this condition received an-
Determining Causation esthesia and surgical lesions to the knee, but no further treat-
●● The Risk Factor Approach ment. The other half of the participants received standard
●● Cigarettes and Disease: Is There arthroscopic knee surgery. The participants agreed to be in
a Causal Relationship? either group, knowing that they might receive sham surgery.
Research Tools The participants, including Colligan, did not know for several
●● The Role of Theory in Research years whether they were in the placebo or the arthroscopic
●● The Role of Psychometrics in surgery group. Moseley discovered, contrary to widespread
Research belief, that arthroscopic knee surgery provided no real ben-
efits beyond a placebo effect. Those who received the sham
QUESTIONS surgery reported the same level of knee pain and functioning
as those who received the real surgical treatment.
This chapter focuses on five basic Moseley’s results suggested that it was the patients’ beliefs
questions: about the surgery, rather than the surgery itself, that provided
such benefits. The placebo effect is a fascinating demonstra-
1. What are placebos, and how
tion of the effect of an individual’s beliefs on their physical
do they affect research and
health. However, the placebo effect presents a problem for re-
treatment? searchers like Moseley who want to determine which effects
2. How does psychology research are due to treatment and which are due to beliefs about the
contribute to health knowledge? treatment.
3. How has epidemiology
contributed to health knowledge?
4. How can scientists determine if
a behavior causes a disease?
5. How do theory and
measurement contribute to
health psychology?
Check YOUR BELIEFS

About Health Research
Check the items that are consistent informative than information research, but scientists try to
with your beliefs. from the study of one person. discount the importance of
such research.
nn 1. Placebo effects can influence nn 6. All scientific methods yield
both physical and psychological equally valuable results, so the nn 10. Scientific breakthroughs
problems. research method is not import- happen every day.
ant in determining the validity
nn 2. Patients who expect a medica- of results. nn 11. New reports of health research
tion to relieve their pain often often contradict previous find-
experience a reduction in pain, nn 7. In determining important ings, so there is no way to use
even after taking a “sugar pill.” health information, studies with this information to make good
nonhuman subjects can be just personal decisions about health.
nn 3. Personal testimonials are a as important as those with hu-
good way to determine treat- Items 1, 2, 5, and 8 are consistent with
man participants.
ment effectiveness. sound scientific information, but each of
nn 8. Results from experimental the remaining items represents a naïve or
nn 4. Newspaper and television re- research are more likely than unrealistic view of research that can make
ports of scientific research give results from observational re- you an uninformed health research con-
an accurate picture of the im- search to suggest the underlying sumer. The information in this chapter
portance of the research. cause for a disease. will help you become more sophisticated
nn 5. Information from longitudi- in your evaluation of and expectations for
nn 9. People outside the scientific health research.
nal studies is generally more community conduct valuable
This chapter looks at the way health psychologists As we described in Chapter 1, health psychology in-
conduct research, emphasizing psychology from the be- volves the application of psychological principles to the
havioral sciences and epidemiology from the biomedi- understanding and improvement of physical health.
cal sciences. These two disciplines share some methods The placebo effect represents one of the clearest ex-
for investigating health-related behaviors, but they also amples of the link between people’s beliefs and their
have their own unique contributions to scientific meth- physical health. Like many people receiving treatment,
odology. Before we begin examining the methods that Colligan benefited from his positive expectations; he
psychologists and epidemiologists use in their research, improved, even though he received a treatment that
let’s consider the situation that Colligan experienced— technically should not have led to improvement.
improvement due to the placebo effect. Most physicians are aware of the placebo effect,
and many may even prescribe placebos when no other
effective treatments are available (Linde et al., 2018; Til-
2-1 The Placebo in burt et al., 2008). However, strong placebo effects can
pose a problem for scientists trying to evaluate if a new
Treatment and Research treatment is effective. Thus, the placebo effect may help
individuals who receive treatment but complicate the
job of researchers—that is, it can have treatment bene-
Learning OBJECTIVES fits but research drawbacks.
2-1 Understand the placebo effect and how
it demonstrates a role of psychological Treatment and the Placebo
beliefs in health The power of placebo effects was nothing new to Mose-
2-2 Contrast single-blind and double-blind ley, as the potency of “sugar pills” had been recognized
research designs in their ability to control for years. Henry Beecher (1955) observed the effects
for placebo effects of placebos on a variety of conditions ranging from
CHAPTER 2 ■ Conducting Health Research 23
Real-World Profile of SYLVESTER COLLIGAN

