Download Social Psychology and Health

_ _ _ _ _ _ _ CHAPTER
21
Social Psychology and Health
RONALD C. KESSLER
JAMES S. HOUSE
RENEE R. ANSPACH
DA VID R. WILLIAMS
Until the early part of the twentieth century.
biomedical researchers attended nearly exclusively
to organic pathogens and assumed that: (I) disease
is a deviation from normal biological functions;
(2) diseases are generic and invariant over time and
space; (3) medicine is a scientifically neutral profession uninfluenced by wider social. cultural, and
political forces; and (4) each disease has a specific
biological cause (Mischler 1981). This last assumption, known as the "doctrine of specific etiology,"
implied that a disease is best controlled by treating
the culpable biological agent. The elimination of
polio via vaccination during the 1950s dramatically epitomized the successful application of this
model.
Despite such successes, some contemporary
critics argued that disease is often a normal biological response to abnormal environmental demands rather than a biological deviation, and that
health varies over time as a function of changing
environmental demands (Dubos 1959). Such notions construed health as a state of adaptation between the individual and his/her environment.
These ideas have deep historical roots. They inspired the public health movement of the midnineteenth century to emphasize the importance of a
benign physical environment for health. In the
early twentieth century. as public health advances
led to a shift in the major causes of death from
acute infectious diseases to chronic diseases. these
ideas were broadened to emphasize the importance
of not only the physical environment (e.g.. clean
air, water, food, and sanitation) but also the psy-
548
chosocial environment (e.g., smoking, lack of exercise. and stress).
The importance of psychosocial influences on
health is now a major concern of biomedical science and also a major focus of social psychological
research. This convergence has led to a new perspective on health which assumes that: (I) illness
has multiple determinants. both biomedical and
psychosocial; (2) what is seen as a disease is not
invariant over time but changes based on sociocultural and biological definitions; and (3) the medical
profession is a social institution that shapes its
members' views based on broad sociocultural considerations that go beyond scientific concerns.
It is impossible to encompass in a single chapter the full range of research that has evolved from
this perspective; our review is necess~rily selective. [n the first half of the chapter, we discuss
research on the psyc~osocial determinants of illness, and in the second half we discuss research on
the psychosocial determinants of illness definition
and response. In each section we present an historical overview. discuss recent developments, and
propose future directions.
PSYCHOSOCIAL DETERMINANTS
OF ILLNESS
Although the organism-environment adaptation
perspective operates at hoth microscopic and macroscopic levels, the two sometimes have been estranged by disciplinary boundaries. The more
microscopic perspective, characteristic of psycho-
physiologi
gists. has f
stimuli anc
port) aile
physiolog)
acteristic 0
demiologi~
gists. has
health and
teristics as
tion. This
historical,
viding ins
perspecti v'
States is a
ofsmokinl
level have
markedly;
past quart
changesincreases
norms. att
duced by
working tl
ganization
opment w.
macroscol
how stres~
social fon
fect psych
served pat
EmergeDI
Adaptatic
During th,
ologists ,
(1956) de
sponses (
related HI:
tric secre
pressure)
sors or c
heat. cold
cial psycl
drome tht
CHAPTER 21
physiologists and psychological social psycholo).'lstS. has focused on how proximal environmental
'>timuli and contexts (e.g., stress and social support) affect individuals' behavior. mood. and
physiology. The more macroscopic approach, characteristic of many sociologists, demographers, epidemiologists. and sociological social psycholo"ists. has focused on the broader distribution of
health and illness in populations by such characteristics as age, race. gender, and geographic locallllO. This macroscopic approach also considers
historical and contextual influences on health. providing insights not apparent from an individual
perspective. The decline in smoking in the United
States is a good illustration. The long-term effects
l1f smoking intervention programs at the individual
level have been modest. Yet smoking has declined
markedly and steadily in the United States over the
past quarter century due to broader contextual
changes-restriction of smoking in public places,
increases in costs, and a changing set of societal
norms. altitudes, and values regarding smoking induced by political and mass media institutions
working through intermediate levels of social organization. An important direction for future development would integrate the more microscopic and
macroscopic traditions in an effort to illuminate
how stress and adaptation are structured by broad
social forces and how microsocial phenomena affect psychophysiological processes to produce observed patterns of health and illness.
Emergence of the Stress and
Adaptation Perspective
During !.he middle of the twentieth century, physiologists Walter Cannon (1932) and Hans Selye
( 1956) described a syndrome of physiological responses (including adrenocortical secretions and
related neuroendocrine activation, increased gastric secretions. and higher heart rate and blood
pressure) to a wide range of environmental stressors or challenges, including infectious agents,
heat. cold, physical pressure and restraint, and social psychological threat. Selye called this syndrome the "general adaptation syndrome" (GAS).
Social Psychology and H~allh
549
According to Selye. GAS originally evolved as an
adaptive response to physical stressors but has become maladaptive in modern society. where many
stressors are chronic and inescapable. In the face of
these modern stresses. GAS can lead to what Selye
called "diseases of adaptation," such as hypertension, heart disease. ulcers. and arthritis.
Although Selye's model provides a useful
framework for understanding how psychosocial
stresses promote physical illness. it does not explain how the SUbjective sense of stress itself is
generated. Subsequently. social psychologists developed the framework known as the stress and
adaptation model. This framework suggests that
characteristics of situations and individuals combine to create perceptions of stress or threat, which
ideally elicit responses that reduce stress and protect health. Failure to do so results in ill health via
mechanisms such as those originally explored by
Cannon and Selye or those identified by more contemporary biopsychosocial researchers. Whether
situations are experienced as stressful and how persons respond to them is now seen as a function of
both preexisting personal dispositions and other
aspects of the situation. sometimes referred to as
moderating. buffering. or vulnerability factors (see
House 198 L Lazarus and Fol kman 1984: McGrath
1970; for variations on this framework).
Since the mid-1970s, the stress and adaptation
framework has stimulated major developments in
the study of the perception of and response to potentially stressful situations in social psychology
and related areas of medical sociology and health
psychology. The evidence linking stress and other
psychosocial factors to health is growing steadily
and. although as of yet not definitive. is made quite
plausible by the convergences of both laboratory
studies of animals and humans and nonexperimental research on broader human populations. recently augmented by intervention studies.
The initial breakthroughs in research on psychosocial determinants of illness occurred as the
psychosocial stress and adaptation perspective was
just emerging. Initiated by physicians rather than
social scientists. such work has been superseded by
more psychosocially sophisticated and empirically
'I
,.,r
550
PART III
Social Siruciure, Relalionshirs, and the Individual
'if
«
Ld
accurate formulations. However. these initial research programs played a critical role in estahlishing that psychosocial factors are important in
the etiology of morhidity and mortality and have
stimulated important continuing developments in
psychosocial research.
Psychosomatic Medicine
Heavily influenced hy the hiomedical model. one
approach to studying psychosocial factors in health
has heen to focus on a speci fic disease and identi fy
putatively distinctive psychosocial characteristics
of individuals with the disease. The earliest systematic efforts of this type were made under the
ruhric of "psychosomatic medicine," which initially involved the extension of psychoanalytic
theory and methods to prohlems of physical illness.
Franz Alexander (ILJS()). an early leader in this
field. expounded a psychosocial doctrine of specific etiology:
1'11('1'(' ;.1' II II wit 'T;d"II"" J!1U/jIlS/ ".I' "('1'/";11 I"I/ltolog;,."IIII;,.roOl'g"";,IIIS !Jl/\'(' " SI,,.,.i/i(' al/illi/I' /f'I'
('''1'/'';11 ol'g"I/.\'. so also ('''1'/'';11 ,.1I1O/;1II1U1 ('(I/I/Ii('/,I
1'0.1',1".1'.1' ,l/w('i/;,;/;,.s "lid (/(col'dillgll' /<'IId /0 "tflid
,'''1'/'';11 ill/,.I'I/"I Ol'g""s
(I',
-+7),
Suhselluent work related personality attrihutes
specific illnesses. Suppressed aggression. for
example. was hypothesized to cause cardiovascular
disease. while dependency conflicts were implicited in an ulcer-prone personality. This tradition
has continued in efforts to identify personality
traits and syndromes causally associated with diseases as diverse as cancer (Levy and Heiden 1l)\I()l.
arthritis (Anderson ILJX5). diahetes (Ohwovoriolc
and Omololu ILJX6l. and heart disease (Friedman
Il)l)(); Friedman and Booth-Kewley I \lX7).
Such research has suffered. however. from
multiple methodological prohlems. Studies arc
mostly cross-sectional or retrospective. rather than
prospective in design. Samples arc often unrepre,cntat ive and analyses often fai I to control adequately for e\ogenous third variahlcs. which may
,puriously produce associations hetween disease
and personality. Thus it is difficult to interpret the
10
associations reported in this literature in a way 111.11
rigorously evaluates the influence of person~illll
on disease (Anderson ILJXS: Ohwovoriole ;11101
Omololu I\lX6).
The psychosomatic research has also ht'l'll
flawed theoretically. Generally. a given person.ilill
variahle has heen studied in relation to only a Sill
gle disease. thus making it impossihle to knOll
whether that variahle may have similar assol'l;\
tions with other diseases. A doctrine of specilll
etiology has often heen assumed rather than elll
pirically demonstrated. Recent careful reviews "I
the literature on personality and multiple dise~lsl'
outcomes. in fact. demonstrate that most "person,1I
ity" variahles that show associations with one dis
case show similar associations with other diseascs,
For example. meta-analyses hy Howard Friedm;1I1
and Stephanie Booth-Kewley (ILJX7) found thai
anxiety and depression are associated with coro
nary heart disease (CHD). asthma. arthritis. ulcers,
and headaches. while a complex of variahles illlli
cating anger/hostility/aggression is associated with
CHD. asthma. and arthritis. though prohably nol
ulcers and headaches. Thus. they argue that a gen
erally "disease-prone personality" syndrome or sci
of trait:-; is more likely to exist than distinctive
"arthritis-prone," "ulcer-prone," and so on personalities. We return to more contemporary research
on personality helow.
:~
:;
1
,~
l
I
j
f,.
t
J
j
I
~
1
t
{'
I
'>
Type A or Coronary-Prone Behavior Pattern
Research initialed hy Meyer Friedman and Ra)
Rosenman ( ILJ74) on what they termed the "coronary-pronc hehavior pattern" or "coronary-prone
personality" played an evcnmore central role in the
emergence of psychosocial theory and research on
the etiology and epidemiology of physical health
and illness. At the same time. this research illuslI'ates the prohlems posed hy the doctrine of speci fic etiology. Friedman and Rosenman were practicing cardiologists who heliL'ved they saw
characteristic patterns of hehavior in many of their
patients. The) termed this the ·'type A" or coronary-prone hehavior pattern. which they conceived
as the result of an interaction hetween personality
"
,~
;j
i
1
I
~
I1
Jispo
high (
time I
via cl
meth(
caron
studit
Prone
Heart
the ty
heart
chole
F
initial
relati(
popul
perha
poses
widel
sugg(
carre
ity ar
recen'
tively
heha\
with,
than
ingly
CHD
teristi
doma
may t
tainty
numh
lates,
factor
disOf(
I
Life I
i
Draw
and C
that I
patho
that c
adapt;
CHAPTER 21
dispositions and challenging situations leading to
high degrees of competitiveness. job involvement.
time urgency, and hostility. Type A, assessed first
via clinical interviews and later via questionnaire
methods, predicted both the onset and course of
coronary heart disease in several major prospective
studies, leading the Review Panel on CoronaryProne Behavior and Heart Disease of the National
Heart. Lung and Blood Institute (1981) to certify
the type A personality as a risk factor for coronary
heart disease. in the same general class as smoking,
cholesterol, and blood pressure.
