{"id":35,"date":"2025-09-21T15:11:49","date_gmt":"2025-09-21T15:11:49","guid":{"rendered":"https:\/\/openpub.libraries.rutgers.edu\/studyhealthdeterminants\/?post_type=chapter&#038;p=35"},"modified":"2026-06-15T13:37:38","modified_gmt":"2026-06-15T13:37:38","slug":"section-3-psychological-determinants-of-health","status":"web-only","type":"chapter","link":"https:\/\/openpub.libraries.rutgers.edu\/studyhealthdeterminants\/chapter\/section-3-psychological-determinants-of-health\/","title":{"raw":"Chapter 3: Psychological Drivers of Health","rendered":"Chapter 3: Psychological Drivers of Health"},"content":{"raw":"<strong>OVERALL OBJECTIVES<\/strong>\r\n<ol>\r\n \t<li>Describe psychological factors that influence physical health<\/li>\r\n \t<li>Discuss the influence of emotion on health behavior and physical health<\/li>\r\n \t<li>Assess the impact of individual some personality traits on health behavior and physical health<\/li>\r\n \t<li>Develop an introductory understanding of psychological contributors to health, including physical health<\/li>\r\n \t<li>Apply concepts of psychological determinants of health to case examples.<\/li>\r\n<\/ol>\r\n&nbsp;\r\n<div class=\"textbox\">\r\n<p style=\"text-align: center\"><strong>Psychological Determinants of Health<\/strong><\/p>\r\n\r\n<\/div>\r\n&nbsp;\r\n\r\nPsychological factors, broadly defined as cognition (thought and problem-solving processes) and emotion (feelings, affect and mood), are essential components of mental health, but also are very significant when it comes to overall health, in combination with physiological factors, social factors, and many other variables, as explained in Engel\u2019s (1980) model. As you read this chapter and throughout this course, consider the following questions:\r\n<ul>\r\n \t<li>How are psychological factors contributors or determinants of overall health?<\/li>\r\n \t<li>How does physical health influence psychological processes and mental health?<\/li>\r\n \t<li>Can psychological factors and emotional health conditions contribute to and be influenced by \u201cphysical\u201d health status?<\/li>\r\n \t<li>Are psychological factors a \u201ccorrelate\u201d of other health status? Not a cause, not an effect, just associated with other health variables and the result of a third factor, such as genetics or environmental variables.<\/li>\r\n<\/ul>\r\n<strong><em>The Influence of Emotions on Health<\/em><\/strong>\r\n\r\n<span style=\"text-align: initial;font-size: 1em\">Our emotional health strongly influences our physical health. Emotional health is regarded as an internal psychological factor, stemming from a person\u2019s emotions and thoughts. When someone experiences strong feelings related to their physical health, it can impact how frequently they seek medical care and how effectively they use healthcare services (Kikas, et al., 2026). Feeling anxious or worried about your health can interfere with getting medical care, following treatment recommendations, and other actions a person takes to prevent or treat health problems.<\/span>\r\n\r\nPeople with more anxiety about their health are more likely to seek services from primary care and specialists. At the same time, they also experience more health-related disability than people who are not anxious about their health (Bobevski, et al., 2016).\r\n\r\n&nbsp;\r\n<p style=\"text-align: center\"><strong><em>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Psychological Health\u00a0 \u2194 <\/em>\u00a0<em>Physical Health<\/em><\/strong><\/p>\r\n&nbsp;\r\n\r\n<strong><em>Health Anxiety<\/em><\/strong>\r\n\r\n&nbsp;\r\n\r\nHealth anxiety, also known as medical anxiety, is a person's belief that they are currently experiencing or will develop a significant health condition (Rutter et al., 2018). Health anxiety is important to identify and address as it relates to worsened quality of life, social functioning, adherence to treatment, health outcomes, and higher healthcare costs (Romanazzo, et al., 2022).\u00a0 Treating health anxiety improves health outcomes for the person (Romanazzo, et al., 2022).\r\n\r\n&nbsp;\r\n\r\nPeople with significant health anxiety lasting more than six months may experience intense fears about their health that make it difficult to access health care. This can lead to a mental health condition known as <em>Illness Anxiety Disorder<\/em>, formerly referred to as hypochondriasis. This condition is characterized by excessive worrying about having or developing a serious, undiagnosed medical condition (French &amp; Hameed, 2023). People affected by this condition can be categorized into two groups: \u201ccare-seeking\u201d or \u201ccare-avoidant\u201d (Kikas et al., 2026). Care-seeking individuals frequently visit healthcare providers to try and alleviate their fears about undiagnosed illnesses, while care-avoidant individuals are likely to refuse medical services altogether (Kikas et al., 2026).\r\n\r\n&nbsp;\r\n\r\nLiving with a chronic health condition can increase medical anxiety. People with these conditions can experience moderate to severe symptoms of anxiety related to:\r\n<ul>\r\n \t<li>managing their illness<\/li>\r\n \t<li>fearing a recurrence of an illness<\/li>\r\n \t<li>interacting with healthcare providers.<\/li>\r\n<\/ul>\r\n(Romanazzo, et al., 2022; Lebel et al., 2020).\r\n\r\n&nbsp;\r\n\r\nFor example, up to 50% of people previously diagnosed with cancer experience an understandable fear of recurrence (Rutter et al., 2018). While the exact reasons for higher anxiety symptoms among people with chronic health conditions are not fully understood, it is suggested that the environment, genetic background, and socio-economic status contribute to the level of anxiety (Romanazzo, et al., 2022; Barbek et al., 2022).\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\">Important Point: Everyone may feel anxious or nervous about their health, but some people can develop unhealthy practices of over- using health care services or psychological barriers to seeking health care.