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An Introduction to Health Psychology

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An Introduction to
Health Psychology
Fifth edition
Val Morrison and Paul Bennett
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First published 2006 (print)
Second edition published 2009 (print)
Third edition published 2012 (print)
Fourth edition published 2016 (print and electronic)
Fifth edition published 2022 (print and electronic)
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ISBN: 978-1-292-26290-1 (print)
978-1-292-26291-8 (PDF)
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British Library Cataloguing-in-Publication Data
A catalogue record for the print edition is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Morrison, Val, 1961- author. | Bennett, Paul, 1955- author.
Title: Introduction to health psychology / Valerie Morrison and Paul
Bennett.
Description: Fifth edition. | Harlow, England : Pearson Education, 2022. |
Includes bibliographical references and index. | Summary: “Well, it’s
that time again . . . time to bring out another edition of the book. As
always, a new edition offers authors an opportunity to update, revise
and generally ‘improve’ the text. This time however the text has faced
additional needs for new material in order to reflect the impact of the
most challenging health threat to the world experienced in this century:
COVID-19. This condition has inspired significant medical developments
and has also presented several challenges to health (and clinical)
psychologists, to public health professions, and to health practitioners
in primary, secondary, and tertiary care across the globe”-- Provided by
publisher.
Identifiers: LCCN 2021061221 (print) | LCCN 2021061222 (ebook) | ISBN
9781292262901 (paperback) | ISBN 9781292262918 (epub)
Subjects: LCSH: Clinical health psychology.
Classification: LCC R726.7 .M77 2022 (print) | LCC R726.7 (ebook) | DDC
616.001/9--dc23
LC record available at https://lccn.loc.gov/2021061221
LC ebook record available at https://lccn.loc.gov/2021061222
10 9 8 7 6 5 4 3 2 1
22 21 20 19 18
Cover design: Kelly Miller
Cover image: Martin Steinthaler/Moment/Getty Images
Print edition typeset in 9.75/13 pts and Times LT Pro by Straive
Printed in Slovakia by Neografia
NOTE THAT ANY PAGE CROSS REFERENCES REFER TO THE PRINT EDITION
Contents
Preface xi
PART I BEING AND STAYING HEALTHY 1

Chapter 1 What is health? 2
Learning outcomes 2
Chapter outline 4
Behaviour, death and disease 5
What is health? Changing perspectives 9
Individual, cultural and lifespan perspectives on health 14
What is health psychology? 27
Summary 32
Further reading 33
Chapter 2 Health differences and inequalities 34

Learning outcomes 34
Chapter outline 36
Health differentials 36
Stress, SES and health 41
Work status and stress 45
Minority status and health 47
Gender and health 50
Summary 53
Further reading 54
Chapter 3 Health-risk behaviour 56

Chapter outline 58
What is health behaviour? 58
Smoking 61
Unprotected sexual behaviour 83
Unhealthy diet 89
Obesity 93
Summary 97
Further reading 98
VI CONTENTS
Chapter 4 Health-protective behaviour 100

Chapter outline 102
Adherence behaviour 102
Healthy diet 106
Exercise 113
Health-screening behaviour 123
Immunisation/vaccination behaviour 132
Summary 136
Further reading 136
Chapter 5 Explaining health behaviour 138

Chapter outline 140
Distal influences on health behaviour 140
Models of health behaviour 147
Sociocognitive models of behaviour change 151
Stage models of behaviour change 168
Summary 176
Further reading 177
Chapter 6 Changing behaviour: mechanisms and approaches 178

Chapter outline 180
Developing public health interventions 180
Approaches to behavioural change 181
Summary 198
Further reading 198
Chapter 7 Preventing health problems 200

Chapter outline 202
Working with individuals 202
Mass persuasion through the media 205
Environmental interventions 210
Public health programmes 214
Using technology 222
Summary 224
Further reading 224
PART II BECOMING ILL 227

Chapter 8 The body in health and illness 228
Chapter outline 230
The behavioural anatomy of the brain 230
The autonomic nervous system 233
The immune system 236
The digestive system 243
The cardiovascular system 247
CONTENTS VII
The respiratory system 254

Summary 258
Further reading 259
Chapter 9 Symptom perception, interpretation and response 262

Chapter outline 264
How do we become aware of the sensations of illness? 264
Symptom perception and interpretation 266
Planning and taking action: responding to symptoms 289
Summary 299
Further reading 300
Chapter 10 The consultation and beyond 302

Chapter outline 304
The medical consultation 304
Factors influencing the consultation 307
Improving communication 310
Moving beyond the consultation 315
Summary 327
Further reading 328
Chapter 11 Stress, health and illness: theory 330

Chapter outline 332
Concepts of stress 332
Types of stress 341
Stress as a physiological response 349
The stress and illness link 359
Summary 364
Further reading 364
Chapter 12 Stress and illness moderators 366

Chapter outline 368
Coping defined 368
Stress, personality and illness 375
Stress and cognitions 385
Stress and emotions 390
Social support and stress 395
Summary 402
Further reading 402
Chapter 13 Managing stress 404

Chapter outline 406
The fundamentals of emotional regulation 406
Stress management training 408
Third-wave therapies 411
VIII CONTENTS
Preventing stress 414

Minimising patient stress in hospital settings 421
Summary 424
Further reading 425
PART III BEING ILL 427

Chapter 14 The impact and outcomes of illness:
patient perspective 428
Chapter outline 430
The prevalence of chronic disease and multiple morbidity 430
The challenges of illness 431
The impact of illness 432
Coping with illness 442
Illness outcomes 445
Quality of life 449
Measuring quality of life 460
Summary 467
Further reading 467
Chapter 15 The impact and outcomes of illness: families

and informal caregivers 470
Chapter outline 472
Illness: a family affair 472
Expectancies of care 478
Family systems and family members 482
Consequences of caring for the caregiver 486
Influences on caring outcomes 490
Summary 502
Further reading 503
Chapter 16 Pain 504

Chapter outline 506
The experience of pain 506
Socio-communication and pain 511
Biological models of pain 511
A psychobiological theory of pain 516
The neuromatrix 520
Helping people to cope with pain 520
Summary 532
Further reading 533
Chapter 17 Improving health and quality of life 534

Chapter outline 536
Coping with chronic illness 536
Reducing distress 537
CONTENTS IX
Managing illness 542

Preventing disease progression 550
Summary 555
Further reading 555
PART IV FROM THEORY TO PRACTICE 557

Chapter 18 From theory to practice 558
Chapter outline 560
The need for theory-driven practice 560
Getting evidence into practice 563
. . . and finally, be positive 570
Summary 571
Further reading 571
Glossary 573
References 583
Index 683
Publisher’s acknowledgements 699
Supporting resources
Lecturer resources
For password-protected online resources tailored to support the use of this textbook in
teaching, please visit go.pearson.com/uk/he/resources
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Preface
Background to this book required that didn’t predominantly focus on health behav-
iours and illness prevention, but gave equal attention to
Well, it’s that time again . . . time to bring out another edi- issues in health differentials, in illness experience, and
tion of the book. As always, a new edition offers authors an in healthcare practice and intervention. In addition, we
opportunity to update, revise and generally ‘improve’ the believed that healthcare training textbooks should be led
text. This time however the text has faced additional needs by psychological theory and constructs, as opposed to
for new material in order to reflect the impact of the most being led by behaviour or by disease. Diseases may vary
challenging health threat to the world experienced in this clinically, but psychologically speaking, they share many
century: COVID-19. This condition has inspired significant things in common; the potential for life or death, behav-
medical developments and has also presented several iour change, distress and emotional growth, challenges to
challenges to health (and clinical) psychologists, to public coping, potential for recovery, involvement in healthcare
health professions, and to health practitioners in primary, and involvement with health professionals. We stick to
secondary, and tertiary care across the globe. Our reader- this ideology; as clearly supported by many other people,
ship includes students of all these specialties. Questions because we have been asked to produce this fifth edition.
have ranged from those at a population level e.g. how do Thank you!
we influence the health or safety behaviours of entire pop- We have maintained our comprehensive coverage of
ulations?, to those at an individual level e.g. What is the health, illness and healthcare, while updating and including
psychological impact of the pandemic and how might we reference to significant new studies, refining some sec-
meet the psychological needs of people who have expe- tions, restructuring others, and basically working towards
rienced COVID-19 or been involved in their care? Each of making this new edition distinctive and (even) stronger
these, and other, issues are addressed within a book that than the last! We believe an understanding of the real-
comes at a time where health psychologists are advising life use of health psychology theory and principles is key
governments and influencing policy and practices perhaps to fully understanding its benefits, and as our readership
more than ever before – thus it is an exciting time to bring includes many people already involved in (or considering)
this to you. training for health professional roles we have integrated
Edition 5 of our book is not just an update on previ- a lot of experiential qualitative findings and several case
ous editions, but has seen a number of significant revi- studies into the chapters to bring the human and clinical
sions, reflecting changes in the developing research base, perspective even more to life.
the academic provision of health psychology teaching in
university courses, and in the practice of health psychol-
ogy. We remain true to our original beliefs i.e. we believe Aims of this textbook
health psychology is an exciting and vibrant discipline to
study at both undergraduate and postgraduate level. It The overall aim of this textbook is to provide a balanced,
has developed into an exciting professional discipline with informed and comprehensive UK/European textbook with
a defined training pathway and increasing numbers of rel- sufficient breadth of material for introductory students,
evant jobs both in healthcare systems and other contexts. but which also provides sufficient research depth to ben-
We wrote the first edition of the book because we believed efit final year students or those conducting a health psy-
that a comprehensive European-focused textbook was chology project, including at Masters level. In addition to
XII PREFACE
covering mainstream health psychology topics such as research. We consider the important influence of current
health and illness beliefs, health behaviour, and health and health status, lifespan, ageing and culture on health, and in
illness outcomes, we include key topics such as socio- doing so illustrate better the biopsychosocial model which
economic influences on health, biological bases, individual underpins health psychology. Chapter 2 describes how
and cultural differences, the impact of illness on family and factors such as social class, income and even postcode
carers, and psychological interventions in health, illness can affect one’s health, behaviour and access to health-
and healthcare. These are all essential to the study of care. Indeed, the health of the general population is influ-
health psychology. enced by the socio-economic environment in which we
In this edition, after some deliberation about alterna- live and which differs both within and across countries and
tives, we have stuck to a format in which chapters follow cultures. Many of today’s ‘killer’ illnesses, such as some
the general principle of issue first, theory second, research cancers, heart disease and stroke, have a behavioural
evidence third, and finally the application of that theory component and in Chapters 3 and 4 we describe how
and, where appropriate, the effectiveness of any interven- behaviours such as self-screening or exercise have health-
tion. This text is intended to provide comprehensive cover- protecting or enhancing effects whereas others, such as
age of the core themes in current health psychology, but non-adherence to medicines, smoking or the use of illicit
it also addresses the fact that many individuals neither drugs, have health-damaging effects. These behaviours
stay healthy, nor live with illness, in isolation. As well as have been examined by health and social psychologists
significant others being addressed in the chapters relating over several decades, drawing on several key theories
to influences on dietary or smoking behaviour, or in provid- such as social learning theory and socio-cognitive theory.
ing support during times of stress, the focus on the role of In Chapter 5 we describe several dominant models which
family and wider social circle in the illness experience has have been rigorously tested in an effort to identify which
been one of this textbook’s unique features since 2006. beliefs, expectancies, attitudes, control and normative fac-
Although other mainstream health psychology texts are tors contribute to health or risk behaviour. By presenting
now better at acknowledging carers and family role in the evidence of the link between behaviour and health and
illness experience, in this 5th edition we continue to devote illness, we highlight that health psychologists have much
all of Chapter 15 to this topic. to offer in terms of understanding or advising on individual
Another goal of ours was to acknowledge that West- factors to target in interventions. The section therefore
ern theorists should not assume cross-cultural similarity of ends with two chapters on intervention. Chapter 6 focuses
health and illness perceptions or behaviours. Our models on theories of behavioural change, setting them within
may not generalize or be upheld when we access research the context of wider, strategic, approaches to changing
samples more inclusively. Therefore, from the first edi- behaviour. The first of these, the PRECEDE-PROCEED
tion to this current edition we have integrated culturally model is now a well-instituted public health approach to
inclusive examples of theory and research wherever pos- determining the targets for health behaviour change involv-
sible. Throughout this text runs the theme of differentials, ing entire populations. The second, the ‘Behaviour Change
whether culture, gender, age/developmental stage, or Wheel’, is a more psychologically sophisticated framework
socio-economic, and, as acknowledged by reviewers and for instituting change at both the individual and population
readers of the previous editions, our commitment to this is level developed by Michie and colleagues. Chapter 7 goes
clearly seen in the inclusion of a whole chapter devoted to on to consider how these theories and frameworks may be
socio-economic differentials in health (Chapter 2). applied, and with what success in interventions designed
to prevent people developing illness and poor health. It
addresses interventions targeted at both individuals and
Structure of this textbook whole populations.
The second section, Becoming Ill, contains six chapters
The textbook continues to be structured into three broad which take the reader through the process of becoming ill:
sections, because they seem to work and have been well from the physiological systems that may fail in illness, that
received since we started out in 2006! first detection of bodily change that takes us to symptom
The first, Being and Staying Healthy, contains seven perception, interpretation and response, whether that be
chapters. In Chapter 1 we consider what is meant by self-medication, lay referral behaviour or presentation to
‘health’ or considered as ‘being healthy’ and examine healthcare; and the psychosocial factors that may contrib-
societal and interpersonal (cognitive, and emotional) fac- ute to the process of becoming ill. We describe theories
tors that contribute to this. We present a brief history of coping with life stress more generally, and in examin-
to the mind–body debate which underpins much of our ing influences on the stress experience, describe various
PREFACE XIII
methods of managing stress. Chapter 8 opens this section the only disease-specific chapter in our text, but we chose
with a whole chapter dedicated to describing biological to contain a chapter on pain and place it at this point
and bodily processes relevant to the physical experience towards the end of our book because, by illustrating the
of health and illness. Chapter 9 describes how we per- multidimensional nature of pain, we draw together much
ceive, interpret and respond to bodily signs and symp- of what has preceded (in terms of predictors and corre-
toms, highlighting individual, sociocultural and contextual lates of illness, healthcare processes, etc.). Pain illustrates
factors that influence the process of healthcare-seeking extremely well the biopsychosocial approach health psy-
behaviour, including the use of lay and online referral sys- chologists endeavour to uphold. In a similarly holistic
tems (how many of us have not ‘googled’ our symptoms manner, Chapter 17 looks at ways of improving health-
at some point?). In Chapter 10 presenting to, and com- related quality of life by means of interventions such as
municating with, health professionals is reviewed with stress management training, the use of social support, and
illustrations of ‘good’ and ‘not so good’ practice. The role illness management programmes. Finally, we close the fifth
of patient involvement in decision-making is an important edition of this text in the same way we closed the first, with
one in current health policy and practice, and the evidence Chapter 18, which we have called From theory to practice.
as to the benefits of patient involvement is reviewed here. This chapter has changed significantly over time in that it
The chapter also considers how health practitioners arrive now has three key foci: (i) how a number of psychological
at clinical decisions under time pressure and information theories can be integrated to guide psychological inter-
poverty: and why they sometimes get them wrong. Chap- ventions, (ii) how the profession of health psychology is
ters 11 and 12 take us into the realm of stress, some- developing in a variety of countries and the differing ways
thing that very few of us escape experiencing from time it is achieving growth, and (iii) how psychologists can foster
to time! We present an overview of stress theories, where the use of psychological interventions or psychologically
stress is defined either as an event, a response or series informed practice in areas (both geographical and medical)
of responses to an event, or as a transaction between the where they are unused. This ends our book therefore by
individual experiencing and appraising the event, and its highlighting areas where health psychology research has
actual characteristics. We also focus on aspects of stress or can perhaps in the future, ‘make a difference’.
beyond the individual, with consideration of occupational Key changes from earlier editions of this book
stress, and how stress impacts on health through consid- include increased opportunity for students to engage in
eration of the growing field of psychoneuroimmunology. critical reflection and many areas of content development.
Chapter 12 presents the research evidence pertaining To start with, major epidemiological updates and greater
to factors shown to ‘moderate’ the potentially negative consideration of global health issues (such as and cultural
effect of seemingly stressful events, from distal anteced- influences on health and health behaviour are found in
ents such as socio-economic resources, social support Chapters 1–5. In Chapter 2 we have tried to reflect more
and aspects of personality (e.g. optimism, conscientious- of this diversity of influences in relation to inequalities in
ness), to specific coping styles and strategies. Chapter 13 health. In Chapters 3 and 4, as well as copiously updat-
turns to methods of alleviating stress, where it becomes ing the epidemiological statistics regarding health risk and
clear that there is not one therapeutic ‘hat’ to fit all, as we health-protective behaviours (which are continually updat-
describe a range of cognitive, behavioural and cognitive- ing) and outlining current health policy and targets where
behavioural approaches. they exist, we continue to describe evidence of individual,
In the third section, Being Ill, four chapters are pre- lifespan, cultural and gender differentials in health behav-
sented which draw heavily on patient and family expe- iours. In Chapter 4, for example, more attention is paid
rience derived from qualitative research as well as to global health, and to influences on immunization and
quantitative findings. Chapter 14 reviews the impact of screening behaviour, in part in relation to the COVID-19
illness and associated treatments on the emotions, well- pandemic. In considering theories of health and health
being and quality of life of the individual affected, identify- behaviour change in Chapter 5 we give fuller consideration
ing the potential presence of positive as well as negative to the temporal dynamics of human behaviour, drawing
outcomes. Chapter 15 is dedicated to addressing the from longitudinal data where possible to demonstrate the
impact of illness and the associated treatments on the complexity of influences, personal, cognitive, emotional,
family and caregivers of these individuals – perhaps unique social, on our health-related behaviours. In particular we
to health psychology textbooks. Chapter 16 addresses a build on predominantly socio-cognitive models to more
phenomenon that accounts for the majority of visits to a fully address the role of emotion and how regulating our
health professional – pain – which has been shown to be mood (or not) plays an important role in our health behav-
much more than a physical experience. This chapter is iour. Chapter 6 of the new edition has also been radically
XIV PREFACE
updated, with, for example, significantly more detailed we need to understand better in an ageing society facing
coverage of the ‘Behaviour Change Wheel’, use of which a significant ‘Care Gap’. Chapters 14–17 have also seen
has grown in popularity since the last edition. major general updates given the wealth of research being
In terms of covering the illness experience, Chapter 8, conducted in this arena since 2016!
in addressing physiological processes, covers a broader Given all the above, we hope you enjoy reading the
range of illnesses, including COVID-19, updates a range of book and learn from it as much as we learned while writ-
treatments, considers some individual case study exam- ing it. Enjoy!
ples and, in response to reviews, provides more signposts
to relevant psychological content presented elsewhere in
the book. In Chapter 9 we incorporate further considera-
tion of the symptom response process, particularly how
Acknowledgements
people use their ‘lay referral networks’or the media when This project has been a major undertaking, conducted to
deciding whether to seek healthcare or not – the impor- a large extent while we have been home working during
tance of this has also been highlighted during the recent a global pandemic. Thank goodness for technology. The
COVID-19 pandemic. The general updating means that revisions have required the reading of literally hundreds of
longitudinal studies of the dynamic and changing nature empirical and review papers published by health, social
of illness perceptions and responses which more fully and clinical psychologists as well as ever changing statisti-
address the underlying theoretical assumptions are con- cal reports from across the globe, many books and book
sidered. In locating illness within a discussion of wider chapters, and many newspapers to help identify some hot
stress, Chapters 11 and 12 have, as elsewhere, increased health issues. The researchers behind all this work are
coverage of cultural influences, lifespan issues and of thanked for their contribution to the field.
affect regulation, and in response to reviews, occupational Many thanks also to the indomitable editorial team at
stress is used more often to illustrate stress processes and Pearson Education, who have also faced many changes
potential outcomes, including PTSD or burnout. We also in recent years. Several development editors have taken
incorporate a more positive view of stress and wellbeing, their turn at the helm and guided us through tricky times
focusing on the concepts of ‘positive psychology’, resil- where juggling academic demands and our own research
ience and wellbeing. Discussion of positive emotions as has prevented us from spending time on ‘the book’. Thank
moderators of the stress or illness experience link us you to all who have pushed, pulled, and advised us up to
onwards to Chapter 13 where the increasingly valued the point where we hand over to the production team, and
concept of mindfulness and mindfulness-based interven- thanks also to the production team for meeting our image
tions is introduced. In fact, positive beliefs become a recur- briefs and in particular that which led to our 5th cover
ring theme and are seen again in Chapters 14 and 15. image – readers seem to enjoy our covers and so again
This fifth edition further highlights research that examines we stick to our theme of getting outdoors and being active.
the dyad’s experience of health, illness and healthcare Even if some of these activities carry some risk, the goal is
(patient–spouse most typically) demonstrating how such wellbeing and health!
studies can add to our understanding and to our inter-
ventions. New to this edition is detailed consideration of Val Morrison & Paul Bennett,
caregiving motivations or willingness to care, something October 2021
1
Part I
Being and staying
healthy
Chapter 1
What is health?
Learning outcomes
By the end of this chapter, you should have an understanding of:
• key and current global health challenges
• historical models of health, illness and disability, including the mind–body debate
• perspectives offered by biomedical and biopsychosocial models
• the contribution of psychology, and specifically the discipline of health psychology, to
understanding health, illness and disability
• the influence of lifestage, culture and health status on lay models of health and illness
• how health is more than simply the absence of physical disease or disability
Health is global
By definition, global health approaches require an understanding of health,
illness and healthcare in an international context, recognising the growing
diversity of national populations and the shifts in population health, depending
on national policy context and healthcare investment, innovation and availability.
Global health approaches recognise that significant increases in international
air travel (which ‘opens the world up’ for individuals), brings with it a need for
global health security and awareness of non-typical illnesses emerging in new
contexts, e.g. symptoms of tropical disease presenting in an individual in the UK
may be more slowly recognised than symptoms of a commonly seen condition.
Population diversity also calls for greater cultural sensitivity and recognition of
the different explanatory models and beliefs around behaviour, health, illness and
healthcare that can exist across cultures and microcultures. All of this became very
evident in the context of the emergence of a novel and severe acute respiratory syn-
drome coronavirus (SARS-CoV-2) in winter 2019 which most readers will know is
the virus leading to COVID-19 infection. Just prior to this virus emerging, the World
Health Organization (WHO) had launched its new five-year strategic plan – the 13th
General Programme of Work – which recognised that:
‘The world is facing multiple health challenges. These range from outbreaks of
vaccine-preventable disease like measles and diptheria, increasing reports of
drug-resistant pathogens, growing rates of obesity and physical inactivity, to
the health impacts of environmental pollution and climate change and multiple
humanitarian crises.’ (WHO, 2019).
The WHO called for society to address ten major threats to health: pollution
and climate change; the rise in non-communicable diseases (e.g. diabetes, cancer,
heart disease) and the role played by physical inactivity; a global influenza pan-
demic; antimicrobial resistance (reduced effectiveness of antibiotics); outbreaks
of Ebola and high-threat pathogens; weak primary healthcare; vaccine hesitancy
causing outbreaks of infectious diseases such as measles; fragile environments
facing drought, famine, conflict; uncontrolled Dengue fever; continuing HIV infec-
tion. They called for these to be addressed from multiple angles and stressed that
global health policies and practice should be based on sound evidence drawn
from a range of disciplines: epidemiology, medicine, public health and, of course,
psychological studies of human behaviour. Few readers will fail to see how this has
been exemplified during the COVID-19 pandemic.
While these threats to health may vary in size and salience around the world,
without doubt many will have relevance to each of us, with clear implications for
human and social behaviour.
This textbook has had to quickly integrate new and emerging evidence from
studies of the global COVID-19 pandemic with longer-standing evidence relating to
other health threats. Across the world, common diseases, with behavioural under-
pinnings, are killing people in large numbers. While health and illness is primarily
a personal experience, the geographical, cultural and social economic setting, the
dominant government and its health policies, and even the time in which we live,
all play a part in wider personal and social wellbeing.
The relevance of global health to an opener in a health psychology textbook is
that the health and wellbeing challenges society faces call for evidence to inform
effective intervention. We hope here to bring together evidence that can not only
educate the aspiring health psychologist, but can also help inform health policy and
practice – the extent to which we achieve this impact will depend on what we ‘do’
with our evidence as described in the final chapter.
Chapter outline
Around the world, in spite of huge differences in life expectancy, there is reasonable con-
sistency in the ‘top killers’ in terms of disease. It is acknowledged that most, if not all, of
these diseases have a behavioural component and thus potentially fall within individual
influence. Knowing this does not mean behaviour will change, because humans are
complex in their thoughts, emotions and actions with regards to their health behaviour.
This chapter introduces the common causes of mortality, before providing an historical
overview of the health concept. It introduces an evolving understanding of how the mind
and body interact throughout history, and the reader will learn of key models on which
our discipline is founded – the biomedical and the biopsychosocial models of illness.
We also illustrate how health and illness belief systems vary according to factors such
as age and developmental differences, culture and cultural norms and health status. To
conclude the chapter we outline the field of health psychology and highlight the ques-
tions health psychology research can address.
BEHAVIOUR, DEATH AND DISEASE 5
Behaviour, death World Bank data drawing from United Nations data and
a range of national data sources. The most long-lived
and disease population continues to be located in Japan, although