Further research, however, has confused the
initial understanding of type A personality and its
relation to CHD. In recent studies of high-risk
populations, type A has failed to predict CHD,
perhaps because the controlling type A style predisposes one to adapt health-promoting behaviors
widely publicized in the 1980s. Other research
suggests that the effects of type A may be due to
correlates (e.g., mistrust) or components (hostility and anger) (Matthews 1985). Finally, more
recent research suggests that as with other putatively disease-specific personality variables or
behavior patterns. type A personality is associated
with a range of health problems and diseases other
than CHD. As research and theory turn increasingly from seeking the psychosocial causes of
CHD to understanding how psychosocial characteristics of persons and situations affect the full
domains of health and illness, the type A construct
may become obsolete, leaving as a legacy the certainty that psychosocial variables. including a
number of key personality and situational correlates and components of type A, are significant risk
factors for a range of physical and psychological
disorders.
Life Events and Change
Drawing somewhat loosely on the ideas of Selye
and Cannon and a variety of research indicating
that major life changes could be stressful and
pathogenic. Holmes and Rahe (1967) hypothesized
that change, whether for better or worse, requires
adaptation, and that high levels of adaptive effort
Social Psychology and Health
551
could produce both physical and psychological disorder. They constructed a Social Readjustment
Rating Scale, which asked individuals to indicate
whether they had experienced each of forty-three
life changes in the preceding year and assigned to
each the average rating of the amount of adjustment involved in a model by a panel of individuals
of varied social backgrounds. The summed total of
adjustment units for an individual has been repeatedly found to predict the onset of a wide range of
physical and psychological disorders (cf. Cockerham 1986, 76-80: Mirowsky and Ross 1989).
Further research has suggested tlaws in both
theory and measures propounded by Holmes and
Rahe (1967). Most important, subsequent research
shows that it is only more serious negative events, not
change per se. that adversely affect health. Further,
the life change weights of Holmes and Rahe provide little more predictive power than a simple
unweighted sum of the number of serious negative
events. the most serious of which (e.g., widowhood, divorce, unemployment) also have been found
to have separate effects on morbidity and mortality,
including cancer (Sklar and Anisman 1981), heart
disease (Wells 1985), and autoimmune diseases
such as rheumatoid arthritis (Solomon 1981). Although research in this area is just beginning, the
available evidence suggests that life events may be
more important in predicting the course of illness
(e.g., speed of recovery, recurrence) than initial
onset (Kessler and Wortman 1988).
A New Focus on Chronic Stress
For a time, the study of life changes and events was
almost synonymous with the study of stress and
health. During the 1980s, however, renewed attention was focused on chronic stress and deprivation
as determinants of illness (Mirowsky and Ross
1989; Pearlin 1989). These new studies suggest
that it is the more enduring stressful sequelae of
such events that explain thei.. effects on health. For
example, the adverse effects of unemployment on
health are partly mediated by resultant financial
stresses (Kessler, Turner, and House 1987), while
the relationship between widowhood and health is
552
PART III
Social StTllcture. Relationships. and the Individual
partly due to the effects of social isolation (Umberson, Wortman. and Kessler 1992).
This renewed attention to chronic stress draws
on two long-standing epidemiologic research traditions as well as on laboratory and field experiments. The first is a tradition of research on work
and health that has suggested that high levels of
physical and psychological demands (e.g .. workload. conflict, responsibility) can adversely affect
health. Early work in this tradition compared aggregate morbidity and mortality profiles of different occupations that are comparable on all known
risk factors other than job stress. yielding striking
evidence that indirectly implicated job stress as a
powerful determinant of ill health (Kasl 197R). A
more recent approach has been to use multivariate
analysis to study the effects of job conditions on
worker health at the individual level of analysis.
The most persuasive studies of this sort have used
longitudinal data to determine the effects of job
conditions on changes in health over time. Several
such investigations have documented significant
effects of job pressures and conflicts on mortality.
coronary artery disease. peptic ulcers. diabetes, and
psychological distress (e.g.. House and Cottington
1986; Karasek and Theorell 1990).
A second basis of the renewed interest in chronic
stress is the persistence in the United States and
most other developed countries of socioeconomic,
racial. ethnic. and gender differences in physical
and mental health, despite substantial progress in
public health and the equalization of access to
medical care (Cockerham 1986; Marmot, Kogevinas, and Elston 1987). Although gaps undoubtedly
remain in access to quality and preventive care. and
although biological factors play some role in these
aggregate differences, a growing body of research
suggests that differences in exposure to chronic
stress as well as other psychosocial risk factors
may be central as well. For example. chronic financial stress plays a significant role in explaining
socioeconomic differences in health. and socioeconomic factors are central to racial differences in
health (House et al. 1992).
A major methodological problem in this research is that measures of chronic stress. which are
typically based on self-reports. may be affected 11\
acute and chronic life conditions and thereby COli
founded with current levels of health. Resolutioll
of this methodological problem will require pro
spective studies that measure perceived levels 01
chronic stress at several points in time and lISl'
these reports to predict subsequent morbidity and
mortality. controlling for health level at the time 01
the measurement of stress. In one effort of this
type. House et al. (19R6) found that men who rcported high levels of chronic occupational stress at
two points in time separated by more than two
years were three times more likely to die over the
succeeding decade than men who reported lower
levels of job stress at either or both times, after
adjustment for age, education. a variety of health
indicators (e.g .. blood pressure and cholesterol),
and health risk (e.g., smoking) at the initial point of
measurement. Similar research is needed on the
effects of financial. marital. parental. and other
chronic stresses.
Until such research is done. experimental studies on animals and humans will continue to provide
the most powerful evidence concerning the effects
of chronic stress on ill health. Several laboratory
experiments and quasi-experimental studies have
exposed humans to mild stress (e.g .• demanding
levels of workload. responsibility. or conflict with
others) and have shown effects on a wide range of
physiologic outcomes. including cardiovascular
functioning (Manuck et al. ]989), neuroendocrine
functioning (Krantz and Manuck 1984). and cellular immune response (Cohen. Tyrell, and Smith
1991). Although the stressors used are, for obvious
ethical reasons. too mild to cause serious or prolonged health impairments. their effects recall the
more marked manifestations of naturally oc<.:Urring
life crises. Animal experiments confirm data on human subjects regarding the pernicious physiological effect of stress. with recent studies documenting
that long-term exposure of mice and monkeys to
threatening social situations leads to impaired immune response to a variety of infections (Cohen et
al. 1992).
In 1960. Jackson et al. demonstrated experimentally that people with chronic role-related
·0
stresses al
per respir,
to a nasa
than a nt
document
tion throu,
is unclear
nificant. F
son (1991
erature. th
stress is ,
control fo
exposure
studies b)
these metI
pie of hea
low dose
neutral sa
subjects f
and contn
ences and
infectivit)
of negati
negative
significar
controll in
ing varial
Interestin.
across the
stress am
(i.e .. the (
to life ev(
once infel
Vulnerat
A consish
gation re\
pie who;
stressful
health pr'
health trit
ally. the'
that have
tion. vari(
pabilities
CHAPTER 21
Social P,ycho!ogy and Health
553
l
I
,tresses are more likely than others to develop upreI' respiratory infection when randomly exposed
to a nasal spray containing viral material rather
than a neutral solution. Although these studies
documented effects of stress on resistance to infection through various aspects of immune function. it
is unclear whether these effects are clinically significant. Further. as noted by Cohen and Williamson (1991) in a comprehensive review of this literature. the few studies that directly document that
stress is associated with infectious illness fail to
control for the confounding effects of differential
exposure or health behaviors. A series of recent
studies by Cohen et al. (1991) resolved many of
these methodological problems by exposing a sample of healthy volunteers via nasal drops to either a
low dose of one of five respiratory viruses or to a
neutral saline solution and then quarantining the
subjects for a full week after exposure to monitor
and control their subsequent environmental experiences and behaviors during the period of potential
infectivity. Results showed clearly that measures
of negative life events. perceived stress, and
negative affect assessed prior to the challenge
significantly increased risk of developing a cold.
controlling for a wide range of potential confounding variables (including prechallenge antibodies).
Interestingly. the pathways of these effects differed
across the three stress measures. with perceived
stress and affectivity increasing risk of infection
(i.e .. the development of antibodies) and exposure
to life events increasing risk of clinical symptoms
once infected.
Vulnerability Factors
A consistent finding across all the areas of investigation reviewed above is that the majority of people who are exposed to all but the most extreme
stressful life experiences do not develop serious
health problems. Current research on stress and
health tries to explain this finding and. more generally. the variation in stress reactivity. The factors
that have been examined include biogenic constitution. various aspects of personality. intellectual capabilities such as cognitive tlexibility and effective
problem-solving skills. interpersonal skills such as
social competence and communication ability, and
social resources. including financial assets and
coping styles. Because full consideration of this
diverse array of studies is beyond the scope of this
chapter. we focus on two classes of variables that
have generated intense interest over the past decade: social relationships and support and dispositional/personality variables. especially what has
variously been termed "control." "efficacy." or
"mastery."
Social Relationships and Support. Current interest in the effects of social relationships and support
on health was triggered by several influential papers published in the mid-1970s that reviewed diverse studies demonstrating that such things as
marital status. geographic stability. and social integration are associated with both mental and physical health (Caplan 1974; Cassel 1976; Cobb 1976).
A theme present in all these associations seemed to
be access to social ties and supports. Here. as in the
case of stress. the available evidence has come
from experimental studies of animals and humans.
as well as from nonexperimental studies of human
populations.
The presence of a familiar member of the same
species buffered the impact of experimentally induced stress on ulcers. hypertension. and neurosis
in rats. mice. and goats. respectively (Cassel 1976).
The presence offamiliar others also reduced physiological arousal (e.g .• secretion of free fatty acids)
in humans in potentially stressful laboratory situations (Back and Bodgonoff 1967). Such effects
may even operate across species, with affectionate
petting by humans reducing the cardiovascular selJuelae of stressful situations among dogs, cats,
horses. and rabbits (Lynch 1979. 163-80) and even
the arteriosclerotic impact of a high-fat diet on
rabbits (Nerem. LeveslJue. and Cornhill 1980).
Nonexperimental studies of human populations have devised scales to measure social integration and support and demonstrated that these
measures are associated with health. The most intluential of these studies examined the effects of
social relationships on subselJuent mortality in pro-
II
,
I
I
:
i
i
t
!
I
554
PART III
Social SlruClure, Rclalinnships, and Ihe Individual
spective surveys of the general population, The
first study of this sort showed that marriage. contact with family and friends. church membership.
and affiliation with other social groups were all
associated with reduced mortality risk over a nineyear follow-up period in a large sample of respondents living in Alameda County. California (Berkman and Syme 1979). Subsequent reports by
Blazer ( 1982) and House. Robbins. and Metzner
( 19lQ) showed similar patterns in other longitudinal community surveys in the United States. since
replicated in a number of European studies (see
House. Landis. and Umberson 1988 for a review).
All of these reports were based on secondary analyses and none contained a comprehensive set of
social support measures, Therefore. though they
provide strong evidence that social relationships
increase longevity. they do not allow an estimate of
the full extent of this inlluence or an understanding
of the precise components of relationships. supportive or otherwise. that are involved.
Similar longitudinal studies have examined
the association between support and onset of physical illness. The most rigorous of these have focused
on coronary artery disease and are reviewed by
Berkman (19R5). Despite broad consistency in
finding some indicator of social relationships or
support associated with decreased morbidity risk.
there are inconsistencies. For example, social ties
are associated with disease incidence but not prevalence in some studies. while in others the only
significant predictors are associated with prevalence, The effects are limited to lower-class women
in one major study and appear only among men in
another. The aspects of social relationships that
seem to promote health vary across studies as well.
Inconsistent findings of this sort further obscure
the mechanisms involved in the effects of support.