Sylvester Colligan was a 76-year-old man who had been having trouble with his right knee for five years (Talbot,
2000). His doctor diagnosed arthritis but had no treatment that would help. However, this physician told
Colligan about an experimental study conducted by Dr. J. Bruce Moseley. Colligan talked to Dr. Moseley and
reported: “I was very impressed with him, especially when I heard he was the team doctor with the [Houston]
Rockets. . . . So, sure, I went ahead and signed up for this new thing he was doing” (Talbot, 2000, p. 36).
The treatment worked. Two years after the surgery, Colligan reported that his knee had not bothered him
since the surgery: “It’s just like my other knee now. I give a whole lot of credit to Dr. Moseley. Whenever I see
him on the TV during a basketball game, I call the wife in and say, “Hey, there’s the doctor that fixed my knee!”
(Talbot, 2000, p. 36).
Colligan’s improvement would not be so surprising, except for one thing: Dr. Moseley did not perform
surgery on Colligan. Instead, Dr. Moseley gave Colligan anesthesia, made some cuts around Colligan’s knee that
looked like surgical incisions, and then sent Colligan on his way home.
headache to the common cold. Beecher concluded that than tablets, and placebos labeled with brand names
the therapeutic effect of the placebo was substantial— work better than generic placebos. Two doses provoke
about 35% of patients showed improvement! Hundreds a larger placebo response than one dose. An injection is
of studies have since examined placebo effects. A recent more powerful than a pill, and surgery tends to prompt
review of this research confirms that placebos can lead an even larger placebo response than an injection does.
to noticeable improvements in health outcomes, espe- Even cost matters; more expensive placebo pills work
cially in the context of pain and nausea (Hróbjartsson better than cheaper pills (Waber et al., 2008)!
& Gøtzsche, 2010). For example, a meta-analysis of mi- Both physician and patient expectations also
graine headache prevention (Macedo, Baños, & Farré, strengthen placebo effects. Physicians who appear
2008) shows a placebo effect of 21%. A more recent re- positive and hopeful about treatment prompt stronger
view (Cepeda et al., 2012) reveals that anywhere from responses in their patients (Moerman, 2003). Placebo
7% to 43% of patients in pain improve after receiving a responses also relate to the practitioner’s other
placebo, with the likelihood of improvement largely at- characteristics, such as their reputation, attention,
tributable to the type of pain experienced. interest, concern, and the confidence they project that a
Placebo effects occur in many other health condi- treatment will be effective (Moerman & Jonas, 2002).
tions. For example, some researchers (Fournier et al., Placebos can also produce adverse effects, called the
2010) argue that the placebo effect is responsible for nocebo effect (Scott et al., 2008; Turner et al., 1994). Nearly
much of the effectiveness of antidepressant drugs, espe- 20% of healthy volunteers given a placebo in a double-blind
cially among people with mild to moderate symptoms. study experienced some negative effect because of the
Furthermore, the strength of the placebo effect asso- nocebo effect. Sometimes, these negative effects appear as
ciated with antipsychotic drugs has steadily increased side effects, which show the same symptoms as other drug
over the past 50 years, suggesting that the effectiveness side effects, such as headaches, nausea and other digestive
of these drugs may be in part due to increases in people’s problems, dry mouth, and sleep disturbances (Amanzio et
beliefs regarding their efficacy (Agid et al., 2013; Ru- al., 2009). When participants are led to believe that a treat-
therford et al., 2014). However, some conditions, such ment might worsen symptoms, the nocebo effect can be
as broken bones, do not respond to placebos (Kaptchuk, as strong as the placebo effect (Petersen et al., 2014). The
Eisenberg, & Komaroff, 2002). presence of negative effects demonstrates that the placebo
The more a placebo resembles an effective treat- effect is not merely improvement; it also includes any
ment, the stronger the placebo effect will be. Big pills change resulting from an inert treatment.
are more effective than little ones, and colored pills How and why do the placebo and nocebo
work better than white tablets. Capsules work better effects occur? Although many people assume that
associate a treatment with getting better, creating situ-

ations in which receiving treatment leads to improve-
ment. Thus, both expectancy and learning contribute to
the placebo effect.
In most situations involving medical treatment,
patients’ improvements may result from a combination
of treatment plus the placebo effect (Finniss & Bened-
Grace Cary/Moment/Getty Images
etti, 2005). Placebo effects are a tribute to the ability of