<\/div>\r\n<\/div>\r\n&nbsp;\r\n\r\n<strong><em>Stress, Vulnerability and Health<\/em><\/strong>\r\n\r\nStress is an external psychological factor that affects a person's emotional well-being by influencing their psychological state, which, in turn, can impact their physical health.\u00a0 See Chapter 2 for an overview of the biological impact of prolonged stress on physical health. This was made most apparent in the Adverse Childhood Experiences (ACEs), a landmark public health study by insurance company Kaiser Permanente and the Center for Disease Control, which examined how childhood adversity is related to adult illnesses (Felitti et al. 1998). They surveyed 9,500 adults about their exposure to specific ACEs. These included childhood abuse, neglect, household dysfunction, physical, emotional, or sexual abuse; domestic violence; parental substance use; mental illness of a parent; incarceration of a family member; and the separation of family members from one another (Kendall-Tackett, 2020; SAMHSA, 2014). Many of these ACEs persist for several months through many years, perhaps an entire childhood.\u00a0 Members of ethnic, racial, and gender minorities are at increased risk, as are people of lower economic status (Trauma-Informed Care Implementation Resource Center, 2021).\r\n\r\n&nbsp;\r\n\r\nThe more ACEs a person reported, the higher the person\u2019s risk for later problems such as depression, substance use, suicide attempts, smoking, heart disease, liver disease, chronic lung disease, and other major causes of illness and death. Since the original study there have been at least 25 additional studies with over 325,000 participants on the impact of childhood ACEs on illnesses in adulthood (Hughes et al., 2017). Eight studies provided sufficient data to assess the impact of each additional ACE in the lives of children (total participants = 197,981). Each additional exposure to Adverse Childhood Experiences (ACEs) was associated with a 13% increase in the odds of having two or more chronic illnesses, often referred to as <em>multi-morbidities (<\/em>Senaratne et al., 2024<em>)<\/em>. These multi-morbidities are defined as the co-occurrence of two or more long-term physical or mental health conditions that typically last for over one year.\r\n\r\n&nbsp;\r\n\r\nThe ACEs Study showed that early adversity is not only a psychological issue but also a major health risk factor. Childhood trauma and household instability can have biological, psychological, and social consequences for health. This includes increased risk for mental illness, increased likelihood of engaging in health-risky behaviors such as substance misuse and sexual promiscuity, chronic diseases, and premature death (Kendall-Tackett, 2020). At the same time, these studies have also found that the impact of ACEs can be reduced by protective relationships, social support, therapy, stable environments, and community resources.\r\n\r\nACEs impacts lifelong health in diverse ways.\r\n<ul>\r\n \t<li>Stress from adverse childhood events can lead to increased levels of <strong>stress hormones and inflammation<\/strong>, both of which are linked to worse health outcomes (Cleveland Clinic, 2025; Kendall-Tackett, 2020). For example, elevated levels of cortisol are normally associated with adaptive short-term changes of the \u201cfight or flight\u201d response. When they are elevated over the long-term due to the prolonged stress due to an ACE, it harms many of the bodies\u2019 systems and organs, including the immune system.<\/li>\r\n \t<li>People who have experienced ACES are also more likely to <strong>engage in risky health behaviors<\/strong> that worsen health, such as substance use, overeating, or unsafe sexual practices (Kendall-Tackett, 2020).<\/li>\r\n \t<li>People exposed to more ACES are more likely to <strong>use substances<\/strong> (e.g., smoking, illicit drugs, and drink heavily), experience mental health issues, and self-directed harm (Hughes et al., 2017).<\/li>\r\n \t<li>More individual and different ACES of childhood are associated with more <strong>multi-morbidities<\/strong>, a term meaning multiple diseases (Senaratne et al., 2024).<\/li>\r\n \t<li>Higher risks of experiencing <strong>negative beliefs about their health<\/strong>, worsening health and increasing the risks of depression (Kendall-Tackett, 2020).<\/li>\r\n<\/ul>\r\n&nbsp;\r\n\r\nThere are several treatments available for managing stress associated with exposure to ACEs. These include practicing stress management techniques, mental health treatment, engaging in cognitive behavioral therapy, and adopting healthy lifestyle behaviors. These actions can help reduce stress and improve overall health outcomes (Cleveland Clinic, 2025; Rutter et al., 2018). If individuals are never exposed to these very adverse experiences in childhood, it can reduce the risk of developing multiple health conditions as an adult\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\">Learn more about ACES here: <a href=\"https:\/\/www.cdc.gov\/aces\/about\/index.html\">https:\/\/www.cdc.gov\/aces\/about\/index.html<\/a><\/div>\r\n<\/div>\r\n<strong><em>Grief and Health Conditions\u00a0<\/em><\/strong>\r\n\r\nGrief is the intense sadness that can arise from loss or significant changes in our lives, and it can negatively affect our health and increase the risk of mortality. This emotional response can result from internal events, like receiving a serious health diagnosis or experiencing a decline in physical abilities, as well as from external factors, like the death of a loved one. The health consequences of grief can include:\r\n<ul>\r\n \t<li>an increased reliance on medication<\/li>\r\n \t<li>higher rates of hospital admissions<\/li>\r\n \t<li>noncompliance or non-adherence to medical treatments<\/li>\r\n \t<li>elevated symptoms of depression<\/li>\r\n \t<li>a greater risk of premature death<\/li>\r\n<\/ul>\r\n(Stroebe et al., 2017; Carrillo-Alarc\u00f3n et al., 2015).\r\n\r\n<em>Receiving news about a new health condition or disease can be challenging, often triggering a grieving process for many individuals.