the figures have dropped by a couple of years over the
past decade and the gender differential has widened. In
The dramatic increases in life expectancy witnessed in Russia, the gender differential exceeds ten years. UK life
Western countries in the twentieth century, partially due expectancy at birth has increased from 47 years in 1900 to
to advances in medical technology and treatments, led over 81 years in 2015, and is now in the top 20, which is
to a general belief, in Western cultures at least, in the a huge change in a relatively short period of time (WHO,
efficacy of traditional medicine and its power to eradicate 2016). Exposure to health risks and behavioural factors
disease. This was most notable following the introduction are thought to account for gender differences (including
of antibiotics in the 1940s (although Fleming discovered earlier healthcare-seeking behaviour among females)
penicillin in 1928, it was some years before it and other (see Chapter 9 ☛).
antibiotics were generally available). Such drug treat- At the other end of this ‘league table’ average life
ments, alongside increased control of infectious disease expectancy drops dramatically from the low–mid 70s
through vaccination and improved sanitation, are partial through to a fairly horrendous average life expectancy
explanations of increases in life expectancy seen globally. of just 53 years, with little gender difference, in Sierra
United Nations figures show that, in 2018, world- Leone and in many other African nations.
wide the average life expectancy at birth is 72.56 years Such life expectancy at birth statistics tell us that, in
(70.39 for males, 74.87 for females), with significant and some countries, reaching a 60th birthday is simply not
sometimes shocking variation between countries (World typical. These cultural variations can be explained to a
Bank, 2019) (see Table 1.1). Notably, within the EU this large extent by political and environmental challenges,
life expectancy figure is almost ten years higher, at 81 for example years of war or famine in some African
years (Eurostat, 2019). Table 1.1 presents a selection countries, or for example in Mozambique, high HIV
from the top and bottom of the ‘league tables’ with the prevalence.
Table 1.1 Life expectancy in selected global countries (2018)
Overall (years) Male (years) Female (years)

Japan 84.2 81.1 87.1
Spain 83.0 81.0 86.0
Australia 83.0 81.0 85.0
Greece 82.0 79.0 84.0
Sweden 83.0 80.6 84.1
Netherlands 82.0 80.0 83.2
UK 81.0 80.0 83.2
USA 79.0 76.0 81.0
Serbia 76.0 74.0 78.0
Hungary 76.0 73.0 80.0
Bulgaria 75.0 72.0 79.0
Russia 73.0 68.0 78.0
Bangladesh 72.0 71.0 74.0
Myanmar 67.0 64.0 70.0
Ethiopia 66.0 64.0 68.0
Afghanistan 64.0 63.0 66.0
Mozambique 60.1 57.7 63.0
Nigeria 54.0 53.0 55.0
Sierra Leone 53.1 52.5 55.0
Source: World Bank, 2021.
6 CHAPTER 1 ● WHAT IS HEALTH?
Differences in lifestyle and diet also play a role since the mid-1990s, with some variations seen between
(Chapter 3 ☛). There is some concern around rising obe- Western, Eastern and central regions (and with a ‘blip’
sity among children and the consequent health effects that increase in 2015, attributed to deaths among over-75s).
may be seen in adulthood and in terms of a life expectancy Declines in some countries, for example Ireland which
a decrease in future generations. This would dispropor- has seen a decline of over 30 per cent, have been attrib-
tionately affect developed countries such as the UK and uted mainly to reductions in deaths from cardiovascu-
the USA which have high levels of obesity and inactiv- lar and respiratory disease, which in turn may reflect
ity (Chapter 3 ☛). In fact, the gains in life expectancy improved living standards and healthcare investment.
achieved every decade within EU countries have been In countries where the decline has been closer to 20 per
slowing since around 2011, with decreases seen in 19 EU cent, for example in Belgium, Greece and Sweden, the
countries by 2015, including UK, France, Germany and countries had lower rates to start with.
Italy. In Wales there has been a 0.1 year decline in life The physical causes of death have changed dra-
expectancy for both sexes since 2010 (ONS, 2017). More matically also. If people living in 1900 had been asked
research is needed to explain this slowdown, as multiple what they thought being healthy meant, they may have
factors may be at play, for example some point to the replied, ‘avoiding infections, drinking clean water, living
damaging effects of austerity in health spending within into my 50s/60s’. Death then frequently resulted from
the UK for example (Raleigh, 2018). highly infectious disease such as pneumonia, influenza or
It is worth noting that life expectancy is not the same as tuberculosis becoming epidemic in communities unpro-
healthy life expectancy – the latter relates to whether gains tected by immunisation or adequate sanitary conditions.
in life expectancy are lived in good health as opposed to However, at least in developed countries over the last
in a state of poorer health, with some illness or disabil- century, there has been a downturn in deaths resulting
ity. Obviously the older you get, the lower the ratio of from infectious disease, and the ‘league table’ makes no
healthy: not healthy years a person has, for example, in mention of tuberculosis (TB), typhoid, tetanus or mea-
Europe it is predicted that we live, from birth, about 80 per sles. In contrast, circulatory diseases such as heart disease
cent of our lives without disability, whereas once we are and stroke, lung and respiratory disease are the ‘biggest
65, only about 50 per cent of our remaining years will be killers’ worldwide (along with ‘accidents’). These causes
lived in health (OECD, 2017). Of course, the measure of have been relatively stable over the past few decades.
‘healthy’ relies often on self-report, varies across countries Alzheimer’s disease and the dementias accounted for
and within individuals, as we discuss later in this chapter 12.5 per cent of deaths in England and Wales in 2019,
(‘What does being healthy mean?’). with a higher proportion seen among females than males,
Much of the fall in annual mortality rates (all causes) explained by females living longer (Office for National
seen in the developed world preceded the major immu- Statistics, 2020).
nisation programmes and likely reflect public health suc- Worldwide in 2019, the top ten leading causes of
cesses following wider social and environmental changes death (all ages) were recorded as listed below, with circu-
over time. These include developments in education and latory diseases, such as heart disease and stroke and other
agriculture, which led to changes in diet, or improve- non-communicable disease (lung cancers, COPD, kidney
ments in public hygiene and living standards (see also disease, dementias, diabetes), accounting for over 44 per
Chapter 2 ☛). Mortality rates within the European cent of global deaths and rising; they now make up 60 per
Union have shown an overall 25 per cent reduction cent of all EU deaths. Lower respiratory tract infections
are the most lethal communicable disease; however these
are declining, as are global deaths from neonatal condi-
tions and diarrhoeal disease – likely due to advances in
mortality healthcare. Likewise deaths from HIV/AIDS have fallen
(death): generally presented as mortality statistics, by 51 per cent during the last 20 years, moving from the
i.e. the number of deaths in a given population
world’s 8th leading cause of death in 2000 to the 19th in
and/or in a given year ascribed to a given
condition (e.g. number of cancer deaths among 2019. In contrast, diabetes has entered the global top 10
women in 2020) for the first time; this can largely be attributed to obesity
(see Chapter 3 ☛).
BEHAVIOUR, DEATH AND DISEASE 7
Although statistics are not recorded similarly in all Within these figures is large geographic variation (see
cases, we present comparable EU figures below (avail- Figure 1.1), but circulatory diseases are consistently the
able for 2017; Eurostat, 2020). See also Figure 1.1. main causes of death. With the exception of lung cancer,
Worldwide (WHO 2020, million) Europe (Eurostat 2020)

Ischaemic heart disease (8.9 m) Circulatory disease (1.7 million, heart disease and stroke; 37% of all deaths)
Stroke (6.2 m) Cancers (1.2 million; 26% of all deaths)
COPD (3 m) Respiratory diseases (COPD, pneumonia) 0.37 million; 8% of all deaths)
Lower respiratory infection (2.6 m) Alzheimers disease and dementias (5% of all deaths)
Neonatal conditions (2.1 m)
Trachea, Bronchus, lung cancer) (1.8 m) Accidents (including suicide) (5% of all deaths)
Alzheimer’s Disease and dementias (1.7 m) Diabetes (2% of all deaths)
Diarrhoeal diseases (1.5 m)
Diabetes mellitus (1.4 million)
Kidney disease (1.3 m)
Main cause of death, 2017

(%)
0 10 20 30 40 50 60 70 80 90 100
Bulgaria
Romania
Lithuania
Latvia
Estonia
Hungary
Slovakia
Czechia
Croatia
Poland
Austria
Slovenia
Greece
Germany
Italy
Finland
Malta
Sweden
Cyprus
Luxembourg
Portugal
Ireland
Spain
Belgium
Netherlands
France (1)
Denmark
United Kingdom
Liechtenstein
Switzerland
Iceland
Norway
Diseases of the circulatory system Cancers Diseases of the respiratory system Other
(1) 2016 data instead of 2017.
Figure 1.1 Main causes of death in EU country, 2017

Source: Causes and occurrence of deaths in the EU, Eurostat.
cancer does not appear in the top ten globally; however drinking plus poorer screening uptake – however, given
within more developed countries, including Australia, that cardiovascular/circulatory disease deaths are in fact
USA and the EU, cancer is consistently placed in the now higher in women, some risk behaviours in women may
top five causes of death. In some countries, for example in fact be higher (see changes in smoking, Chapter 3 ☛).
in Denmark, Ireland, France and the Netherlands, can- It has been known for several decades now that a sig-
cers were the main causes of death (Eurostat, 2020; see nificant proportion of cancer deaths are attributable, in
Figure 1.2). EU figures attribute 26 per cent of all deaths part at least, to our behaviour, from early estimates of
to cancer in 2017 (23 per cent of female deaths, 29 per up to 75 per cent of those deaths (e.g. Peto and Lopez,
cent of male deaths, OECD/EU, 2020). 1990) to a more currently estimated 40 per cent (Cancer
What has perhaps become obvious in reading this is Research UK, 2021). The upturn in cancer deaths seen
that the leading causes of death have a behavioural compo- over the last century is also, however, due to people living
nent, linked, for example, to smoking, excessive alcohol longer with other illnesses they previously would have
consumption, sedentary lifestyles and poor diet/obesity. died from; thus they are reaching ages where cancer inci-
The higher incidence of cancer deaths among men are dence is greater.
attributed to lifestyle – behaviours such as smoking and There is room for optimism, however, as awareness of
behavioural risks grows and behaviour changes are made
(see Chapters 3 and 4 ☛) along with medical advances
incidence
in treatment- UK statistics point to a significant decline
the number of new cases of disease occurring
(over 40 per cent for both genders) in age-standardised
during a defined time interval – not to be confused
with prevalence, which refers to the number of deaths from circulatory (heart) diseases over the past 20
established cases of a disease in a population at years and a lower but significant (13–15 per cent ) fall
any one time for cancer and for respiratory disease, (20–26 per cent)
(Office for National Statistics 2020).
Lung Colorectal
Stroke
5% 3%
8%
Breast
Ischaemic 2%
heart Diseases of Cancers
diseases circulatory 26%
12% system Prostate
37 % 1%
All deaths
4 640 113
Diabets Respiratory
2% diseases COPD
8% 3%
External
Alzheimer’s + causes
dementias 5% Pneumonia
5% 2%
Accidents
Suicide 3%
1%
Figure 1.2 Main causes of mortality in EU, 2017 (2016 for France)
Source: EU Eurostat Database 2018.
WHAT IS HEALTH? CHANGING PERSPECTIVES 9
that included mental and physical aspects; however as we