humans to heal themselves, and practitioners can enlist
this ability to help patients become healthier (Ezekiel
& Miller, 2001; Walach & Jonas, 2004). Therefore, the
placebo effect can be a positive factor in medical and
behavioral therapies, as it was for Colligan, whose knee
The more a placebo resembles an effective improved because of sham surgery. However, the pla-
treatment, the stronger the placebo effect. These cebo effect makes it difficult to separate the effect of a
sugar pills, which look like real pills, are likely to have
treatment from the effect of people’s beliefs about the
strong placebo effects.
treatment, so researchers often design studies to try to
disentangle these effects, as we will describe.
improvements due to placebos are psychological—“It’s
in people’s heads”—research suggests that they have
both a physical and psychological basis (Benedetti, 2006; Research and the Placebo
Scott et al., 2008). For example, a placebo analgesic For researchers to conclude that a treatment is effec-
alters brain activity levels in ways that are consistent tive, the treatment must show a higher rate of effective-
with the activity that occurs during pain relief from ness than a placebo. This standard calls for researchers
analgesic drugs (Wager et al., 2004). The nocebo to use at least two groups in a study: one that receives
response also activates specific areas of the brain and the treatment and another that receives a placebo.
acts on neurotransmitters, giving additional support to Both groups must have equal expectations concerning
its physical reality (Scott et al., 2008). However, placebos the effectiveness of the treatment. To create equal ex-
are likely to have unique physiological effects that differ pectancy, not only must the participants be unaware of
from those attributable to a standard medical treatment. whether they are receiving a placebo or a treatment; the
For example, in an antidepressant clinical trial (Zilcha- experimenters who dispense both conditions must also
Mano et al., 2019), participants who believed that they be “blind” as to which group is which. The arrangement
received an antidepressant showed less activity in the in which neither participants nor experimenters know
amygdala—a brain region associated with processing about treatment conditions is called a double-blind
threat-related emotions of fear, anxiety, and aggression— design. As the Would You Believe . . .? box points out,
compared to those were unsure of whether they received this design strategy creates ethical dilemmas.
an antidepressant or placebo, showing that people’s Psychological treatments such as counseling,
expectations can have unique effects on brain activity. hypnosis, biofeedback, relaxation training, massage, and
Expectancy is a major component of the pla- a variety of stress and pain management techniques also
cebo effect (Price, Finniss & Benedetti, 2008; Stewart- produce expectancy effects. That is, the placebo effect
Williams, 2004). People act in ways that they think they also applies to research in psychology, but double-blind
should. Thus, people who receive treatment without designs are not easy to perform with these treatments.
their knowledge do not benefit as much as those who Placebo pills can look the same as pills containing
know what to expect (Colloca et al., 2004). In addition, an active ingredient, but providers of psychological
culture influences the placebo response. For example, or behavioral treatments always know when they are
cultures that place greater faith in medical interven- providing a sham treatment. In these studies, researchers
tions show stronger responses to placebos that resem- use a single-blind design in which the participants
ble a medical intervention (Moerman, 2011). Learning do not know if they are receiving the active or inactive
and conditioning also factor in the placebo response. treatment, but the providers are not blind to treatment
Through classical and operant conditioning, people conditions. In single-blind designs, the control for
expectancy is not as complete as in double-blind designs; particular treatment provides benefits beyond placebo
creating equal expectancies for participants, however, is effects, health researchers also investigate a variety of
usually the more important control feature. Although other questions with several other research designs,
health researchers often want to know whether a which we will describe in the next section.
Would You
Prescribing Placebos May Be Considered Ethical
BELIEVE...?
Cebocap, a capsule available only by ethically permissible to study the procedure, k nown as informed
prescription, may be a wonder drug. effects of placebos on IBS symptoms. consent, stipulates that participants
The ingredients in Cebocap can be In one experimental condition must be informed of factors in the
remarkably effective in relieving many of this study, researchers told patients research that may influence their
health problems with few serious side to take placebo pills twice daily, willingness to participate before they
effects. Yet, many people would be describing them as “made of an inert consent to participate.
upset to learn that their doctor pre- substance, like sugar pills, that have When participants in a clinical
scribed them with Cebocap. been shown in clinical studies to trial agree to take part in the study,
Cebocap is a placebo pill made produce significant improvement in they receive information about the
by Forest Pharmaceuticals. Why IBS symptoms through mind-body possibility of getting a placebo rather
would a physician prescribe Cebocap, self-healing processes” (Kaptchuk et than a treatment. Those participants
and could it ever be ethical to do so? al., 2010, p. el5591). Patients in the who find the chances of receiving a
Although it is unclear how often control condition did not receive any placebo unacceptable may refuse to
physicians prescribe placebos such treatment at all. Indeed, the placebo participate in the study. Colligan, who
as Cebocap, many doctors already re- treatment—even when prescribed in participated in the study with arthro-
port prescribing treatments that they this completely transparent manner— scopic knee surgery, knew that he
consider to be placebos, such as vita- led to fewer symptoms, greater might be included in a sham surgery
mins or antibiotics for a viral infection improvement, and better quality of group, and he consented ( Talbot,
(Tilburt et al., 2008). However, nearly life compared with no treatment. 2000). However, 44% of those inter-
three-quarters of doctors who admit Thus, placebos can be both ethically viewed about that study declined to
to prescribing a placebo describe it prescribed and effective in treatment. participate (Moseley et al., 2002).
simply as “[m]edicine not typically Can placebos be ethically used in Despite the value of placebo
used for your condition but might research? Typically, clinical researchers controls in clinical research, some
benefit you” (Tilburt et al., 2008, p. 3). do not seek to show that placebos physicians and medical ethicists con-
This is truthful and preserves the ac- can work. Rather, they seek to show sider the use of ineffective treatment
tive ingredient of placebos: positive that another treatment performs bet- to be ethically unacceptable because
expectations. However, critics of this ter than using a placebo. Thus, clinical the welfare of patients is not the
practice argue that the physician is researchers may have to assign pa- primary concern. This is a valid con-
deceiving the patient by withholding tients to an experimental condition cern if a patient-participant receives
the fact that the treatment has no in- that they know constitutes an effec- a placebo instead of the accepted
herent medical benefit. tive treatment. How do researchers standard of care (Kottow, 2007).
Could a placebo still be effective reconcile this ethical difficulty? These critics contend that control
if the provider fully informed the pa- Par t of the answer to that groups should receive the standard
tient that the treatment was merely question lies in the rules governing treatment rather than a placebo, and
a placebo? One team of researchers research with human participants that placebo treatment is acceptable
set out to answer this question, by (American Psychological Association only if no treatment exists for the
prescribing placebo pills to patients [ A PA ] , 2 0 0 2 ; W o r l d M e d i c a l condition. Thus, opinion regarding
with irritable bowel syndrome (IBS) Association, 2004). Providing an the ethical acceptability of placebo
(Kaptchuk et al., 2010). IBS is a chronic ineffective treatment—or any other treatment is divided, with some find-
gastrointestinal disorder, character- treatment—may be considered ing it acceptable and necessary for
ized by recurrent abdominal pain. ethical if participants understand the research and others objecting to the
With few other effective treatments risks fully and still agree to participate failure to provide an adequate stand-
available for IBS, many view it as in the study. This element of research ard of treatment.
a high-fiber content? Some cereals are intentionally