While research on social relationships and
physical health has focused primarily on direct effects. research on social relationships and mental
health has been more concerned with stress-buffering effects. In an influential research program. for
example. Brown and Harris (llI7R) showed that the
impact of stressful life events on depression was
substantially reduced among respondents who 10.,.1
an intimate confiding relationship with a l,il'lId "
relative. While nearly 40 percent of the .,1'"" ,\
women studied without a confidant becanll' I k
pressed. only 4 percent of those with a conlld.II'1
did so. This paradigm has subsequently been Il",11
cated in many studies. and the general paltl'lII ,,,
results clearly shows that access to a confidalll :111,1
perceived availability of crisis support arc a.. ,.,\l1 I
ated with a reduced impact of stressful life cn'II"
on depression and anxiety (Cohen and Wills I'His
Kessler and Mc Leod 1985).
Another line of investigation has used nwas
ures of social relationships and support to predlll
adjustment to specific life crises. such as widow
hood (e.g., Umberson. Wortman. and Kessler 199.',
and unemployment (e.g .• Kessler. Turner, and HOll'"
1987). Almost all of these studies have been con
cerned with mental health outcomes. and l11o.,1
have found that measures of social relationship"
obtained shortly before or after a crisis are sigl1lt I
cant predictors of subsequent emotional adjusl
ment. Moreover. these focused studies begin 10
suggest that specific kinds of supportive ties may
be most helpful for particular problems. For example. Hirsch (1979) showed that low-density net
works that facilitate contact with new people arc
particularly useful when the coping task is to ob
tain new information or adopt a new role. Interventions aimed at providing coping skills and support
have been shown to reduce adverse health const:quences of unemployment (Price. van Ryn. and
Vinokur 1992) and widowhood (Raphael 1977).
Studies of specific life events or crises also
provide an opportunity to examine social support
processes in relation to other determinants of adjustment. such as appraisals and coping strategie~.
and in this way clarify the mechanisms through
which support may protect against illness. Life
crisis studies conducted to date have not fully realized this potential but have provided two very provocative and consistent results. One of these involves miscarried support efforts. and the other
involves the distinction between perceived support
and received support.
The first
,'\aminatiom
IV hat support
Such studies
aujustment
l'fforts can a
'!uences. suc
lent (Coyne.
portive actio
limes can lea
\upport had
1l}86). Evide
interest in de
ics of actual
developing tl
nping suppor
This evi
support tram
linding: whil
able is aSSOCi
to stress. the
lion is medi:
One possiblt
the perceptio
promotes adj
actual receipt
several ways
ity might leal
as less threa
chological et
Alternativel),
"safety net" ,
efforts (Rool
ceived SLlPP!
some unmea~
cially compe
support and
and Swindle
to evaluate e:
rod. and Clal
!l}l}() ).
Personality.
sonality trait
illnesses pro
CHAPTER 21
The first of the two results is based on focused
'''lminations of exactly what supporters do and
what support recipients think about these efforts.
'illl:h studies show that while support can promote
.Idjustment to stress, well-intentioned support
,'Ilorts can also have unintended negative conse'1l1~nces, such as making recipients feel incompekill (Coyne, Wortman, and Lehman 19H8). Supportive actions can also create social costs that at
tlllles can lead to greater emotional distress than if
'lipport had not been obtained at all (Lieberman
I'lX6). Evidence of this sort has led to a heightened
l'i1~rest in detailed descriptive work on the dynamIl~ of actual support transactions, both as an aid in
d~veloping theory and as a practical guide to devel"ping support interventions (Sandler et al. 1988).
This evidence on the mixed effects of actual
~lIpport transactions has led to another important
Iinding: while the perception that support is avail:Ihle is associated with good emotional adjustment
10 stress, there is little evidence that this associalion is mediated by the actual receipt of support.
One possible interpretation of this finding is that
Ihe perception of support availability itself actively
promotes adjustment to stress over and above any
:Iclual receipt of support. This could occur in any of
,everal ways. The perception of support availabilIty might lead to an appraisal of stressful situations
a~ less threatening, thereby decreasing their psylhological effects (Wethington and Kessler 1986).
\lternatively, it could provide a psychological
"~afety net" that helps motivate self-reliant coping
efforts (Rook 1990). The putative effects of perleived support on health may actually be due to
,orne unmeasured common cause; for example, solially competent people may be more able to attract
,upport and to manage stressful situations (Heller
,lI1d Swindle 1983). Ongoing research is attempting
to evaluate each of these possibilities (Cohen, Sherrod. and Clark 1986; Sarason. Pierce, and Sarason
IYYOl.
Personality. Although the early search for per,tmality traits uniquely associated with particular
Illnesses proved fruitless. more sophisticated cur-
Social Psychology and Health
555
rent research has focused on personality dispositions that can affect a broad range of health problems, either directly or as vulnerability factors.
This new approach to the investigation of personality effects on health has gained momentum only in
the 1980s and is therefore less well-developed than
research on social relationships and support. In
particular, there are few good prospective data on
personality and health nor have the causal pathways linking personality to health been investigated in great detail. Only a few studies of personality and health have gone beyond main effects
analyses to examine whether there are interactions
between personality and stress in predicting ill
health.
Most studies that have examined stress-buffering effects of personality are either studies of mental illness or laboratory studies of stress and infectious disease. The former have documented the
stress-buffering effects of self-esteem, perceived
control, and hardiness and the stress-exacerbating
effects of neuroticism and interpersonal dependency (Pearlin et al. 1981; Cohen and Edwards
1989). The latter have shown that introversion,
social skills, and negative affectivity all modify the
effects of mild stress on infection (Cohen and Williamson 1991).
One of the most intriguing areas of investigation in this literature concerns a personality disposition variously termed self-efficacy, mastery, or
control. Sutton and Kahn (1984) reviewed a variety
of laboratory and field studies on this concept and
found consistent evidence suggesting that individuals who have a greater chance to predict, understand, and control events in their lives experience less stress and fewer adverse effects of stress
on their physical and mental health. In a related
research program, Karasek and Theorell (1990)
have shown that lack of control over one's work
environment is a risk factor for cardiovascular disease and psychological distress, both directly and
through a tendency to exacerbate the deleterious
effects of other occupational stresses. Pearlin and
colleagues ( 1981 ) have shown that a sense of mastery promotes mental health and buffers the impact
II
I
1
i1
t
!~f:
i
t
I
:
t
Ii
t
[
!
!f
I
I
I
556
PART III
Social Structure, Relationships, and the Individual
of acute and chronic stress on mental health, A
major program of research by Rodin (19R6) and
others has demonstrated that increased control over
one's social environment can promote better physical and mental health, and even longer life, perhaps
especially for older persons. Langer and Rodin
(1976) designed an inexpensive set of structural
interventions in nursing homes to create opportunities for mastery experiences. Markedly positive effects on psychological well-being, physical health,
and even the longevity of nursing home residents
were documented.
Finally, research on cancer and personality
suggests that feelings of helplessness and hopelessness, as well as repression or denial of emotions,
may both predispose people to the onset of cancer
and exacerbate its course (Levy and Heiden 1990).
Here animal studies yield especially dramatic results. Animals induced to become helpless through
behavioral restraint and repeated exposure to stress
(e.g., electric shocks) have lower rates of tumor
rejection, earlier appearance of tumors, and faster
tumor growth than control animals exposed to implanted tumors (e.g .. Shavit et al. 19R4: Visintainer,
Volpicelli, and Seligman 1982). Although there are
obviously no analogous experimental human studies, several prospective studies have consistently
supported the hypothesis. A study of Veterans Administration patients found clear evidence of
greater repression of negative affectivity on the
MMPI among men who subsetjuently developed
cancer (Dattore, Shontz, and Coyne 1980), and a
prospective community study in Yugoslavia over
ten years reported similar results (GrossarthMaticek 1980). A prospective study by Greer, et al.
(1985), subsequently replicated, found that helplessness/hopelessness is also associated with poor
prognosis in cancer patients after controlling for
objective predictors.
These epidemiologic studies provide scant information on the mechanisms involved in the effect of personality on onset and course of cancer.
According to the most widely endorsed hypothesis,
a sense of efficacy and control affects the immune
system, which, in turn, affeels host resistance to
malignant transformation of cells. This hypothesis
is consistent with both the broader literature on
personality and immunity (Jemmott and Locke
19R4) and an observed association between personality and immune competence among cancer patients (Levy et al. 1985). However, it is impossible
to preclude the possibility that the association is
due to an effect of illness severity on personality.
Further research is needed to determine whether
baseline measures of personality among cancer patients predict changes in immune function.
Another area for future research involves investigation of the structural determinants of healthrelated personality dispositions (Kohn et al. 1983).
In one of the few studies to examine this issue,
Harburg, et al. ( 1973) found that suppressed hostility was significantly increased in high-stress residential neighborhoods versus low-stress areas.
More research of a similar sort is needed to identify
the structural causes of personality and to specify
the mediating effects of personality on the relationships of these structural variables to ill health. In
addition, research is needed to determine whether
the effects of personality on health vary depending
on structural contexts. [n one of the rare studies to
investigate this issue, James et al. ( 1987) found that
an active predisposition to master stress was associated with increased risk of high blood pressure
among low socioeconomic status African Americans but not among either whites or higher socioeconimic status African Americans, presumably retlecting the fact that social circumstances make it
unlikely that active mastery will effectively reduce
stress in the face of the environmental barriers
that face lower socioeconomic status African
Americans. More research is needed to investigate other interactions between personality dispositions and environmental conditions.
Psychosocial Determinants of
lIIness: Overview
The past several decades of research and theorizing
have clearly established the role of psychosocial
factors in the etiology of illness. The major focu,
and contribution of this work has been to estahlish
a theoretical rationale and empirical evidence for a
number of
health risk
(2) chroni
ships and
efficacy, 01
(5) high Ie'
personal rf
psychologi
sion) is bo
and itself a
mortality.
Resear
needed. Fil
and Jongitu
about caus.
tinuing nee
the broad p
quential fOI
ological m
For exampl
negative lif
health. but
precisely w
terious ane
chronic ane
of social re
arguably 01
smoking, b
what it is a
tive of he2
produces Sl
Sociolc
emphasized
focus more,
psychosoci.
by a broad
people are
gender, an,
1992: Pearl
search sugg
cit fferences
socioeconol
ciation of 1
risk factors
behaviors te
Verbrugge I
CHAPTER 21
number of psychosocial factors as consequential
health risk factors: (I) major negative life events;
(2) chronic stress; (3) lack of social relationships and supports; (4) lack of sense of control,
efficacy, or mastery over one's work and life; and
(5) high levels of hostility and/or mistrust in interpersonal relations. This research also shows that
psychological distress (e.g., anxiety and depression) is both a consequence of these risk factors
and itself a risk factor for physical morbidity and
mortality.
Research and theoretical development are still
needed. First, there is need for more prospective
and longitudinal research to increase our certainty
about causal relationships. Second, there is a continuing need for research to specify what aspects of
the broad psychosocial risk factors are most consequential for health, and through what psychophysiological mechanisms these effects are produced.
For example. we have learned that it is only major
negative life events which are most deleterious for
health. but we are only beginning to understand
precisely what it is about those events that is deleterious and through what pathways they affect
chronic and infectious disease. We know that lack
of social relationships is a risk factor for mortality,
arguably of a magnitude comparable to cigarette
smoking, but we are only beginning to understand
what it is about social relationships that is protective of health and through what mechanisms it
produces such effects.
Sociological social psychologists have recently
emphasized the need for theory and research to
focus more on the interrelations among these various
psychosocial risk factors and how they are shaped
by a broader social structural context in which
people are stratified along lines of race/ethnicity,
gender. and socioeconomic status (Aneshensel
1992: Pearl in 1989; Williams 1990). Current research suggests that many of the persistently large
differences in health by gender, race/ethnicity, and
socioeconomic status can be explained by the association of these variables with the psychosocial
risk factors just considered and the health-related
behaviors to which we now tum (House et al. 1992;
Verbrugge 1989). In quite a different vein. research
Socia) Psychology and Health
557
on the interplay between psychosocial and genetic
factors in the etiology of health and illness is being
reported just now. We return to these themes at the
end of the chapter.