<\/em> For instance, people diagnosed with diabetes may experience profound grief as they come to terms with their condition and the potential serious health implications of uncontrolled blood sugar levels, such as vision loss and peripheral artery disease (Carrillo-Alarc\u00f3n et al., 2015). Additionally, individuals who have lost a limb due to diabetes-related complications may endure significant grief, which can lead to depression, increased pain, and slower healing and recovery (Spiess et al., 2014).\r\n\r\n<em>Bereavement, or the grief experienced after the death of a partner, parent, or child, can lead to prolonged sadness that negatively affects both emotional and physical health<\/em> (Stroebe et al., 2007). It can disrupt appetite, sleep, and energy levels, increasing the risk of diseases and premature mortality (Stroebe et al., 2007). Healthcare costs for those who are grieving are higher than for others, and research suggests that grief can weaken the immune system, leading to changes in cardiovascular and endocrine health (Stroebe et al., 2007). Individuals who have lost their spouses, such as widows and widowers, are particularly vulnerable to premature death; however, this risk can be reduced through positive lifestyle choices, socioeconomic status, and social support (Ennis &amp; Majid, 2021).\r\n\r\nGrief and bereavement are important psychological determinants of health. To address grief and enhance both emotional and physical well-being, grief counseling and supportive therapy are recommended interventions (Stroebe et al., 2007; Carrillo-Alarc\u00f3n et al., 2015; Ennis &amp; Majid, 2021).\r\n\r\n&nbsp;\r\n<p style=\"text-align: center\"><strong>Habits and Goals: Foundations of Good Health<\/strong><\/p>\r\n&nbsp;\r\n\r\nAn essential psychological factor influencing health is the daily habits and behaviors we actively choose to maintain our physical well-being. These practices are sometimes called \u201cself-regulatory capacities,\u201d or \u201cthe extent to which individuals possess skills or techniques that they can actively apply to alter or regulate their health behavior\u201d (Haggar, 2025, p.831).\u00a0 Self-regulation is important for good health outcomes because it moves a person into an active role in their health management.\r\n\r\n&nbsp;\r\n\r\n<strong><em>Goal-Setting Practices<\/em><\/strong>\r\n\r\n<em>\u00a0<\/em>\r\n\r\nManaging our health effectively requires consistent actions that enhance our well-being. Activities such as seeking preventative care and engaging in physical exercise require motivation. One effective strategy for improving and maintaining health behaviors is to set a large goal, break it down into smaller, more manageable goals, and then take small steps towards achieving them. Goal-setting practices are widely recognized for increasing physical activity (Swann et al., 2021). Research indicates that by establishing and accomplishing health-related goals, individuals can enhance various outcomes related to health, including \u201c[health-related] self-efficacy, quality of life, medication adherence, disease symptoms, depression, diet control, and HbA1c control\u201d (Tabaei-Aghdaei et al., 2023, p.157). Additionally, some evidence suggests that goal-setting can improve blood pressure, health anxiety, functioning, and body mass index (Tabaei-Aghdaei et al., 2023). By repeatedly setting health goals, we can positively transform our health behaviors.\r\n\r\n<strong><em>Habit Formation<\/em><\/strong>\r\n\r\nA habit is an action that we take for our health without thinking about it.\u00a0 Positive examples of a health habit could be brushing your teeth or taking a shower in the morning, and negative examples of a health habit could be smoking or eating too much.\u00a0 These events do not have to be planned and occur on most days. Building a new habit, or changing an old one, takes time and practice, and the belief that you can do it (Haggar, 2025).\u00a0 Positive health habits can change our behaviors and can improve our overall health (Gardener, 2015). Building habits can also build our motivation to make additional changes for our health (Gardener, 2015).\u00a0 For example, someone who has improved their eating habits may feel more confident that they can start walking more.\r\n<div class=\"textbox\">\r\n<p style=\"text-align: center\"><strong>Resilience, Coping and Personal Strengths Support Health<\/strong><\/p>\r\n\r\n<\/div>\r\n&nbsp;\r\n\r\n<strong><em>Use of Coping Strategies in Health<\/em><\/strong>\r\n\r\n<em>\u00a0<\/em>Stress, especially how a person perceives and manages it, influences physical health. Managing physical symptoms, treatments, and uncertainties can negatively affect our emotional well-being, which in turn impacts our ability to heal and recover from health issues problems over time.\u00a0 Coping strategies are the actions that help to manage stress, reduce distressing emotions, and navigate challenges.\u00a0 Healthy coping strategies can improve health outcomes, and longevity.\u00a0 Each person's way of coping with difficulties is unique, and what proves most helpful varies from individual to individual. Coping often relies on sufficient sleep and rest, nutritious food, limiting alcohol, journaling, support from others, and physical activity (CDC, 2026).\r\n\r\n&nbsp;\r\n\r\nFour categories of <strong>adaptive coping strategies<\/strong> that support overall health include:\r\n<ol>\r\n \t<li>Problem-focused: Efforts to address the problem directly through planning or time management<\/li>\r\n \t<li>Emotion-focused: Efforts to minimize distressing emotions by using positive reframing, humor or acceptance<\/li>\r\n \t<li>Meaning-focused: Efforts to change how one thinks about a situation through a lens of meaning and focus<\/li>\r\n \t<li>Social-focused: Strategies that focus on finding social support for a situation.<\/li>\r\n<\/ol>\r\n(from Algorani, Gupta, 2023)\r\n\r\n&nbsp;\r\n\r\nMaladaptive coping strategies, such as avoidance or disengagement, can worsen mental health and physical health outcomes.