IN SUMMARY named to highlight fiber: All Bran, Multi-Bran, Fiber
A placebo is an inactive substance or condition hav- One, Fiber 7. This fascination with fiber may have been
ing the appearance of an active treatment. It may at its peak in 1989, when the American television show
cause participants in an experiment to improve or Saturday Night Live aired a mock advertisement for
change behavior because of their belief in the pla- “Colon Blow,” a cereal with 30,000 times the fiber con-
cebo’s effectiveness and their prior experiences with tent as compared to regular oat bran cereals!
receiving effective treatment. Although placebos Why were Americans so seemingly obsessed with
can have a positive effect from the patient’s point of fiber in the 1980s? One reason for this obsession was
view, they are a problem for the researcher. In gen- the belief that a high-fiber diet could reduce one’s risk
eral, a placebo’s effects are about 35%. Its effects on for cancer, particularly colon cancer. This link between
reducing pain may be higher, whereas its effects on fiber and cancer was first suggested in the early 1970s
other conditions may be lower. Placebos can influ- by Denis Burkitt, a British surgeon who worked in
ence a wide variety of disorders and diseases. sub-Saharan Africa. Dr. Burkitt observed a very low in-
Experimental designs that measure the efficacy cidence of colon cancer among native Ugandans. At the
of an intervention, such as a drug, typically use a time, the Ugandan diet differed greatly from the typical
placebo so that people in the control group (who Western diet. Ugandans ate plenty of fruits, vegetables,
receive the placebo) have the same expectations raw grains, and nuts but little red meat. Westerners, on
for success as do people in the experimental group the other hand, ate more red meat and fewer vegetables
(who receive the active treatment). Drug studies and nuts, and the grains they consumed were typically
are usually double-blind designs, meaning that processed rather than raw. In short, Ugandans had a
neither the participants nor the people administer- high-fiber diet and a low incidence of colon cancer. Dr.
ing the drug know who receives the placebo and Burkitt proposed a seemingly intuitive explanation for
who receives the active drug. Researchers in psy- this link: Dietary fiber speeds up certain digestive pro-
chological treatment studies are often not “blind” cesses, leaving less time for the colon to be exposed to
concerning the treatment, but participants are, thus possible carcinogens.
creating a single-blind design for these studies. Dr. Burkitt’s belief in the benefits of dietary fiber
was widely publicized and led to the marketing of fiber
in foods and to decades of research on the possible con-
Apply What You’ve Learned nection between diet and cancer. In this section, we will
review some of this research to illustrate a number of
1. Think about a time when you received treatment important aspects of health research. Most importantly,
for a health problem. How did your interaction with we will describe the different types of study designs that
the treatment provider influence your beliefs about health researchers can use to investigate a question. We
whether the treatment would work?
describe the strengths and weaknesses of these designs,
as well as how our confidence in study results can de-
pend on the strength of a research design. Addition-
2-2 Research Methods in ally, we will show how health research is a continually
Psychology evolving pursuit, where old beliefs are often replaced by
newer discoveries as researchers acquire and synthesize
new evidence.
LEARNING Objectives
2-3 Identify the strengths and limitations of Correlational Studies
correlational, cross-sectional, longitudinal, When researchers seek to identify possible factors that
experimental, and ex post facto research predict or are related to a health condition, they use
designs correlational studies. Correlational studies are often
the first step in the research process, as they yield in-
When you stroll through the breakfast food aisle of your formation about the degree of relationship between two
supermarket, do you notice how many cereals boast variables. Correlational studies describe this relationship
and are, therefore, a type of descriptive research design. correlation of over 0.80, showing that countries with
Although scientists cannot use a single descriptive study high meat consumption had significantly higher rates
to determine a causal relationship—such as whether of colon cancer than countries with low meat consump-
diet causes cancer—the degree of relationship between tion. However, simply knowing this correlation did
two factors may be exactly what a researcher wants to not allow the researchers to know whether red meat or
know. some other aspect of diet caused cancer. High red meat
To assess the degree of relationship between two consumption is generally related to other practices,
variables (such as diet and cancer), the researcher meas- such as low consumption of fiber, fruits, and vegetables,
ures each of these variables in a group of participants and could be related to environmental factors as well.
and then calculates the correlation coefficient between Thus, this correlational study suggested a link between
these measures. The calculation yields a number var- diet and cancer risk but could not answer questions of
ying between −1.00 and +1.00. Positive correlations causality directly. Nevertheless, it pointed to a strong
occur when the two variables increase or decrease to- association between diet and colon cancer, which fue-
gether. For example, physical activity and longevity are led the public’s interest in consuming foods that might
positively correlated. Negative correlations occur when prevent cancer. This finding, together with Dr. Burkitt’s
one of the variables increases as the other decreases, highly publicized focus on dietary fiber, led to a wide-
as is the case with the relationship between smoking spread public perception of a causal link between fiber
and longevity. Correlations that are closer to 1.00 (ei- intake and colon cancer.
ther positive or negative) indicate stronger relation-
ships than correlations that are closer to 0.00. Small
correlations—those less than 0.10—can be statistically
Cross-Sectional and Longitudinal
significant if they are based on a large number of obser- Studies
vations, as in a study with many participants. However, When health researchers seek to understand how health
such small correlations, though not random, offer the problems develop over time, they use cross-sectional
researcher very little ability to predict scores on one var- or longitudinal studies. Cross-sectional studies are
iable from knowledge of scores on the other variable. those conducted at only one point in time, whereas
In one of the first examinations of the link between longitudinal studies follow participants over an ex-
diet and cancer, Armstrong and Doll (1975) utilized a tended period. In a cross-sectional design, the inves-
correlational design. These researchers examined the tigator studies a group of people from at least two
correlation between over 20 countries’ average meat different age groups to determine the possible differ-
consumption and the countries’ incidence of colorectal ences between the groups on some measure.
cancer. Indeed, the study noted a large and positive Longitudinal studies can yield information that
cross-sectional studies cannot because they assess the
same people over time, which allows researchers to
identify developmental trends and patterns. However,
longitudinal studies have one obvious drawback: They
take time. Thus, longitudinal studies are costlier than
cross-sectional studies, and they frequently require a
large team of researchers.
Cross-sectional studies have the advantage of
speed, but they have a disadvantage as well. Cross-
sectional studies compare two or more separate groups
klyots/Shutterstock.com
of individuals, which make them incapable of reveal-

ing information about changes in individuals over a
period of time. Cancer incidence increases with age, so
a cross-sectional study comparing the cancer rates of
Blood pressure is a risk factor for cardiovascular young adults to those of older adults would undoubt-
disease, which means that people with high blood edly show that older adults have higher rates of cancer.
pressure are at increased risk, but not that high However, only a longitudinal study looking at the same
blood pressure causes cardiovascular disease. people over a long period of time could confirm that
Another random document with
no related content on Scribd:
LEGEND:
(A) = H₂O Content, (%)
(B) = Accel. Chloropicrin Service Time, (Min.)
(C) = Chloropicrin
(D) = Phosgene
(E) = Hydrocyanic Acid
(F) = Arsine
(G) = Cyanogen Chloride
(H) = Trichloromethylchloroformate
(I) = Chlorine
Service Time, Minutes

Standard Conditions
(B)
No. Charcoal Nation (A)
(G) (H) (I)
(C) (D) (E) (F)
Poor U. S. A.
1 0 10 120175 20 18 55 50 270
cocoanut
Medium U. S. A.
2 0 30 350260 25 25 65 65 370
cocoanut
Good U. S. A.
3 0 60 620310 27 30 75 70 420
cocoanut
Same as U. S. A.
4 No. 2 but 12 18 320330 35 16 35 95
wet
No. 2 U. S. A.
5 0 35 400700 70 400 70 190 510
impregnated
6 Wood French 0 2.5 25 75 9 0 1 20
7 Wood British 0 6 70 90 18 4 5 30
8 Peach stone British 0 16 190135 30 25 65 60
Treated German
9 0 42 230105 20 20 22 25
wood
No. 9 German
10 30 9 90320 16 1110 120
impregnated
Standard Conditions of Tests