THE SOCIAL PSYCHOLOGY OF HEALTH
DEHAVIOR AND ILLNESS DEHAVIOR
The study of health behavior and illness behavior
encompasses how people perceive, define, and act
toward symptoms, how they utilize medical care,
how they act to promote health and produce risks,
and how they adhere to medical regimens. Interest
in health behavior and illness behavior grew out of
a set of practical problems in medicine and public
health concerning the fact that many people delay
seeking medical attention, even in the face of serious and life-threatening symptoms (Leventhal,
Meyer, and Nerenz 1980; Rodin 1985), while others seek medical help for complaints with no discernable organic basis (Mechanic 1992b). Furthermore, many patients refuse to do what is seemingly
in their rational self-interest. continuing to smoke,
drink, and overeat despite the warnings of physicians and health educators (Sackett and Haynes
1976). Finally, large numbers of patients, perhaps
as many as 50 percent. fail to comply with medical
advice even when this noncompliance endangers
their lives (Conrad 1985; Haynes, Taylor, and
Sackett 1979; Tebbi et al. 1986). These behavior
patterns result in increased morbidity and mortality
(Sackett and Haynes 1976), contribute to escalating medical costs (Fuchs 1974), and frustrate those
who provide care (Mechanic 1992b).
These observations could not be explained using the traditional biomedical model and led health
researchers to distinguish analytically between two
orders of phenomena: disease-an organic and biological process; and illness-a psychological, social, and cultural process that includes symptom
recognition, decision making, and utilization. It
was argued that illness could not be reduced to
disease (e.g., Barondess 1979; L. Eisenberg and
Kleinman 1981). While early work expanded the
medical model to include psychosocial factors in
patient behavior, the research questions remained
558
PART III
Social Structure. Relationships. and the Individual
largely medical: understanding why patients procrastinate. take risks. or fail to follow medical advice to modify these medically inappropriate behaviors (Schneider and Conrad 1983). In this
framework. medical judgments about appropriate
actions were the "gold standard" against which
actual patient behaviors were judged and found
wanting. From a social psychological standpoint.
this medical orientation excluded many important
empirical issues from consideration (Mechanic
1978; Zola 1972).
Increasingly aware of these limitations. a number of social psychologists carried out patientcentered analyses of health behavior and illness
behavior that moved in three broad directions:
( I ) away from abstract models of rational choices
about health care and toward understanding the
logic of lay theories and representations of illness
problems: (2) away from an exclusive focus on the
decision to seek medical care and toward an emphasis on patterns of health and illness behavior
that do not invol ve physicians: and (3) a way from
a focus on individual characteristics as detenninants of health and illness behavior toward underslanding how the social environment, including the
healthcare system, shapes these behaviors. Several
social psychological perspectives contributed to
this work. After brietly reviewing these perspectives, we examine how they are retlected in empirical research on health behavior. illness behavior,
and adherence to medical regimens.
Theoretical Perspectives
pirically (Cockerham 1986: Mechanic 1978). More
recent work has moved toward explanatory approaches, emphasizing that the structure of social
and healthcare institutions. as well as the culture of
care seekers. shape health and illness behavior.
Integrative Models, Several e<.:lectic approaches
depict illness behavior as resulting from an interplay of biologi<.:aL sociocultural. and psychological
factors. The best-known example of this approach
is Mechanic's theory of help seeking. Basing his
model on a large body of theory and research.
Me<.:hanic identifies ten cognitive. social, and psychological factors that influence the decision to
seek help: ( I) the visibility and salience of symptoms: (2) the extent to which symptoms are perceived as serious: (3) the extent to which they disrupt sodal activities; (4) the frequency and
persistence of symptoms; (5) the tolerance level of
those who experien<.:e symptoms: (6) available information, knowledge, and cultural assumptions:
(7) basic needs that lead to denial: (8) other needs
that compete with illness responses; (9) wmpeting
interpretations that can be assigned to symptoms:
and ( 10) the available resources, physical proximity of care, and l:Osts of taking action (Mechani<.:
197X). The strength of this approach is its effort to
develop a comprehensive, biopsychosocial approach to care seeking. However, as Mechani<.:
himself acknowledges, the model is physiciancentered, focusing on the decision to seek conventional medical <.:are (S<.:hneider and Conrad 1983),
though it could be broadened to include other
sources of care.
Culture. Social Structure, and Patient Behavior.
Social psychologists with a cultural or social structural orientation have found that social groups differ in their responses to symptoms and patterns of
care seeking and have attributed these differences
to cultural orientations or structural constraints.
Researchers have examined ethnic differences in
the response to pain and symptoms as wcll as ethnic, socioeconomic. and gender differences in utilization patterns. Early research in this area often
used purely correlational, cross-se<.:tional designs
that postulated reasons (often <.:ultural) for group
differences. rather than demonstrating them em-
Cognitive Models of Decision Making.
Social
psychologists have examined the cognitive processes at work in decisions to take preventive action.
to seek help, and to follow medical advice. Until
re<.:ently, most psychologists employed one of a
number of rational choice models that assume thaI
people make health behavior choices on the basis
of cost-benefit ratios. Perhaps the best-known rational <.:hoice theory is the health belief model.
According to this model. people decide to take
preventive action or follow medical advice on the
basis of their subjective beliefs about the severity
of the i1lnl
ing ill. and
action (e.g
1958: Ros.
This r
\ufficient
tradition. ,
to conside
lions on in
\implify t~
ing rationa
'tandards c
1985: Tver
ics argue t~
theories, pr
how decisil
quate desC'
made.
More r
emotion in
(1977). for,
making occ
fonnation p
they are aw.
have hope,
they have er
cause of the
CIS Ions, peol
live coping
ddherence tl
\ive avoidan
([Janic).
Other h
the role of c
,ymptoms a
People who (
,If them by n
,entations st,
lIons about t~
l'llurse, and p
lIl,m, and GI
,ymptom pro
processor of
liCOl'S perspe
1,lins a medic:
Illfomlation p
II'y common-
CHAPTER 2t
Ill' the illness. their susceptihility or risk of hecom-
ing ill. and the costs. benefits. and harriers to taking
.lction (e.g .. Becker and Maiman 1975; Hochhaum
195~; Rosenstock and Kirscht 1979).
This model has heen criticized for giving in,ufficient attention to the role of cultural values.
tradition. and emotion in decision making. failing
to consider cognitive and organizational limitations on information processing that lead people to
,implify the decision-making process. and eqllatII1g rational choices with those that conform 10 the
,tandards of Western medicine (Garro I<.JX5; Good
I\)X5; Tversky and Kahneman 1974). In short. critICS argue that this model. like other rational choice
theories. provides a prescriptive. idealized view of
how decisions should he made rather than an adequate description of how decisions actually are
made.
More recent approaches consider the role of
emotion in health decisions. Janis and Mann
(1\)77). for example. propose that optimal decision
making occurs when people engage in "vigilant information processing'" which can occur only when
they arc aware of the risks allached to each choice.
have hope of finding an alternative. and helieve
they have enough time to del iherate. However. hecause of the anxiety-provoking nature of health dec'isions. people often resort to one of several defective coping strategies. including unconflicted
adh('rence to their present course of action. defcn,ive avoidance (procrastination). or hyperv igilance
[panic).
Other health psychologists have focused on
[he role of cognitive schemas in making sense of
,ymptoms and deciding what to do ahout them.
People who experience bodily changes make sense
\1f them by means of common-sense illness repre,cntations stored in memory and include attrihutlons ahout the identity. causes. consequences. time
C:l)urse. and potential for cure (Leventhal. Zimmerman. and Gutmann 19X-l). Cognitive models of
,ymptom processing depict the patient as an active
processor of information and emphasize the patiL'nt's perspective. However. this approach main[~\ins a medical orientation by emphasizing flaws in
Information processing. stressing: the need to modIfv common-sense representations to bring them
Social p,yL'iwlnilY anu Hcalth
559
into line with medical ones. and neglecting environmental and structural factors .
Phenomenological Analyses ofDecision Making.
Phenomenological approaches. developed in anthropology and social psychology. provide the
most patient-centered perspectives on health hehavior and illness hehavior. These perspectives
consider patterns of care outside the professional
sector and attempt to discover the logic of patient
decisions rather than analyzing them in terms of
models the researcher formulates a priori. These
models include everyday ideas ahout the etiology.
anticipated course. and consequences of a partiClIJar illness. Explanatory model research has gone
heyond cognitive approaches to explore how models of doctors and patients collide in medical
encounters. how explanatory models relate to
hroader cullUralthemes. and how they assume difkrent forms in different cultural contexts (Kleinman I<.JXO).
Other cognitive anthropologists have developed formal models of decision making in which
the researcher el icits from patients their actual considerations in making medical decisions. develops
a formal model of the criteria used in health decisions. and tests the model's validity hy comparing
it to the aClllal decisions of community memhers
(Garro I YX5). Sociologists have developed a phenomenological approach to the experience of illness that examines how patients notice something
is wrong. develop lay thenj'ies and explanations.
decide to seek help. manage relationships with
signi ficant others and health professionals. and
cope with the stigma attached to their illness. Researchers emphasize the importance or studying
nonhospitalized patients and examining self-medication practices that do not involve professionals
(Schneider and Conrad I<.JX3).
Empirical Applications
Health Behavior. Health behavior refers to the
actions of well people that have consequences for
their future health. such as smoking. diet. exercise.
and substance ahuse (Mechanic !Yl)O). A numher
of programs have heen developed to change health
560
PART III
Soci~1 SlrUClllr~" R~I~lion,hips. ~llLllhe Indl\ldll,li
behaviors. Most are based on psychological models of hehavior change and. with a few notable
exceptions. have generally not succeeded in effecting lasting changes in health behavior (Mechanic
1990. 1992a). In fact. a review of the long-term
outcomes of many programs shows that as many as
three of every four people who successfully change
risk behaviors arc unable to sustain these changes
for as long as one year (Brownell et al. 1(86).
Critics have attributed these failures to the inaccurate assumptions of some psychological models of health behaviors and have proposed new
ideas about ways to modify interventions. Findings
concerning the importance of cognitive representations. for example. have led to the suggestion that future interventions identify and alter
participants' representations of risk. provide them
with self-regulation skills. and encourage them to
perceive that they can effect change (Leventhal.
Zimmerman. and Gutmann 1(84). Other health
psycilOlogbts have called for programs that enhance perceptions of control. This recommendation is hased on research showing that participants
in weight reduction programs are more likely to
succeed when they attribute change to their own
etlorts (Rodin 11)85). Conversely. participants are
less likely to relapse pennanently when they attribute lapses to situational causes (Marlatt and Gordon 1(85).
Some sociological social psychologists have
also suggested that traditional interventions fail because they treat health behavior as an individual
rather than a social phenomenon (Mechanic [990;
Syme and Alcalay 1(82). In particular. health behaviors may have other meanings that interfere
With behavior change (Mechanic 1(90). Smoking,
for example. can he a mark of status and a symbol
of defiance in adolescent culture (lessor, Donovan.
and Costa )990: Osgood et al. 1988: Rodin 1985).
Successful interventions to modify health behaviors need to consider such symbolic meanings. This
can be done by providing the individual with resources to resist interpersonal pressures. An example is Michelson's (1986) Social Skills Training
Program. a wide-ranging program that teaches
adolescents to evaluate health behavior options
and to resist interpersonal pressures to engage in
risk hehaviors. Alternately. one may attempt to
change the cultural meanings of health behaviors.
One of the most successful examples of this approach is the antismoking movement in the United
States. a movement that changed the symbolic
value of smoking in the middle class (Mechanic
!1)90: Syme and Alcalay 1982) and resulted in a
substantial long-term reduction in smoking (Warner 1(77).
The importance of facilitating social and structural conditions is not limited to symbolic meanings. It is also important to consider the functions
of health behaviors in the lives of the people whose
behaviors we seek to change. Alcohol and tobacco,
for example. appear to be used as coping resources
by many people. This raises the question of
whether interventions to change the structural conditions that lead to chronic stress make more sense
than interventions aimed at removing the coping
resources used by people to manage chronic stress.