WHAT DO YOU THINK? describe below, this broad view has not held dominance
As stated above, the world is facing multiple throughout history.
health challenges. The COVID-19 pandemic has Early understanding of illness is reflected in archaeo-
brought the need for investment and cooperation logical finds of human skulls from the Stone Age where
in responsive public health initiatives (testing, trac- small neat holes found in some skulls have been attrib-
ing, immunising), in biomedical science (vaccine
uted to the process of ‘trephination’ (or trepanation),
and treatment development) and in our health and
social care systems. To what extent do you think whereby a hole was made in order to release evil spir-
psychology has, and can continue to, contribute to its believed to have entered the body from outside and
these initiatives and our responses to them? caused disease. Another early interpretation of disease
seen in Ancient Hebrew texts is that disease was a punish-
ment from the gods (1000–300 BC). As will be described
So, if as a reader you have been asking yourself, ‘why in Chapter 9 ☛, similar beliefs remain today in some
do all these figures matter?’ the answer should now be cultures. Understanding such variations in belief systems
clear. Our own behaviour contributes significantly to is therefore extremely important to our understanding of
our health and mortality. As health psychologists, gain- individuals’ response to illness. Also important however
ing an understanding of why we behave as we do and is the shaping, over time, of views of the association
how behaviour can change or be changed, is a core part between the mind and the body.
of our remit. It therefore is something we discuss a lot
in this and the subsequent six chapters! Key behaviours
are explored more fully in Chapters 3 and 4 ☛, but the Mind–body relationships
increased recognition of the role individual behaviour Humans have physical bodies formed of molecular,
plays in the experience of illness is a critical starting point genetic, biological, biochemical and measurable compo-
in this health psychology text. nents that enable the ‘machine’ to work, and within those
First we address the evolving way of thinking about they have a physical brain. However a broader concept,
the relationship between the human mind and the human that of the ‘mind’ has been considered to be non-physical,
body and the dominant models of thinking about health, reflecting our consciousness, thoughts and emotions that
illness and function. have no physical properties per se. The extent to which
history has seen these existing as separate, independent
entities (dualistic thinking) with either the body influ-
What is health? Changing encing the mind or the mind influencing the body, can
be seen in part as the story of the development of health
perspectives psychology.
The ancient Greek physician Hippocrates (circa 460–
377 BC) considered the mind and body as linked. His
Health is a word that most people will use without real- humoral theory of illness attributed health and disease
ising that it may hold different meanings for different to the balance between four circulating bodily fluids
people, at different times in history, in different cultures, (called humours): yellow bile, phlegm, blood and black
in different social classes, or even within the same fam- bile. It was thought that when a person was healthy the
ily, depending, for example, on age or gender. Potential
differences in perspectives on health can present chal-
lenges to those concerned with measuring, protecting,
enhancing or restoring health. The root word of health theory
is ‘wholeness’, and indeed ‘holy’ and ‘healthy’ share
a general belief or beliefs about some aspect of
the same root word in Anglo-Saxon: this is perhaps why the world we live in or those in it, which may or
many cultures associate one with the other: e.g. medicine may not be supported by evidence – for example,
men have both roles. Having linguistic roots in ‘whole- women are worse drivers than men
ness’ also suggests the early existence of a view of health
four humours were in balance, and when they were ill- to have little control over their health, whereas priests,
balanced due to external ‘pathogens’, illness occurred. in their perceived ability to restore health by driving out
The humours were attached to seasonal variations and demons, did. The Church was at the forefront of society
to conditions of hot, cold, wet and dry, where phlegm at this time and so the search for non-religious, scientific
was attached to winter (cold–wet), blood to spring (wet– explanations were slow to emerge, and in fact scientific
hot), black bile to autumn (cold–dry), and yellow bile investigation such as dissection was prohibited! The mind
to summer (hot–dry). Hippocrates thought that the level and body were generally viewed as working together, or
of specific bodily humours related to particular person- at least in parallel, but due to constrained medical study,
alities: excessive yellow bile was linked to a choleric or understanding developed slowly and mental and mysti-
angry temperament; black bile was attached to sadness cal explanations of illness predominated. Such causal
and melancholia; excessive blood was associated with an explanations elicited treatment along the lines of self-
optimistic or sanguine personality; and excessive phlegm punishment, abstinence from sin, prayer or hard work.
with a calm or phlegmatic temperament. Humoral the- These religious views persisted until the early fourteenth
ory attributed disease states to bodily functions but also and fifteenth centuries when a period of ‘rebirth’, a Renais-
acknowledged that bodily factors impacted on the mind. sance, began. During the Renaissance, individual thinking
Healing at this time involved attempts to rebalance the became increasingly dominant and the religious perspective
humours, for example, through bleeding or starvation, became only one of many. The scientific revolution of the
or even this far back in time, through eating healthily early 1600s led to huge growth in scholarly and scientific
(Helman 1978). study and consequently, the understanding of the human
This view continued with Galen (c. AD 129–199), body, and the explanations for illness, became increasingly
another influential Greek physician in Ancient Rome. organic and physiological. (It should be noted that this left
Galen considered there to be a physical or pathological little room for psychological explanations however).
basis for all ill health (physical or mental) and believed During the early seventeenth century, the French phi-
not only that the four bodily humours underpinned the losopher René Descartes (1596–1650), like the ancient
four dominant temperaments identified by Hippocrates Greeks, proposed that the mind and body were separate
but also that these temperaments could contribute to the entities. Physicians acted as guardians of the body –
experience of specific illnesses. For example, he proposed viewed as a machine amenable to scientific investigation
that melancholic women were more likely to get breast and explanation – whereas theologians acted as guard-
cancer, offering not a psychological explanation but a ians of the mind – a place thought not amenable to scien-
physical one because melancholia was itself thought to be tific investigation! This is defined as dualism, where the
underpinned by high levels of black bile. This view was mind exists, but is considered to be ‘non-material’ (i.e.
therefore that the mind and body were interrelated, but conscious thoughts and feelings are not objective or vis-
only in terms of physical and mental disturbances both ible) and independent of the body, which is ‘material’ (i.e.
having an underlying physical cause. The mind itself was made up of real mechanical ‘stuff’, physical matter such as
not thought to play a role in illness aetiology. While this our brain, heart and cells). Where the ancient Greeks had
view dominated thinking for many centuries, it lost pre- the body ‘in charge’, classical dualism placed the mind
dominance in the eighteenth century when organic medi- in charge – the non-physical mind was thought to control
cine, and in particular cellular pathology, developed and the physical body and its reactions. Descartes proposed
failed to support the humoral underpinnings. Galen’s
descriptions of personality types were however still in
use in the latter half of the twentieth century (Marks
et al., 2000: 76–7). aetiology
During the early Middle Ages (fifth–sixth century), (etiology): the cause of disease
health became increasingly tied to faith and spirituality. dualism
At this time illness was seen as God’s punishment for the idea that the mind and body are separate
misdeeds or, similar to very early views, the result of entities (cf. Descartes)
evil spirits entering one’s soul. Individuals were thought
that interaction between the two ‘domains’ was possi- Biomedical model of illness
ble, although initially understanding of how this interac-
tion could happen was limited, for example, how could a In this model, health is defined as the absence of dis-
mental thought, with no physical properties, cause a bod- ease, and any symptom of illness is thought to have an
ily reaction (e.g. a neuron to fire) (Solmes and Turnbull underlying pathology that will hopefully, but not inevi-
2002)? The suggested communication between mind and tably, be cured through medical intervention. Adhering
body was thought to be under the control of the pineal rigidly to the biomedical model would lead to propo-
gland in the midbrain (see Chapter 8 ☛) (interactive, nents dealing only with objective facts and assuming a
Cartesian dualism), but the process of this interaction was direct causal relationship between illness or disability, its
also unclear. However, because Descartes believed that the symptoms or underlying pathology (disease), and adjust-
soul (the ‘mind’?) left the human body at the time of death, ment outcomes.
dissection and autopsy study now became acceptable to the This biomedical thinking, is reflected in the World
Church and as a result the eighteenth and nineteenth cen- Health Organization’s 1980 International Classifica-
turies witnessed a huge growth in medical understanding. tion of Impairment, Disabilities and Handicaps (WHO
Anatomical research, autopsy work and cellular pathology IC I-D-H model, also the classification of the conse-
concluded that disease was located in human cells, not in quences of disease). This introduced a hierarchical model
ill-balanced humours. The dualist notion of the body as a which was utilised in a large body of research exploring
machine (a mechanistic viewpoint), understandable only responses to disease. In this, impairments (abnormali-
in terms of its constituent parts (molecular, biological, ties or losses at the level of a person’s organs, tissues,
biochemical, genetic), meant that illness was understood structures or appearance), lead to disability (defined as a
through the study of cellular and physiological processes. restriction or inability to function as ‘normal for a human
Treatment during these centuries became more tech- being’) which places disability firmly within the individ-
nical, diagnostic and focused on physical evidence, with ual, and in turn disability creates inevitable individual
individuals perhaps more passively involved than pre- handicap (whereby a person experiences disadvantage in
viously (when at least they had been expected to pray fulfilling their normal social roles).
or exorcise their demons in order to return to health).
This approach underpins the biomedical model of ill-
ness. Within this approach, the ‘mind’ is considered
part of the material ‘stuff’ by virtue of it being a func-
tion of the brain, and the study of mental processes is mechanistic
then mapped through physical, neural processes of the a reductionist approach that reduces behaviour
to the level of the organ or physical function –
brain (this monist materialism reduces the mind to
associated with the biomedical model
objectifiable brain processes, and is supported by the
huge growth in neuropsychology and brain imaging biomedical model
research). Behaviourism is similarly monist, and at its a view that diseases and symptoms have an
underlying physiological explanation
extreme, rejects the study of the non-visible mind and
its thought processes in favour of observeable stimuli monist
and responses. Humanism (e.g. Carl Rogers) in contrast the idea that the non-physical mind cannot be
would argue that only through understanding the unique studied separately from the physical brain
human subjective experience will we gain understanding behaviourism
of individual behaviour. this approach emphasises objectifiable actions
Where we are today in relation to mind–brain–body and the environmental factors that shape action/
debates, is that we seek scientific evidence to help explain behaviour (c.f. Skinner, classical conditioning)
the human experience – be it objective, subjective, or humanism
demonstrating a relationship between these, although the this approach emphasises the inner feelings and
growth in neuroscience might suggest materialism cur- needs of individuals (c.f. Rogers, Maslow)
rently has the upper hand!
The assumption is that removal (i.e. treatment) of of life, an exclusion from normal function and roles, and,
the pathology through medical intervention will lead as many studies have shown, increased depression. For
to restored health (i.e. illness or disability results from others, disability presents a challenge, a fact of life to be
disease either originating outside the body (e.g. germs) lived with, rather than something which prevents them
or through involuntary internal changes (e.g. cell muta- living fully (see Chapter 14 ☛). As seen in relation to
tions)). This relatively mechanistic view of how our body developing concepts of illness, evidence of individual
and its organs work, fail and can be treated, allows little variation in the response to impairment and disabil-
room for subjectivity. ity challenges biomedical thinking and opens the door
The biomedical view has been described as reduction- for biopsychosocial thought. People do not inevitably
ist: i.e. the basic idea that mind, matter (body) and human become equally or similarly ‘disabled’ or ‘handicapped’
behaviour can all be reduced to, and explained at, the even where impairment is similar (e.g. Johnston and
level of cells, neural activity or biochemical activity. How Pollard 2001).
then would we deal with evidence of debilitating, but While aspects of reductionism and dualistic thinking
medically unexplained symptoms? (see Chapter 9 ☛). have been useful, for example, in furthering our under-
What then are the implications of such a medical and standing of the aetiology and course of many acute and
positivistic/functionalistic view for the treatment of infectious diseases, the role of the ‘mind’ in the manifes-
impairments (especially if we believe in a need to nor- tation of, and response to, illness is crucial to furthering
malise)? For example, are cochlear implants for those our understanding of the complexities of health and ill-
with hearing impairments a more appropriate response ness. Psychology has played a significant role in this
than those around the individual with hearing difficul- altering perspective. For example, a key role was played
ties learning sign language? Whose ‘problem’ is hearing by Sigmund Freud in the 1920s and 1930s when he
impairment? redefined the mind–body problem as one of ‘conscious-
Reductionism also tends to ignore evidence that ness’ and postulated the existence of an ‘unconscious
different people respond in different ways to the same mind’ seen in a condition he named ‘conversion hys-
underlying disease pathology because they vary in, for teria’. Following examination of patients with physical
example, personality, cognition, social support resources symptomatology but no identifiable cause, and by using
or cultural beliefs (see later chapters). hypnosis and free association techniques, he identified
While the biomedical model underpins many suc- unconscious conflicts which had been repressed. These
cessful treatments, including immunisation programmes unconscious conflicts were considered to ‘cause’ the
which have contributed to the eradication of many life- physical disturbances including paralysis and loss of
threatening infectious diseases, significant challenges to sensation in some patients where no underlying physi-
dualism, and to a purely biomedical approach exist, as we cal explanation was present (i.e. hysterical paralysis, e.g.
discuss more fully below. Freud and Breuer 1895). Freud stimulated much work
into unconscious conflict, personality and illness, link-
ing the mind with the body and ultimately leading to the
Challenging dualism and the development of the field of psychosomatic medicine (see
emergence of (bio)psychosocial later section).
As a discipline, psychology has highlighted the
models of health and illness need for medicine to consider the role played in the
In terms of mind–body associations, what is perhaps aetiology, course and outcomes of illness, by psycho-
closer to the ‘truth’, as we understand it today, is that logical and social factors. Consider, for example, the
there is one type of ‘stuff’ (monist) but that it can be extensive evidence of ‘phantom limb pain’ experienced
perceived in two different ways: objectively and subjec- in amputees – how can pain exist in an absent limb?
tively. For example, many illnesses have organic under- Consider the widespread acknowledgement of the pla-
lying causes, but also elicit uniquely individual responses cebo effect – how can an inactive (dummy) substance
due to the action of the mind, i.e. subjective responses. lead to reported reductions in pain or other symptoms
For some people, acquiring a disability signifies the end which are equivalent to reductions described by those
Photo 1.1 Having a disability does not equate with a lack of health and fitness
Source: flySnow/iStock/Getty Images.
receiving an active pharmaceutical substance or treat- mind–body split’ and noted that simply because neurosci-
ment (Chapter 16 ☛)? In addition, a linear model, such ence enables us to explore the ‘mind’ and its workings
as seen in the WHO ICIDH would fail to explain how a ‘objectively’ by the use of increasingly sophisticated scan-
Paralympian in spite of sensory or physical impairments, ning devices and measurements, this did not mean we are
functions at a level of physical performance many of us furthering our understanding of the subjective ‘mind’ –
without such impairments perform? How do we describe the thoughts, feelings and the like that make up our lives
the person with juvenile diabetes who has ‘impairment’ and give it meaning. Their comment that ‘conceptualis-
in terms of pancreatic dysfunction (see Chapter 8 ☛), ing our mental life as some sort of enclosed world living
but as long as they adhere to medication, function as inside our skull does not do justice to the reality of human
any typical adolescent, without any evidence of disabil- experience’ (p. 1434), combined with the fact that this
ity? This same juvenile may, however, skip school as editorial was presented in a medical journal with a tradi-
a result of perceived stigma and therefore miss out on tionally biomedical stance was evidence of a weakened
the associated social relationships and potential long- Descartian ‘legacy’.
term employment benefits (i.e ‘handicap’ without dis- This is not to say that healthcare professionals did
ability). An individual’s context and their subjectivity not believe in the role played by psychological or social
in terms of beliefs, expectations and emotions interact factors in illness, it was just not an explicit part of their
with bodily reactions to play an important role in the operational frameworks, nor to a large extent was it inte-
illness or stress experience (see Chapter 9 ☛ in terms gral to their training. Shifts in thinking over time have
of symptom perception, and Chapter 11 ☛ in terms of enabled the field of health psychology to emerge, a field
stress reactivity). which adopts a biopsychosocial perspective on health,
Evidence of such changed thinking was nicely, and illness and disability/activity limitation which can offer
importantly, illustrated in an editorial in the British potential for a range of interventions, not solely targeting
Medical Journal twenty years ago (Bracken and Thomas pathology or physical symptomatology. This approach is
2002). The authors suggested a need to ‘move beyond the reflected in this textbook.
Biopsychosocial model of illness is trying to function within, and on their own personal
characteristics, behavioural and illness related beliefs and
The biopsychosocial model signals a broadening of a feelings (Quinn et al. 2013) (see Chapter 9 ☛).
disease or biomedical model of health to one encompass-
ing and emphasising the interaction between body and
mind, between biological processes and psychological
and social influences (Engel 1977, 1980). In doing so, it
offers a complex and multivariate, but potentially a more
Individual, cultural and
comprehensive model with which to examine the human
experience of illness. As a result of the many challenges to
lifespan perspectives
the biomedical approach described above, the biopsycho-
social model is employed in several allied health profes-
on health
sions, such as occupational therapy, as well as in health Given the previously presented evidence of the changes
psychology. Although also increasingly assimilated within in what people are dying from, and changed views of
the medical profession there exists some pessimism that it whether and how our minds can influence our bodies, it
is feasible to address all components, no matter how valu- is perhaps not surprising that views of what health is have
able, given constraints facing our healthcare systems (see also changed over time. In the eighteenth century, health
editorial by Lane, 2014). Health is, however, recognised was considered an ‘egalitarian ideal’, aspired to by all
as more than simply the absence of disease. This text will and potentially under an individual’s control. However,
illustrate that psychological, behavioural and social fac- doctors were available to the wealthy as ‘aids’ to keeping
tors can add to the biological or biomedical explanations oneself well, but were less available to the poor. By the
and, rather than replacing these explanations of health and mid-twentieth century, accompanied or perhaps preceded
illness experiences, build on them. by new laws regarding sickness benefit, and medical and
Reflecting these changes in thinking over recent dec- technological advances in diagnostic and treatment pro-
ades, a subsequent WHO model, the International Classi- cedures, health became increasingly and inextricably
fication of Functioning, Disability and Health (ICF, WHO linked to ‘fitness to work’. Doctors were required to
2001) takes a much broader approach than its original declare whether individuals were ‘fit to work’ or whether
ICIDH model. The ICF presents a universal, dynamic and they could adopt the ‘sick role’ (see also Chapter 10 ☛).
non-linear model whereby alterations in bodily structure Many today continue to see illness in terms of its effects
or function (replaces impairment); activities and limita- on their working lives, although research increasingly
tions therein (replaces disability), and participation or addresses the opposite direction of effects, i.e. the influ-
restrictions therein (replaces handicap) can potentially all ence work role and conditions have on illness (see discus-
interact and affect each other. Furthermore, the ICF rec- sion of occupational stress in Chapter 11 ☛).
ognises that the relationship between structures, activities Also perhaps changing over time is the assumption
and participation are influenced by both external, environ- that traditional medicine can, and will, cure us of all ills.
mental and personal factors. A person’s ability to perform Over recent decades, many more people have acknowl-
at ‘capacity’ (i.e. at the best possible, given their physical edged the potential negative consequences of some phar-
status) is not solely due to the level of impairment (think macological treatments (consider for example long-term
of a Paralympian). Disability no longer resides within the use of anxiolytics such as Valium), and as a result the
individual, but is a response to other factors including ‘complementary’ and ‘alternative’ medicine industry has
the physical, social and cultural environment the person burgeoned.
Most countries are seeking, in what is known as
the ‘post 2015 development agenda’, to better measure
biopsychosocial their populations health and wellbeing, given the chang-
ing nature of disease (from acute infectious disease to
a view that diseases and symptoms can be
explained by a combination of physical, social, chronic disease) and the population (an ageing one).
cultural and psychological factors (cf. Engel 1977) Within the United Nations, 17 Sustainable Development
Goals were set as part of a 2030 Agenda for Sustainable
INDIVIDUAL, CULTURAL AND LIFESPAN PERSPECTIVES ON HEALTH 15
Development (United Nations, 2015); one of which is to (poor/fair; good; very good/excellent) influenced these
ensure healthy lives and promote wellbeing at all ages. judgements: those in poor/fair health based their health
Within this goal is a specific target to reduce by one-third assessment on recent symptoms or indicators of poor
the premature mortality arising from non- communicable health, whereas those in good health considered more
diseases through prevention and treatment and, in rec- positive indicators (being able to exercise, being happy).
ognising that health is not simply about the absence of Consistent with this, subjective health judgements were
physical disease, to promote mental health and wellbeing. more tied to health behaviour in ‘healthier’ individuals
They seek to gain an additional two ‘healthy life years’ in (Benyamini et al., 2003).
everyone living in their member states. Although some people have been shown to find it hard
to distinguish health from an absence of illness, health is
generally viewed as a state of equilibrium across various
Lay theories of health aspects of the person, encompassing physical, psycho-
Health and wellbeing are clearly important at a policy logical, emotional and social wellbeing (e.g. Herzlich,
level; however if a fuller understanding of health and ill- 1973). Bennett (2000: 67) considers these representations
ness is to be attained, it is necessary to find out what of health to distinguish between health as ‘being’, i.e. if
people think health and illness are. The simplest way of not ill, then healthy; ‘having’, i.e. health as a positive
doing this is to ask them! resource or reserve; and ‘doing’, i.e. health as represented
In a now classic study exploring lay perceptions of by physical fitness or function (as seen in Benyamini
health, Bauman (1961) asked ‘What does being healthy et al.’s study above). Bauman’s respondents appear to
mean?’. She found that people with diagnoses of quite have focused more on the ‘being’ healthy and ‘doing’
serious illness made three main types of response aspects, which may be in part because ‘having’ health as
whereby being healthy was: a resource was not prominent in the minds of her patient
sample. It does seem that health is considered differently
1. considered as a ‘general sense of wellbeing’;
when it is no longer present, i.e. it is considered to be
2. identified with ‘the absence of symptoms of disease’; good when nothing is wrong (perhaps more commonly
3. seen in ‘the things that a person who is physically fit thought in older people) and when a person is behaving
is able to do’. in a health-protective manner (perhaps more commonly
thought in younger people).
Bauman argued that these three types of response
Another classic, but more representative picture of
reveal health to be related to:
the health concept was perhaps obtained from a large,
● feeling questionnaire-based Health and Lifestyles Survey of
● symptom orientation 9,003 members of the general public, of whom 5,352 also
completed assessment seven years later (Cox, Huppert
● performance.
and Whichellow, 1993). This survey asked respondents to:
However it was noted that study respondents in this
● Think of someone you know who is very healthy.
study did not answer in discrete categories, with nearly
half of the sample providing two of the above response ● Define who you are thinking of (friend/relative etc. –
types, and 12 per cent using all three types. This high- do not need specific name).
lights the multifaceted way in which we may think ● Note how old they are.
about health. In addition, Bauman’s sample consisted of ● Consider what makes you call them healthy.
those with quite serious illness. We now know that cur-
● Consider what it is like when you are healthy.
rent health status influences subjective views of health
and reports of what ‘health is’. For example, among
almost 500 elderly people asked to rate factors in order
health behaviour
of importance to their subjective health judgements,
behaviour performed by an individual, regardless
the most important factors related to physical function- of their health status, as a means of protecting,
ing and vitality (being able to do what you need/want promoting or maintaining health, e.g. diet
to do). However, the current health status of the sample
About 15 per cent could not think of anyone who was ● Health as psychosocial wellbeing: health defined in
‘very healthy’, and about 10 per cent could not describe terms of a person’s mental state; e.g. being in harmony,
what it was like for them to ‘feel healthy’. This inability to feeling proud, or, more specifically, enjoying others.
describe what it is like to feel healthy was particularly evi- ● Health as function: the idea of health as the ability
dent in young males, who believed health to be a norm, a to perform one’s duties or meet role expectations,
background condition so taken for granted that they could i.e. being able to do what you want when you want
not put it into words. By comparison, a smaller group without being handicapped in any way by ill health or
of mostly older women could not answer for exactly the physical limitation (relates back to the WHO concept
opposite reason – they had been in poor health for so long of handicap, now described as participation/participa-
that either they could not remember what it was like to tory restriction, described earlier, and see Figure 1.3).
feel well or they were expressing a pessimism about their
condition to the interviewer (Radley 1994: 39). Such findings suggest that health concepts are perhaps
The categories of health identified from the survey even more complex than initially thought, with evidence
findings were: that the presence of health is considered as something
more than physical, i.e. as something encompassing
● Health as not ill: i.e. no symptoms, no visits to doctor, psychosocial wellbeing. Categories generally seem to fit
therefore I am healthy. with dimensions of ‘being’ and ‘doing’ and in ‘health as
● Health as reserve: i.e. come from strong family; not ill’ and seem to be fairly robust (at least in Western
recovered quickly from operation. culture; see later section for culture differences).
● Health as behaviour: i.e. usually applied to others It also appears that subjective evaluations are typi-
rather than self; e.g. they are healthy because they look cally reached through comparison with others, and in
after themselves, exercise, etc.
● Health as physical fitness and vitality: used more often
by younger respondents and often in reference to a
psychosocial
male – male health concept more commonly tied to
an approach that seeks to merge a psychological
‘feeling fit’, whereas females had a concept of ‘feel- (more micro- and individually oriented) approach
ing full of energy’ and rooted health more in the social with a social approach (macro-, more community-
world in terms of being lively and having good rela- and interaction-oriented), for example, to health
tionships with others.
Health condition
(disorder or
disease)
Body structure and Activity

Participation
functions (functional
(disability)
(impairments) limitations)
Personal Environmental
factors factors
Figure 1.3 The international classification of functioning, disability and health.

Source: WHO (2002b).
this way one’s concept of what health is, or is not, can from lung, colon and prostate cancers in men, and breast
be shaped. For example, Kaplan and Baron-Epel (2003) and colorectal cancers in women, and reductions in drink-
found that young Israelis reporting suboptimal health did ing and smoking incidence also among young adults (see
not compare themselves with people of the same age, Chapter 3 ☛).
whereas many older people in suboptimal health did com- It is clear that health policy acknowledges the evi-
pare themselves with similar aged peers. This suggests denced relationship between people’s behaviour, life-
that people try to get the best out of their evaluations – a styles and their health (broadly defined). What has often
young person will tend to perceive their peers as gener- been less explicitly acknowledged and addressed are the
ally healthy, so if they feel that they are not healthy, they socio-economic and cultural influences on health, ill-
will be less likely to draw this comparison. In contrast, ness and health decisions which is why we have, ever
older people in poorer health are more likely to compare since this textbook first emerged in 2006, dedicated a full
themselves with same-aged peers, who may also have chapter to these important influences to build this aware-
normatively poorer health, thus their own health status ness (see Chapter 2 ☛). More recently the focus has
seems less unusual. Asking a person to consider what it in fact shifted to policies that recognise the social deter-
is that they would consider as ‘being healthy’ inevitably minants of health and illness as well as the individual
will lead people into making these types of comparison. determinants, for example in the UK the Health Founda-
Health is a relative state of being. tion introduced a ‘healthy lives strategy’ in 2017 (Health
Foundation, 2017) that prioritises health as an asset rather
than ill health as a burden and in doing do seeks to pro-
World Health Organization mote social policies that promote health lifestyles. This
definition of health fits with the Public Health England campaign for Better
Health 2020 and 2021 (Public Health England, 2021) (see
The dimensions of health described in the preceding par- Chapters 3 and 4 ☛).
agraphs are reflected in the WHO (1947) definition of Other more context-aware definitions of health do
health as a ‘state of complete physical, mental and social exist, for example Bircher (2005) defines health as ‘a
wellbeing and . . . not merely the absence of disease or dynamic state of well-being characterized by a physical
infirmity’. Some have questioned whether the WHO use and mental potential, which satisfies the demands of life
of the term ‘complete’ in relation to physical wellbeing is commensurate with age, culture, and personal respon-
unrealistic given the changing population age and preva- sibility’. This view places the individual centrally in
lence of chronic disease and the likelihood that most of the experience of health and illness whereas the WHO
us will have some symptomatology as we age (Huber definition does not. Individual beliefs play a major role
et al. 2011). That aside, the definition saw individuals as in the experience of health, illness, and disability. Fur-
ideally deserving of a positive state, an overall feeling of thermore health should not be seen in one dimension or
wellbeing, fully functioning and has helped shape global in black or white, but instead as something experienced
health targets ever since and many national policy docu- on a continuum from optimal wellness, through minor
ments with their own specific targets. In general, as stated and major illness, to death, as described by Antonovsky
earlier in this chapter, these have, and will, set targets (1987). The fascination for many health psychologists is
for reductions in deaths from the leading disease causes how people respond differently to experiences along this
(i.e. heart disease, lung disease, strokes, cancer etc.) or continuum and how health psychology can help identify
more explicitly targeted the associated behaviours (see factors that might help to optimise health or reduce the
Chapters 3 and 4 ☛). For example in the Netherlands negative impact of illness.
(‘A longer and healthier life’, Ministry of Health, 2003)
the targets were disease incidence reductions, whereas
in Belgium the targets were more behavioural: reducing Cross-cultural perspectives
smoking behaviour, fat intake, fatal accidents, increasing
uptake of vaccination programmes and increasing health
on health
screening in the over-50s. Progress has been made over What is considered to be ‘normal’ health varies across
the past 20 years or so with reductions seen in mortality cultures and as a result of the economic, political and
cultural climate of the era in which a person lives. Cul- considered a punishment for past sins within the family
tures vary in their health belief systems, health attribu- (Katbamna et al., 2004; Mackenzie, 2006). Such belief
tions and health practices. Think of how pregnancy is systems can have profound effects on living with ill-
treated in most Western civilisations (i.e. medicalised) ness or, indeed, caring for someone with an illness or
as opposed to many developing regions (naturalised). disability – in Ghana, children with disability may be
The stigma of physical disability, mental illness, or of viewed as non-human ‘spirit-children’, although thank-
dementia, among African, South Asian communities, fully related infanticide is thought to be low (Grischow
and some Eastern European groups, may have conse- et al., 2018).
quences for the family which would not be considered In addition to beliefs of spiritual influences on health,
in Caucasian families: for example, having a sibling studies of some African regions consider that the com-
or a child with a disability, or a relative with dementia munity or family work together for the wellbeing of all.
or depression, may affect siblings’ marriage chances This collectivist approach to staying healthy and avoid-
or the social standing of the family (Ahmad, 2000; ing illness differs from our individualistic approach to
Grischow et al., 2018; Mackenzie, 2006). Such beliefs, health (consider how long the passive smoking evidence
often related to negative attributions of illness causal- was ignored, or more recently, arguments played out
ity and blame, can influence disclosure of symptoms on social media and in policy around imposing mask-
and health-seeking behaviour (Vaughn et al., 2009) (see wearing to protect others from potential coronavirus
Chapter 9 ☛). transmission). Generally speaking, Western European
Westernised views of health differ in various ways cultures are found to be more individualistic, with Eastern
from conceptualisations of health in non-Westernised and African cultures exhibiting more holistic and col-
civilisations. In an early work, Chalmers (1996) astutely lectivist approaches to health. For example, in a study of
noted that Westerners divide the mind, body and soul
in terms of allocation of care between psychologists and
psychiatrists, medical professions and the clergy, whereas
in some African cultures, these three ‘elements of human collectivist
nature’ are integrated in terms of how a person views a cultural philosophy that emphasises the individual
them, and in how they are cared for. This holistic view is as part of a wider unit and places emphasis
similar to that found in Eastern and in Aboriginal Australian on duties above rights, with actions motivated
cultures (e.g. Swami et al. 2009) where the social (e.g. by interconnectedness, reciprocity and group
membership, rather than individual needs and wants
social and community norms and rituals) as well as the
biological, the spiritual and the interpersonal, are integral individualistic
to explaining health and illness states. a cultural philosophy that places responsibility at
Spiritual wellbeing as an aspect of health has gained the feet of the individual and emphasises rights
above duties; thus behaviour is often driven
credence following inclusion in many quality of life
by individual needs and wants rather than by
assessments (see Chapter 14 ☛), and, although faith community needs or wants
or God’s reward may sometimes be perceived as sup-
porting health, attributing one’s health to a satisfied coronavirus
ancestor may nonetheless raise a few eyebrows if stated one of a group of RNA viruses that cause a variety
of diseases – most recently SARS-CoV-2 virus has
aloud. Negative supernatural forces such as ‘hexes’ or
caused COVID-19 disease (SARS: severe acute
the ‘evil eye’ sometimes share the blame for illness respiratory syndrome)
and disability. For example, Grischow and colleagues’
holistic
review of stigma and disability in Ghana (Grischow
root word ‘wholeness’; holistic approaches are
et al., 2018) reveals evidence that a child’s disability
concerned with the whole being and its wellbeing,
may be perceived as a punishment for parental wrongs, rather than addressing the purely physical or
and among Hindus and Sikhs, in particular, it has been observable.
reported that disability and even dementia may also be
preventive behaviour to avoid endemic tropical disease relating to maintaining balance between poles of ‘hot’
in Malawians, the social actions to prevent infection (e.g. and ‘cold’. In Eastern cultures illness or misfortune is
clearing reed beds) were adhered to more consistently commonly attributed to predestination; African Ameri-
than the personal preventive actions (e.g. bathing in piped cans and Latinos are more likely than White Americans
water or taking one’s dose of chloroquine) (Morrison et to attribute illness causes externally (e.g. to the will of
al. 1999). Collectivist cultures emphasise group needs God) (e.g. Vaughn et al., 2009).
and find meaning through links with others and one’s Clearly, therefore, to maximise effectiveness of health
community to a greater degree than individualistic ones promotion efforts, it is important to acknowledge the exist-
which emphasise the uniqueness and autonomy of its ence and effects of such different underlying belief sys-
members i.e. promote and validate ‘independent selfs’ tems and resultant behaviours (see Chapters 6 and 7 ☛).
(Morrison et al. 1999: 367). This belief in a community It is also worth noting that variations exist within as well
of individuals working together for the good of all can as between, cultures, especially where there may have
however lead to problems if a person is ill or disabled and been exposure to multiple cultural influences for example
considered unable to contribute, with consequent stigma, as reported by Wong et al. (2011) from studies in Singa-
disenfranchisement and sometimes even the experience pore where both Asian and Western influences coexist
of personal harm (Grischow et al. 2018). but have differential effects on subjective wellbeing rat-
Cultures that promote an interdependent self are more ings. In the Western world, the perceived value of alter-
likely to view health in terms of social functioning rather native remedies for health maintenance or treatment of
than simply personal functioning, fitness, etc. For exam- symptoms is seen in the growth of alternative medicine
ple classic studies by George Bishop and colleagues (e.g. and complementary therapy industries; however, Western
Bishop and Teng, 1992; Quah and Bishop 1996) noted medicine dominates. In contrast, in non-Western coun-
that Chinese Singaporean adults view health as a har- tries a mixture of Western and non-medical/traditional
monious state where the internal and external systems medicine can often be found. For example in Malaysia,
are in balance, and, on occasions where they become while Western-style medicine is dominant, traditional
imbalanced, health is compromised. Yin – the positive medicine practice by ‘bomohs’ (faith healers) is avail-
energy – needs to be kept in balance with the yang – the able (Swami et al., 2009). Similarly among some Abo-
negative energy (also considered to be female!). Other riginal tribes spiritual beliefs in illness causation coexist
Asian cultures, e.g. the Vietnamese, use mystical beliefs with the use of Western medicines for symptom control
(Devanesen, 2000), with traditional medicine and heal-
ing processes consistent with cultural and spiritual beliefs
still used by some in the treatment of cancer (Shahid
et al., 2010).
These examples illustrate that the biomedical view
is acknowledged and assimilated within different cul-
tures’ belief systems, and show that, while access to
and understanding of Western medicines’ methods and
efficacy grows, better understanding of culturally rele-
vant cognitions regarding illness and health behaviour is
needed (see Kitayama and Cohen, 2007; Vaughn et al.,
2009). We also need more research which considers the
role religion plays in health across and within cultures.
Swami et al. (2009) for example, in their study of 721
Malaysian adults, found that Muslim participants had
Photo 1.2 Visiting a herbalist to choose individually tailored higher beliefs in religious factors and fate as influences
remedies. on recovering from illness than did Buddhist or Catholic
Source: Marcus Chung/E+/Getty Images. participants and they were also more likely to believe
that their likelihood of becoming ill was uncontrollable. think of childhood asthma, juvenile arthritis, or diabetes,
As we will discuss in a later chapter (Chapter 9 ☛), for example. If health professionals are to promote the
responses to symptoms, including the use of healthcare physical, psychological, social and emotional wellbeing
either traditional or Western, will in part be determined of their patient or client whatever their age, then some
by the nature and strength of such cultural values and reli- understanding of ‘typical’ cognitive and psychosocial
gious beliefs. Illness discourse will reflect the dominant development will be helpful in cases where illness may
conceptualisations of individual cultures and religions, have disrupted this. The subsequent section introduces
and, in turn, how people think about health and illness lifespan issues in relation to health perceptions, but it is
will shape expectations, behaviour, and use of health recommended that interested readers also consult a devel-
promotion and healthcare resources. Chapter 2 ☛ opmental health psychology text for fuller coverage (e.g.
will describe the social inequalities in health and address Turner-Cobb, 2014).
further cultural and social economic influence, but one
issue worth noting here is that of social exclusion, Developmental theories
defined by Macleod et al. (2016). Poor health has been
confirmed as both a predictor and as an outcome of The developmental process is a function of the interaction
social exclusion based on data from four waves of data between three factors:
from Understanding Society, the UK Household Longi- 1. Learning: a relatively permanent change in knowl-
tudinal Study (Sacker et al, 2017). Those from minority edge, skill or ability as a result of experience.
cultures, and also those of older age, are more likely to
2. Experience: what we do, see, hear, feel, think.
be socially excluded.
3. Maturation: thought, behaviour or physical growth,
attributed to a genetically determined sequence of
Lifespan, ageing and beliefs development and ageing rather than to experience.
about health and illness
Psychological wellbeing, social and emotional health
social exclusion
are affected by illness, disability, treatments and hospi-
a multidimensional process through which
talisation, which can be experienced at any age. While
individuals become disengaged from mainstream
growing older may be associated with decreased func- society, depriving people of the rights, resources
tioning and increased disability or dependence, it is not and services available to the majority
of course only older people who live with chronic illness:
STOP and THINK problem, with abusers seen as deviant, to a disease,