Mesh of absorbent 8-14
Depth of absorbent layer 10 cm.
Rate of flow per sq. cm. per min. 500 cc.
Concentration of toxic gas 0.1 per cent
Relative humidity 50 per cent
Temperature 20°
Results expressed in minutes to the 99 per cent efficiency points.
Results corrected to uniform concentrations and size of particles.
Soda-Lime
Charcoal is not a satisfactory all-round absorbent because it has too little capacity
for certain highly volatile acid gases, such as phosgene and hydrocyanic acid, and
because oxidizing agents are needed for certain gases. To overcome these
deficiencies the use of an alkali oxidizing agent in combination with the charcoal has
been found advisable. The material actually used for this purpose has been granules of
soda-lime containing sodium permanganate. Its principal function may be said to be to
act as a reservoir of large capacity for the permanent fixation of the more volatile acid
and oxidizable gases.
The development of a satisfactory soda-lime was a difficult problem. The principal
requirements follow: Its activity is not of vital importance, as the charcoal is able to take
up gas with extreme rapidity and then later give it off more slowly to the soda-lime.
Absorptive capacity is of the greatest importance, since the soda-lime is relied upon to
hold in chemical combination a very large amount of toxic gas. Both chemical stability
and mechanical strength are difficult to attain. The latter had never been solved until
the war made some solution absolutely imperative.
Composition of Regular Army Soda-Lime

The exact composition of the army soda-lime has undergone considerable
modification from time to time as it has been found desirable to change the raw
materials or the method of manufacture. A rough average formula which will serve to
bring out the interrelation between the different constituents is as follows:
Composition of Wet Mix

Per Cent
Hydrated lime 45
Cement 14
Kieselguhr 6
Sodium hydroxide 1
Water 33
After Drying
Moisture content 8
After Spraying
Moisture content 13 (approx.)
Sodium permanganate content 3 (approx.)
Within limits, the method of manufacture is more important than the composition or
other variables, and has been the subject of a great deal of research work even on
apparently minor details. The process finally adopted consists essentially in making a
plastic mass of lime, cement, kieselguhr, caustic soda, and water, spreading in slabs
on wire-bottomed trays, allowing to set for 2 or 3 days under carefully controlled
conditions, drying, grinding, and screening to 8-14 mesh, and finally spraying with a
strong solution of sodium permanganate with a specially designed spray nozzle. The
spraying process is a recent development, most of the soda-lime having been made by
putting the sodium permanganate into the original wet mix. Many difficulties had to be
overcome in developing the spraying process, but it eventually gave a better final
product, and resulted in a large saving of permanganate which was formerly lost during
drying, in fines, etc.
Function of Different Components

Lime. The hydrated lime furnishes the backbone of the absorptive properties of the
soda-lime. It constitutes over 50 per cent of the finished dry granule and is responsible
in a chemical sense for practically all the gas absorption.
Cement. Cement furnishes a degree of hardness adequate to withstand service
conditions. It interferes somewhat with the absorptive properties of the soda-lime and it
is an open question whether the gain in hardness produced by its use is valuable
enough to compensate for the decreased absorption which results.
Kieselguhr. The loss in absorptive capacity due to the presence of cement is in
part counterbalanced by the simultaneous introduction of a relatively small weight
though considerable bulk, of kieselguhr. In some cases, there seems to be a reaction
between the lime and the kieselguhr, which results in some increase in hardness.
Sodium Hydroxide. Sodium hydroxide has two primary functions in the soda-lime
granule. In the first place, a small amount serves to give the granule considerable more
activity. The second function is to maintain roughly the proper moisture content. This
water content (roughly 13-14 per cent after spraying) is very important, in order that the
maximum gas absorption may be secured.
Sodium Permanganate. The function of the sodium permanganate is to oxidize
certain gases, such as arsine,[30] and to act as an assurance of protection against
possible new gases. The purity of the sodium permanganate solution used was found
to be one of the most important factors in making stable soda-lime. It was, therefore,
necessary to work out special methods for its manufacture. Two such methods were
developed, and successfully put into operation.
Careful selection of other material is also necessary, and this phase of the work
contributed greatly to the final development of the form of soda-lime.
CHAPTER XIV
TESTING ABSORBENTS AND GAS MASKS
One of the first necessities in the development of absorbents and

gas masks was a method of testing them and comparing their
deficiencies. While the ultimate test of the value of an absorbent,
canister or facepiece is, of course, the actual man test of the
complete mask, the time consumed in these tests is so great that
more rapid tests were devised for the control of these factors and the
man test used as a check of the purely mechanical methods.
Testing of Absorbents[31]
Absorbents should be tested for moisture, hardness, uniformity of
sample and efficiency against various gases.
Moisture is simply determined by drying for two hours at 150°.
The loss in weight is called moisture.
The hardness or resistance to abrasion is determined by shaking
a 50-gram sample with steel ball bearings for 30 minutes on a Ro-
tap shaking machine. The material is then screened and the
hardness number is determined by multiplying the weight of
absorbent remaining on the screen by two.
The efficiency of an absorbent against various gases depends
upon a variety of factors. Because of this, it is necessary to select
standard conditions for the test. These were chosen as follows:
The absorbent under test is filled into a sample tube of specified
diameter (2 cm.) to a depth of 10 cm. by the standard method for
filling tubes, and a standard concentration (usually 1,000 or 10,000
p.p.m. by volume) of the gas in air of definite (50 per cent) humidity
is passed through the absorbent at a rate of 500 cc. per sq. cm. per
min. The concentration of the entering gas is determined by analysis.
The length of time is noted from the instant the gas-air mixture is
started through the absorbent to the time the gas or some toxic or
irritating reaction product of the gas begins to come through the
absorbent, as determined by some qualitative test. Quantitative
samples of the outflowing gas are then taken at known intervals and
from the amount of gas found in the sample the per cent efficiency of
the absorbent at the corresponding time is calculated.
p.p.m. entering gas - p.p.m.