\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\"><em>Cross-chapter link: See chapter 2 for a deeper dive into the biological impact of stress and how it influences physical health<\/em>.<\/div>\r\n<\/div>\r\n&nbsp;\r\n\r\n<strong><em>Personal Strengths in Health Management<\/em><\/strong>\r\n\r\n&nbsp;\r\n\r\nAnother perspective about improving health management and addressing chronic conditions is to identify and use personal strengths. Focusing on strengths can enhance health self-management and help identify the resources a person has to support their health (Kristjansdottir et al., 2018).\r\n\r\nResearch suggests that people navigating chronic health conditions can identify their strengths, which can support emotional health and disease management. In one study, people with chronic health conditions suggested that focusing on strengths such as personal attributes (perseverance, curiosity, etc.), close relationships, and community supports would be helpful for their health (Aungst et al.,2019).\u00a0 A focus on strengths in chronic disease management may be particularly relevant to managing diabetes, addressing overuse of medical services, and building motivation in health conditions that require ongoing behavior change (Aungst et al., 2019).\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\">\r\n\r\n<em>Supplemental Activity<\/em>: Explore your personal strengths. Identify the strengths you possess that positively support your health.\r\n\r\n<a href=\"https:\/\/www.viacharacter.org\/\">https:\/\/www.viacharacter.org\/<\/a>\r\n\r\n<\/div>\r\n<\/div>\r\n&nbsp;\r\n\r\n<strong><em>Religion\u00a0and\u00a0Spirituality\u00a0<\/em><\/strong>\r\n\r\n&nbsp;\r\n\r\nOur self-perception, upbringing, and beliefs about meaning, purpose, and connection can also significantly influence our health. Furthermore, individuals who regularly practice religion and spirituality tend to experience lower levels of stress, live longer, and have a reduced risk of heart disease and hypertension (Koenig, 2012). In addition, involvement in religious and spiritual practices is associated with decreased pain and improved overall physical well-being (Kruk &amp; Aboul-Enein, 2024). Individuals with strong religious beliefs are more likely to engage in health-promoting behaviors. These behaviors include avoiding substances such as cigarettes and alcohol, participating in physical activity, and maintaining a balanced diet (Kruk &amp; Aboul-Enein, 2024; Koenig, 2012).\r\n\r\n&nbsp;\r\n\r\n<strong><em>Personality and Self-Efficacy<\/em><em>\u00a0<\/em><\/strong>\r\n\r\n&nbsp;\r\n\r\nThis chapter has highlighted various external factors and actions that influence our emotions and their interaction with physical health. Another important aspect to consider is how we perceive our health. This section will briefly review some personality traits that affect our health and the cognitive perspectives that shape our understanding of it.\r\n\r\n&nbsp;\r\n\r\nPsychologists have studied personality traits to gain insights into their impact on physical health. Personality traits are defined as a consistent aspect of our identity and tend to remain stable over time (Hagger, 2024). Research has identified several traits that are commonly associated with positive health outcomes, including:\r\n<ul>\r\n \t<li>Conscientiousness: paying attention to the minute details of health such as following up with medical care, engaging in preventative care and following directions<\/li>\r\n \t<li>Optimism: believing that one\u2019s actions for health will lead to positive changes.<\/li>\r\n \t<li>Extroversion: finding support from others to improve health and interest in engaging in new activities with others.<\/li>\r\n<\/ul>\r\n(Haggar, 2024; Obara-Go\u0142\u0119biowska&amp; Micha\u0142ek-Kwiecie\u0144, 2020)\r\n\r\n&nbsp;\r\n\r\nThese psychological traits influence our health, but people with other personality traits can also make positive changes to their health and well-being. Particularly when they consider how they <em>think <\/em>about their health.\r\n\r\n&nbsp;\r\n\r\n<strong><em>Self-efficacy and Outcome\u00a0expectations\u00a0<\/em><\/strong>\r\n\r\nOne of the important theories about health behaviors is the Social Cognitive Theory by Bandura (2004).\u00a0 This theory has several components, but the most studied are <strong>self-efficacy<\/strong> and <strong>outcome expectations<\/strong>. Self-efficacy refers to a person's belief in their ability to utilize their existing skills to overcome challenges (Bandura, 2004). It is essential for achieving health goals and making health behavior changes (Bandura, 1994).\r\n\r\nA strong belief in one's ability to make changes in health\u2014known as self-efficacy\u2014is directly linked to improvements in health outcomes, such as increased physical activity and better management of blood sugar levels in individuals with diabetes (Baghbani et al., 2023; Jiang et al., 2019; Zechner &amp; Gill, 2016).\r\n\r\nOutcome expectations, which refer to a person's belief that taking specific actions will result in a particular outcome, are a crucial factor in maintaining health (Bandura, 2004). For example, when someone believes that reducing their sugar intake or exercising more will help them lose weight, this belief can motivate them to engage in those activities. Research indicates that patients with various health conditions believe that taking proactive steps will enhance their health. For example, patients have seen improved treatment outcomes and overall health with conditions such as:\r\n<ul>\r\n \t<li>Heart disease<\/li>\r\n \t<li>Stroke<\/li>\r\n \t<li>Serious injury<\/li>\r\n \t<li>Cancer<\/li>\r\n \t<li>Musculoskeletal conditions<\/li>\r\n \t<li>Recovery from surgical procedures<\/li>\r\n \t<li>Mental health recovery<\/li>\r\n<\/ul>\r\n<div>\r\n\r\n(Bohlen et al., 2022; Laferton et al., 2022; Lafterton et al., 2017)\r\n\r\n<\/div>\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\">\r\n\r\n<em>Important Point: <\/em>Our personality and beliefs shape our health habits and outcomes. Regardless of personality traits, believing that we CAN make changes for our health (e.g., self-efficacy) and that the changes we make will make us feel better and lead to better health outcomes (e.g., outcome expectations) are critical to making health behavior changes.