with alcohol dependent patients treated in clinics. Simi-
Conclusions reported in textbooks such as this are only larly smoking, once viewed as a glamorous, even desir-
based on what is reported in the research (i.e. in sur- able behaviour (1930s–1980s), is now more commonly
vey responses). As noted by a large European statistics viewed as socially undesirable and indicative of a weak
reporting body (Health at a Glance, OECD/EU, 2018, will – perhaps reflecting this, the smoking prevalence
p. 98): ‘Cross-country differences in perceived health has declined. Furthermore, what is normal (or deviant)
status can be difficult to interpret because social and and what is defined as sick (reflecting illness) in a given
cultural factors may affect responses.’ The way in which culture can have consequences for how others respond:
certain behaviours are viewed can vary across cultures, consider how societal responses to illicit drug use have
and also shift over time and this may affect self-reporting. ranged from prohibition through criminalisation to an ill-
For example, mainstream views of alcohol dependence
have shifted from it being viewed as a legal and moral
ness requiring treatment (see Chapter 3 ☛ ).
An early maturational framework for understanding adult development – young adulthood, middle adulthood,
cognitive development (Piaget, 1930, 1970) provides a maturity). Each stage varies across different dimensions,
good basis for understanding the developmental course of including:
concepts regarding health, illness and health procedures.
● cognitive and intellectual functioning;
Piaget proposed a staged structure to which, he consid-
ered, all individuals follow in sequence as below:
● language and communication skills;
● the understanding of illness;
1. Sensorimotor (birth–2 years): an infant understands
the world through sensations and movement, and
● healthcare and maintenance behaviour.
moves from reflexive to voluntary action, but lacks Each of these dimensions is important to the health
symbolic thought. psychologist and to healthcare practitioners. Deficits or
2. Preoperational (2–7 years): symbolic thought devel- limitations in cognitive functioning (due to age, acci-
ops, enabling imagination and intellectual devel- dent or illness) may, for example, influence the extent to
opment through the emergence of simple logical which an individual can understand or execute medical
thinking, play and language, although preoperational instructions, report their symptoms or emotions or even
children are generally egocentric. have their healthcare needs assessed. Children’s acquisi-
3. Concrete operational (7–11 years): logical thought tion of language is fundamental to their development as
develops; can perform mental operations (e.g. men- it enables interaction in their social world and thus social
tal arithmetic) and manipulate objects to enable development (Vygotsky, as reported in Daniels, 1996).
problem-solving; others’ perspectives can also be Communication deficits or limited language skills can
understood. impair a person’s willingness to place themselves in social
situations, or impede their ability to express their pain or
4. Formal operational (age 12 to adulthood): abstract
distress to health professionals or family members. Intel-
thought and imagination develop as does deductive
lectual development further affects the understanding an
reasoning, metacognition and introspection. Not eve-
individual has of their symptoms or their illness which is
ryone may attain this level.
also crucial to their healthcare-seeking behaviour and to
Piaget’s work was influential in terms of providing their adherence with any healthcare intervention. Finally,
an overarching structure within which to view cogni- behaviour, specifically health-risk or health-enhancing
tive development although it has been noted that he may behaviour, also varies across the lifespan and influences
have underestimated children’s capacities and also the one’s perceived and/or actual risk of illness. Cognitive,
role complex adult language and communication play in a communicative and behavioural aspects with relevance
child’s development. In this regard and of more relevance to health and illness experience are extensively covered
here, is work that more specifically addresses children’s in this textbook but we cannot assume that explanations
developing beliefs, understanding and expression of or models of adult thoughts, feelings or behaviour can
health and illness constructs. be applied to children, given normative cognitive devel-
Erik Erikson (Erikson 1959; Erikson et al. 1986) opment, or to adolescents, given variations in the sali-
described eight major life stages (five related to child- ence of social influence (Holmbeck, 2002). We present
hood development – infancy, early childhood, pre- some further details of child development as relevant to
school, school age, adolescence, and three related to health and illness concepts here using Piagetian stages as
a broad framework.
Sensorimotor and preoperational

egocentric stage children
self-centred, such as in the preoperational stage
(age 2–7 years) of children, when they see things Little work with infants at the sensorimotor stage is pos-
only from their own perspective (cf. Piaget) sible in terms of identifying health and illness cogni-
tions, as language is very limited. At the preoperational
stage, children develop linguistically and cognitively, still unable to distinguish between mind and body until
and symbolic thought means that they develop aware- around age 11.
ness of how they can affect the external world through
Illness concept
imitation and learning, although they remain very ego-
Bibace and Walsh found explanations of illness among
centric. In preoperational children, health and illness
8 to 11 year olds to be more concrete and based on a
are considered in black and white, i.e. as two opposing
causal sequence:
states rather than as existing on a continuum. Children
are slow to see or adopt other people’s viewpoints or ● Contamination: i.e. children understand that illness
perspectives i.e. they lack a ‘theory of mind’, which is can have multiple symptoms, and they recognise that
crucial if one is to empathise with others. Thus a preop- germs, or even their own behaviour, can cause illness:
erational child is not very sympathetic to an ill family e.g. ‘You get a cold if you get sneezed on, and it gets
member, not understanding why this might mean they into your body’.
receive less attention. ● Internalisation: i.e. illness is within the body, and the
Illness concept process by which symptoms occur is partially under-
It is important that children learn over time some respon- stood. The cause of a cold may come from outside
sibility for maintaining their own health; however, few germs that are inhaled or swallowed and enter the
studies have examined children’s conception of health bloodstream. These children can differentiate between
which would be likely to influence their health behaviour. body organs and function and can understand specific,
Research has however examined the developing illness simple information about their illness.
concept. Bibace and Walsh’s (1980) findings from chil- In this concrete operational stage, medical staff are
dren aged 3–13 years suggested that an illness concept still seen as having absolute authority, but children can
develops gradually. Children were asked questions about also see the role of personal action as returning them to
illness knowledge – ‘What is a cold?’; experience – ‘Were health. Children can now begin to weigh up the pros and
you ever sick?’; attributions – ‘How does someone get a cons of actions and medical staff actions might be criti-
cold?’; and recovery – ‘How does someone get better?’ cised/avoided: e.g. reluctance to give blood, accusations
Responses revealed a progression of understanding and of hurting unnecessarily. Importantly children here can
attribution for causes of illness, and six developmentally be encouraged to take some personal control over their
ordered descriptions of how illness is defined, caused and illness or treatment – which can help the child to cope.
treated emerged. They also need to be encouraged to express their fears
Under-7s generally explained illness on a ‘magical’ and to recognise the importance of communication. Par-
level – explanations are based on association: ents need to strike a balance between monitoring a sick
● Phenomenonism: until around 4 years old, illness was child’s health and behaviour and being overprotective,
a sign or sound that the child has at some time asso- as this can detrimentally affect a child’s social, cognitive
ciated with illness, but with little grasp of cause and and personal development and may encourage feelings of
effect: e.g. a cold is when you sniff a lot. dependency and disability (see Chapter 15 ☛ for further
discussion of coping with illness in a family).
● Contagion: from around age 4, illness was caused by
a person or object that is close by, but not necessar-
ily touching the child; or it can be attributed to an
Adolescence and formal
activity that occurred before the illness: e.g.: ‘You get
measles from people’. If asked how? ‘Just by walking
operational thought
near them’. Adolescence is a socially and culturally created concept
only a few generations old, and indeed many primitive
societies do not acknowledge adolescence, and instead
Concrete operational stage children children move from childhood to adulthood with a ritual
Piaget described children over 7 as capable of thinking performance rather than the years of transition Western
logically about objects and events, although they are societies consider a distinct period in life. Puberty is a
period of both physical and psychosocial change. During Overall, childhood sees the development of health and
early adolescence (11–13 years), as individuals prepare for illness concepts and of attitudes and patterns of health
increased autonomy, independence and peers take on more behaviour which impact on the person’s future health sta-
credence than parents, much of life’s health-damaging tus (see Chapter 3 ☛). How children communicate their
behaviour commences, e.g. smoking (see Chapter 3 ☛). symptom experience to parents and healthcare staff, their
ability to act on health advice, and the level of personal
Illness concept responsibility for disease management taken is, accord-
Bibace and Walsh describe illness concepts at this ing to such staged theories, determined by the level of
stage as being at an abstract level, based on interactions cognitive development attained. This approach has not
between the person and their environment: met with universal support whereby illness concepts are
thought to derive from a range of influences, such as past
● Physiological: children now reach a stage of physi-
experience and knowledge, rather than from relatively
ological understanding where most can define illness
fixed stages of cognitive development. Illustrating this
in terms of specific bodily organs or functions (e.g.
germs cause white blood cells to get active to try and point, a survey of 1,674 Canadian children aged 5–12
fight them), and begin to appreciate multiple physical years old (Normandeau et al., 1998) which asked par-
causes, e.g. genes plus pollution plus behaviour. ticipants to consider health in terms of their daily experi-
ences (what signified good health in their friends; what
● Psychophysiological: in later adolescence (from
behaviours are necessary to be healthy; what the con-
around 14 years) and in adulthood, many people grasp
sequences are of being healthy, and what things are dan-
the idea that mind and body interact, and understand
gerous to health) identified they held three main criteria
or accept the role of stress, worry, etc. in the exacer-
for good health:
bation and even the cause of illness. However, many
people of all ages fail to achieve this level of under- 1. being functional (practising sports, absence of
standing about illness and continue to use more cog- disease);
nitively simplistic explanations. 2. mental health (wellbeing, looking healthy, feeling
It should be noted that Bibace and Walsh’s study good about oneself, good relationships with others);
focuses predominantly on the issue of illness causal- 3. lifestyle health behaviour (healthy diet, good hygiene,
ity. Extending illness cognitions further, other work has sleeping well).
shown that children and young people are able to think
about health and illness in terms of other dimensions, The child’s age was found to effect some compo-
such as controllability and severity (e.g. Forrest et al., nents of these dimensions: for example, among older
2006; Gray and Rutter, 2007) (see Chapter 9 for fuller children functionality was more associated with sports
discussion of illness perceptions ☛). participation and physiological functioning, whereas in
Adolescents perceive more personal control over the younger children it was more related to ‘going outside’.
onset and course of illness and are more aware that their Older children also considered ‘not being sick’ as more
actions can influence outcomes. Advice and interven- important. In terms of lifestyle behaviour, older children
tions are more fully understood as are complex remedial more often referred to good diet than did younger chil-
and therapeutic procedures: e.g. they understand that dren; and in terms of mental health, older children more
taking blood can help monitor the progress of a disease often referred to self-concept, whereas younger children
or a treatment. They may, however, choose to be non- referred more to the quality of relationships with oth-
adherent if treatment is thought to disrupt one’s goals ers. No effects were found in terms of gender or socio-
or lose peer approval, or if they are mistrustful of the economic background. In the context of this section on
confidentiality around their heath disclosures to a health life stage and health concept, the important finding is that
professional (Berlan and Bravenderm, 2009). In addition children as young as 5 elicited multidimensional con-
any efforts to minimise a child’s autonomy (from pre- cepts of health that were more complex than suggested
adolescence onwards) can be counterproductive (Holm- by a shift from concrete to abstract thinking as described
beck et al., 2002). by stage theorists. Very early on, children’s conceptions
WHAT DO YOU THINK?

Is middle age simply a state of mind? Are you ‘as
young as you feel’? Think of your parents, aunts
and uncles or of family friends in their 40s. Do they
seem to share outlooks on life, expectancies and
behaviours that are significantly different to those
of you and your friends? How do you view growing
older? Think about how it makes you feel and ques-
tion these feelings.
Photo 1.3 Which of these are healthy? You can’t always tell by adulthood, new perspectives develop from experience
looking. Neither would you know by looking which of these rated across the lifespan, and what is learned is ideally applied
themselves as ‘extremely healthy’ would you? Health is more to achieving future life goals. In relation to health, adults
than objective symptoms.
are less likely than adolescents to adopt new health-risk
Source: Syda Productions/Shutterstock.
behaviour and are generally more likely to engage in pro-
tective behaviour: e.g. screening, exercise, etc. for health
reasons (see Chapter 4 ☛).
included a mental health dimension, which is contrary In contrast to generally positive views of early adult-
to that found in early research. Perhaps the methodol- hood, middle age has been identified as a period of doubt
ogy of inviting children to talk about their concepts in and anxiety, reappraisal and change. Some of this may
relation to their own lives and experience as opposed to be triggered by uncertainty of one’s role when children
more hypothetical questioning, accounts for this differ- become adults and leave home, i.e. ‘the empty nest’ syn-
ence. In addition, the way in which children are spoken drome, and some by awareness of physical changes asso-
to or in which questions are asked may impact on their ciated with ageing – greying hair, weight gain, stiff joints,
understanding and thus their responses. Communicating etc. On a positive note these perceptions of ageing can
with children about their health, illness, or any necessary trigger positive health behaviour change (see Chapter 3
treatments needs to be age appropriate (e.g. Leonhardt and 4 ☛).
et al., 2014).
Ageing and health

Adulthood 17/18
In the UK, as elsewhere in the world, the ageing pop-
Adulthood tends to be divided between early (17–40), ulation (accepting the cut-off age for ‘older people’ to
middle age (40–60) and elderly (60/65). Early adulthood be 60 or over) has burgeoned, but more particularly the
blends out of adolescence as the person forges their iden- percentage of persons living into their late 70s or 80s
tity and assumes the roles and responsibility of adulthood – has increased and is projected to increase further. World-
a time of consolidation. In contrast to the years from 3–13 wide 11.7 per cent of the population are aged over 60
which Laslett (1991) describes as the ‘1st age’, where years (compared to 8.6 per cent in 1980); 7 per cent over
dependency, childhood and education are key, adoles- 65 years, and 1.7 per cent are over 80 years old – this
cence and adulthood is considered as the ‘2nd age’, a latter percentage translates to 120,199,000 individuals
period of developing independence, maturity and respon- (>120 million) (United Nations, 2013). A worldwide
sibility. Early adulthood typically sees all sorts of transi- increase is expected in the proportion of the population
tions, such as graduating from school and college, taking aged over 65. Within the UK (ONS, 2018), projections are
on new careers, pregnancy, marriage, childbirth; many that by 2030 about a fifth of the population will be aged
will divorce, some will lose a parent. Although Piaget 65 or older, and a further 10 per cent will be over the age
did not describe further cognitive developments during of 75. Globally the United Nations predict a 7.6 per cent
increase in those aged 60+ by 2050, with older people this should not be seen as implying that ageing is itself a
outnumbering children by 2047 and representing half of problem, in spite of the ageist attitudes that exist in many
those defined as ‘dependants’ by 2075. industrialised countries.
The shift in proportions of older persons living in The elderly often report expecting to have poor health.
our society is underpinned by many factors, including Such expectations can result in poor healthcare checks
reduced birth numbers/slower population growth, as well and maintenance as they regard health protective behav-
as the reasons associated with longer life expectancy iour as pointless. They may think loss of mobility, poor
cited earlier. The implications for health and social care foot health and poor digestion are an inevitable and una-
resources are obvious, given the epidemiology of illness: voidable part of ageing and so may not respond to symp-
i.e. the fact that the incidence of many diseases increases toms as they should (e.g. Sarkisian et al., 2001). Exercise
with longevity. Of course, not all become ill or infirm tends to decline in old age in the belief that it will over-
as they enter older age; in fact Laslett (1996) describes exert the joints, heart, etc. In fact, the elderly tend to
the ‘3rd age’ of those aged 65+ as a period of fulfilment. underestimate their own physical capacities, yet as we
However, the English Longitudinal Study of Ageing shall see in Chapter 4 ☛, exercise is both possible and
(see also Chapter 14 ☛) (Steptoe et al., 2012), notes beneficial. Even in the face of ‘objective’ signs of illness,
that an increased risk of dying prematurely is associated many older people retain a positive view of their health.
with poorer enjoyment of life. This highlights the role of If we can identify factors associated with ‘successful age-
subjective wellbeing, whatever the age. The ‘4th age’, ing’, then health promotion efforts can target the factors
however, is more strongly associated with disability and associated with this. What is ‘successful ageing’?
dependence, relating to the ‘oldest old’ of those aged over
80 where health does decline more rapidly. Successful ageing
In an ageing society disability is common; 85 per cent
Bowling and Iliffe (2006) describe five progressively
may experience some chronic condition (Woods, 2008),
more inclusive ‘models’ of successful ageing and the
with the main problems being associated with memory
variables considered within each model. Variables were
loss, incontinence, depression, falls or immobility (UN,
all categorised or dichotimised: e.g. presence/absence of
2014). Does the process of ageing influence how an older
diagnosis; sense of purpose/no sense of purpose, etc., in
person thinks about themselves and their health?
order for each model to identify whether a person was
Empirical research has shown that self-concept is rela-
‘successfully aged’ or not:
tively stable through ageing (e.g. Baltes and Baltes, 1990;
Coleman, 1999) and that changes in self-concept are not Biomedical model: based on physical and psychiatric
an inevitable part of the ageing process. While growing functioning – diagnoses and functional ability.
older may present an individual with new challenges, Broader biomedical model: as above but includes
social engagement and activity.
Social functioning model: based on the nature and
epidemiology frequency of social functioning and networks, social
support accessed.
the study of patterns of disease in various
populations and the association with other factors Psychological resources model: based on personal
such as lifestyle factors; key concepts include characteristics of optimism and self-efficacy and on
mortality, morbidity, prevalence, incidence, sense of purpose, coping and problem solving, self-
absolute risk and relative risk. Type of question:
confidence and self-worth (see Chapter 12 ☛ for a
Who gets this disease? How common is it?
discussion of many of these positive cognitions).
self-concept Lay model: based on the above variables plus socio-
that knowledge, conscious thoughts and beliefs economic variables of income and ‘perceived social
about yourself that allow you to feel you are distinct
from others and that you exist as a separate
capital’, which included access to resources and facili-
person ties, environmental quality and problems (e.g. crime,
traffic, pollution, places to walk, feelings of safety).
The study assessed all the above variables in a sample was next best among those classified on the broader bio-
of 999 individuals aged over 65 years and assigned them medical model (3.2 × more likely), than the biomedical
either as successfully aged or not based on achieving the model (2.6 × more likely), the psychological (2.4 × more
‘good’ score on each variable, e.g. no physical conditions likely) and social models (1.99 × more likely).
versus one or more. The authors then tested which of these Such findings highlight the importance of multidimen-
models ‘best’ distinguished those participants that rated sional models of health in that medical or psychological
quality of life (QoL) as ‘Good’ (included ‘So good, could or social variables are all important, but a more holistic
not be better’, or ‘Good’) instead of ‘Not good’ (included model is ‘better’. A broader model also opens up a range
‘Alright’ or ‘So bad, could not be worse’). Although each of opportunities for intervention; the challenge now is to
model could independently predict QoL (Chapter 15 ☛), use such findings to develop and evaluate health promo-
the strongest prediction was achieved by the lay model. tion interventions with older populations (see Chapters 6
Those individuals who scored as ‘successfully aged’ on and 7 ☛). Of note, however, is that the sample in this
the basis of lay model variables were more than five times study was 98 per cent white and thus the model of suc-
more likely to rate their QoL as ‘Good’ rather than ‘Not cessful ageing best associated with QoL in this sample
good’. The odds of a ‘good’ QoL rating versus ‘not good’ may not hold for non-white samples.
IN THE SPOTLIGHT
Measuring self-rated or subjective report poorer health and furthermore the same asso-
ciations are not always found for both genders. Across
health status
all EU countries sampled for the data presented above
Health is commonly viewed in terms of how we feel and (OECD, 2018), men were more likely to rate their health
what we do. Our ‘health status’ is not simply whether as good or better, and rating declined markedly after
we are alive or dead, nor is it defined simply on the age 45 in many countries and then again after age 65
basis of the presence or absence of symptoms – (see also Figure 1.4). Socio-economic influences on
it is something we perceive for ourselves, sometimes health experiences and SRH reports are also reported
referred to as ‘subjective health status’. In fact, gen- (OECD, 2018; Link et al., 2017) (see Chapter 2 ☛ )
erally the relationship between subjective health and whereby nearly 80 per cent of those in the highest
markers of ‘objective’ health is weak (e.g. Berg et al., income quintile report good health, compared to about
2006); however, self-ratings of health (SRH), often 60 per cent of those in the lowest income quintile.
assessed as a simple single item (e.g. ‘How is your
health in general? Is it very good, good, fair, bad, Addressing measurement issues, Sargent-Cox and
very bad?’), have been found to predict major health colleagues conducted a study of over 2,000 Australian
outcomes, including mortality (e.g. Bond et al., 2006; adults over the age of 65 assessed seven times between
Sargent-Cox et al., 2010). In almost all European 1992 and 2004. They used three different measures of
countries a majority of the adult population will rate SRH – comparing self with previous self (a temporal
their health as good or very good, although this does comparison); comparing self with other people of the
not mean that the actual health within the countries same age (an age-group comparison) and a no-com-
depicted is ‘objectively’ better (OECD, 2018). These parison global rating (simply rated current health). They
are self-reports, and with this type of data come some hypothesised that the age-group social comparison
challenges. would show an increase as the sample increasingly
engaged in downward social comparison (with those
For example, data are potentially influenced by the age worse off) so as to enhance their self-rating; and that
composition of the sample, as older people generally the temporal comparison would show worsened SRH.
WHAT IS HEALTH PSYCHOLOGY? 27
negative (in men but not those aged 65 on commence-