FurthernlOre. if interventions do attempt to remove
these coping resources there is a need to provide
alternate resources. See House and Cottington
(1986) and Williams (1990) for a discussion. A
similar question can be raised about the logic of
attempting to change individual health behavior
when powerful economic interests continue to promote risk taking (McKinlay 1990: Symeand Alcalay 1(82). It is noteworthy in this regard that state
licensing boards permit more retail outlets for the
sale of alcohol in poor and African American
neighborhoods than in more affluent areas (Rabow
and Watts 1(82). Furthennore, more than 70 percent of billboards in the United States that advertise tobacco and alcohol are targeted to African
Americans (Hacker. Collins. and Jacobson 1(87).
It is difficult to avoid the conclusion. based on
these results. that there are systematic structural
forces at work that impede individual efforts to
reduce the problems of substance use among disadvantaged sectors of American society. Based on
this conclusion. there is a growing belief that structural change is needed to guarantee the success of
widespread health behavior change (McKinlay
1990 ).
",
J..
i:
Illness B
ways peo
tions and
symptom:
and in res
(Mechani
issues in
tenninant
that infl Ul
recognize
influence
ations in
matic em
with illne
Rese,
are substa
tions to m
and socia
creating tl
1986). Fo
ethnic gro
to symptc
and TursI
An espec
generally
symptom~
nize and
1986). Th
the lower
women ar
bodily Cl
comes fro
radiograpl
study self
visits for
women w
were near
report reCI
Resea
the ways c
of bodily
tenns. Re:
arrive at a
to illness (
neutralize.
symptoms
!
r
II
I
~
CHAPTER 21
Illness Behavior.
Illness behavior refers to the
ways people define and respond to bodily sensations and experiences that might be seen as signs or
symptoms of illness, both before seeking treatment
and in response to the recommendations of healers
(Mechanic 1986). Important social psychological
issues in the study of illness behavior include determinants of initial symptom recognition, factors
that influence how symptoms are interpreted once
recognized, and social and individual variables that
influence willingness to adopt the sick role. Variations in these ways of responding can have dramatic effects on the social impairment associated
with illness.
Research on illness behavior shows that there
are substantial individual differences in predispositions to monitor bodily sensations and that cultural
and social experiences play an important part in
creating these dispositions (Hansell and Mechanic
1986). For example, early research discovered that
ethnic groups differ dramatically in their responses
to symptoms and perceptions of pain (Sternbach
and Tursky 1965; Zborowski 1952; Zola 1966).
An especially intriguing result is that women
generally seem more sensitive than men to bodily
symptoms and are therefore more likely to recognize and seek help for health problems (Kessler
1986). This sex difference is more pronounced at
the lower end of symptom severity, suggesting that
women are more likely than men to monitor subtle
bodily complaints. An interesting illustration
comes from the work of Davis (1981), who used
radiographic examination data on osteoarthritis to
study self-reported knee pain and recent doctor
visits for knee pain. These data documented that
women with objective evidence of osteoarthritis
were nearly twice as likely as comparable men to
report recent doctor visits for this problem.
Research on symptom sensitivity has explored
the ways cognitive schemas are used to make sense
of bodily sensations and define them in illness
terms. Research also has shown that most people
arrive at a definition of their bodily changes as due
to illness only after concerted efforts to normalize,
neutralize, or minimize the significance of their
symptoms, a practice that may account for com-
Social Psychology and Health
561
mon delays in seeking help (e.g., Davis 1971;
Mechanic 1972; Schneider and Conrad 1983).
These interpretations often involve the use of social networks. Parents, spouses, friends, and even
physicians often collaborate in the normalization
process (Davis 1971; Schneider and Conrad 1983).
The literature on illness representations documents many dramatic cases that illustrate this
process. For example, people who are alone when
they first experience a mild heart attack commonly
delay calling an ambulance due to uncertainty
about what has happened to them. Instead, before
calling an ambulance they will call a friend or relative, describe the symptoms, and ask whether the
other person thinks it was really a heart attack.
This delay is associated with a dramatically increased risk of long-term cardiac damage (Alonzo
1986).
Illness behavior research also has examined
how groups differ in utilization patterns. Beginning with Koos's (1954) early work on socioeconomic differences in help seeking, research has
documented that the poor use health services less
frequently than those more favorably situated in
the social structure. Although expanded public insurance coverage has dramatically decreased socioeconomic differences in overall utilization, continuing differences in utilization patterns suggest a
two-class system of health care. While higher socioeconomic groups use private physicians, the
poor use a public healthcare system of outpatient
clinics and hospital emergency rooms (Cockerham
1986). Early cultural explanations attributed these
di fferences to a greater tendency of poor patients to
normalize or neutralize symptoms (Koos 1954) or,
alternatively, to a present-oriented culture of poverty that led poor patients to eschew prevention and
delay seeking help until emergencies arose (e.g.,
Kosa, Antonovsky, and Zola 1969). However,
more recent "systems" or "culture of medicine"
explanations suggest that the highly alienating,
impersonal, bureaucratic atmosphere and low quality of care in the public healthcare system leads
poor patients to view medical care as a measure
of the last resort (e.g., Dutton 1978; Reissman
)981).
562
PART 1lI
Social Structure, Relationships, and the Individual
Current research has moved away from an exclusive focus on the decision to seek medical care
and toward a focus on care that extends beyond
conventional medicine (e.g., Garro 1985). While
early studies viewed the use of alternative practitioners as a deviant pattern of utilization confined
to lower socioeconomic classes or ethnic enclaves
using parochial referral networks, it has become
clear based on more recent studies that many patients with chronic medical problems are turning to
alternative practitioners, such as chiropractors and
acupuncturists, who offer hope of symptomatic relief and more personal attention (D. Eisenberg et al.
1993; Kotarba 1983).
Although most research on illness behavior
continues to study patient responses from the viewpoint of the medical establishment, a growing number of studies are questioning professional definitions of illness and giving more attention to the
patient viewpoint (e.g., Roth and Conrad 1987).
Whereas earlier studies invidiously contrasted lay
explanations with professional ones, several contemporary researchers portray both lay and medical
decisions as socially constructed. These analyses
suggest that professional diagnosis and treatment
decisions are influenced by the cultural assumptions of providers, the perceived characteristics of
patients, and the social setting in which decisions
are made (Todd 1989).
Another current trend in illness behavior research is to focus on patient self-care. This research
has shown that many people diagnose and treat
their own symptoms (Zola 1983). Furthermore, patients who are receiving medical treatment for
chronic conditions commonly search for patterns in
their symptoms, make note of antecedents to flareups, develop and test hypotheses, and sometimes
even devise strategies thought to control symptom
expression (e.g., Schneider and Conrad 1983).
Treatment Adherence. Patient failure to follow
medical advice is a widespread phenomenon that
reduces the effectiveness of therapy (Rodin and
Salovey 1989) and may significantly increase morbidity and mortality (Sackell and Haynes 1976).
Buckalew and Sallis (1986) estimated that roughly
one-third of the 750 million new prescriptions Will
ten each year in the United States and the UlIil~'d
Kingdom are not taken at all and another one-third
are taken incorrectly. Nonadherence for medicI
tion and lifestyle changes recommended to trcal
chronic conditions is estimated at roughly 50 per
cent (Haynes, Taylor, and Sackett 1979). Surpri,
ingly, these high rates exist even for those paticllh
with life-threatening and seriously disabling condl
tions. For example, Tebbi et al. (1986) found lhal
only 50 percent of adolescent cancer patients took
their prescription medications as directed, whlk
Conrad (1985) found that only 50 percent of Cpl
leptics took their medications correctly.
Determinants of adherence include a wide variety of individual and environmental factors (Dr·
Malleo and DiNicola 1982). As in the case of illness behavior, social and symbolic meanings 01
medications figure importantly in adherence. Pa
tients view medications alternatively as an indica
tor of the degree of their disorder, a ticket to nor
mality that can increase self-reliance, a symbol 01
dependence, or a reminder of deviance and stigma.
Nonadherence is powerfully affected by thc~~'
meanings. For example, some epileptic paticlII,
stop taking their medication against medical advin~
when they view drugs as a symbol of their depend
ence and wish to reassert their independence or
when they view drugs as a reminder of differcnt
ness and want to escape the stigmatizing connolations (Schneider and Conrad 1983).
Illness representations also have been shown
to play a prominent role in adherence. Research
consistently shows that there are major discrepall
cies between the illness representations of patienh
and of healthcare providers and that these diffcrences play an important part in adherence. LevclI
thaI et al. (1984), for example, proposed that mall}
patients with chronic, asymptomatic illnesses farl
to follow physician advice because they use all
"acute disease schema" to interpret their medical
problems. That is, they believe their disease to tx·
caused by external agents that are short-terlll,
symptomatic, and treatable by medications that fl'
move the symptoms and cure the disease. WhclI
their experiences in treatment clash with these pcr
ceptions. th
ic'nt with th
(iutmann (I
,ive patient~
pressure bei
aches and f.
uf the patie
,panse to t
Illcnts defie
,orne to stol
high blood
~tn acute disc
Ilcnts with ;
drop out of
'hese. there i
distribution (
and investig
,ense represt
1986).
The litt:
shows clearl
elicit inform
i !lness repre
between the~
recommenda
tient's theori
cate in these
adherence (\
experimental
live show th.
,icians chan
patients. Inu
documented 1
lion style wit
a single twoccnt increase
among patienl
physicians. S
number of ott
\cntions (Me
Research
,hows that at
Illunication st
()f informatio
questions-in
I969: Freem(
CHAPTER 21
"l'ptions. they often terminate treatment. ConsisIl'nt with this perspective. Meyer. Leventhal. and
l Jutmann ( 1985) found that 90 percent of hyperten,ive patients believed they could "feel" their blood
pressure being elevated by such symptoms as headal'hes and face tlushing, This perception led some
Df the patients to adjust their medications in response to these feelings, even when the adjustIllents defied physician instructions, It also led
,orne to stop taking medications when feelings of
Iligh blood pressure persisted. The persistence of
~m acute disease schema may also explain why patients with asymptomatic, chronic illnesses often
drop out of treatment. Based on findings such as
these. there is much current interest in studying the
distrihution of illness representations (Bishop 1987)
~md investigating ways to modify these commonsense representations to promote adherence (Cleary
1986).
The literature on doctor-patient interactions
shows dearly that it is critical for the doctor to
dicit information about patient expectations and
illness representations, to confront discrepancies
hetween these cognitions. and to explain treatment
recommendations in a way congruent with the patient's theories of illness. Doctors who communicate in these ways have consistently higher rates of
adherence (Whitcher-Alagna 191'3). Furthermore.
~xperimental interventions based on this perspective show that adherence can he improved by physicians changing their style of interacting with
patients. Inui. Yourtee, and Williamson (1976)
documented that changes in physician communication style with hypertensive patients resulting from
a single two-hour training session led to a 30 percent increase in effective blood pressure control
among patients experimentally assigned to the trained
physicians. Similar results have been reported for a
number of other cognitively-based adherence interventions (Meichenbaum and Turk 1987).