\r\n\r\n&nbsp;\r\n\r\n<\/div>\r\n<\/div>\r\n<strong><em>Navigating Health Conditions with Grit<\/em><em>\u00a0and Perseverance<\/em><\/strong>\r\n\r\nLiving with health problems and chronic health conditions can be overwhelming.\u00a0 While some people experience grief with chronic health conditions, others use internal strengths and their determination and passion to help them successfully manage these conditions.\r\n\r\nPerseverance in managing health outcomes reflects a person's strong belief that they can and will improve their health (Magon et al., 2024). Grit is defined as the combination of perseverance and passion for achieving long-term goals. It has been associated with the development of positive lifestyle habits, which can enhance overall quality of life for cardiac patients (Yu-Shiu et al., 2024). Additionally, grit plays a significant role in fostering healthy habits, reducing depression and anxiety, and preventing emotional distress in individuals with chronic conditions, as well as in supporting regular physical activity routines (Datu, 2021).\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\"><em>Important Point<\/em>: Having grit and perseverance helps people build healthy habits and manage chronic health conditions<\/div>\r\n<\/div>\r\n&nbsp;\r\n<p style=\"text-align: center\"><strong>Health Literacy and Theories about Psychological Factors in Health<\/strong><\/p>\r\n<strong>Health literacy is knowledge about and familiarity with health and health care, thus developing a level of comfort discussing and making decisions about<\/strong> these issues. It is foundational because people need to access, understand, and use health information to judge risk about themselves or loved ones, understand treatment options, and anticipate the benefits of treatment. With low health literacy, an individual might not fully understand health threats and may over- or under-emphasize their seriousness. This can affect motivation to engage in treatment and distort estimates of how much impact the self can have, also known as <strong>self-efficacy.<\/strong>\r\n\r\nVarious theories have been developed to understand psychological factors in health. Each considers health literacy to be critical. Together, these theories explain health behavior as a process that begins with understanding that leads to action.\r\n<ul>\r\n \t<li>The <strong><em>Theory of Planned Behavior<\/em><\/strong><strong> (TPB:<\/strong> Ajzen 1971); explains behavior as the result of a person\u2019s <strong>intention<\/strong> to act, this applies to behaviors related to health and health promotion as well. Intention is shaped by 1) <strong>attitude<\/strong>, or whether the person views the planned behavior positively or negatively; 2) <strong>subjective norms<\/strong>, or whether family, members, peers and others are perceived as approving or disapproving of the behavior; and 3) <strong>perceived behavioral control<\/strong>, or whether the person believes they can perform the behavior.<\/li>\r\n \t<li><strong><em>Self-efficacy Theory<\/em><\/strong><strong> (Bandura, 1977) <\/strong>Already introduced above this theory emphasizes, \u201cCan I do this? If I can, will the outcome be positive?\u201d Thus, to change, an individual must both think they can bring the change but also believe it will result in desirable outcomes.<\/li>\r\n \t<li><strong><em>Transtheoretical Stages of Change Model<\/em><\/strong> developed by Prochaska and DiClemente (1982)<strong> has shaped many health interventions<\/strong>. At any given moment, people differ in readiness to address health conditions or change health behaviors and thus need distinct kinds of help. Someone in precontemplation may need basic awareness and health-literacy support, while someone in preparation may need a concrete plan. This approach looks at the bridge between intention and behavior by emphasizing different interventions: action planning, coping planning, self-monitoring, and relapse recovery depending on the individual\u2019s stage of readiness<\/li>\r\n \t<li>H<strong><em>ealth Action Process Approach<\/em><\/strong><strong> (HAPA) model<\/strong>, self-efficacy and the stages of change applied to health behavior expanded across the change process: confidence to start, confidence to maintain the behavior, and confidence to recover after setbacks.<\/li>\r\n<\/ul>\r\n<strong>\u00a0<em>Applying Health Theory to Health Behavior<\/em><\/strong>\r\n<ol>\r\n \t<li><em>Theory of Planned Behavior (TPB). <\/em><\/li>\r\n<\/ol>\r\nIn the context of health behavior, TPB can be used to plan interventions to help someone who intends to exercise regularly, eat healthier, quit smoking, engage in safe sex practices, take medication, or get vaccinated. Each of these takes a level of intention and advanced planning. \u00a0For example, a person might attend a smoking cessation program emphasizing the benefits of quitting. This is often in a group setting to develop positive attitudes towards smoking cessation and develop peer pressure and support for the intentions. This strengthens <strong>subjective norms and can increase<\/strong> peer and familial support. Personal c<strong>ontrol is enhanced<\/strong> by offering nicotine replacement, learning coping strategies, and phone support for when a person is tempted to resume smoking.