People aged 16–44 years ment); and while the self-comparative ratings became
Males 88.3% more negative, a ceiling effect is seen whereby, over
Females 86.3% time, participants became more likely to rate themselves
as having stayed the same as previously.
People aged 45–64 years
Such findings demonstrate the important fact that the
Males 67.3%
measures we use can influence the results we find
Females 65.4%
and thus the interpretations we make. For example,
People aged 65 and over a self-comparison measure is seen to plateau in the
Males 43.1% context of an ageing population, perhaps out of a feel-
Females 36.%% ing that ‘my health cannot get any worse’. By scor-
ing SRH as being ‘same as the year previously’, this
could be misinterpreted as implying that health is bet-
Figure 1.4 Self-perceived health in the EU 2018: good and
very good ter than expected given the passing of time and an
assumption that actual health deteriorates over time.
Source: EU Eurostat (2020b).
Such findings have relevance also for constructs other
In fact all three ratings worsened over time but the extent than self-rated health, for example. Chapter 5 ☛
and rate of worsening varied: the global rating showed describes how the comparator used in questions
a steep decline over the 12 years; contrary to expecta- regarding drinking behaviour, or disease risk, can also
tions, the age-group comparative ratings became more change responses.
This chapter has described what is often meant by

‘health’. In focusing on health, we have acknowledged
that health is a continuum, not simply a dichotomy of
sick versus healthy. Most of us will experience in our
lifetime varying degrees of health and wellbeing, with
periods of illness at one extreme and optimal wellness at
the other. Some may never experience optimal wellness.
‘Health refers to a state of being that is largely taken
for granted’ (Radley, 1994: 5) and is often only appreci-
ated when lost through illness. In the final section of this
chapter we want to introduce what is broadly considered
as the discipline of health psychology. The final chap-
ter of this book addresses careers in health psychology
(Chapter 18 ☛).
What is health
psychology?
Before defining health psychology, let’s first look at
psychology as a discipline generally. Psychology can be
defined as the scientific study of mental and behavioural
functioning. Studying mental processes through behav-
Photo 1.4 Many activities can be enjoyed at any age. iour is limited, however, in that not all behaviour, such as
Source: Radius Images/Design Pics/Alamy Images. our thoughts, are observable. For many aspects of human
behaviour we therefore have to rely on self-report, the to play in maintaining it. As such, we can address ques-
problems of which are described elsewhere. tions such as:
Psychology aims to describe, explain, predict and,
● Why do some people behave in a healthy way when
where possible, intervene to control or modify behavioural
others do not? Is it all a matter of personality?
and mental processes, from language, memory, attention
and perception to emotions, social behaviour and health
● Does a person who behaves in a healthy manner in
behaviour, to name just a few. The key to scientific meth- one way, for example by choosing not to smoke,
ods employed by psychologists is the basic principle that also behave healthily in other ways, for example, by
the world may be known through observation = empiri- attending dental screening? Are we rational and con-
cism. Empirical methods go beyond speculation, infer- sistent beings?
ence and reasoning to actual and systematic analysis of ● Does gender, age or socio-economic status affect
data. Scientific research starts with a theory, which can be health either directly or indirectly via their effects on
defined as a general set of assumptions about how things other things such as lifestyle?
operate in the world. Theories can be vague and poorly ● Why do some people appear to get ill all the time
defined (e.g. I have a theory about why sports science while others stay healthy? What relationship is there
students generally sit together at the back of our psychol- between the mind and the body?
ogy lectures) to very specific (e.g. sports science students ● What psychosocial and contextual factors can help a
sit at the back of lectures because they feel like ‘outsid-
person adjust to, or recover from, illness and can these
ers’ when placed with the large numbers of psychology
be targeted in psychologically informed interventions?
majors). Psychologists scientifically test the validity of
their hypotheses and theories. On an academic level this Health psychology integrates many cognitive, devel-
can increase understanding about a particular phenom- opmental and social theories and applies them solely to
enon, and on an applied level it can provide knowledge health, illness and healthcare. Health psychology was
useful to the development of interventions. described at an early stage by Matarazzo as ‘the aggre-
Psychologists use scientific methods to investigate gate of the specific educational, scientific and profes-
all kinds of behavioural and mental processes, from the sional contribution of the discipline of psychology to the
response activity of a single nerve cell to the physical promotion and maintenance of health, the promotion and
adjustments required in old age, and the research method treatment of illness and related dysfunction’ (1980: 815).
employed will depend on what specific questions are This definition highlights the main goals of health psy-
being asked. You obviously would not use the same chology, i.e. we seek to develop understanding of biopsy-
methods to establish the extent of language in a two-year- chosocial factors involved in:
old as you would to identify which areas of the brain were ● the promotion and maintenance of health;
activated during speech. This text highlights the methods
most commonly employed by health psychologists: for
● improving healthcare systems and health policy;
example, the use of questionnaires, interviews and psy- ● the causes of illness: e.g. vulnerability/risk factors.
chometric assessments (such as of personality). ● the prevention and management of illness
Unlike some other domains of psychology (such as

What connects psychology cognitive science), health psychology can be considered
as an applied science, although not all health psychology
to health? research is predictive. For example, some research aims
As already introduced, people have beliefs about health, only to quantify (e.g. what percentage of school pupils
are often emotional about it and have a behavioural role drink under age?) or describe (e.g. what are the beliefs
of under-age drinkers regarding the effects of alcohol?).
Descriptive research ideally provides the foundation for
empiricism the generation of more causal questions: e.g. do beliefs
arising from a school of thought that all knowledge about alcohol in primary schoolchildren predict age of
can be obtained through experience onset of under-age drinking? By simply measuring health
beliefs and attitudes, we can begin to grapple with the
issue of predictors (see Chapters 3–5 ☛). In other words hostility and heart disease associations, for example).
we need to develop understanding first, then prediction, Until the 1960s, psychosomatic research was predomi-
and then ideally we can develop evidence-based interven- nantly psychoanalytical in nature, focusing on psychoan-
tions that can be applied and evaluated in practice. alytic interpretations of illness causation, such as asthma,
ulcers or migraine being triggered by repressed emotions.
However, one negative by-product of this work is that
Health psychology and among those with a biomedical viewpoint, illnesses with
other fields no identifiable organic cause were often dismissed as
nervous disorders or psychosomatic conditions for which
Health psychology has grown out of many fields within
medical treatment was often not forthcoming. Illnesses
the social sciences and it adopted and adapted models and
with no physical evidence are known as psychogenic (see
theories originally found in social psychology, behaviour-
Chapter 8 ☛ for a discussion of chronic pain which some-
ism, clinical psychology, cognitive psychology, etc. In
times falls into such considerations, and Chapter 9 ☛
fact you should also pick up an introductory psychology
for discussion of medically unexplained symptoms).
text and look at the learning, motivation, social, devel-
Psychosomatic medicine today is more concerned with
opmental and cognitive sections in more detail. Health
mixed psychological, social and biological/physiological
psychology in Europe is, as in the USA and Australasia,
explanations of illness i.e. illnesses are often viewed as
linked with other health and social sciences (e.g. psycho-
‘psychophysiological’. The increased acceptance dur-
somatic medicine, behavioural medicine, medical soci-
ing the 1970s that psychological factors can affect any
ology and, increasingly, health/behavioural economics)
physical condition led to the emergence of an integrated
and with medicine and allied therapeutic disciplines. Few
discipline known as behavioural medicine, and to health
academic or practitioner health psychologists work alone;
psychology itself.
most are involved in an array of inter- and multidisci-
plinary work and in fact this is increasingly valued and
encouraged by our university employers and our research Behavioural medicine
funders (see Chapter 18 ☛). In each of the above named
This is essentially an interdisciplinary field drawing on
disciplines dualist thinking regarding mind–body separa-
a range of behavioural sciences, including psychology,
tion has been challenged, but each have differences in
sociology, health education, and behavioural economics,
their theoretical underpinning (i.e. sociological, medical,
and applying them to medicine and medical conditions
psychological) and in the resulting methods of assess-
(Schwartz and Weiss, 1977). As its name suggests, behav-
ment, research and intervention suggested or employed.
ioural principles (i.e. that behaviour results from learning
through classical or operant conditioning) were applied
Psychosomatic medicine to the evaluation of prevention and rehabilitation, as well
as of treatment. In furthering the view that the mind had a
Developed in the 1930s, this initially was the domain of
direct link to the body (e.g. anxiety can raise blood pres-
now well-known psychoanalysts, e.g. Alexander, Freud,
sure, fear can elevate heart rate), some of the therapies
and offered an early challenge to biomedicine as dis-
cussed earlier. ‘Psycho-somatic’ refers to the fact that the
mind and body are both involved in illness, and where an
organic cause is not easily identified the mind may offer
motivation
the trigger of a physical response that is detectable and
memories, thoughts, experiences, needs and
measurable. In other words, mind and body act together. preferences that act together to influence (drive)
Early work asserted that a certain personality would lead the type, strength and persistence of our actions
to a certain disease (e.g. Alexander’s ‘ulcer-prone per-
operant conditioning
sonality’; Freud’s ‘hysterical paralysis’), and while evi-
attributed to Skinner, this theory is based on the
dence of direct causality is limited, these developments in
assumption that behaviour is directly influenced
thinking certainly did set the groundwork for fascinating by its consequences (e.g. rewards, punishments,
studies of physiological processes that may link person- avoidance of negative outcomes)
ality type to disease (see Chapter 11’s ☛ discussion of
proposed, such as biofeedback (see Chapter 13 ☛) and responses to the external world and obviously takes a
work on the principle of operant conditioning and feed- psychological rather than a sociological perspective. The
back. Prevention however receives less attention within growth over time of a more critical and reflective health
behavioural medicine than rehabilitation and treatment psychology may make the boundaries between medical
of illness, which highlights one of the key differences sociology and health psychology more blurred and cer-
between it and health psychology. tainly in our textbook we address the contextualisation of
Matarazzo distinguished between ‘behavioural health’ individual behaviour, thought and emotion in every chap-
and ‘behavioural medicine’, with the former being more ter; however we still look to sociology more for wider
concerned with health enhancement and disease pre- sociopolitical considerations.
vention rather than focusing on those with illness as
behavioural medicine does. ‘Behavioural health’ is not Clinical psychology
however a stand-alone discipline but has been assimilated
into others, including those areas of health psychology we Health psychology and health psychologists are often
describe in the following three chapters, i.e. behaviour confused with clinical psychology and clinical psycholo-
and lifestyle factors associated with health and illness. gists as both are concerned with psychological explana-
tions of human health and behaviour. At a basic level,
clinical psychology has traditionally been concerned
Medical psychology with mental health and the diagnosis and treatment of
In the UK, medical psychologists would now tend to mental health problems (e.g. personality disorders, pho-
be termed health psychologists who do not dispute bias, anxiety and depression, eating disorders). Clinical
the biological basis of health and illness but who have psychologists are typically practitioners working within
adopted a more holistic model. In other parts of Europe, the healthcare setting, delivering assessments, diagnoses
for example the Netherlands, the term ‘medical psycholo- and psychological interventions that are derived from
gist’ describes a professional working in a medical set- behavioural and cognitive principles, e.g. CBT. While
ting who has completed a psychology degree and Health health psychology research may also be used to guide
Psychology Masters training (one or two years), followed cognitive-behavioural interventions (see later chapters),
by a two-year internship for generalist practitioner cer- and increasing health psychologists are employed in the
tification, or clinical psychology training (as for Health health sector, the populations with whom we work are
Psychology but adding a further four years to get full typically those experiencing physical health concerns or at
state specialist certification) (Soons and Denollet 2009). risk of those via their behaviours. The professional practi-
In the USA the term is used to describe a clinical psy- tioner status of our discipline differs across countries and
chologist who incorporates somatic (physical) medicine you are referred to your national psychological associa-
into their consideration of mental illness, and in some tions for more information and also to Chapter 18 ☛
cases they can even prescribe medicines. Thus ‘medical where we describe health psychology careers.
psychology’ is a term more aligned to a profession than
to a specific cognate discipline.
Health psychology
Health psychology is fundamentally a discipline within
Medical sociology the larger discipline of psychology: we are first and
Medical sociology exemplifies the close relationship foremost psychologists. As mentioned earlier, health
between psychology and sociology, with health and psychology emerged in the late 1970s and takes a biopsy-
illness being considered in terms of the wider social, chosocial approach to health and illness. This means that
political and contextual factors that may influence indi- it considers biological, social and psychological factors
vidual experience. It takes a wider (macro) approach to involved in the aetiology, prevention or treatment of
the individual in that they are considered within family, physical illness, as well as in the promotion and mainte-
kinship, culture. While health psychology also considers nance of health. Health psychologists also need a basic
external influences on health and illness, it has tradition- (or good!) understanding of body systems and their
ally focused more on the individual’s cognitions/beliefs function including that of the nervous system, endocrine
system, immune system, respiratory and digestive sys- microsystem components, for example the reciprocal
tems (see Chapter 8 ☛). influences between a person and their family or healthcare
Health psychology has developed over time, both aca- systems during illness experience (see Chapter 15 ☛),
demically and professionally, with different terminology macrosystem factors, contextual factors such as health-
and roles in different corners of the globe. Some health care policies, systems and access to them, sociocultural
psychologists increasingly align themselves with public norms and shared values, and exosystem factors, such
health to address issues such as immunisation, infectious as the more indirect influences such as the role played
disease control, epidemics, and implications for health by mass media in portraying a health condition (think
education and promotion (see McManus, 2014, letter to of COVID-19, AIDS, liver failure) or the role played by
The Psychologist); and others embrace critical health psy- medical training in the care subsequently received. This
chology, which addresses criticism that health psychol- model acknowledges that the biological, psychological,
ogy has been too individualistic in focus, at the expense social/interpersonal and contextual factors interact in a
of the social, although this is less valid now than when reciprocal and dynamic way with the salience or ‘central-
we produced our first textbook 15 years ago! To address ity’ of factors changing over time as each or all change
early concerns raised by critical health psychology, we – for example, a person’s illness beliefs may shift as bio-
have incorporated throughout this textbook a considera- logical aspects of an illness change or as they move from
tion of wider influences on health, and on illness, such as hospital to home, or from home to work, where different
culture, lifespan and socio-economic variables. Humans forms and systems of care are available.
do not operate in a vacuum but are interacting social Society (local, regional, national, global) and politics
beings shaped, modelled and reinforced in their thoughts, plays a significant role in the human experience of health
behaviour and emotions by people close to them, by less and illness. There is a greater and growing acknowledge-
known people, by politicians, by their culture, and even ment of the rich diversity of cultures in the UK and the
by the era in which they live. Consider, for example, rest of Europe, and how variation in their beliefs and
women and work stress – this was not an issue in the expectancies influence health and illness behaviour.
1900s, when society neither expected nor particularly
supported women to work, whereas in the twenty-first
century we have a whole new arena of women’s health variable
issues that in part may relate to the way women’s roles (noun): something that can be measured or is
have shifted in society. Where the biopsychosocial model reported and recorded as data, such as age,
was initially often treated by health psychologists as if the mood, smoking frequency or physical functioning
three components were simultaneous but separate influ- microsystem
ences (Crossley, 2000), research today acknowledges the a person’s immediate direct contacts including
interplay and integration between the biological, social family, friends, class mates or colleagues
and psychological, with the role of cultural and ethnic-
mesosystem
ity influences at a more macro level advocated also (e.g.
where multiple aspects of a person’s microsystem
Suls and Rothman, 2004) although these are less consist-
interconnect and act upon the individual, for
ently addressed. More recently, Lehman et al.’s (2017) example communications between a person’s
dynamic biopsychosocial model of health has provided family member and a healthcare provider
a more contextualised approach to health, with fuller macrosystem
consideration given to interpersonal dynamics and the
a person’s wider setting including socioeconomic,
passage of (historical and developmental) time than the environmental and cultural factors that frame the
typical biopsychosocial model taken from Engel (Engel, structures and relationships between all other
1977). Borrowing concepts from theories such as Bron- systems
fenbrenner’s ecological systems theory (1979; 1986), exosystem
Lehman’s model considers microsystem factors which where individuals are affected by systems they
are a person’s immediate context of family, friends, col- are not part of, for example a partner’s inflexible
leagues, healthcare provider for example, mesosystem workplace policies, media coverage of a health issue
factors which refer to interpersonal interactions between
Through review, critique and reflection, the still rela- In conclusion, this textbook considers personal, cultural
tively new discipline of health psychology has developed and social perspectives on health and illness in an integrated
and strengthened. As potential health psychologists of the manner and is aligned with mainstream psychological
future, readers should be aware of the risks of compla- thinking. Moving from theory, through robust and meth-
cency and the importance of reflection and critique! odologically rigorous research, we highlight the central
The professional title ‘health psychologist’ is recog- goal of developing a theoretical and empirical understand-
nised now in many countries, including, for example, the ing of human health and illness. Only then can we apply
British Psychological Society and the Health Professions that understanding to the development of interventions in
Council UK, The American and Australian Psychologi- healthcare practice or to the communication of science to
cal Societies. In the UK we distinguish between an HPC those tasked with shaping health policy. For a discipline to
registered Health Psychologist Practitioner with certified continue to evolve, ongoing methodological and theoreti-
competencies in ethical practice, research, teaching, con- cal review, critque and development are important and so
sultancy and interventions, and who may be employed we point out the limitations of some general assumptions
within our National Health Service within the pain ser- of the field and of some study findings as we proceed. It is
vice, or in rehabilitation for example, and an Academic important that current readers hear what I often say to my
Health Psychologist who is also educated to Doctoral own students – ‘just because it is published doesn’t mean it
level but whose work is generally within higher education is perfect’, and while introductory textbooks seek to sum-
and confined to teaching and research (often in collabo- marise the current state of knowledge in an area, they do so
ration with health professional practitioners). Academic in a relatively superficial way. Readers need also to pursue
Health Psychologists would not be eligible to work some of the many references to empirical studies cited. As a
directly in practice with patients’ but may consult with starting point, see de Bruin and Johnston’s commentary (de
those practitioners to develop effective interventions or Bruijn and Johnston, 2012), which offered a timely review
to evaluate them. Interested readers should refer to their of research methods within health psychology and which
own professional bodies for current role descriptors and led to stimulating and ongoing reflection and debate within
career opportunities. our European Health Psychology Society.
SUMMARY
This chapter has introduced key areas of interest to ○ Culture can be grounded in collective or indi-
health psychologists, including: vidualistic orientations, and these will influence
explanations for health and illness as well as
● What is health? the behaviour of those within the culture.
○ Health appears to consist broadly of domains ● What influence might lifespan play on how health
of ‘having’, ‘doing’ and ‘being’, where health is perceived?
is a reserve, an absence of illness, a state of ○ Children can explain health and illness in com-
psychological and physical wellbeing; is evi- plex and multidimensional terms; and human
dent in the ability to perform physical acts, as expectations of health change over our lifespan
fitness, and is generally something that is taken as a function of experience as well as of cogni-
for granted until it is challenged by illness. tive development.
● How have health and illness been viewed over
● What is health psychology?
time? ○ Health psychology is the study of health, ill-
○ Views of health have shifted from fairly holistic ness and healthcare practices (professional
views, where mind and body interact, to more and personal).
dualist views, where the mind and body were ○ Health psychology aims to understand, explain
thought to act independently of one another. and ideally predict health and illness behav-
This has shifted back towards holism, with the iour in order that effective interventions can
medical model being challenged by a more be developed to reduce the physical and emo-
biopsychosocial approach. tional costs of risky behaviour and illness.
● What influence does culture have on how health ○ Health psychology offers a holistic but funda-
is perceived? mentally psychological approach to issues in
health, illness and healthcare.
FURTHER READING 33
Further reading The European Health Psychology Society website provides