Research on doctor-patient interaction also
shows that other characteristics of physician communication style--quantity of information. quality
of information. and willingness to let patients ask
Ljuestions-importantly affect adherence (Davis
1969: Freemon et al. 1971: Roter and Hall 191'9:
Social Psy<'ho[ogy and Heallh
563
Svarsted 1976), Many studies demonstrate that
physicians frequently fall short on all of these dimensions. There is currently a good deal of interest
in the structural determinants of these aspects of
physician communication behavior aimed at understanding why many doctors interact in ways that
produce the very nonadherence they find so troublesome. Some researchers argue that the logic of
differential diagnosis. coupled with the demands
associated with rapidly processing information in
bureaucratic organizations. drastically limits what
doctors can accomplish in the medical interview
(Cicourel 191'1), Others have suggested that as
health care comes to be delivered increasingly in a
colleague-dependent conte xt of referral. physicians
become oriented to the wishes of colleagues rather
than the wishes of their patients. Subsequently.
effective doctor-patient communication is impaired (Freidson 1970). A related observation is
that providers' cultural assumptions can make
them less inclined to encourage active patient participation. For example. Anspach (1993) observes
that many providers have a "common-sense social
psychology" that underestimates patients' competence to participate in medical decisions and overestimates the likelihood of deleterious psychological consequences that can result from participating
in medical decisions. Providers' cultural assumptions also include social schemata that lead professionals to underestimate the ability of lower-class
Hispanic patients to participate in certain medical
decisions (Anspach 1993). In short, physicians curtail patient participation. thereby discouraging adherence. less because of conscious choice than because of organizational restraints and misguided
cultural assumptions.
The Social Psychology of Health Behavior and
Illness Behavior: Overview
A growing body of research shows that psychosocial factors are crucial to understanding and modifying health and illness behavior. Researchers differ as to whether they examine psychosocial
processes in an effort to change patient behavior in
ways that will improve health outcomes or take a
564
PART III Social Structure, Relationships, and the Individual
...
··1··'····!.·
. .··•
patient-centered approach that examines a broader
set of issues concerning lay representations of
health problems and other meanings of health and
illness behaviors, Researchers also focus variably
on processes involved in the creation of health and
illness behaviors or on the impact of macrosocial
contexts on these behaviors, Unlike most other
areas of social psychological research, there are
many opportunities here for developing and implementing large-scale interventions that can be useful
both in applying social psychological knowledge
and advancing the knowledge base, A challenge for
the future is to integrate research on the structural
determinants of health and illness behaviors with
research on the mechanisms linking meaning structures to behavioral responses and to devise methods of intervening at a more structural level than
we have at present.
RETROSPECT AND PROSPECT
Theory and research on social psychology and
health have developed remarkably over the past
few decades, contributing to a major reorientation in the way the scientific community anti
society think about the nature, causes, and course
of illness. The social environment and its social
psychological consequences have become recognized as central to understanding and improving
health.
Much of this work has focused on individuallevel variables. Much remains to be clarified anti
learned at this level of analysis. Greater emphasis
on macrosocial factors is already apparent in new
Iines of research on the macrosocial determinants of health and illness behaviors (Anehensel
1992; Mirowsky and Ross 1989; Pearlin 1989;
Williams 1990). Such new work is beginning to
document systematic structural patterns of a broad
array of psychosocial determinants of health and
health-related behaviors and provides important
avenues for intervention (House et al. 1992). No
problem is more central to our well-being than
health, and in no area does social psychology have
greater opportunities for advancement over the
coming years.
Berkman,
netw(
year t
ArneI',
NOTE
Work on this chapter was partially supported by grants
K02 MH00507 from the National Institute of Mental
Health and PO I AG0556I and R29 AG07904 from the
National Institute on Aging. The authors are indebted to
Karen Cook. Gary Fine. Catherine Ross. and especially
David Mechanic for their constructive comments on previous drafts.
REFERENCES
Alexander, Franz. 1950. Psychosomatic Medicine; Its
Principles and Applications. New York: Norton.
Alonzo, Angelo A. 1986. The impact of the family and
lay others on care-seeking during life-threatening
episodes of suspected coronary artery disease. Social Science and Medicine 22: 1297-1311.
Anderson, Karen O. [985. Rheumatoid arthritis: Review
of psychological factors related to etiology effects
and treatment. Ps."c1wlogical Bulletin 98:358-387.
Aneshensel. Carol. 1992. Social stress: Theory and research. Annual Rel'iew ofSociologv 18: 15-38.
Anspach. Renee R. 1993. Deciding Who Lires; Fatefitl
Choi,'es in the Intensh'e-Care Nurser\'. Berkeley,
CA: University of California Press.
Back, Kurt W., and Morton D. Bodgonoff. 1967. Buffer
conditions in experimental stress. Behavioral Science 12:384-390.
Barondess, Jeremiah A. 1979. Disease and illness: A
crucial distinction. American Journal of Medicine
66:375-376.
Becker, Marshall H.: and Lois A. Maiman. [975. Sociobehavioral determinants of compliance with
health and medical care recommendations. Medical
Care 13:10-24.
Berkman, Lisa F. [985. The relationship of social networks and social support to morbidity and mortality.
pp. 241-262 in Social Support all£! Health, ed. Sheldon Cohen and Leonard Syme. New York: Academi<:.
,
"
..
~
. ••."~'
"
.
.
I
""
Bishop, G
symp
127Blazer, Da
elderl
ofEpl
Brown, Ge:
cial C
Disor
Brownell,
stein,
and pi
765-1
Buckalew,
ance,
cal P.I
Cannon, \\
York:
Caplan, Ge
Menta
Cassel. Jot
host n
104:H
Cicoure[, I
micro
Admn
~\'ard ,
gies. e
Route
Cleary, Pal
resear,
tidisci/
Plenul
Cobb, Sidr
life Sll
Cockerham
ed. En
Cohen, She
ality c
ship b
Admn
Stress.
Cohen, She:
Stephe
affiliat
man P'
CHAPTER 21
Berkman, Lisa F., and S. Leonard Syme. 1979. Social
networks, host resistance. and mortality: A nineyear follow-up study of Alameda county residents.
American Journal of Epidemiology 109: 186-204.
Bishop, George D. 1987. Lay conceptions of physical
symptoms. Journal of Applied Psychologv 17:
127-146.
Blazer. Dan G. 1982. Social support and mortality in an
elderly community population. Amerimll Jourl/al
of Epidemiology 115:685-694.
Brown, George W., and Tirril O. Harris. ed. 1978. Social Origins of Depression: A StudY of" Psychiatric
Disorder in Women. New York: Free Press.
Brownell, Kelly D., G. Alan Marlatt, Edward Lichtenstein, and G. Terence Wilson. 1986. Understanding
and preventing relapse. American PHchologist 41:
765-782.
Buckalew, L. W., and R. E. Sallis. 1986. Patient compliance with medication perception. Journal of Clinical Psychology 42: 161-167.
Cannon, Walter B. 1932. The Wisdom of the Body. New
York: Norton.
Caplan, Gerald, ed. 1974. Support Systems in Community
Mental Health. New York: Behavioral Publications.
Cassel, John. 1976. Contribution of the environment to
host resistance. American Journal of Epidemiology
104: 107-223.
Cicourel, Aaron V. 1981. Notes on the integration of
micro and macro levels of analysis. Pp. 1-40 in
Advances in Social Theory and Methodology: Toward an Integration of Macro- and Micro-Sociologies. ed. K. Knorr-Cetina and A. Cicourel. London:
Routeledge & Kegan Paul.
Cleary, Paul D. 1986. New directions in illness behavior
research. pp. 343-354 in Illness Behavior: A Multidisciplinary Model. ed. S. McHugh. New York:
Plenum.
Cobb. Sidney. 1976. Social support as a moderator of
life stress. Psychosomatic Medicine 38:300-314.
Cockerham, William C. 1986. Medical Sociology. 3rd.
ed. Englewood Cliffs, NJ: Prentice Hall.
Cohen, Sheldon, and Jeffrey R. Edwards. 1989. Personality characteristics as moderators of the relationship between stress and disorder. Pp. 235-283 in
Advances in the Investigatioll of Psychological
Stress. ed. R. W. J. Neufeld. New York: Wiley.
Cohen. Sheldon, Jay R. Kaplan, Joan E. Cunnick, and
Stephen B. Manuck. 1992. Chronic social stress,
affiliation and cellular immune response in nonhuman primates. Psychological Science 3:301-304.
Social Psychology and Heahh
565
Cohen. Sheldon. Drury R. Sherrod, and Margaret S.
Clark. 1986. Social skills and the stress-protective
role of social support. Jourl/al of Persollality and
Social Psychology 50:963-973.
Cohen. Sheldon, D. A. J. Tyrell, and A. P. Smith. 1991.
Psychological stress and susceptibility to the common cold. New England Journal of" Medicine 325:
606-612.
Cohen, Sheldon, and Gail M. Williamson. 1991. Stress
and infectious disease in humans. Psychological
Bulletin 109:5-24.
Cohen. Sheldon, and Thomas A. Wills. 1985. Stress.
social support, and the buffering hypothesis. Psychological Bulletin 98:310-357.
Conrad. Peter. 1985. The meaning of medications: Another look at compliance. Social Science Medicine
20:29-37.
Coyne, James, Camille B. Wortman. and Darrin Lehman. 1988. The other side of support: Emotional
over-involvement and miscarried helping. Pp. 305330 in Marshalling Social Support, ed. B. H. Gottlieb. Beverly Hills: Sage.
Dattore, Patrick 1.. Franklin C. Shontz, and Lolafaye
Coyne. 1980. Premorbid personality differentiation
of cancer and noncancer groups: A test of the hypothesis of cancer proneness. Journal of Consulting Clinical Psychology 48:388-394.
Davis. Milton. 1969. Variations in patients' compliance
with doctors' advice: An empirical analysis of patterns of communication. American Journal ofPublic Health 58:274-288.
- - - . 1971. Variation in patients' compliance with
doctors' advice: Medical practice and doctor-patient interaction. Psychiatry and Medicine 2:31-54.
- - - . 1981. Sex differences in reporting osteoarthritic symptoms: A sociomedical approach. Journal of Health and Social Behavior 22:298-309.
DiMatteo, M. Robin, and D. Dante DiNicola, ed. 1982.
Achieving Patiellts Compliance. Elmsford, NY:
Pergamon.
Dubos. Rene. 1959. Mirage of Health. New York: Harper & Row.
Dutton, D. B. 1978. Explaining the use of health services by the poor: Costs, attitudes, or delivery systems'? American Sociological Review 43:348-368.
Eisenberg, David M., Ronald C. Kessler, Cindy Foster,
Frances E. Norlock, David R. Calkins, and Thomas
L. Delbanco. 1993. Unconventional medicine in the
United States: Prevalence, costs, and pattems of use.
Nell' Englalld JO/lrnall!f"Medicille 328:246-252.
566
PART 1II
Social Structure. Relationships. and the Individual
Eisenberg, Leon. and Arthur Kleinman. 1981. The Releral/ce of Social Sciel/ce .tilr Medicil/e. Boston:
Reidel.
Freemon. B., Vida Negrete, Milton Davis, and Barbara
Korsch. 1971. Gaps in doctor-patient communication. Pediatric Research 5:298-311.
Freidson, Eliol. 1970. Professioll oj' Medicille, New
York: Dodd-Mead.
Friedman, Howard S .. ed. 1990. Persollalitl' allli Diselise. New York: Wiley.
Friedman, Howard S.. and Stephanie Booth-Kewley.
1987. The disease-prone personality: A meta-analytic view of the construcl. Americall P.ITclwlogist
~2:539-555.
Friedman, Meyer, and Ray H. Rosenman. 1974. Type A
Behal'ior alld Your Heart. New York: Knopf.
Fuchs. Victor R. 1974. Who Shall Live ~ Health. EcolIomics. alld Social Choice. New York: Basic
Books.
Garro. Linda. 1985. Decision-making models of treatment choice. Pp. 173-1 XX in Illness Belllll'ior: A
Multidisciplillary Model. ed. S. McHugh and T. M.
Vallis. New York: Plenum.
Good. Byron 1. 19X5. Explanatory models and careseeking: A critical account. Pp. 161-173 in 111111'.1'.1'
Behl/l'ior: A Multidisciplinary Model. ed. S.
McHugh and T. M. Vallis. New York: Plenum.
Greer, Steven. Keith Pettingale, Tina Morris, and 1.
Haybittle. 1985. Mental attitudes to cancer: An additional prognostic factor. Lallcet 3:750.