\r\n<ol start=\"2\">\r\n \t<li><em>Self-Efficacy and Social Cognitive Theory<\/em><\/li>\r\n<\/ol>\r\nSelf-efficacy theory holds that people are more likely to initiate and sustain health behaviors when they believe they can execute it successfully. For a change in health behavior, self-efficacy influences whether a person attempts a behavior, how much effort they invest, how they respond to setbacks, and whether they persist over time. For example, a person trying to make a health-related change such as: stopping smoking, increasing physical activity or following a medication regimen is more likely to succeed if they believe they can do it in \u201creal-life\u201d situations, including when stressed or experiencing temptation. Self-efficacy can be strengthened through mastery experiences, modeling of the behavior by others, encouragement from trusted people, and learning to overcome barriers. Many health self-management interventions build confidence gradually through achievable, incremental goals, skills training, feedback, problem solving, and relapse-prevention planning. Knowledge alone is often insufficient; people also need confidence that they can translate knowledge into action. A foundational reference is Bandura\u2019s <em>Self-Efficacy: The Exercise of Control<\/em> (1997), and a health-specific application is Bandura\u2019s \u201cHealth Promotion by Social Cognitive Means\u201d (2004).\r\n\r\nA more detailed example of\u00a0 health promotion by social cognitive means can be found in the development of a diabetes self-management program. Rather than simply giving information to participants, the program builds self-efficacy through incremental. achievable goals, practice, and modeling by peers to develop the conviction\u201d \u201cI can do it.\u201d A modest walking goal might be set due to its achievability. There would be the opportunity to observe peers with diabetes and hear how they manage barriers, practice meal-planning, and track blood glucose. It is also important to address 1) outcome expectations\u2014improved self-management will improve energy and lessen symptoms\u2014and 2) environmental and social supports, family involvement, access to healthy foods, reminders, and follow-up contacts.\r\n<ol start=\"3\">\r\n \t<li><em>Planning for Health &amp; Readiness to Change Health Behaviors<\/em><\/li>\r\n<\/ol>\r\nThere are many aspects of planning that are essential for promoting one\u2019s health. For example, regular exercise must consider factors such as inclement weather, work schedules, and family responsibilities. Managing illnesses, including mental health conditions, cardiac disorders, and cancer, requires careful scheduling of appointments, remembering to take multiple medications regularly, self-monitoring of symptoms, and implementing other self-care strategies. Conditions like diabetes involve strict medication adherence, which may include taking both pills and injections as prescribed. Additionally, it requires nutritional planning, purchasing and preparing the appropriate foods in the right quantities, monitoring glucose levels, and engaging in regular exercise. All these activities necessitate thoughtful planning in advance.\r\n\r\nHaving good intentions is rarely enough, which is why are they so hard to implement. Another theory called the Transtheoretical <strong>Stages of Change Model<\/strong> (Stages of Change) sheds light on how health behavior change is a process proceeding through stages, rather than a single decision. It proposes that people move through stages: <strong><em>precontemplation<\/em><\/strong>, when they are not yet considering change; <strong><em>contemplation<\/em><\/strong>, when they are thinking about change; <strong><em>preparation<\/em><\/strong>, when they are getting ready to act; <strong><em>action<\/em><\/strong>, when they actively change the behavior; and <strong><em>maintenance<\/em><\/strong><em>,<\/em> when they work to sustain the new behavior and prevent relapse.\r\n\r\nStages of Change is useful in health changes because motivation strategies can be matched to a person\u2019s readiness. For example, someone in precontemplation may benefit from hearing about smoking risks or even just the raising of doubt \u201cI notice you cough a lot,\u201d \u201cyou seem to get shortness of breath easily.\u201d A person in the contemplation phase might consider using a decisional balance, to weigh the pros and cons of smoking. Meanwhile someone in preparation phase may need a concrete plan to quit or assistance with nicotine replacement.\r\n\r\nRegardless of the stage, social support and encouragement are important, but they are particularly essential during the maintenance phase. Relapse, or returning to the old, unwanted behavior often happens, it is best to develop a plan for what to do before it happens.\r\n\r\nTo motivate change, health professionals can assess a person\u2019s stage of readiness to change health behavior and use stage-appropriate strategies rather than giving the same advice to everyone. In the context of diet, exercise, medication adherence, smoking cessation, or substance use, early-stage interventions often focus on creating doubt, providing education, encouraging emotional reflection, and discussing the pros and cons of change. In contrast, later-stage interventions tend to emphasize goal setting, skill building, self-monitoring, coping strategies, rewards, and relapse prevention.\r\n\r\nThis model is particularly useful because it acknowledges that ambivalence and relapse are normal parts of the change process. Resistance to change is not seen as denial or a lack of commitment; instead, it is recognized as a natural element of behavior change. Practitioners are encouraged to \"roll with resistance,\" viewing it as an expected aspect of the journey toward change. These techniques stem from motivational interviewing. A key references is Prochaska and DiClemente (1982). Other papers authored by Prochaska and DiClemente on motivational interviewing are included in the reference list.\r\n\r\n&nbsp;\r\n<p style=\"padding-left: 80px\"><em>Resistance to Change<\/em><\/p>\r\nFrom the perspective of the stages of change model, the focus is on helping the person help themselves. Hopefully, the individual comes to identify the change they want and will develop ideas about how to change. This can include identifying an inconsistency between a stated goal and an unhealthy behavior that potentially needs to be changed. Here are some examples:\r\n<ul>\r\n \t<li>Ted claims to highly value his relationship with his daughter and wife, yet his habitual drinking keeps him away from them, out of his home, and worsens these relationships.