access to useful information about research across Europe,
S. Kitayama and D. Cohen (eds) (2007). Handbook of Cultural health psychology in practice, and access to the European
Psychology. New York: Guilford Press. health Psychologist Bulletin:
This 30-chapter text has become a leader and a landmark http://www.ehps.net/index.php?option=com_content&view=
text for anyone interested in the role culture plays at all levels article&id=1&Itemid=118
in terms of perceiving self and others, and in terms of cogni-
tion, emotion and motivation, and development. While not Those interested in health psychology as applied to public
focusing on health specifically, it is worth a look. health issues may find this organisation useful; they also
address behavioural science more broadly:
Turner-Cobb, J. (2014). Child Health Psychology. London:
Sage. https://www.bsphn.org.uk/
This book goes a significant way towards filling a gap in the If you have an interest in global health issues and sustainable
market of health psychology textbooks in that it focuses spe- development goals, this site is worth a look at and is regularly
cifically on psychosocial and developmental aspects of child updated.
health and illness, including, as pertinent to this chapter, dis- https://sdgs.un.org/publications/transforming-our-world-
cussion of the health concept. 2030-agenda-sustainable-development-17981
The British Psychology website is useful for defining health
psychology as a discipline and as a profession in the UK (see
also Chapter 18 ☛ ):
http://www.bps.org.uk/careers-in-psychology
Chapter 2
Health differences and
inequalities
Learning outcomes
• the impact of poverty on health
• causes of variations in health between and within countries
• the impact of socio-economic deprivation on health and theories of why this occurs
• the relationship between work stress, unemployment and health
• the health impact of having a minority status in society
• the impact of gender on health
Viruses cause ill health throughout the world – but
not always in the way you think
Governments across the world are trying to make us healthier. We are urged
to eat healthily, exercise and avoid drinking too much alcohol. But is this drive
to healthy behaviours hiding an insidious fact – and one governments would
like us to ignore? Perhaps the most important contributor to our health is not
what we do, but where in society we are. A job is better for your health than no
job at all. But better jobs are better for your health. People who live in deprived
areas are likely to live 10 or more years less than those in less deprived areas.
Women are more likely to experience work stress and its associated ill health
than men. People in ethnic minorities may experience poorer working conditions
and stress related to prejudice. They have also proven more susceptible to dis-
eases evident throughout society such as COVID-19. These factors are easy to
identify – difficult to change. And at a time of economic stringency, which many
industrialised countries are now facing, health disparities due to work and social
pressures, as well as difficult economic conditions, are likely to increase rather
than decrease. The health as well as the wealth of nations may well suffer in the
next few years as a result of a range of government policies and the economic
pressures resulting from events such as the COVID-19 pandemic.
36 CHAPTER 2 ● HEALTH DIFFERENCES AND INEQUALITIES
Chapter outline
This chapter considers differences in health status that arise not as a result of individual
behaviour but from the social context in which we live. Among other things, it considers
why better-off people tend to live longer than those who are less well off, why women
generally live longer than men, and why people from ethnic minorities are more likely to
die earlier than those from majority populations. The greatest killer in the world is pov-
erty, which is associated with poor nutrition, unhealthy water supplies, poor healthcare,
and other factors that directly influence health. Among people who do not experience
such poverty, more subtle social and psychological factors influence health. Men’s
health, for example, may be influenced by a general reluctance to seek medical help
following the onset of illness. People who are economically deprived may experience
poorer health because of problems of accessing healthcare, and greater levels of stress
than the more economically well off. This chapter examines how social and psychologi-
cal processes differentially influence health as a result of socio-economic status (SES),
ethnicity, gender and working environment.
Health differentials intertwined. People with relatively low incomes, for

example, may engage in more health-damaging behav-
iours and also have jobs or experience work practices that
Where we live, as well as our social and economic cir- increase their risk of disease. Accordingly, although this
cumstances, can have a profound effect on our health. chapter attempts to identify the specific health gains or
The biomedical model of health and ill-health has typi- risks associated with different social contexts, it should
cally focused on biological factors such cholesterol and be remembered that many individuals face multiple
blood pressure influences on health. Psychological per- advantages or disadvantages as a result of occupying
spectives have generally focused on health behaviours several social contexts.
such as exercise and diet, and factors that may influence
them, including attitudes, perceived norms, and self-
efficacy (see Chapters 3, 4, and 11 ☛). However, there Evidence of health differentials
is a strong body of evidence that environmental and social
There are clear health differentials between countries.
factors may have an equal, if not greater, influence on
As can be seen in Table 2.1, all the countries whose
our health. The better-off tend to live longer than the less
well off. People who occupy minority roles in society as
a result of ethnic or other factors may experience more socio-economic status
illness or die earlier than the majority population. Even a measure of the social class of an individual; dif-
findings that women live longer than men now appear ferent measures use different indicators, including
to have psychosocial as well as biological explanations. income, job type or years of education; higher sta-
This chapter considers how and why people experi- tus implies a higher salary or higher job status
ence differences in health and longevity as a result of health differential
their socio-economic status (SES), ethnicity, gender, a term used to denote differences in health status
and working conditions. It considers each factor sepa- and life expectancy across different groups
rately, although in reality each of them may be intimately
HEALTH DIFFERENTIALS 37
Table 2.1 Life expectancy, by gender, in years for the highest with the industrialised nations, where the key causes of
and lowest ranked countries by World Health Review, 2019 death are chronic disease and abuse of drugs such as
Top 5 Male Female tobacco and alcohol.
One particular issue still facing many countries in
Hong Kong 81.88 87.66 Africa is that of HIV infection and AIDS. In sub-Saharan
Japan 81.41 87.59
Africa, an estimated 19.6 million people, 6.8 per cent of
Macau 81.20 87.1
Switzerland 81.76 85.53 the population, were living with HIV in 2017 (Avert,
Singapore 81.41 85.65 2021). Southern Africa was the worst affected region
Bottom 5 and is considered to be the ‘epicentre’ of the global
Ivory Coast 53.39 56.37 HIV epidemic. Here, Swaziland had the highest HIV
Nigeria 53.72 55.39 rate of infection in the world, with 27.2 per cent of its
Central African Republic 51.83 55.86
population living with HIV; South Africa had a lower
Chad 52.40 54.89
Sierra Leone 52.05 53.37 prevalence, but as a much larger country had nearly
9 million people living with the virus. By comparison, the
Source: http://worldpopulationreview.com/countries/
life-expectancy/. prevalence of HIV in West and East Africa is considered
‘low’ to ‘moderate’ averaging a 1.9 per cent prevalence
rate across its various countries, while the rate in the UK
populations experience the shortest life expectancy are
in the same period was 0.017 per cent.
in Africa. Countries with the best health are scattered
around the world; although the top five are now, with
only one exception, in relatively rich Asian countries. Even the ‘haves’ experience
Given these data, one may expect that populations of
rich nations simply live longer than those of the poorer
health differentials
nations. This is generally, but not universally, true. The While the industrialised world may not have the profound
USA, for example, fared rather badly in the 2019 World levels of poverty and illness found in the developing
Population rankings, at only 45th place (one below world, there are gradients of wealth within these countries,
Lebanon), with an overall life expectancy of 79.7 years. and differentials in health that match them. The richer
Clearly the wealth of a country is not the sole indicator people within most industrialised countries are likely to
of the health of its citizens. live longer than the less well-off and be healthier while
Despite recent health gains (https://childmortality. alive: see Hosseinpoor et al.’s (2012) confirmatory data
org/), nearly one-third of deaths in developing countries across 57 countries. One example of this can be found in
occur before the age of 5 years while a further third of data reported by Rasulo et al. (2007). They calculated the
deaths occur before the age of 65 years. This contrasts expected ‘healthy life expectancy’ of individuals living
with the average two-thirds of deaths that occur after in 8,797 specified areas of the UK and the level of social
the age of 65 years within the industrialised countries. deprivation of each area using a measure of deprivation
The factors that contribute to these differences are eco-
nomic, environmental and social. People in many devel-
oping countries may experience significant health risks;
from lack of safe water, poor sanitation, inadequate lower respiratory tract infection
diet, indoor smoke from solid fuels, and poor access to infection of the parts of the respiratory system
healthcare. including the larynx, trachea, bronchi and lungs
The WHO has estimated that poverty causes around prevalence
12 million deaths each year in children under the age of the percentage or total number of people to have
5 living in the developing world, with the most common a disease in a given population at any one time;
causes of death being diarrhoea, dysentery and lower contrasts with incidence, which is the number or
percentage of people who develop a particular
respiratory tract infections (https://afro.who.int/health-
disease within a particular time frame – prevalence
topics/poverty). Major killers among the adult population is the number or percentage of existing cases, inci-
include being underweight, tuberculosis and malaria. This dence is the number of new cases
high risk for death through infection contrasts markedly
known as the Carstairs’s deprivation score. This measures influence following a range of more acute health chal-
levels of household overcrowding, male unemployment, lenges, including risk of death from COVID-19 (e.g.,
economic deprivation, and car ownership. They then cal- Williamson et al., 2020).
culated how long people were expected to live in good
health across the varying levels of deprivation and found
a linear relationship between deprivation scores and Explanations of socio-economic
expected ‘healthy life expectancy’ (see Figure 2.1). They health inequalities
reported a staggering 13.2-year difference between those
in the least and most deprived areas. A number of explanations for health inequalities within
Even more worryingly, similar data across England industrialised countries have been proposed, some of
and Wales between 2012/4 and 2015/7 revealed increased which attribute responsibility to the individual. Others
inequalities over this time (Office for National Statistics suggest that factors related to occupying different socio-
2019). Typical findings included evidence that women economic groups may directly impact on health. But the
living in the most deprived areas of Wales lived up to 11 first issue that has to be addressed is the causal direction
years in a poorer state of health than their counterparts between SES and health. Does SES influence health, or
in the least deprived areas. In England, men resident in does health influence SES?
the least deprived areas could expect 13.3 years of good
health from 65 years of age, but only 5.8 years if they
Social causation versus social drift
lived in the most deprived areas. Despite these stark sta-
tistics, it is important to note that the relationship between Explanation for socio-economic health differentials
SES and health is linear, indicating not just that the very pits a social explanation against a more individual one.
poor die earlier than the very rich: instead, it indicates The first, the social causation model, suggests that low
that quite modest differences in wealth can influence SES ‘causes’ health problems – that is, there is some-
health throughout society. Finally, it should be noted thing about occupying a low socio-economic group that
that while most diseases linked to SES and premature adversely influences the health of individuals. The oppos-
mortality or morbidity are chronic ‘lifestyle’ diseases, ing view, the social drift model, suggests that when an
being economically deprived can also have an adverse individual develops a health problem, they may be unable
to maintain or obtain the quality of job required to main-
tain their standard of living. They therefore drift down
Years of healthy life expectancy the socio-economic scale: that is, health problems ‘cause’
80
low SES.
75 Longitudinal studies have provided evidence relevant
70 to these hypotheses. These typically identify a representa-
tive population of several thousand healthy individuals
65
who are then followed over a number of years to see what
60 diseases they develop and from what causes they die. Dif-
ferences in measures taken at baseline between those who
55
do and do not develop disease indicate likely risk factors
50 for disease: people who die of cancer, for example, are
45 more likely to have smoked at baseline than those who
Lowest Highest did not, suggesting smoking contributes to risk for devel-
deprivation deprivation
oping cancer.
Each of the studies using this form of analysis has
Figure 2.1 Years of healthy life expectancy according to found that baseline measures of SES predict subsequent
Carstair’s deprivation scores in the UK
health status, while health status is less predictive of SES
Source: From ‘Inequalities in health expectancies in England and
Wales: small area analysis from 2001 Census’, Health Statistics
or a lowering of SES (e.g. Pulford et al., 2018). Other
Quarterly, 34 (Rasulo, D., Bajekal, M. and Yar, M. 2007). data supporting the social causation model show that as
HEALTH DIFFERENTIALS 39
people move from employment to unemployment or inse- of the socio-economic differences in health, they do not
cure jobs as a result of factors unrelated to their health, provide the full story. In a study of over 8,000 US older
younger and middle-aged adults may experience dete- men and women, for example, Nandi et al. (2014) found
riorating health (Van Aerden, Gadeyne and Vanroelen, that smoking, alcohol consumption and low levels of
2017), while older individuals experience higher mortal- physical inactivity explained 68 per cent of the variance
ity rates (Montgomery et al., 2013). Accordingly, while in deaths over a 10-year period. The rest was accounted
there may be some modest downward drift due to ill- for by SES. Interestingly, the influence of SES appears
health, SES is generally seen as a cause of differences in to vary across populations. Stringhini et al. (2011)
health status rather than a consequence. found that health behaviours attenuated the association
Such inequalities may even be embedded in childhood. between SES and mortality in a UK population by 75
There is an emerging literature indicating childhood fac- per cent. In a similar mainland European population,
tors are equally as important as, if not more important they reported the degree of attenuation averaged only
than, concurrent factors in determining health. This may 19 per cent.
be due to the early establishment of difficult to change What is perhaps worth considering here is why
factors linked to low SES, including childhood obesity, people in the lower socio-economic groups engage in
that result in long-term metabolic problems such as dia- more health-compromising behaviours. It does not
betes (Tamayo, Christian and Rathmann, 2010). It may appear to be the result of lack of knowledge (Narevic
be even more fundamental. Austin et al. (2018) found and Schoenberg, 2002). Rather, it may be a deliberate
early life SES disadvantage directly predicted measures choice based on a calculation of the costs and benefits
of cellular ageing, with no mediation through concurrent of such behaviours. These may include smoking as
SES or health-related behaviours, while Loucks et al. a means of coping with stress (e.g., Kobayashi and
(2016) found that changes in gene expression related to Kondo, 2019) to more subtle factors such as threatened
obesity during childhood were directly related to mid-life loss of social contacts should an individual quit smoking
body mass index. It seems that at least some risk profiles (Hitchman et al., 2014). Similarly, Wood et al. (2010)
established in childhood may be relatively immutable found that many working-class mothers were aware
over time. of government guidelines on healthy eating, but this
knowledge was often superficial and only formed part
of their decision making in relation to eating. Priority
Different health behaviours in food choice was often based on taste, being filling,
We identified in Chapter 1 ☛ how a number of behav- hot, and appetite-satisfying. Eating unhealthy foods was
iours influence our health. With this in mind, one obvious justified in various ways, and many mothers considered
potential explanation for the higher levels of ill-health their meals acted as a form of emotional support that
and premature mortality among people in the lower could improve other aspects of family wellbeing. The
socio-economic groups is that they engage in more type of health-behaviour choices we make, and in some
health-damaging and less health-promoting behaviours cases the availability of such choices may be strongly
than those in the higher socio-economic groups. This influenced by the social context in which we live.
does seem to be the case. People in lower socio-economic
groups in industrialised countries tend to smoke and drink
Access to healthcare
more alcohol, eat a less healthy diet and take less leisure
exercise than the better-off (e.g. Casetta et al., 2017). Access to healthcare is likely to differ according to the
However, there is consistent evidence that while dif- healthcare system with which the individual is attempting
ferences in health-related behaviours account for some to interact. Many studies of this phenomenon, for exam-
ple, have been conducted in the USA, where different
healthcare systems operate across the social divide. Here,
premature mortality the Affordable Care Act (‘Obama Care’) improved many
death before the age it is normally expected. Usu- Americans’ access to healthcare; but very real differences
ally set at deaths under the age of 65 years in access and quality of care remain (Dickman, Himmel-
stein and Woolhandler, 2017).
By contrast, in the UK where the economic barriers to (see discussion later in the chapter). Finally, even in con-
healthcare are less obvious than in the USA, people in lower texts where treatment may be available without prescrip-
socio-economic groups typically access healthcare more tion, there may be inequalities in access. In the USA,
frequently than those in the higher SES groups, suggesting for example, Bernstein et al. (2009) found that nicotine
that no such economic division is found in the UK. Unfortu- replacement therapy, a central element of any smoking
nately, these data do not address whether the increased use cessation programme (see Chapter 6 ☛), was less avail-
of healthcare resources is sufficient to counter the additional able and more expensive in pharmacies in the poorer sub-
levels of poor health associated with low economic status. urbs of New York than the more affluent ones. Cigarettes
What evidence there is suggests this is not the case. A report were equally accessible throughout the city.
by Audit Scotland (2012), for example, highlighted find-
ings that patients from deprived areas in Scotland received
more than 20 per cent fewer cardiology treatments than
Environmental factors
would be predicted by rates of disease while those from A third explanation for differences in health across social
the least deprived areas received over 60 per cent more groups suggests that people in lower socio-economic
treatments than would be predicted. Public Health England groups are exposed to more health-damaging environ-
(2017) subsequently reported similar problems in health ments, including working in dangerous settings such as
and social care among deprived areas of England. building sites, and have more accidents than those in the
As well as the provision of services, a range of subtle higher socio-economic groups throughout their working
factors may contribute to differences in healthcare. People life. In addition, they may experience home conditions
living in rural areas may have poorer access to health- of low-quality housing, dampness and higher levels of air
care or make choices based on the difficulties of travel to pollution than those in the higher socio-economic groups
available medical treatment. Nelson, Bennett and Rance (World Health Organization, 2010). The economically less
(2019), for example, found that men living in rural areas well-off are likely to live closer to main roads carrying high
of Wales were more likely to opt for a ‘watch and wait’ levels of traffic, airports, polluting industry, rubbish dumps,
choice rather than active treatment such as radiotherapy and power stations. These risks may be particularly prob-
for their prostate cancer than those in urban centres. These lematic for children as a consequence of their physical sta-
choices reflected the difficulties of repeated long journeys tus and their chronic exposure to such pollutants. Schools
to hospitals providing radiotherapy necessary for this form tend to be close to children’s homes, so if a child lives in a
of treatment. Similar decisions may be involved in both polluted environment, they are also likely to experience this
clinician and patient decisions in relation to a range of adverse condition at school. Excessive exposure to adverse
other treatments such as entry into cardiac rehabilitation environments may interact with poor health behaviours and
programmes (see Chapter 8 ☛; e.g., Kachur et al., 2019). health status in a multiplicative risk to health (WHO, 2010).
Also relevant are peoples’ attitudes to healthcare or Environmental factors may also work through social
their cultural beliefs. People from lower socio-economic and psychological pathways. Distance from exercise facili-
groups may be less likely to seek appropriate medical ties, poor traffic safety, or poor environmental conditions
care even when it is available (Wamala et al., 2007). may reduce levels of exercise, including walking to school
Muslim women, for example, may be unwilling to access (Panter et al., 2010), among both children and adults (e.g.
healthcare provided by male doctors and lack appropriate Page et al., 2010). The most commonly reported neigh-
medical care where there is a shortage of female doctors bourhood barriers to healthy weight control reported by
Jilcott Pitts et al. (2015) included not enough bicycle lanes,
pavements, or affordable places to exercise; too much
WATCH AND WAIT
crime; and low availability of pre-prepared healthy meals
The treatment of prostate cancer is often one of combined with high access to fast food outlets. Higher lev-
equipoise (see Chapter 10 ☛ ) with options of els of perceived barriers to exercise were associated with
‘watch and wait’ to identify if and when more active higher BMI. Healthy foodstuffs remain difficult to access
treatment is necessary, such as radiotherapy or sur- by many poor Americans, while closer access to poor qual-
gery; the cancer is usually slow developing, so watch
ity food in convenience stores has been linked to a range of
and wait can be a viable and safe treatment choice.
unhealthy lifestyle choices (Sharkey et al., 2013).
STRESS, SES AND HEALTH 41
A second pathway may be a direct consequence of associated with housing tenure even after controlling for
poor living conditions. Both adults and children living in the quality of housing, and the age, sex, income and self-
poor housing, for example, are more likely to suffer from esteem of their occupiers. They interpreted these data to
a range of conditions including poor respiratory health suggest that the type of tenure itself is directly associated
and asthma (e.g. Baker et al., 2016), which may be miti- with health. They suggested that the degree of control we
gated to some extent by improvements to the fabric of the have over our living environment may influence mood,
houses (Thomson et al., 2013). levels of stress, and perceived control over a wider set
The impact of housing may not simply be physi- of health behaviours; all of which may contribute to ill
cal, however. One example of this can be found in the health. In addition, negative social comparisons, con-
relationship between ownership or otherwise of peo- sidering one’s own house as worse than others’ houses,
ples’ homes. Simply put; tenants report higher rates of appear to have a direct effect on self-esteem, anxiety, and
long-term illness than owner-occupiers. Woodward depression, which may in turn influence health (Ellaway
et al. (2003), for example, found that after adjusting for et al., 2004).
age, male renters were one-and-a-half times more at
risk of developing coronary heart disease (CHD) (see
Chapter 8 ☛) than male owner-occupiers; women rent-
ers were over twice as likely to develop CHD as their
owner-occupier counterparts. More fundamentally,
Stress, SES and health
Clair and Hughes (2019) found that levels of C-reactive The implication of the previous section is that poor hous-
protein (a marker of immune activation associated with ing leads to stress, which in turn leads to ill-health. This
high levels of stress and infection) were higher in renters argument can be widened to suggest that differences in
than home-owners. Similarly, those in detached houses stress experienced as a result of a variety of factors may
had lower levels of C-reactive protein than those living combine to contribute to differences in health across the
in semi-detached, terrace houses or flats. social groups. This seems a reasonable hypothesis, as we
Some of the reasons for these differences may be indi- know that people in lower SES groups experience more
rect and lie in other factors linked to renting by people in stress than their more affluent counterparts (e.g. Marmot
difficult economic circumstances. Sandel et al. (2018), for et al,. 1997), have less personal resources to help them
example, found a range of factors, including stress asso- cope with them (Finkelstein et al., 2007), and that stress
ciated with multiple moves and rental arrears, impacted can adversely impact on health (see Chapter 11 ☛).
on the health of both children in a household. Very low- Some of the stresses and restricted life opportunities
income renters may also experience food insecurity; experienced by people in lower socio-economic groups
itself a stress factor and contributor to poor personal include:
and child health (Frank et al., 2006). However, a further
potential pathway raises some interesting psychological ● Childhood: family instability, overcrowding, poor
issues. MacIntyre and Ellaway (1998) found a range of diet, restricted educational opportunities;
mental and physical health measures to be significantly ● Adolescence: family strife, exposure to others’ and
own smoking, leaving school with poor qualifications,
unemployment or low-paid and insecure jobs;
● Adulthood: working in hazardous conditions, finan-
coronary heart disease cial insecurity, periods of unemployment, low levels
a narrowing of the blood vessels that supply blood of control over work or home life, negative social
and oxygen to the heart; results from a build-up interactions;
of fatty material and plaque (atherosclerosis); can ● Older age: no or small occupational pension, inad-
result in angina or myocardial infarction
equate heating and/or food.
C-reactive protein
a marker of immune activation associated with Wilkinson (1990) took the stress hypothesis one stage
high levels of stress and infection further. He compared data on income distribution and
life expectancy across nine Western countries and found
that, while the overall wealth of each country was not association between social capital and the incidence of
associated with life expectancy, the income distribution acute coronary events in different areas of California and
across the various social groups (i.e., the size of the eco- found that higher levels of community-level social capital
nomic gap between the rich and poor) within each coun- were associated with an 11 per cent lower rate of coro-
try was. The correlation between the two variables was a nary events. This protective effect was largely confined
remarkable 0.86: the higher the income disparity across to people whose household income was below $54,000
the population, the worse its overall health. (around the 60th US income percentile). In reality, while
In his explanation of these phenomena, Wilkinson low social capital is associated with low SES, it may exert
suggested a ‘hierarchy-health hypothesis’. According to an independent influence on health. Aida et al. (2013), for
Wilkinson, awareness of being low in the hierarchy and example, found both SES and social capital to be related
of one’s relative lack of resources is itself stressful and and independent influences on health.
may cause negative emotional responses, regardless of A further factor related to social capital that may co-
more objective measures of wealth or status. Support for vary with SES is the social support available to the indi-
this approach can be derived from the findings of Singh- vidual. A large number of positive social relationships
Manoux, Marmot and Adler (2005), who found subjec- and few conflictual ones may buffer individuals against
tive SES was a better predictor of health than actual the adverse effects of the stress associated with low eco-
measured SES. nomic resources. Conversely, a poor social support sys-
Wilkinson later shifted this explanation to suggest that tem may increase risk for disease (Barth et al., 2010).
wealth disparities were associated with lower levels of Sadly, the potentially protective effect of good social
social cohesion and social capital in lower SES groups support may be less available than it was previously. In
(Wilkinson and Pickett, 2010). Low social capital is asso-
ciated with both individual distrust and dissatisfaction,
and social factors such as high levels of crime. It involves social capital
not feeling safe in the community in which you live: a feelings of social cohesion, solidarity and trust in
perception that is inherently stressful. In one study of one’s neighbours
this phenomenon, Scheffler et al. (2008) examined the
Photo 2.1 Just kids hanging around. But how will their life circumstances affect their health (and
perhaps that of others)?
Source: LeoPatrizi/E+/Getty Images.
STRESS, SES AND HEALTH 43
contrast to research conducted in the 1950s, people in education (and hence, SES), were related to metabolic
the higher social groups now appear to have more social syndrome through a pathway involving low levels of
support than those in the lower social groups, particularly reserve capacity (defined as low levels of optimism,
where low socio-economic status is combined with high self-esteem, and social support). Thus, they argued,
levels of social mobility and frequent changes of address risk for disease may be associated with a lack of coping
(Chaix et al., 2007). resources rather than stress per se.
This social capital/support model is compatible with
theorising of Matthews and Gallo (2011) who noted
that stress may well contribute to health inequalities
metabolic syndrome
but found an even stronger relationship between poor
health and what they termed lack of ‘reserve capac- the presence of three of: central obesity, high
blood pressure, high blood sugar, high serum
ity’; the capacity to cope with this stress (to which triglycerides, low serum high-density lipoprotein.
both social capital and social support would contrib- These increase risk of cardiovascular disease and
ute). They noted, for example, in one analysis con- type 2 diabetes
ducted by Matthews et al. (2008) that low levels of
RESEARCH FOCUS
Does ethnicity influence risk and following a cohort of over half a million people aged
impact of Covid-19? between 40 and 69 years across the UK. People in the
cohort were considered to have been hospitalised with
Lassale, C., Gaye, B., Hamer, M. et al. (2020). Ethnic COVID-19 if they had a positive COVID-19 swab test
disparities in hospitalisation for COVID-19 in England: between the 16 March and 26 April, when testing was
the role of socioeconomic factors, mental health, largely restricted to in-hospital cases. Accordingly, a
and inflammatory and pro-inflammatory factors in a positive test result was seen as indicating the presence
community-based cohort study. Brain, Behavior, and of severe COVID-19 infection. The study only included
Immunity, 88: 44–49. participants living in England, as neither Wales nor Scot-
land had these data.
The authors note that among UK and US patients
known to have COVID-19, some ethnic groups appear
to have the highest risk of needing intensive care and Measures
are the most likely to die from the infection. Some of
this increased risk may be attributed to neighbourhood ● Ethnicity: this categorised people into one of six cat-
deprivation and comorbidity, but other causes need to egories: White, Mixed, Asian or Asian British, Black
be considered. Issues to be considered include over- or Black British, Chinese, and Other.
crowded living, occupations involving contact with the ● Socioeconomic measures: included highest edu-
public, mental health, and lifestyle factors associated cation level, household income, occupation, and
with pro-inflammatory conditions and chronic disease. Townsend Index of Area Deprivation.
The chronic stress of occupying minority or low socio- ● Lifestyle measures: physical activity, smoking
economic status may also result in impaired immuno- and alcohol consumption measured by question-
logical functioning and contribute to risk. naire. Activity measured by the International Physi-
cal Activity Questionnaire, measuring duration of
various levels of activity. Results categorised as
Method
inactive, somewhat active below guidelines, and
Data were obtained from the database of a massive meeting activity guidelines (>150 min/week moder-
prospective study known as UK Biobank, which is ate to vigorous; >75 mins vigorous activity).
(continued)
● Comorbidities: Body Mass Index calculated from were at over four times the risk of being hospitalised
weight and height. Self-report of other conditions/ for COVID-19 than their age and gender matched
illnesses. Mental health measured by the Patient White equivalents (odds ratio [OR]: 4.32; 95% con-
Health Questionnaire, and verbal numerical reason- fidence intervals [CI] 3.00–6.23). Those of Asian ori-
ing task used to measure cognitive function. gin were at double the risk (OR: 2.12; 95% CI: 1.37,
● Biomarkers: blood samples measured C-reactive 3.28). The importance of covariates in predicting risk
protein (measure of inflammation), haemoglobin, were measured by adding them in the sequence
HbA1c (test of diabetes) (see Chapter 8 )☛ described above. The results are reported in terms
and total and high density lipoprotein (HDL) (see of the degree of attenuation (e.g., how much their
Chapter 8 ☛ ). inclusion reduced risk of hospitalisation) of each risk
factor in each ethnic group. They show the highest
Statistical analysis risk of hospitalisation was in the Black population fol-
lowed by Asians and ‘Others’. This risk was reduced
Comparisons were made between hospitalised and non- when taking into account SES, with reductions in risk
hospitalised patients via t-tests and Chi-squared. of 24.5% for Blacks, 31.9.3% for Asians, and 30.0%
Logistic regression was used to estimate odds ratios for Others. Addition of lifestyle, comorbidities, and
(ORs) of associations between ethnicity and hospitali- biomarkers of disease reduced risk a further 33.0%
sation for COVID-19. To quantify the contribution of for Blacks, 52.2% for Asians and 43.0% for Others
factors to the ethnic differences, they first ran a ‘com- compared to the base model.
parator model’ where ORs were adjusted for age and
sex. They subsequently fitted five models with addi-
tional covariates: (i) socio-economic, (ii) lifestyle, (iii) Discussion
comorbidities, (iv) biomarkers, and (v) all covariates.
These data show increased risk of hospitalisation
The percentage change following each additional
for COVID-19 among the non-White population of
covariate was reported.
England. The regression analysis showed that differ-
ences in risk were at least partially attributable to a
Results range of co-variates including lifestyle, existing health
The analysis was conducted on 340,966 individuals, differences and SES. Nevertheless, these differences
of which 640 were COVID-19 cases. Characteristics remained significant for each group, and in particular
of those hospitalised with COVID-19 in comparison Black people. Clearly, there are psychosocial factors
with the non-hospitalised group were older, less that predict risk, which although not directly found
likely to be female, lower education, living in deprived in this study may contribute to the findings. These
neighbourhoods, less active and higher smoking, higher include the higher prevalence of public-facing jobs
co-morbidities in terms of illness and markers of poor held by people in ethnic minorities and living in more
health (greater BMI, HbA1c levels, total cholesterol, lower crowded housing (both leading to lower social dis-
HDL-cholesterol and lung function. In comparison to tancing). Lifestyle factors may also contribute to risk,
White participants, there were three times more Blacks while poorer mental health and inflammation also
and two times more Asians hospitalised with COVID-19. carry risk. The latter may be exacerbated by factors
Table 1 provides a summary of some key findings). such as racism. Future research needs to identify fac-
tors that influence risk at a more molar level, digging
down into how being in a lower socio-economic group
Modelling risk confers risk and to identify the factors beyond those
Regression analysis showed that compared to White identified in this study which contribute to the remain-
participants, people from a Black ethnic background ing differences.
WORK STATUS AND STRESS 45
Not hospitalised Hospitalised p-value