Grossarth-Maticek. Ronald. 1980. Social psychotherapy
and course of the disease: First experiences with
cancer patients. Psvchorherapy and Psyclwsol1lllfiI'S 33: 129-138.
Hacker, George A., Ronald Collins, and Michaellacobson. 1987. Marketillg Boo:e to Blacks. Washington. DC: Center for Science in the Public Interesl.
Hansell. Steven. and David Mechanic. 1986. The socialization of introspection and illness behavior.
Pp. 253-260 in Illness Behal'ior: A MultidisciplilIaTl' Model. ed. S. McHugh. New York: Plenum.
Harburg, Ernest. lohn C. Erfurt. L. Havenstein. C.
Chape, W. Schull, and M. Anthony Schork. 1973.
Socioecological stress. suppressed hostility, skin
color. and black-white male blood pressure. Psyclwsomatic Medicille 35:276--296.
Haynes, R. Brian. D. W. Taylor. and David L. Sackett,
ed. 1979. Compliallce ill Hl'lIltli Carl'. Baltimore:
lohns Hopkins University Press.
Heller. Kenneth, and Ralph V. Swindle. 19X~, ,>".
networks. perceived social support, and l "1'11
with stress. Pp. 87-103 in Prevelltive PI'vcil"/,, ..
Research and Practice ill Comlllullity IlIte1"1'1'1I11' ./.
ed. R. D. Feiner, L. A. lason, 1. Moritslll-!I1,'"'1
S. S. Farber. New York: Pergamon.
Hirsch. Barton 1. 1979. Psychological dimensl"ns "I
social networks: A multi method analysis. ,\"" /I
call Journal of COIllIllUllit\, P.n·dwlogy 7:26,~ .'"
Hochbaum. G. 1958. Public participation in 111""1' ,01
screening programs: A sociopsychological sln"l
DHEW publ. no. [PHS] 572. Washington. 1)(
U.S. Government Printing Office.
Holmes, Thomas H.. and Richard H. Rahe. 1967. III,'
social readjustment rating scale. Joun/al ofP.II1 il"
,\,(II/llitic Re.l'earch II :213-218.
House. lames S. 19X I. Work Stress lIlId Social SUI'I'II/ I
Reading. MA: Addison-Wesley.
House. lames S., and Eric M. Cottington. 1986. I kalrll
and the workplace. Pp. 382-415 in Applicatio/ls III
Socilll Sciellce to Clillical Medicine lind HI'alrl,
Polin', ed. L. H. Aiken and David Mechanic. N",\;
Brunswick. Nl: Rutgers University Press.
House, lames S .. Ronald C. Kessler. A. Regula Herwl-!.
Richard P. Mero. Ann M. Kinney. and Martha J
Breslow. 1992. Social stratification. age, ;11111
health. Pp. 1-32 in Aging. Health Behaviors, II/ltl
Health Owcollles, ed. K. Warner Schaie, Dan
Blazer. and lames S. House. Hillsdale, Nl: J-:r I
baum.
House. lames S., Karl R. Landis. and Debra Umberson,
1988. Social relationships and health. Science 2~ I'
5~0-545.
House. lames S., Cynthia Robbins. and Helen I ..
Metzner. 1982. The association of social relationships and activities with mortality: Prospective evidence from the Tecumseh Community Health
Study. American Journal of Epidellliology 116:
123-140.
House, lames S .. Victor 1. Strecher. Helen L. Metzner.
and Cynthia A. Robbins. 1986, Occupational stress
and health among men and women in the Tecumseh
Community Health Study. Journal of Health and
Social Behavior 27 :62-77.
Inui, Thomas S .. E. L. Yourtee, and 1. W. Williamson.
1976. Improved outcomes in hypertension after
physician tutoriais: A controlled trial. Anllals of
Illternal Medicine 84:646--651,
lackson, G. G .. H. F. Dowling. T. O. Anderson, L. Riff,
1. Saporta, and M. Turck. 1960. Susceptibility and
immunit:
[ions: Th
cille 53:i
I:lIlles, Sherm
Ramsey.
ism. and
C((II Jour
J <mis. Irwin L
A IISI'£'hl
cO/lllI/itill
krnmott. loh
chosocia
human s
much dc
78-108.
lessor. Richa
Costa, I'
and ado
Healt" H
and F. L(
Karasek. Robt
Work. Ne
Kasl. Stanis/a'
to the sll
Work, ell
Wiley.
Kessler. Rona
health seJ
Mllilidis£'
Thomas I
Kessler. Rona
support a
Pp.219Cohen an
Kessler. Rom
House. I'
ship bet...
logical M
Kessler. Ronal
psycholol
86 in Hm
H. E. Fre
Nl: Prent
Kleinman. An
COlltext I.
fornia Pre
Kohn, Melvin
A. Miller
1983. W..
III/pact of
CHAPTER 21
immunity to common upper respiratory viral infections: The common cold. Annals of Intel"l1al Medicine 53:719-738.
James, Shennan A., David S. Strogatz, S. Wing, and D.
Ramsey. 1987. Socioeconomic status. John Henryism, and hypertension in blacks and whites. American Journal of Epidemiolog.l' 126:664-673.
Janis, Irwin L.. and Leon Mann. 1977. Decision making:
A psychological analysis of' conflict, choice. and
commitment. New York: Free Press.
Jemmott, John B., and Steven E. Locke. 1984. Psychosocial factors, immunologic mediation and
human susceptibility to infectious disease: How
much do we know'! P.Hclwlogical Bulletin 95:
78-108.
Jessor. Richard. John E. Donovan, and Frances M.
Costa. 1990. Personality, perceived life chances.
and adolescent health behavior. Pp. 25-41 in
Hl'IIlth Ha:ards in Adolescence, ed. K. Hurrelmann
and F. Lose!. New York: Aldine de Gruyter.
Karasek. Robert A.. and Thores Theorell. 1990. Healthv
Work. New York: Basic Books.
Kasl, Stanislav V. 1978. Epidemiological contributions
to the study of work stress. Pp. 3-48 in Stress at
Work, ed. C. Cooper and R. Payne. New York:
Wiley.
Kessler, Ronald C. 1986. Sex differences in the use of
health services. Pp. 136-148 in Illness Behavior: A
Multidisciplinary Model. ed. S. McHugh and
Thomas M. Vallis. New York: Plenum.
Kessler. Ronald C .. and Jane D. McLeod. 1985. Social
support and mental health in community samples.
Pp. 219-240 in Social Support and Health. ed. S.
Cohen and L. Syme. New York: Academic.
Kessler. Ronald C.. J. Blake Turner. and James S.
House. 1987. Intervening processes in the relationship between unemployment and health. Pn'chological Medicine 17:949-96/.
Kessler. Ronald c., and Camille Wortman. 1988. Social
psychological factors in health and illness. Pp. 6986 in Handbook of Medical Sociology. 4th ed .. ed.
H. E. Freeman and S. Levine. Englewood Cliffs:
NJ: Prentice Hall.
Kleinman, Arthur. 1980. Patiellts and Healen' in the
Colltext of' Culture. Berkeley: University of California Press.
Kohn. Melvin L.. Canni Schooler, Joanne Miller, Karen
A. Miller. Carrie Schoenbach, and R. Schoenberg.
1983. Work and Personality: An Inquiry into the
Impact ofSocial Stratification. Norwood. NJ: Ablex.
Social Psychology and Health
567
Koos, E. 1954. The Health of'Regionvilie. New York:
Columbia University Press.
Kosa. J., A. Antonovsky. and Irving K. Zola. ed. 1969.
Poverty and Health: A Sociological Analysis. Cambridge. MA: Harvard University Press.
Kotarba. Joseph. 1983. Chronic Pain: Its Social Dimensions. Beverly Hills: Sage.
Krantz, David S.. and Stephen B. Manuck. /984. Acute
psychophysiologic reactivity and risk of cardiovascular disease: A review and mcthodologic criti4ue.
p,\·.I'c!wlogiclil Bulletill 96:435-464.
Langer. Ellen 1.. and Judith Rodin. 1976. The effects of
choice and enhanced personal responsibility for the
aged: A field experiment in an institutional setting.
Journal of' Per.wllolin· and Social Psycholo!?\' 34:
191-198.
Lazarus. Richard S.. and Susan Folkman. 1984. StreH.
Appraisal and Coping. New York: Springer.
Leventhal, Howard, Daniel Meyer, and David R. Nerenz. 1980. The common-sense representation on
illness danger. Pp. 7-30 in Medical Psvclwlog.l'.
vol. 2, ed. S. Rachman. New York: Pergamon.
Leventhal, Howard. Richard Zimmennan, and Mary Gutmann. 1984. Compliance: A self-regulation perspective. Pp. 369-436 in Handbook of' Bellllvioral
Medicine. ed. W. D. Gentry. New York: Guilford.
Levy, Sandra M.. and Lynda A. Heiden. 1990. Personality and social factors in cancer outcome. Pp. 254279 in Per.wlIlalitr and Disl'llse. ed. Howard S.
Friedman. New York: Wiley.
Levy, Sandra M.. Ronald B. Herbennan, A. Maluish,
Bernadene Schlien. and Marc Lippman. 1985. Prognostic risk assessment in primary breast cancer by
behavioral and immunological parameters. Health
Psychologr 4:99-113.
Liebennan, Morton A. 1986. Social supports: The conse4uences of psychologizing-A commentary.
JOl/mal of' Consulting lind CliniCIII Psychology 54:
461-465.
Lynch, James J. 1979. nIl' Broken Heart: Medical Consequences of'Loneliness. New York: Basic Books.
Manuck, Stephen B.. Alfred L. Kasprowicz. Scott M.
Monroe, Kevin T. Larkin, and Jay Kaplan. 1989.
Psychophysiologic reactivity as a dimension of individual differences. Pp. 365-382 in Handbook of
Re.\'earch Methods in Cardiovascular Behavioral
Medicine, ed. N. Schneidennan. S. M. Weiss, and
P. G. Kaufmann. New York: Plenum.
Marlatt. G. Alan. and Judith R. Gordon, ed. 1985. Relapse Prl'l'entioll: Maintenance Strategies in the
568
PART III
Social Slruclure, Relarionships, and the Individual
Treatlllellt 01" Addictive Behlll'iors. New York:
Guilford.
Mannol, Michael G .. M. Kogevinas, and Mary A. Elston. 1987. Social/economic status and disease.
Pp. 111-135 in Annual Rel'iew 01" Public Health,
vol. 8, ed. L. Breslow, J. E. Fielding, and L. B.
Lave. Palo Alto, CA: Annual Reviews.
Matthews, Karen A. 1985. Assessment of type A behavior. anger. and hostility in cardiovascular disease.
Pp. 153-183 in Measuring P,I'ychosocial Variahles
in Epidemiologic Studies 01" Cardio\'{/scular Disease: Proceedin/{s 01" a Workshop, ed. A. M. Ostfeld and E. D. Eaker. NIH publ. no. 85-2270.
Washington DC: National Institute of Health.
McGrath, Joseph. 1970. Social alld PsYcho!ogical
Factors ill Stress. New York: Holt, Rinehart &
Winston.
McKinlay, John B. 1990, A case for refocussing upstream: The political economy of illness. Pp. 510520 in The Sociologv ol"Health and I/Il1ess: Critical
Perspectil'es, ed. Peter Conrad and R. Kern. New
York: SI, Martin's.
Mechanic, David. 1972. Social psychologic factors affecting the presentation of bodily complaints. NeH'
Englalld }ournal of Medicine 286: 1132-1139.
- - - . 1978. Medical Sociology. New York: Free
Press.
- - - . 1986. The concept of illness behaviour: Culture, situation, and personal predisposition. P,I"\'chological Medicine 16:1-7.
- - . 1990. Promoting health. Socien' (Jan.-Feb.):
17-22.
- - . 1992a. Health and illness behav ior. Pp. 795800 in Encvclopedia 01" Sociology. ed. E. F. Borgatta and M. L. Borgatta. New York: Macmillan.