<\/li>\r\n \t<li>Amanda very much wants to see her young grandchildren grow up but persists in smoking heavily.<\/li>\r\n \t<li>Miguel wants to live a full life, he has diabetes and his glucose levels are out of control, he does little to control them, leading to substantial changes in his levels of \u201cenergy\u201d sleepiness, and even more inactivity.<\/li>\r\n<\/ul>\r\nAre Ted, Amanda, &amp; Miguel simply resistant to change, \u201cin denial,\u201d being difficult, or self-destructive? Perhaps. But within the Stages of Change framework, their resistance to change derives from the fact they are not yet ready for change. Just because someone needs care, does not mean they are ready to receive it, let alone participate in it actively. The practitioner\u2019s role is to help them become ready and consider changes.\r\n<div class=\"textbox textbox--examples\">\r\n<div class=\"textbox__content\"><em>Important Point: <\/em>Stages of Change Theory suggests that people change their health behavior in stages, including precontemplation, contemplation, preparation, action, and maintenance.\u00a0 Because changing health is challenging, people often revert to old habits (relapse), and the process begins again.<\/div>\r\n<\/div>\r\n&nbsp;\r\n<ol start=\"4\">\r\n \t<li><em>Health Action Process Approach<\/em><\/li>\r\n<\/ol>\r\nAn application of the Stages of Change model to health and healthcare the Health Action Process Approach (HAPA). HAPA is a health behavior-change model developed by Schwarzer that explains how people move from thinking about change to starting and maintaining the desired behavior (Schwarzer, 2008). It has two broad phases: an <em>intentional<\/em> phase, where the individual develops an intention based on risk awareness, expected outcomes, and action self-efficacy; and a <em>volitional<\/em> phase, where intention is translated into behavior through planning, action control, maintenance self-efficacy, and recovery self-efficacy (Schwarzer, 2008, 2016). For example, a person may know they are at risk for diabetes, believe exercise will help, and feel capable of starting; HAPA then emphasizes making a daily exercise plan, monitoring progress, identifying and overcoming barriers, and recovering after setbacks that are experienced (Schwarzer &amp; Luszczynska, 2008).\r\n\r\nHAPA is related to the Theory of Planned Behavior because both models view intention as important, but HAPA goes further by explaining the intention\u2013behavior gap: why people may intend to change but fail to act (Schwarzer, Lippke, &amp; Luszczynska, 2011). It is also related to the Stages of Change Model because both recognize that behavior change unfolds over time with readiness varying. HAPA focuses less on stages and more on the psychological processes that move someone from inaction to action (Schwarzer, 2008, 2016). For health promotion, HAPA is useful for designing self-management of illnesses, sustained self-regulation (Schwarzer, Lippke, &amp; Luszczynska, 2011; Zhang et al., 2019). Together, these theories explain health behavior as a process that begins with understanding, moves through motivation, and depends on confidence, planning, and support to become action (Schwarzer &amp; Luszczynska, 2008; Zhang et al., 2019).\r\n\r\n<strong><em>Summary on Theories<\/em><\/strong>\r\n\r\nPsychological and physiological disorders interact all the time. In fact, the distinction psychological from physiological is often artificial. Where else are thinking and emotion processed but in the brain, the nervous system, and to some extent the rest of the body? This does not mean that an effective intervention needs to be physiological, such as medication. Alternatively, it could be psychological or social in nature, such as different types of therapy or social support.\r\n\r\n&nbsp;\r\n<div class=\"textbox\">\r\n<p style=\"text-align: center\"><strong>Case Illustrations<\/strong><\/p>\r\n\r\n<\/div>\r\n&nbsp;\r\n\r\nIn this next section we will consider several case studies based upon the real-life stories to illustrate the inter-connectedness of physical and emotional well-being\r\n\r\n<strong><em>Kevin \u2013 An Example of a Physiological Disorder\u2019s First Sign being Cognitive<\/em><\/strong>\r\n\r\nWhy should some physical health conditions result in psychiatric symptoms? It is not fully understood; many disorders are associated with inflammation, which can harm the nervous system. Others result in neurohormonal changes, the release of hormones that affect the nervous system and how the person thinks and feels. For persons with and without psychiatric disorders, an infection or disorder in any bodily system can cause psychiatric symptoms. For example, one of the most common examples of this includes urinary tract infections (UTI) in both men and women, especially older adults. UTIs \u00a0can be associated with cognitive and affective (emotional) symptoms. Some even develop symptoms of psychosis, losing touch with reality. Kevin\u2019s symptoms were noticeable, but not so extreme.\r\n\r\n<em>Kevin, a 55-year-old male, had several urinary tract infections in his life. Early warning symptoms of a UTI is that he became lethargic and a bit pessimistic, but hardly noticeable. He had another unusual early warning sign. Before he experienced the typical UTI symptoms of irregular urination, difficulty starting, excessive volume, persistent urgency, urine smelling like ammonia, he noticed that his thinking would become confused and he had trouble solving problems that he could normally work out. After that it happened more than once. he later realized that his \u201cthinking problem\u201d was an early symptom of\u00a0 UTI.<\/em>\r\n\r\n<strong><em>Anna \u2013 Experiences of Anxiety &amp; Panic<\/em><\/strong>\r\n\r\nFor many conditions, the origin is not known, whether it is primarily psychological or physiological, and it is an oversimplification to say it is one or the other.