Per cent ×
effluent gas
efficiency = 100.
p.p.m. entering gas
These efficiencies are plotted against the minutes elapsed from
the beginning of the test to the middle of the sampling period
corresponding to that efficiency point. A smooth curve is drawn
through these points and the efficiency of the absorbent is reported
as so many minutes to the 100, 99, 95, 90, 80, etc., per cent
efficiency points.
The apparatus used in carrying out this test is shown in Fig. 74.
Descriptive details may be found in the article by Fieldner in The
Journal of Industrial and Engineering Chemistry for June, 1919. With
modifications for high and low boiling materials, the apparatus is
adapted to such a variety of gases as chlorine, phosgene, carbon
dioxide, sulfur dioxide, hydrocyanic acid, benzyl bromide,
chloropicrin, superpalite, etc.
As the quality of the charcoal increased, the so-called standard
test required so long a period that an accelerated test was devised.
In this the rate was increased to 1,000 cc. per minute, the relative
humidity of the gas-air mixture was decreased to zero, and the
concentration was about 7,000 p.p.m. The rate is obtained by using
a tube with an internal diameter of 1.41 cm. instead of 2.0 cm.
Canisters
After an absorbent has been developed to a given point, and is
considered of sufficient value to be used in a canister, the materials
are assembled as described in Chapter XII. While the final test is the
actual use of the canister, machine tests have been devised which
give valuable information regarding the value of the absorbent in the
canister and the method of filling.
Fig. 74.—Standard Two-tube Apparatus for Testing

Absorbents,
Showing Arrangement for Gases Stored in Cylinders.
The first test must be that for leakage. The canister must show no
signs of leaking when submitted to an air pressure of 15 inches of
mercury (about half of the normal atmospheric pressure).
The second factor tested is the resistance to air flow. This is
determined at a flow of 85 liters per minute and should not exceed 3
inches. The latest canister design has a much lower resistance (from
2 to 2½ inches).
The third test is the efficiency of the canister against various
gases. For routine work, phosgene, chloropicrin and hydrocyanic
acid are used against the standard mixture of charcoal and soda-
lime: Chloropicrin is usually used against straight charcoal fillings,
while phosgene and hydrocyanic acid are used against soda-lime.
Fig. 75.—Apparatus for Testing Canisters Against

Chloropicrin.
Different types of apparatus are required for these gases. They
are very complicated, as may be seen from the sketch in Fig. 75,
and yet a man very quickly learns the procedure necessary to carry
out a test of this kind. The gas is passed through the canister under
given conditions, until at the end of the apparatus a test paper or
solution indicates that the gas is no longer absorbed but is passing
through unchanged. This point is called the “break point,” and the
time required to reach this point is known as the life of the canister.
This time is also the time to 100 per cent efficiency. Other points,
such as 99, 95, 90 and 80 per cent efficiency are determined. These
are used in comparing canisters.
The canister tests were of two general classes: continuous and
intermittent. In the first the air-gas mixture was drawn through
continuously until the break point was reached. The results obtained
in this way, however, did not give the time measure of the value of a
canister in actual use. The intermittent test differs only in that the
flow of air-gas mixture is intermittent, corresponding to regular
breathing. Special valves were adapted to this work.
Canisters must also be tested as to the protection they offer
against smoke. These methods are discussed in Chapter XVIII.
Man Tests
The final test of the canister is always carried out by means of the
so-called “man test.” Special man-test laboratories were built at
Washington, Philadelphia and Long Island. These are so constructed
that, if necessary, a man may enter the chamber containing the gas
and thus test the efficiency of the completed gas mask. In most
cases, however, the canister is placed inside or outside the gas-
chamber and the men breathe through the canister, detecting the
break point by throat and lung irritation.
The following brief description of the man test laboratory at the
American University will give a good idea of the plan and procedure.
[32]
The man test laboratory is a one-story building, 56 ft. in length
and 25 ft. in width. The main part is occupied by three gas
chambers, laboratory tables, and various devices for putting up and
controlling gas concentrations in the chambers. A small part at one
end is used as an office and storeroom.
Good ventilation is of great importance in a laboratory of this
nature. This is secured by means of a 6 ft. fan connected to suitable
ducts. The fan is mounted on a heavy framework outside and at one
end of the building. The fan is driven at a speed of about 250 r.p.m.
by a 10 h.p. motor. The main duct is 33 in. square, extending to all
parts of the building. A connection is also made to a small hood used
when making chemical analyses.
The gases, fumes, etc., drawn out by the fan, are forced up and
out of a stack 30 in. in diameter, extending upward 55 ft. above the
ground level.
The main features of each of the three gas chambers are
identical. Auxiliary pieces of apparatus are used with each chamber,
the type of apparatus being determined by the characteristics of the
gas employed.
Fig. 76.—Man Test Laboratory,
American University.
Each chamber is 10 ft. long, 8 ft. wide and 8½ ft. high, having,
therefore, a capacity of 680 cu. ft. or 19,257 liters. The floor is
concrete, and the walls and ceiling are constructed on a framework
of 2 × 4 in. scantling, finished on the outside with wainscoting and on
the inside with two layers of Upson board (laid with the joints lapped)
covered with a ½ in. layer of special cement plaster laid upon
expanded metal lath. The interior finish is completed by two coats of
acid-proof white paint. The single entrance to the chamber is from
outside the laboratory, and is closed by two doors, with a 36 × 40 in.
lock between them. These doors are solid, of 3-ply construction, 2½
in. thick, with refrigerator handles, which may be operated from
either inside or outside the chamber. The door jambs are lined with ³/
₁₆ in. heavy rubber tubing to secure a tight seal.
At the end of the chamber opposite the doors, a pane of ¼ in.
wire plate glass, 36 × 48 in., is set into the wall, and additional
illumination may be secured by 2 headlights, 12 in. square, set into
the ceiling of the chamber and of the air-lock, respectively, and
provided with 200 watt Mazda lamps and Holophane reflectors.
Openings into the chamber, five in number, are spaced across this
end beneath the window and 9 in. above the table top.
Fans are installed for keeping the concentration uniform.
Fig. 77.—Details of Canister Holder.
Various devices have been installed for attaching the canister to