Number 427,594 900
Ethnicity (%) <0.001
Black 1.8 6.0
Asian 2.2 5.1
Other 1.9 3.1
White 94.1 85.8
Women (%) 55.0 44.4 <0.001
Age, years (mean, SD) 56.4 (8.1) 57.2 (9.0) 0.001
Per cent
Higher education 32.6 26.0 0.001
Household ≥ 4 people 19.3 21.8 0.004
Neighbourhood deprivation highest quintile 19.6 33.0 <0.001
Physical activity
Inactive 18.2 26.3 <0.001
Alcohol intake <0.001
Never/rarely 31.4 41.7
Heavy drinking 32.7 29.8
Cigarette smoking <0.001
Never 55.4 46.7
Current 10.0 11.4
Hypertension 58.0 65.8 <0.001
Diabetes 5.0 9.9 <0.001
Cardiovascular disease 5.3 10.3 <0.001
Chronic bronchitis 1.4 3.1 <0.001
Psychological distress (PHQ4 ≥ 3) 23.7 28.6 0.001
Mean (SD)
BMI, kg/m2 27.4 (4.8) 29.1 (5.4) <0.001
C-reactive protein (mg/L) 2.51 (4.17) 3.50 (6.39) <0.001
HbA1c (mmol/mol) 36.0 (6.6) 38.1 (8.9) <0.001
Cholesterol (mmol/L) 5.70 (1.14) 5.43 (1.22) <0.001
HDL-cholesterol (mmol/L) 1.45 (0.38) 1.32 (0.33) <0.001
Lung function: Forced expiratory volume 2.82 (0.8) 2.70 (0.82) <0.001
Source: Lassale, Gaye, Hamer et al. (2020).
Work status and stress blue-collar workers (e.g., Kouvonen et al., 2005). Other
psychological research has focused on theories which sug-
gest there is something intrinsic to different work environ-
Some of the excess mortality associated with low SES ments that impacts directly on health – work stress.
may also be a consequence of the different work environ- One of the first theoretical models to systematically
ments experienced by people across the socio-economic consider elements of the work environment that contrib-
groups. This may partly reflect the physical risks asso- uted to stress and illness was developed by Karasek and
ciated with particular jobs. However, subtle work fac- Theorell (1990). Their model (Figure 2.2) identified three
tors may also influence behaviour. Binge drinking, for key factors that contribute to work stress:
example, has been associated with job alienation, job
1. the demands of the job;
stress, inconsistent social controls, and a work drinking
culture (e.g., Bacharach et al., 2004). Similarly, long work 2. the degree of freedom to make decisions about how
hours, lack of control over work and poor social support best to cope with these demands (job autonomy);
have been associated with high levels of smoking among 3. the degree of available social support.
stroke (as well as type 2 diabetes) among individuals with

High decision control
high job strain. By contrast, there is no evidence that job
strain is related to the development of cancer.
An alternative model of work stress has been pro-
Dentist posed by Siegrist et al. (1990). They suggested that work
Sales person Bank manager stress is the result of an imbalance between perceived
Architect Physician
Scientist School teacher efforts and rewards. High effort with high reward is seen
as acceptable; high effort with low reward combine to
High demand
Low demand
result in emotional distress and adverse health effects.

In a five-year longitudinal study tracking over ten thou-
sand British civil servants (Stansfeld et al., 1998) both
Night watchman Telephone operator Karasek’s and Siegrist’s theories received some support:
Janitor Cook
lack of autonomy, low levels of social support in work,
Lorry driver Waiter
Carpenter Secretary and effort–reward imbalance each independently pre-
dicted poor self-report physical health. Later studies, such
as Dragano et al.’s (2017) study of over 90,000 workers
have also revealed modest but significant associations
Low decision control
between effort-reward imbalance and the development
of heart disease.
Figure 2.2 Some of the occupations that fit into the four
quadrants of the Karasek and Theorell model Even more impressively, Bosch et al. (2009) found
that high levels of work stress, indicated by high work-
Source: Karasek and Theorell (1990).
load, low social support, and high effort–reward imbal-
The theory differs markedly from previous theories ance were associated with increasingly impaired immune
that suggested occupational stress was an outcome of function, to the extent they considered work stress to
the demands placed on the person – the classic ‘stressed ‘contribute to immunological aging’. Summarising the
executive’. Instead, it suggests that only when high levels data to date, Siegrist and Li (2017) noted that effort-
of demands are combined with low levels of job auton- reward imbalance was consistently associated with
omy, and perhaps low levels of social support (a situa- altered blood lipids, and risk of metabolic syndrome. The
tion referred to as high job strain), will the individual feel model was less consistently associated with high blood
stressed and be at risk for disease. When an individual pressure and/or heart rate, altered immune function and
experiences high levels of demand combined with high inflammation, and cortisol levels.
levels of autonomy (e.g. being able to choose when and Finally, shift work has also been associated with poor
how to tackle a problem) and good social support, they will health. Summarising the data from 38 meta-analyses and
experience less stress. In contrast to the ‘stressed execu- 24 systematic reviews, Kecklund and Axelsson (2016)
tive’ model, those in high-strain jobs are often blue-collar concluded that shift work was consistently associated
workers or people in relatively low-level supervisory posts. with increased risk for accidents, and modest but sig-
The majority of studies exploring the health outcomes nificant increases in risk for type 2 diabetes, weight gain,
of differing combinations of these work elements support coronary heart disease, stroke, and cancer. Importantly,
Karasek’s model. Kuper and Marmot (2003), for exam- this impact seems to be primarily associated with the loss
ple, found that within their cohort study of over 10,000 of sleep associated with night and early morning shifts,
UK civil servants, those with low decision latitude and
high demands were at the highest risk of developing coro-
nary heart disease. Similarly, Clays et al. (2007) reported
ambulatory blood pressure
that average ambulatory blood pressure at work, home
blood pressure measured over a period of time
and while asleep was significantly higher in workers with using an automatic blood pressure monitor which
high job strain compared with others. Consistent with this can measure blood pressure while the individual
finding, Kivimäki and Kawachi’s (2015) meta-analysis wearing it engages in their everyday activities.
revealed a 10-40 per cent increased risk for CHD and
MINORITY STATUS AND HEALTH 47
not shift work per se. This is likely to exert its influence those with few savings or low financial security, which
through its negative impacts on immune function, and may be the key determinant of whether or not individu-
metabolic changes including those associated with obe- als experience ill-health (Tøge, 2016), particularly where
sity and heart disease (Haus and Smolensky, 2013). this is perceived as likely to last a significant time (Lam,
Stress does not stop at work, and it does not stay Cheung and Wu, 2019). The threat of unemployment may
at home. The stresses involved in both settings may also be sufficient to adversely influence health. Dragano
combine to jointly impact on both mental and physical et al. (2005) found a combination of work stress (based
health. One form of this combined risk can be found in on the effort–reward model) and the threat of redundancy
a phenomenon known as work–home spillover: the con- was associated with a four-fold higher prevalence of self-
tinuation of responsibilities within the home after work. reported poor health than among individuals without
Although there are some exceptions, this still affects these problems.
more women than men (Mennino, Rubin and Brayfield, Increasing numbers of individuals are now working
2016), and where it occurs it can adversely impact on in ‘precarious’ jobs: the so-called ‘gig economy’. Inter-
health. Hämmig et al. (2009), for example, found that estingly, this type of job has the potential to improve
around 12.5 per cent of their sample of Swiss employ- both mental and physical health (Benavides et al., 2000).
ees had a high work–life spillover, and those in this However, where this pattern of work is associated with
category were most likely to report poor health, anxiety low job security or high work–home conflict it has a
and depression, lack of energy and optimism, serious negative effect on mental health and a range of physi-
backache, headaches, sleep disorders and fatigue. High cal health problems (Virtanen et al., 2002; Mutambudzi
work stress combined with high work–home spillover et al., 2017).
can combine to be particularly deleterious (Oshio, Inoue
and Tsutsumi, 2017).
Spillover effects may also influence the health of WHAT DO YOU THINK?
the wider family. Devine et al. (2006) found that moth- At a time of economic stress, jobs become more
ers experiencing work–home spillover, especially those difficult to find, careers more difficult to develop.
from lower socio-economic groups, may compromise on The stress associated with precarious employment,
things like the quality of food they cook to help cope with failing to find a satisfying job that leads to a desired
the time challenges of their work. Shimazu, Bakker and career, or having no job at all, can affect people
throughout the lifespan. How may these different
Demerouti, (2009) found a clear association between high stresses affect individuals early in their working life,
work–home spillover and reduced quality of intimate rela- in middle age, and when approaching retirement?
tionships among Japanese workers, which impacted nega- And how may individuals, employers, or even the
tively on the worker’s partner’s health. More positively, government moderate any negative experiences at
when work practices are adjusted to reduce the frequency each stage within the working life?
of spillover these changes may reduce smoking and
excess drinking, increase levels of exercise and healthy
eating, and improve sleep (Moen, Fan and Kelly, 2013).
Minority status and health

Insecure/precarious work and
A second factor that delineates between people in society
unemployment is whether or not they occupy majority or minority status
Having a stressful job impacts on health. But not hav- within the population. These difference, may be physi-
ing a job may also have adverse health consequences. cally obvious through skin colour or visible evidence
Gallo et al. (2006), for example, found that 51–61-year- of disability. They may be less obvious, as in the case
olds who involuntarily lost their jobs were at particularly of people from the LGBTQ+ plus community, but may
high health risk, experiencing significantly higher rates spring from similar factors, including ‘minority stress’;
of heart attacks and stroke than those still in work. Not experience of, or anticipated, discrimination; higher lev-
surprisingly, the impact of unemployment is worst for els of health-risk behaviours (Westwood et al., 2020);
reluctance to seek care due to fear of discrimination; and Differential health behaviours
relatively high experiences of economic difficulties (Phil-
lips et al., 2020). Of particular note is that people from The behavioural hypothesis suggests that variations
some ethnic groups, including people of colour, appear to in health outcomes may be explained by differences
have been disproportionately affected by the COVID-19 in behaviour across social and ethnic groups. In a UK
pandemic, with a higher proportion of people from these study, Bhopal et al. (2002), for example, reported that
populations both developing and dying from COVID-19 male Bangladeshi immigrants had a higher fat diet than
infection than white patients (e.g., Sapey et al., 2020; most other ethnic groups, while Europeans were typically
see also ‘Research focus’). By contrast, while members more physically active than people with families of origin
of the LGBTQ+ community appear not to have been from India, Pakistan or Bangladesh (Hayes et al., 2002).
directly affected in terms of the impact of COVID-19, In the US, Sharma et al. (2004) found that non-Hispanic
they may be more at risk of mental health problems as Black men were twice as likely as the other ethnic groups
a consequence of the pandemic perhaps due to a lack of they sampled (Whites and Hispanics) to engage in CHD-
emotional support and even increased discriminating atti- risk behaviours. Smalley, Warren and Barefoot (2016)
tudes (Phillips et al., 2020). identified a number of what they described as ‘stark’
In searching for explanations of the relatively poor differences in health compromising behaviour across
health among people in minorities, a number of issues groups with differing gender identities or orientations.
have to be borne in mind. Perhaps the most important is Groups who engaged in particularly high levels of health
that a disproportionate number of them also occupy low risk behaviours included transgender women (poor
socio-economic groups. Before suggesting that being in diet and exercise), cisgender men (high alcohol-related
a minority alone influences health, the effects of these risk-taking), bisexual people (substance use), and both
socio-economic factors need to be excluded. This can be transgender and pansexual men (self-harm). Similarly,
done by comparing disease rates between people in minor- Loza et al. (2020) found that young adults in sexual or
ities and people from the majority population matched for gender minorities were more likely to engage in health
income or other markers of SES, or by statistically par- compromising behaviours including smoking, marijuana
tialling out the effects of SES in comparisons between use, high alcohol consumption, and HIV risk behaviours.
majority and minority populations. Once this is done, any Despite these differences, they may only account for a
differences in mortality between the two groups lessen proportion of the increased health risk such individuals
markedly. In one US study of ethnic disparities in risk for experience. Other explanations are also relevant.
CHD, for example, Karlamangla et al. (2010) concluded
that the majority of excess risk among Black and Hispanic
men was largely related to their socio-economic status:
Stress
the impact of ethnicity while of relevance was less strong. A second explanation for the health disadvantages of
Socio-economic status also exerts an influence within people in minority groups focuses on the psychosocial
ethnic groups. People in higher socio-economic groups impact of occupying minority status. People from minori-
generally live longer and have better health through- ties may experience wider sources of stress than majority
out their life than those with less economic resources populations as a consequence of specific stressors such as
(Karlamanga et al., 2010). However, there are some discrimination, harassment, and the demands of maintain-
exceptions to this rule. In the US, for example, Merkin ing or shifting culture. So powerful is this effect, Carter
et al. (2009) found a strong SES-health gradient among et al. (2019) found that genetic changes indicating more
Black Americans, but none among citizens of Mexican rapid ageing were predicted by early life experiences
origin or Caucasians. Similarly, Tobias and Yeh (2006) of discrimination. In a longitudinal study of a cohort of
found a strong relationship between SES and health African Americans, they found that high levels of dis-
among New Zealand Maoris, but no such gradient among crimination experienced between the ages of 10–15 years
Pacific and Asian populations. Despite these cautionary were predictive of depression between the ages of 20–29
notes, there is a general consensus that ethnicity impacts years (the final age this cohort was studied), which in turn
on health, albeit to differing degrees, and a number of was significantly associated with ‘accelerated cellular-
explanations for these differences have been proposed. level aging’. Discrimination explained 32 per cent of the
MINORITY STATUS AND HEALTH 49
variance in aging at this time. This effect was independ- not ‘accept it’: individuals who perhaps became angry in
ent of health behaviours, such as smoking and alcohol response to racist behaviours. Accordingly, one contribu-
consumption. From a similar perspective, Todorova et al. tor to high blood pressure in young black people may be
(2010) identified depression as a pathway through which chronically high arousal as part of a negative emotional
discrimination towards Puerto Ricans living in the USA or behavioural response to a variety of stressors, includ-
led to higher levels of a number of diseases. ing racism.
The link between stress, depression and disease opens
the potential for wider links between discrimination and
health. Noh et al. (2007), for example, identified what Accessing healthcare
they termed ‘overt’ and ‘subtle’ discrimination, and A third explanation for the relatively poor health among
found the experience of overt discrimination was asso- some ethnic groups may be found in the problems access-
ciated with low positive affect, while the experience of ing healthcare. The situation in the USA was succinctly
subtle discrimination was associated with high levels of summarised in a report produced by the US Institute of
depressive symptoms, both of which may increase risk Medicine (2002), which noted that:
for a number of diseases. Within the LGBTQ+ com-
munity, there is a clear association between these types
● African-Americans and Hispanics were likely to
of individual discrimination and depression (e.g., Logie receive lower quality of care across a range of diseases,
et al. 2017). Discrimination at a wider, population, level including cancer, CHD, HIV/AIDS and diabetes;
can also impact on mental health. The term ‘neighbour- ● African-Americans were more likely than whites to
hood racial discrimination’ has come to mean discrimina- receive less desirable services, such as amputation of
tion at multiple levels including limited access to valued all or part of a limb;
resources including jobs, education, and targeting by ● disparities were found even when clinical factors, such
police. Above these functional issues is the higher-level as severity of disease, were taken into account;
perception that one’s racial group is devalued in society. ● disparities were found across a range of clinical set-
These processes and beliefs have been shown consist-
tings, including public and private hospitals, and
ently to predict mental health problems including depres-
teaching and non-teaching hospitals;
sion (e.g. Russell et al., 2018) and lie at the heart of the
Black Lives Matter movement (https://blacklivesmatter.
● disparities in care were associated with higher mortal-
com). These influences may also clearly be relevant to ity among minorities.
other communities such as LGBTQ+. This situation is not limited to this time period (see
Discrimination may impact via number of biological Becker and Granzotti, 2018), the US (e.g., Szcepura
pathways, including impaired immune function associated 2005), or people distinguished by their ethnic group.
with chronic stress. Giurgesu et al. (2016), for example, Ayhan et al.’s (2020) review, for example, revealed up
found higher levels of systemic inflammation in preg- to 42 per cent of respondents across a number of studies
nant African American woman than comparable controls, reported having experienced discrimination as a conse-
while Currie et al. (2020) found discrimination scores to quence of their gender or sexual identity. This typically
explain 22 per cent of allostatic load scores (an index of took the form of discriminatory attitudes and the refusal
‘wear and tear’ and accumulated loss of effectiveness of of what was viewed as necessary medication.
a range of systems including the cardiac, metabolic and Accessing preventive health can also be problematic
immune systems). In an interesting experimental study for people in some ethnic groups; at least in part because
of one potential mechanism, Clark and Gochett (2006) they may choose not to access any available services.
measured blood pressure, perceived racism, and the cop- Low numbers of female family doctors in some areas of
ing responses a sample of black American adolescents the UK, for example, have negatively impacted on Asian
used in response to racism. They found blood pressure women’s uptake of screening, while language and lack of
did not vary according to the level of racism the par- knowledge can be a barrier even in culturally diverse geo-
ticipants reported having experienced. However, blood graphical areas (Thomas, Saleem and Abraham, 2005). In
pressure was highest among those individuals who were addition, many Muslim women do not access screening
both subject to racism and whose coping response was to programmes as a result of a fatalistic attitude towards
IN THE SPOTLIGHT
As noted in the main text, almost all ethnic minorties in ● On a related issue, people in ethnic minorities may
the UK have experienced higher levels of COVID-19 and be in less stable jobs than the majority population,
worse prognoses if infected. A number of psychosocial making it more difficult to change or leave jobs they
reasons for this increased risk have been posited by a are concerned may increase their risk of infection.
range of authorities such as the US, Centers for Disease They may also be less likely to take time off work if
Control including: they feel ill, leading to higher severity of symptoms
and disease transmission.
● Significantly less people in a range of ethnic minori-
● People in ethnic minorities are more likely to live in
ties reported a decrease in working hours (e.g., on
crowded or poor housing, making it difficult to follow
furlough) than those in the majority population. In
prevention strategies.
addition, a higher proportion of people from eth-
● People in ethnic minorities were more likely than the
nic minorities work in essential areas of high risk
majority of the population to already have co-morbidities
of COVID-19 infection, including factories, public
that placed them at increased vulnerability to COVID-19,
transport and caring roles.
including cardiac disease and diabetes.
developing cancer (In sha’Allah: ‘if it is God’s will’) the earlier onset of CHD in men than in women. Nearly
or the belief that developing cancer would be a sign of three-quarters of those who die of a myocardial infarction
God’s punishment, embarrassment in relation to female (MI) (see Chapter 8 ☛) before the age of 65 years are
circumcision, as well as more practical problems such men. However, of the men and women who do survive to
as use of language and difficulties in travel (e.g. Padela the age of 65 years, women are still likely to live the long-
et al., 2014). Accordingly, differential use of healthcare est. Okamoto (2006), for example, found that Japanese
resources by people from some ethnic groups may result women aged 65 years were likely to live a further 22.5
from a complex interaction between the types of health- years; men were likely to live an additional 17.4 years.
care available to them and choices they make on whether As can be seen in Table 2.2, a greater proportion of
and how to access them. men die from a range of disorders before the age of 65
than do women. Despite these differences in disease rates
and mortality, though, men typically report higher levels
Gender and health