- - - . 1992b. Health and illness behavior and patientpractitioner relationships. Social Science and Medicine 34: 1345-1350.
Meichenbaum, Donald, and Dennis C. Turk, ed. 1987.
Facilitating Treatment Adherence: A Practitioner's
Guide. New York: Plenum.
Meyer, Daniel. Howard Leventhal. and Mary Gutmann.
1985. Common-sense models of illness: The example of hypertension. Health Psw'hology 4: 115-135.
Michelson. Larry. 1986. Cognitive-behavioral strategies
in the prevention and treatment of antisocial disorders in children and adolescents. pp. 275-310 in
Prel'ention of Delinquellt Behavior, ed. J. Burchard
and S. Burchard. Newbury Park, CA: Sage.
Mirowsky. John. and Catherine Ross. 1989. Soc;o!
Cau.les 01" P.I·ychologiml Distress. New York: A III
ine de Gruyter.
Mischler, E. G. 1981. Critical perspectives on thl'
biomedical model. Pp. 1-23 in Social Contexts of
Health. I/Illess, a/l(1 Patient Care. ed. E. G. Mis·
chler. L. Amara Singham. S. T. Hauser, R. Liem, S.
D. Osherson. and N. G. Waxler. Cambridge, UK.
Cambridge University Press.
Nerem, Robert M.. Murina J. Levesque, and J.
Frederick Comhil!. 1980. Social environment as
a factor in diet-induced atherosclerosis. Science 20X:
1475-1476.
Ohwovoriole, A. E.. and C. Butler Omololu. 1986. Pcr
sonality and control of diabetes mellitus. Briti.lh
}oufllal ol"Medical P.I·YchologY 59:101-104.
Osgood, D. Wayne, Lloyd D. Johnston, Patrick M.
O'Malley, and Jerald G. Bachman, 1988. The gener·
ality of deviance in late adolescence and early adulthood. AlIlerical1 Sociologiml Review 53:81-93.
Pearl in. Leonard I. 1989. The sociological study of
stress. }ournal 01" Health and Social Behavior 30:
241-256.
Pearlin, Leonard L Elizabeth G. Menaghan. Morton A.
Liebennan, and Joseph T. Mullan. 1981. The stress
process. }oufllal 01" Hw!th alld Social Behavior 2~:
337-356.
Price, Richard H.. Michelle van Ryn, and Amiram Vi·
nokur. 1992. Impact of a preventive job search
intervention on the likelihood of depression amon!!
the unemployed. }oufIlallJI" Health and Social Be·
hl/\'ior 33: 158-167.
Rabow, Jerome. and Ronald K. Watts. 1982. Alcohol
availability, alcohol beverage sales and alcohol-re·
lated problems. }oufIlal 01" Studies on Alcohol 4-':
767-801.
Raphael. Beverley. 1977. Prevention intervention wnh
the recently bereaved. Archil'es 1~1" General PSI'
chiatf\' 34: 1450-1454,
Reissman, C. K. 1981. Improving the use of health serv
ices by the poor. Pp. 541-546 in The Sociologv o!
Health alld I/Illess. ed. P. Conrad and R. Kern. NCII
York: SI, Martin's.
Review Panel on Coronary-Prone Behavior and Heart
Disease. 1981. Coronary-prone behavior and coro
nary heart behavior and coronary heart disease: ;\
critical review. Circulatioll 63:1199-1215.
Rodin, Judith. 1985. The application of social psychoI
ogy. Pp. 805-881 in Handhook of Social Psycho!
ogl', e(
RandOl
--.19~
control
Rodin. Judit
ogy.AI
Rook. Karer
com par
chologi
port: AI
G. Sara:
Rosenstock.
people
Psycho,
hen. an,
Roter. Debr:
doctor-,
Heliith
Roth. Julius.
ellce w/,
in the S,
CT: JAJ
Sackett, Dav
plilll1C1:'
Johns H
Sandler, lrwi
Kallgrer
data to r
gram 1'01
!ing Son
ed. B. H
Samson, Irw
Sarason.
esses: A
ing, activ
01" Socia,
Schneider. Jo
lep,I·Y. Pt
Selye. Hans.
McGraw
Shavil, J., J.
beskind.
pressive
ity. Sciel
Sklar. Lawrer
and canc
Solomon, Gel
factors ir
ease. pan
I
I
i
CHAPTER 21
ogr. ed. G. Lindzey and E Aronson. New York:
Random House.
- - . 1986. Aging and health: Effects of the sense of
control. Scit'llct' 233: 1271-1276.
Rodin. Judith. and Peter Salovey. 19R9. Health psychology. Allllual Rt'I'it'H' or PSI'cllOlog\, 40:533-579.
Rook. Karen S. 1990. Social relationships as a source of
companionship: Implications for older adults' psychological well-being. Pp. 219-250 in Social Support: All IIIIt'ractiollal Vit'u', cd. B. R. Sarason. Irwin
G. Sarason. and Gregory R. Pierce. New York: Wiley.
Rosenstock. Irwin M.. and John P. Kirsch!. 1979. Why
people seek health care. Pp. 161-IR8 in Ht'alth
Psrchology: A Halldbook. ed. G. C. Stone. F. Cohen. and N. E. Adler. San Francisco: Jossey-Bass.
RoteI'. Debra L.. and Judith A. Hall. 1989. Studies of
doctor-patient interaction. All/lual Rt'I'it'H' o(Puhlic
Ht'alth 10: 163-80.
Roth. Julius. and Peter Conrad. ed. 1987. Tht' Erpt'l'i(,I/et' alld Mallagt'ult'llt orChrollic 1I111t'ss. Research
in the Sociology of Health Care. vol. 6. Greenwich.
CT: JAI Press.
Sackett. David L.. and R. Brian Haynes, ed. 1976. CO/llplimlct' with Thl'rapt'IlIic Rt'gilllt'IIS. Baltimore:
Johns Hopkins University Press.
Sandler. Irwin N.. J. C. Gersten, K. Reynolds. Carl A.
Kallgren. and R. Ramirez. 198R. Using theory and
data to plan support interventions: Design of a program for bereaved children. Pp. 53-R3 in Marsllllllillg Social Support: Fomllits. Proet'sst's, alld EftlxtS.
ed. B. H. Gottlieb. Newbury Park. CA: Sage.
Sarason. Irwin G.. Gregory R. Pierce. and Barbara R.
Sarason. 1990. Social support and interactional processes: A triadic hypothesis. Special issue: Predicting. activating and facilitating social support. lOllnral
of Socialalld Persollal Rt'latiollshiIJ,1 7:495-506.
Schneider. Joseph. and Peter Conrad. 1983. Hal'i/lg EpiIt'psY. Philadelphia: Temple University Press.
Selye, Hans. 1956. The Strns or ure. New York:
McGraw-Hill.
Shavit. J.• J. Lewis. G. Tennan. R. Gale. and J. Liebeskind. 1984. Opioid peptides mediate the suppressive effect of stress on natural killer cytotoxicity. Sciellce 223:188-190.
Sklar. Lawrence S.. and Hymie Anisman. 19R I. Stress
and cancer. PsYchological Bulletill 89:369-406.
Solomon. George F. 1981. Emotional and personality
factors in the onset and course of autoimmune disease. particularly rheumatoid arthritis. Pp. 159-182
Social Psychology and Health
569
in Psrc1lO/lcllroi/lllllHllologl·. cd. R. Ader. New
York: Academic.
Sternbach. R. A.. and B. Tursky. 1965. Ethnic differences among housewives in psychophysical and
skin potential response to electric shock. PsrchoIJ!lI'siology 1:241-246.
Sutton. Robert I.. and Robert L. Kahn. 1984. Prediction.
understand ing. and control as antidotes to organizational stress. Pp. 272-2R5 in Hal/dbook of 01'galli:atiOlIllI BelllIl'ior. cd. J. Lorsch. Cambridge,
MA: Harvard University Press.
Svarsted, Bonnie. 1976. Physician-patient communication and patient conformity with medical advice.
Pp. 220-238 in The Crml'tll or Bureaucratic Ml'dicil/I'. ed. David Mechanic. New York: Wiley.
Syme. Leonard. and Rina Alcalay. 19lC. Control of
cigarette smoking from a social perspective. AIlIIl/al RI'I'it'w or Pllblic Health 3: 179-199.
Tebbi. Cameron K.. K. Michael Cummings. Michael A.
Zevon. L. Smith. Mary E. Richards. and Janis C.
Mallon. 1986. Compliance of pediatric and adolescent cancer patients. Callca 58: 1179-1184.
Todd. Alexandra. 1989. Illtimatt' Adl·t'/'.wril's: Cultural
C,m/lin "etll'l'l'lI Doctors alld WOII/I'll Patil'IIts.
Philadelphia: University of Pennsylvania Press.
Tversky, Amos. and Daniel Kahneman. 1974. Judgment
under uncertainty: Heuristics and biases. Sciellet'
IR5: I 124--1 13 I.
Umberson. Debra. Camille B. Wortman. and Ronald C.
Kessler. 1992. Widowhood and depression: Explaining long-tenn gender differences in vulnerability. loumal or Health a/ld Social Bl'lll/l'ior 33:
10-24.
Verbrugge. Lois M. 1989. The twain meet: Empirical
explanations of sex differences in health and mortality. lOllmal of Ht'alth illld Social Behal'ior 30:
2X2-304.
Visintainer. Madelon A.. Joseph R. Volpicelli. and Martin E. Seligman. 19X2. Tumor rejection in rats after
inescapable shock. Science 216:437-439.
Warner. Kenneth E. 1977. The effects of the anti-smoking campaign on cigarette consumption. American
loumal oj' Puhlic Health 67:645-650.
Wells. James A. 19R5. Chronic life situations and life
change events. Pp. I05-12X in Measl/ring Ps\,clwsocial Varia!JIe in Epidemiologic Studies oj'
Cardiol'lls(,l/Iar Discase. ed. A. M. Ostfeld and
E. A. Eaker. Washington. DC: U.S. Department of
Health and Human Services.
I
tf
II
J
!
r
i
I
I
r
I
!
f
f
t
i
t
t
;
,~
l
t
I
I
1
f
t
I
I
f
!
I
II
I
!
}
570
PART III
Social Struclure. Relationships, and the Individual
Wethington. Elaine. and Ronald C. Kessler. 1986. Perceived support, received support, and adjustment to
stressful life events. Journal of Health and Social
Behavior 27:78-89.
Whitcher-Alagna, Sheryle. 1983. Receiving medical
help: A psychosocial perspective on patient reactions. Pp. 131-161 in New Directions in Helpinx,
cd. A. Nadler, 1. D. Fisher, and B. M. DePaulo.
New York: Academic.
Williams, David R. 1990. Socioeconomic differentials
in health: A review and redirection. Social Psvcho/OX." Quarterll' 52:81-99.
Zborowski. M. 1952. Cultural components ill 1<",1"" •
to pain. Journa/ of Socia/ Issues 8: 16-.\0.
Zola, Irving K. 1966. Culture and syrnpllllll' \ ..
analysis of patients' presenting complaints. I,." "
can SocioloXical Review 31 :615---630.
- - - . 1972. Studying the decision to sec a d'h I'"
Review, critique and corrective. Pp. 21 h .' III ,"
Advances in Psychosomatic Medicine. vol. X. <'d /
Lipowski. Basel: Karger.
- - - . 1983. Socio-Medical Inquiries: Recoil," 1/"".
Reflections, and Reconsiderations. Philadl'll'llI.1
Temple University Press.
This chapte
peets of so
that occur i
have histor
lective beh
behavior re
lem-solving
collective a,
tions. to be
phenomena
movements
umbrella co
among sch(
1992; Tum!
theoretical '
cial movetr.
events, sucl
crowd acti(
of both of 1
tations WOl
we focus p
do include
lective bet
themes ane
chapter. 2
As witl
is ambiguit
tion of soci
ent theoreti
what dlfferl
most conce
ments: chaI