be tested (Fig. 77). This arrangement allows the canister to be
changed at will without any necessity for disturbing the concentration
of gas by entering the chamber.
Arrangements for removing the gas from the chamber consist of
a small “bleeder” which allows a continuous escape of small
amounts and a large blower for rapidly exhausting the entire
contents of the chamber.
Other general features of the equipment deal with the
determination of the physical condition surrounding the tests, often a
matter of considerable importance. The temperature of the gas
inside the chamber is easily ascertained by means of a thermometer
suspended inside the window in such a position as to be read from
the outside. The relative humidity of the mixture of air and gas in the
chamber is determined by means of a somewhat modified Regnault
dew point apparatus mounted on the built-in table.
Pressure Drop and Leak Detecting

Apparatus
Another piece of apparatus consists of a combined pressure drop
machine and leak tester (Fig. 78) for measuring the resistance of
canisters and testing them for faulty construction. This is mounted on
a small table, with the motor and air pump installed on a shelf
underneath. The resistance, or pressure drop, of canisters is
measured by the flow meter A and the water manometer B. Air is
drawn through the canister and the flow meter A at the rate of 85
liters per min., the flow being adjusted by the needle valve. The
pressure drop across the canister is read on the water manometer B,
one end of which is connected to the suction line, the other open to
the air. The reading is generally made in inches, correction being
made for the resistance of the connecting hose and the apparatus
itself.
Canisters are tested for leaks by the apparatus shown at D in Fig.
78. The canister is clamped down tightly by wing nuts against a
piece of heavy ¼-in. sheet rubber large enough to cover completely
the bottom of the canister and prevent any inflow of air through the
valve. Suction is then applied, and a leak is indicated by a steady
flow of air bubbles through the liquid in the gas-washing cylinder E. A
second gas-washing cylinder, empty, is inserted in the line between
E and the canister as a trap for any liquid drawn back when the
suction is shut off. If a leak is shown, it can be located by applying air
pressure to the canister and then immersing it in water.
Fig. 78.—Apparatus for Determining Pressure Drop

and for Detecting Leaks in Canisters.
Methods of Conducting Tests

Three general methods of conducting man tests are followed:
(1) Canisters are placed in the brackets outside the chamber or
fastened to the wall tubes within the chamber. The subjects of the
test remain outside the chamber, and the facepieces of the masks
are connected directly to the canisters, in the first case, and to the
wall tubes connecting with the canisters, in the second case. The
concentration is established and the time noted. Then the men put
on the masks and breathe until they can detect the gas coming
through the canisters. Reading matter is provided for the men during
the test period. When gas is detected, the time is again noted and
the time required for the gas to penetrate the canister is reported as
the “time to break down” or “service time” of the canister. Ten
canisters are tested at one time, and the average of the results for
the 10 canisters is taken for that type of canister. Much less accurate
results are obtained when the final figure is based on a small number
of canisters. This is largely due to the various breathing rates and
sensitiveness of different men.
(2) The canisters are placed as in (1), but it is only necessary to
know if they will give perfect protection for a given length of time.
The procedure is the same as in (1), except that the test is arbitrarily
stopped at the end of the indicated time, and the number of canisters
and the service times of the same noted.
(3) When the canisters are of such a type that they cannot be
properly tested as in (1), or when it is desired to test the penetrability
of the facepiece, the men wear the complete mask and enter the
chamber. They remain until gas penetrates the canister or the
facepiece, as the case may be, or until it is determined that the
desired degree of protection is afforded. The service time is
computed as in (1).
(4) Maximum-breathing-rate tests are made either by men in the
chamber or by the men outside, in which they do vigorous work on a
bicycle ergometer. In this test the average man will run his breathing
rate up to 60 or 70 liters per min.
The concentration of the gas is followed throughout the test by
aspirating samples and analyzing them.
Type of Masks Used. In the future the 1919 model will be used
for all tests. In general, during the War, the following procedure held,
although variations occurred in special cases:
When men entered a gas-chamber, the full facepiece was, of
course, required. The type of facepiece was determined by the
nature of the gas. If the gas was most easily detected by odor or eye
irritation, a modified Tissot mask was used. If it was most easily
detected by throat irritation, a mouth-breathing mask was employed.
When men were outside the chamber, the choice was made in
the same manner, except in the case of detection of the gas by
throat irritation. In this case the mouthpiece was attached to two or
three lengths of breathing tubes and a separate noseclip was used.
The facepiece was not needed and the men were much more
comfortable without it.
Disinfection of Masks. Mouthpieces are disinfected after use by
first holding them under a stream of running water and brushing out
thoroughly with a test tube brush; then the latter is dipped into a 2
per cent solution of lysol, and the inner parts of the mouthpiece are
brushed out well; finally the mouthpiece and exhaling valve are
dipped bodily into the lysol solution and allowed to dry without
rinsing. Tissot masks are wiped out with a cloth moistened in alcohol,
followed by another cloth moistened in 2 per cent lysol solution. The
flexible tubes are given periodic rinsings with 95 per cent alcohol.
Applicability of Man Tests. Man tests are applicable to all gases
which can be detected by the subject of the test before he breathes
a dangerous amount.
The man test laboratory described above provides facilities for
obtaining information concerning the efficiency of canisters,
facepieces, etc., within very short periods of time, without waiting for
the construction of special apparatus required for machine tests. To
get satisfactory results from machine tests, a delicate qualitative
chemical test for the gas is essential. Man tests can be made when
such a qualitative test is not known. Further, man tests can be made
with higher concentrations of some gases than is practicable with
machines. Evolution of excessive amounts of moisture when high
concentrations of some gases are used causes much more trouble
with machine tests than with man tests.
On the other hand, man tests are adversely affected by the
varying sensitiveness and lung capacities of the men, and the
humidity of the air-gas mixture is not subject to as exact control as is
the case with machine tests.
Field Tests
It will be observed that all of the above tests are concerned only
with the efficiency of the absorbent and its packing in the canister.
No attempt was made to determine the comfort and general “feel” of
the mask. For this purpose field tests were devised, covering periods
from two to five hours. The first test was a five-hour continuous
wearing test. It was assumed that any mask which could be worn for
five hours without developing any marked features of discomfort
could, if the occasion demanded it, be worn for a much longer period
of time. A typical test follows:
8:00 to Instruction and adjustment of gas
8:30 mask.
Gas-chamber tests
8:30 to Games involving mental and physical
9:30 activity
9:30 to Cross-country hike with suitable
11:30 periods of rest
11:30 to Tests of vision
12:00
12:00 to Games to test mental condition of
12:30 subjects
12:30 to Gas-chamber fit test
1:00
Fig. 79.—Hemispherical Vision Chart.
Vision was tested by means of a hemispherical chart (Fig. 79).