of self-rated health and contact medical services less fre-
quently than women, while women report higher levels
of physical symptoms and long-standing illnesses than
We have already considered the health of people in the men (Lahelma et al., 1999). It is worth noting that while
LGBT+ community in the context of minority status and this pattern of mortality is common among industrialised
discrimination. Here we return to the more traditional countries, the pattern of health advantage is often dif-
binary approach to gender, comparing the health of men ferent in industrialising countries. Here, differences in
and women. An average woman’s life expectancy in the life expectancy of men and women are smaller and
almost all industrialised countries is significantly greater in some cases are reversed: women are more likely to
than that of men. In the UK, for example, women have an experience higher rates of premature illness and mortality
average life expectancy of around four years longer than than men as a result of the experience of pregnancy and
men (81.6 years for women; 77.4 years for men: www. its associated health risks, as well as inadequate health
statistics.gov.uk). A large contributor to this difference is services.
GENDER AND HEALTH 51
Table 2.2 Relative risk of men dying prematurely (before the A second apparently biological cause of higher lev-
age of 65) from various illnesses in comparison with women els of disease in men involves their greater physiologi-
Cause Male/female ratio cal response to stress than women. Men typically have
greater increases in stress hormones and blood pressure
1. Heart disease 1.5 in response to stressors than women, which may place
2. Cancer 1.4
them at more risk for CHD. However, there is increasing
3. Stroke 1.0
4. Chronic obstructive lung disease 1.3 evidence these differences may not be the result of innate
5. Accidents 2.2 biological differences between the genders. Sieverding
6. Diabetes 1.4 et al. (2005) found that blood pressure reactivity of men
7. Alzheimer’s disease 0.7 and women did not differ during a simulated job inter-
8. Influenza and pneumonia 1.4 view but did vary according to the degree of stress they
9. Kidney disease 1.4
reported during the interview. Similarly, Newton et al.
10. Septicaemia (blood infection) 1.2
All causes 1.4 (2005) found no gender differences between men’s and
women’s blood pressure and heart rate during discus-
Source: UK Office for National Statistics (https://www.ons.gov.uk).
sions with previously unknown individuals. Dominance,
and not gender, was consistently associated with blood
pressure reactivity; with men who were challenged by a
Biological differences highly dominant male partner experiencing the greatest
increase in blood pressure (and probably the most stress).
Perhaps the most obvious explanation for the health dif- It seems that it is not so much the gender of the individual
ferences between men and women is that they are bio- that drives their physiological reactivity: rather, it is the
logically different: being born female may bring with type of stresses that the person is exposed to or the psy-
it a natural biological advantage in terms of longevity. chological response they evoke.
Women, for example, appear to have greater resist-
ance to infections than men across the lifespan. Other
biological explanations have considered the role of sex Behavioural differences
hormones. For some years, it was thought that high lev-
Further evidence that gender differences in health and
els of oestrogen in pre-menopausal women delayed the
mortality are not purely biological stems from studies that
onset of CHD by reducing the tendency of blood to clot
show clear and consistent health-related behavioural dif-
and keeping blood cholesterol levels low, and this idea
ferences between men and women. In results typical of
still holds some traction. However, data from a variety of
this type of study, Kritsotakis et al. (2016) examined the
sources, including Lawlor et al. (2002) who reported rates
prevalence of a range of health promoting/risky behav-
of CHD in women living in the UK and Japan, found no
iours and how they clustered in a population of 100 young
evidence of any reduction of risk prior to the menopause
males and females. Overall, men had higher aggregate
or increase in risk following it. In addition, replacing oes-
risk scores, with lower rates of health-promoting behav-
trogen following the menopause has not been found to
iours such as oral hygiene, and higher rates of a range of
decrease the risk for CHD (The Women’s Health Initia-
unhealthy behaviours including consumption of red meat
tive Steering Committee, 2004).
and junk food, binge drinking, use of cannabis, a higher
Our understanding of the role of testosterone in men
number of sexual partners, and higher BMIs. Women
has also changed over time. High levels of testosterone
were thought to increase risk levels of atheroma, and
increase risk for MI. Now, the reverse appears to be true,
and the majority of studies (e.g. Malkin et al., 2010) sug- atheroma
gest high levels of testosterone are considered to be pro- fatty deposit in the intima (inner lining) of an artery
tective against CHD, probably as a consequence of its HDL cholesterol
impact on lipids within the blood: high testosterone is the so-called ‘good cholesterol’: see Chapter 8 ☛
associated with low levels of HDL cholesterol.
were less likely to smoke, and no gender differences were Unfortunately, inequalities in power between the
found in the prevalence of protected sex, breakfast and sexes may also adversely impact on women’s health. One
fruit and vegetable consumption, and the frequency of example of this can be found in the context of sexual
having been sunburnt. In a similar study involving an behaviours, in which women are frequently less empow-
even larger population, Olson, Hummer and Harris (2017) ered than men. Blythe et al. (2006), for example, found
extended these analyses to calculate that 40 per cent that 41 per cent of young women aged 14–17 years in
of men in their general population sample clustered their US sample reported having unwanted sex during a
into a group characterised by unhealthy behaviour (e.g., three-month period. This was associated with lack of sex-
poor diet, no exercise, substance use), compared to only ual control and lower use of condoms (see also Hoffman
22 per cent of women. et al., 2006). Similarly, Chacham et al. (2007) found that
Not only do men engage in more health-risking Brazilian women aged between 15 and 24 years old who
behaviours, they are also less likely than women to seek had been victims of physical violence by a partner or
medical help when necessary. Men visit their doctor less whose partners restricted their mobility were less likely to
frequently than do women, even after excluding visits use condoms than those with more autonomy and control.
relating to children and ‘reproductive care’. Socially dis- Such behaviours clearly place them at risk of a variety of
advantaged men are even less likely to consult a doc- sexually transmitted diseases.
tor than their higher SES counterparts when they are ill
(Wang et al., 2013). The reasons for these behavioural
differences may be social in origin. Dolan’s (2011) Economic and social factors
interview-based study, for example, is one of many link- The negative impact of adverse socio-economic factors
ing a range of masculinity beliefs that lead to low uptake discussed earlier in the chapter does not affect men and
of medical treatment: women equally. In the UK, for example, nearly 30 per cent
of women are economically inactive, and those in work
I think men have got to be tougher. They don’t want
are predominantly employed in clerical, personal and
to be a sissy going to the doctor all the time . . . Hypo-
retail sectors in low-paid work (Office for National
chondria is something you would associate with a
Statistics 2020). About two-thirds of adults in the poorest
woman . . . And women well they have their troubles.
households in the UK are women, and women make up
They have got more complicated bits . . . In a way it’s
60 per cent of adults in households dependent on Income
all right for a woman to admit that she is physically
Support (a marker of a particularly low income) (see
failing . . . somehow it is easier in a way. But for a
also discussion in World Economic Forum 2015). Social
man to say he is having physical problems . . . it’s just
isolation is also more frequent among women than men:
not as easy.
women are less likely to drive or to have access to a
Further showing the power of gender stereotypes, car than men, and older women are more likely than
Mahalik et al. (2007) found that masculine beliefs were older men to be widowed and to live alone. Women
stronger predictors of risky health behaviours including also appear more vulnerable to disrupted or poor
smoking and alcohol abuse than demographic variables social networks than men. Irregular social contact or
such as education and income. These may be established dissatisfaction with a social network has been associated
relatively early in life: adolescents with traditional mas- with levels of both chronic disease (Cantarero-Prieto,
culine beliefs are less likely to attend their doctor for Pascual-Sáez and Blázquez-Fernández, 2018) and
a physical examination than those with less traditional mortality. Iwasaki et al. (2002), for example, found that
beliefs (Marcell et al., 2007). We noted earlier that the in a population of older Japanese adults, women who
one health-promoting behaviour that men consistently were single and in irregular or no contact with close
engage in more than women is leisure exercise. This relatives were likely to die earlier than those with more
may also act as a marker of masculinity and power and relative contacts. In women with established diseases,
carry a social message as well as having implications including cancer, social isolation can also lead to a
for health. poorer prognosis (Kroenke et al., 2017).
SUMMARY 53
WHAT DO YOU THINK? we adopt the American model of ‘opportunity’ to

become upwardly economically mobile, and those
If health is, at least in part, a result of the social left behind fend for themselves? If society does
and environmental contexts in which we live, then take responsibility for reducing social inequalities,
how can society go about changing them? Most how can it set about doing so? And what about the
health promotion has focused on changing individ- health disadvantages of people in ethnic minori-
ual behaviours, such as smoking, lack of exercise, ties and women with children at work? How much
and so on. But is this just tinkering at the edge? should society, and in particular psychologists
Should society work towards changing the health and others involved in healthcare, involve itself in
inequalities associated with low SES? Or should improving the health of these groups?
SUMMARY
Poverty is the main cause of ill health throughout the ● The financial uncertainties associated with unem-
world. However, psychosocial factors may also influ- ployment also appear to have a negative impact
ence health where the profound effects of poverty on health.
are not found.
A third factor that may influence health is being
One broad social factor that has been found to part of a minority group as a consequence of vis-
account for significant variations in health within ible or invisible differences from the majority of the
societies is the socio-economic status of different population. The experience of prejudice, in particu-
groups. This relationship appears to be the result of lar, may contribute significantly to levels of stress
a number of factors including: and disease.
● differential levels of behaviours, such as smoking ● As many people in minority groups may also
and levels of exercise; occupy lower socio-economic groups, they may
● differing levels of stress associated with the living experience further stress as a result of this double
environment, levels of day-to-day stress, and the inequity.
presence or absence of uplifts; ● Unequal access to healthcare may also impact in
● differential access to healthcare and differential obvious and more subtle ways.
uptake of healthcare that is provided;
Gender may influence health, but not only because
● low levels of social capital and its associated
of biological differences between the sexes. Indeed,
stress in some communities.
many apparent biological differences may result from
the different psychosocial experiences of men and
The relationship between work and health is com-
women. In addition:
plex. Having a job is better for one’s health than not
having a job. However, if the strain of having a job
● men engage in more health-compromising behav-
is combined with significant demands away from
iours than women;
the job, this can adversely impact on health. Many
women, for example, appear to have high levels of ● men are less likely to seek help following the onset
work–home spillover, with its adverse effects on both of illness than women;
mental and physical health. ● many women are economically inactive or in lower
paid jobs than men. This makes them vulnerable to
● Jobs with high levels of demand and low levels of the problems associated with low socio-economic
autonomy appear to be more stressful and more status.
related to ill-health than other types of job.
Further reading An interesting qualitative study of how men’s attitudes

towards their masculinity can influence their health-related
Websites behaviour and health.
http://www.instituteofhealthequity.org/ Hart, C.G., Saperstein, A., Magliozzi, D. et al. (2019). Gender

and health: beyond binary categorical measurement. Journal
Website of the University College, London Institute of Health
of Health and Social Behavior, 60(1): 101–118.
Equity, which is aimed at ‘reducing health inequalities on the
social determinants of health’. An unashamedly activist site, The chapter has largely treated gender as a binary outcome.
intended to provide information to ensure improvements in But of course, new models of sexuality are emerging which
health across the world. Its key publication is the ‘Marmot counter this simplistic notion of gender. This paper explores
Review’, which is linked to the website. this more complex understanding of sexuality and its impact
on health.
http://www.sphsu.mrc.ac.uk/
Gaffney, A. and McCormick, D. (2017). The Affordable
Another resource website. The Medical Research Council’s
Care Act: implications for health-care equity. Lancet, 389:
Social and Public Health Sciences Unit based at Glasgow
1442–1452.
University, with links to research on the impact on health of a
range of social factors. How much has Obama Care reduced the existing health
inequalities? This critical review considers this issue.
Books and papers

YouTube
Wilkinson, R. and Pickett, K. (2010). The Spirit Level: Why
Equality is Better for Everyone. Harlow: Penguin. https://www.youtube.com/watch?v=h-2bf205upQ
And its follow-up: Michael Marmot, a leading researcher into health inequalities
gives a talk. There are many more talks by him on YouTube.
Wilkinson, R. and Pickett, K. (2018). The Inner Level: How
This one is longer, but really interesting if you can cope with the
More Equal Societies Reduce Stress, Restore Sanity and
length: https://www.youtube.com/watch?v=UZlYnE3OhRE
Improve Everyone’s Well-being. Harlow: Penguin.
https://www.youtube.com/watch?v=r0cJ7CX1lCA
Very accessible psycho-socio-economic arguments related
to health inequalities, and its counterpart . . . The Glasgow effect – the impact of neighbourhood on health.
Snowdon, C.J. (2010). The Spirit Level Delusion: Fact- https://www.youtube.com/watch?v=T2mirYemCmo

checking the Left’s new Theory of Everything. London: Post-Obama care, the care of racial minorities is far from opti-
Democracy Institute/Little Dice. mal. Nice use of implicit bias in healthcare.
Dolan, A. (2011). ‘You can’t ask for a Dubonnet and lemon-
ade!’: working class masculinity and men’s health practices.
Sociology of Health and Illness, 33: 586–601.
Visit the website at go.pearson.com/uk/he/resources for additional resources to help you

with your study.
Chapter 3
Health-risk behaviour
Learning outcomes
• how to define and describe health behaviour
• the prevalence of key health behaviours associated with elevated disease risk
• the range and complexity of influences upon the uptake and maintenance of health-risk
behaviour
• some of the challenges facing health behaviour research
The health costs of our behaviour
The World Health Organization (2019) have noted that pollution is the greatest
environmental risk to health globally due to its impact on respiratory disease and
some forms of cancer for example. Both large-scale industrial or agricultural
practices, use of harmful chemicals and personal behaviours such as driving
high emission cars, irresponsible waste disposal, or choice of aerosols can con-
tribute to this. The next biggest risks to our health are smoking, drinking, eating
and lifestyle behaviours which contribute to non-communicable diseases, such
as heart disease, cancer and diabetes, which are leading causes of death. In
fact, it is thought that approximately a third of deaths from such diseases could
be eliminated by behaviour change. The cancer statistics, recorded across dif-
ferent countries, show clear associations with behavioural variations, for exam-
ple, between countries with continued high smoking rates (e.g. eastern Europe),
or obesity and low activity rates (e.g. UK, Spain). Behaviours often set down
in childhood, adolescence or in young adulthood play a major role in mortal-
ity and morbidity, yet we rarely consider the long-term consequences of such
behaviours, for example, smoking, when we start!
58 CHAPTER 3 ● HEALTH-RISK BEHAVIOUR
Chapter outline
Behaviour is linked to health. This has been shown over decades of painstaking
research that has examined individual lifestyles and behaviour and identified relation-
ships between these and the development of illness. For example, it has been estimated
that up to three-quarters of cancer deaths are attributable to a person’s behaviour. As
health psychologists, one of our primary goals is to gain better understanding of the
factors that predict and maintain human behaviour, in order to help develop interven-
tions to reduce risk behaviours (this chapter) and enhance healthy behaviours (the next
chapter). We provide an overview of the prevalence of key behaviours of unhealthy diet,
smoking, excessive alcohol consumption or bingeing, illicit drug use and unprotected
sexual intercourse, and review evidence regarding the negative health consequences of
each. Both the health-risk behaviour described here and the health-enhancing behav-
iour described in Chapter 4 ☛ provide the impetus for many educational and public
health initiatives worldwide.
What is health However many decades of behaviour research have

demonstrated that people may be motivated to engage
behaviour? in a variety of apparently health-related behaviour,

such as exercise, by reasons other than health promo-
tion or disease prevention. For example, a person may
Kasl and Cobb (1966a: 246) defined health behav- exercise to lose weight, as a means of making social
iour as ‘any activity undertaken by a person believing contact or simply for pleasure! Nevertheless, whether
themselves to be healthy for the purposes of preventing intentional or not, engaging in health behaviour may
disease or detecting it at an asymptomatic stage’. This result in reduced disease risk, limit the impact or slow
definition was influenced by a medical perspective in the progression of disease where it already exists. An
that it assumes that healthy people engage in particular elaboration of definitions of health behaviour was
behaviour, such as exercise or seeking medical attention, provided by Matarazzo (1984), who distinguished
purely to prevent their chance of disease onset. Harris between what he termed behavioural pathogens and
and Guten (1979), in contrast, defined health behaviour behavioural immunogens, which in this text we call
as ‘behaviour performed by an individual, regardless health-risk behaviours and health-protective behaviours
of his/her perceived health status, with the purpose of
protecting, promoting or maintaining his/her health’.
According to this definition, health behaviour could
include the behaviour of ‘unhealthy’ people. For exam- behavioural pathogen
ple, an individual who has heart disease may change their a behavioural practice thought to be damaging to
diet to help to limit its progression, just as a healthy per- health, e.g. smoking
son may change their diet in order to reduce their future behavioural immunogen
risk of heart disease. a behavioural practice considered to be health-
These two definitions make a crucial assumption, i.e. protective, e.g. exercise
that the behaviour is motivated by the goal of health.

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I

An Introduction to Health Psychology

We combine innovative learning technology with trusted

From classroom to boardroom, our curriculum materials, digital

Every day our work helps learning flourish, and

To learn more, please visit us at www.pearson.com/uk

PART I BEING AND STAYING HEALTHY 1

Chapter 2 Health differences and inequalities 34

Chapter 3 Health-risk behaviour 56

Chapter 4 Health-protective behaviour 100

Chapter 5 Explaining health behaviour 138

Chapter 6 Changing behaviour: mechanisms and approaches 178

Chapter 7 Preventing health problems 200

PART II BECOMING ILL 227

The respiratory system 254

Chapter 9 Symptom perception, interpretation and response 262

Chapter 10 The consultation and beyond 302

Chapter 11 Stress, health and illness: theory 330

Chapter 12 Stress and illness moderators 366

Chapter 13 Managing stress 404

Preventing stress 414

PART III BEING ILL 427

Chapter 15 The impact and outcomes of illness: families

Chapter 16 Pain 504

Chapter 17 Improving health and quality of life 534

Managing illness 542

PART IV FROM THEORY TO PRACTICE 557

Our ambition is to purposefully contribute to a world where:

• Everyone has an equitable and lifelong opportunity to succeed through learning.

• Please contact us with concerns about any potential bias at:

and disease population continues to be located in Japan, although

Table 1.1 Life expectancy in selected global countries (2018)

Overall (years) Male (years) Female (years)

Worldwide (WHO 2020, million) Europe (Eurostat 2020)

Main cause of death, 2017

(1) 2016 data instead of 2017.

Figure 1.1 Main causes of death in EU country, 2017

that included mental and physical aspects; however as we

Body structure and Activity

Figure 1.3 The international classification of functioning, disability and health.

STOP and THINK problem, with abusers seen as deviant, to a disease,

Sensorimotor and preoperational

WHAT DO YOU THINK?

Ageing and health

negative (in men but not those aged 65 on commence-

This chapter has described what is often meant by

Unlike some other domains of psychology (such as

Further reading The European Health Psychology Society website provides

Health differentials intertwined. People with relatively low incomes, for

Not hospitalised Hospitalised p-value

stroke (as well as type 2 diabetes) among individuals with

result in emotional distress and adverse health effects.

Minority status and health

Gender and health

WHAT DO YOU THINK? we adopt the American model of ‘opportunity’ to

Further reading An interesting qualitative study of how men’s attitudes

http://www.instituteofhealthequity.org/ Hart, C.G., Saperstein, A., Magliozzi, D. et al. (2019). Gender

Books and papers

Snowdon, C.J. (2010). The Spirit Level Delusion: Fact- https://www.youtube.com/watch?v=T2mirYemCmo