This chart was 6 ft. in diameter and was constructed of heavy paper
laid over a wire frame. A hinged head rest was provided for holding
the subject’s head firmly in position with the center directly between
the eyes. The subject wearing the mask took up his position, and
with one eye closed at a time, indicated how far along the meridian
of longitude he could see with the other eye. The observer sketched
in the limit of vision by outlining the perimeter of the roughly circular
field allowed by each eyepiece. The intersection of the two fields
gave the extent of binocular vision possible with the mask.
Various other tests were also used, in order that the extent and
nature of the vision could be accurately determined.
Aside from the problems of comfort, protection, vision and other
important features of gas mask efficiency, the question arose as to
whether certain designs of masks or canisters were mechanically
able to withstand the rough treatment they were certain to receive in
actual field service. A test was, therefore, developed to simulate
such service as transportation of masks from base depots to the
front, carrying of supplies and munitions by men wearing masks in
the “alert” position, exposure to rain and mud, hasty adjustment of
masks during gas alarms and typical mistreatment of masks by the
soldiers.
All these tests were of great value in the development of a good
gas mask.
CHAPTER XV
OTHER DEFENSIVE MEASURES
Protective Clothing
Protective clothing was an additional feature of the general
program of protection. As far as factory protection is concerned, the
use of protective garments was more or less of a temporary
expedient and they were abandoned as fast as automatic machinery
and standard practice made their use less necessary. It is likewise a
question regarding their value at the front. It is very certain that the
garments developed needed to be made lighter and more
comfortable to be of much value to the fighting unit.
The first development of protective clothing was along the lines of
factory protection. The large number of casualties in connection with
the manufacture of mustard gas made it imperative that the workmen
be protected not only from splashes of the liquid mustard gas, but
also from its vapors. The first suit developed provided protection to
the entire body. The ordinary clothing materials and even rubberized
fabrics offered little protection but it was found that certain oilcloths
were practically impermeable to mustard gas. The suit was a single
garment, buttoning in the back, with no openings in the front, no
pockets and with tie-strings at wrists and ankles. The head was
protected by means of an aluminium helmet, supported by means of
a head band resting on the head like a cap and slung from the inside
of the helmet; this permitted slight head motions independent of the
helmet. In order to provide cooling and ventilating and pure air
breathing, the suit was inflated by pumping a considerable volume of
air into the suit through a flexible hose long enough to permit
considerable freedom of movement.

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Health Psychology: An Introduction to

Behavior and Health 10th Edition Linda

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Part 1 Foundations of Health Psychology

PART 2 Stress, Pain, and Coping

PART 3 Behavior and Chronic Disease

PART 4 Behavioral Health

PART 5 Looking Toward the Future

Name Index 523

Subject Index 565

About the Authors xvii Would You BELIEVE...? Prescribing Placebos

2 Conducting Health Research 21 3 Seeking and Receiving Health

Check YOUR BELIEFS About Health Research 22

Would You BELIEVE...? Pets May Be Better Questions 152

Check Your HEALTH CARE PREFERENCES

12 Smoking Tobacco 305 13-1 A Brief History of Alcohol

Check Your Health Risks Regarding Alcohol and

Real-World Profile of Famous Former Real-World Profile of Daniel Radcliffe 336

12-6 Effects of Quitting 328 Drug Misuse and Abuse 361

Cardiovascular Health 404

Approaches to Losing Weight 382 Would You BELIEVE...?

15 Exercising 399 BECOMING HEALTHIER 421

15-1 Types of Physical Activity 399 IN SUMMARY 424

Check Your Health Risks Regarding Exercise and

16-1 Challenges for Healthier People 427 IN SUMMARY 446

Real-World Profile of Dwayne and Robyn 428 Questions 447

●● Psychology’s Relevance for

Real-World Profile of COVID-19 Pandemic

Alissa Eckert, MS; Dan Higgins, MAMS/CDC

Leading causes of death, 1900

Liver disease 5.2%

Leading causes of death, 2017

Diabetes mellitus 3.0%

European Hispanic African Asian

FIGURE 1.3 Decline in infant mortality in the United States, 1900–2013.

Technology in medicine is one reason for escalating medical costs.

TABLE 1.2 Definitions of Health Held by Various Cultures

Culture Time Period Health Is . . .

diseases as the leading causes of death and disability.

1-2 Psychology’s Relevance The Contribution of

Will & Deni McIntyre/Science Source

The Emergence of Health behaviors, as well as encouraging regular exercise,

FIGURE 1.4 The biopsychosocial model: Biological, psychological, and sociologi-

associations, publish their research in journals devoted

Real-World Profile of ANGELA Bryan

Health psychology is a relatively new and fascinating field of psychology. Health

Questions to chronic diseases, (2) the increase in medical

Check YOUR BELIEFS

Real-World Profile of SYLVESTER COLLIGAN

associate a treatment with getting better, creating situ-

etti, 2005). Placebo effects are a tribute to the ability of

a high-fiber content? Some cereals are intentionally

of individuals, which make them incapable of reveal-

Service Time, Minutes

Standard Conditions of Tests