\r\n\r\n<em>Anna has often experienced panic attacks when she leaves the house. In the past, she narrowly avoided a few car accidents and once witnessed a violent crime. As she prepares to go to work, she rushes around the house, which causes her heart rate to increase slightly, her breathing to quicken, and she begins to sweat a little. These modest changes often occur when people are getting ready to leave home, and most people may or may not notice them. It's typical for someone who is hurrying to leave for work. However, as Anna becomes aware of these changes, her heart starts pounding, she experiences shortness of breath, and she feels a sense of impending doom. When she finally steps outside, panic sets in, but this feeling dissipates when she returns indoors. <\/em>\r\n\r\n<em>Over time, she developed a fear of going outside and tries to stay indoors as much as possible. She has sought help for her panic attacks throughout the years. She learned to use positive self-talk, a technique she began practicing on her own even before a therapist suggested it. She also mastered controlled breathing to help calm her breathing back to normal. Both methods have been effective in reducing her anxiety and preventing panic, although not entirely. <\/em>\r\n\r\n<em>As she got older, Anna underwent a routine cardiac evaluation, which revealed a mitral valve prolapse\u2014a minor anomaly in the heart valve's functioning that can cause sensations like an increased heart rate. Sometimes, she mistakenly attributed these sensations to external factors. She was prescribed medication that improved the function of her heart valve, and for the first time, her panic attacks completely stopped.<\/em>\r\n\r\n&nbsp;\r\n\r\nWere these psychological symptoms completely caused by this specific physiological cause?\u00a0 Research has established that some portion of panic attacks are caused by this heart valve anomaly. But why, if it was a physiological cause, did the psychological interventions help even before the medication? That might seem illogical, but it\u2019s not. Often, the treatment that works is not the reversal of the cause but brings relief through another mechanism. Sometimes there is the interaction of physiological and psychological functions that causes this type of anxiety disorder. Other times it may be one or the other.\r\n\r\n<strong><em>John \u2013 Maintaining Positive Change for Cardiac Health<\/em><\/strong>\r\n\r\nJohn, who is 63, has had more than two dozen cardiac procedures since his 30s. While these have been successful, in that he has survived and has had a normal work life and a full family life, intermittently he becomes fatalistic, giving up on his self-care. He has made successful lifestyle changes, successfully managed his weight and quit smoking, He has the experiences of self-efficacy having achieved these goals, but he is disappointed in the outcomes, He had high expectations for feeling much better.\r\n\r\n<em>John resumed smoking but later quit again. He had lost weight; he regained a significant amount after intentionally abandoning his diet and regular exercise. During his recent visit to the cardiologist, he loudly claims he does not care about the risk, he will eat as much as he wants, and that exercise is a waste of time, at least the food isn\u2019t as bad as smoking. His cardiologist frowns a bit and shakes his head.<\/em>\r\n\r\nHe is tempted to confront John, and take issue with his thinking, taking on his resistance and denial head on. Instead, he decides to roll with it. He asks him, \u201cHow are you feeling?\u201d John says he has some shortness of breath and less energy than usual and had to leave his daughter\u2019s party early which upset him. He missed another social gathering due to not feeling well.\r\n\r\n<strong>\u00a0<\/strong>John\u2019s doctor, for example, knows that the survival of his cardiology patients is affected by psychological factors, even when the cardiac techniques have been successful, death or disability are more likely among persons who are depressed or very anxious.\u00a0 He understands the stages of change approach and that readiness for change varies. He noticed that John had been in the maintenance phase of change successfully controlling his weight through adoption of\u00a0 a long-term diet and regular exercise but has now relapsed. Tempted to simply tell him he is going down a dangerous path, and he must lose weight again, he knows from experience with John and other patients that he is likely to react negatively, become stubborn, and resistant to change. The doctor has developed sufficient rapport with John to help him identify the discrepancy between his values and his behaviors. For example, John very much values his family life with his adult children and the driving trips with his wife on weekends away from home. When not feeling well, secondary to his weight gain and worsened cardiac symptoms, he remains home and isolated. This is a discrepancy between what he wants to do, what he values, and his current behavior of being indifferent to his weight. John\u2019s doctor will point this out to him and develop a plan for resolving this discrepancy between what John wants and how his behavior hurts those pursuits.\r\n\r\n&nbsp;\r\n\r\n<strong><em>Tomas \u2013 A Dangerous Co-morbidity<\/em><\/strong>\r\n\r\nTomas has Type II diabetes and is experiencing depression at the same time, a co-morbidity, two medical disorders at once, including a psychiatric disorder. His trouble seemed to begin with when he did not have much personal energy for a few months. He felt down and pessimistic. He started becoming more sedentary, just moved around less, sometimes isolating himself from others.\r\n\r\n<em>Tomas went to the doctor who diagnosed diabetes. The doctor also noted a certain pessimism and negative outlook by Tomas. He was beginning to show the signs of depression. He is very unhappy most of the time. He can no longer eat his favorite foods as often as he would like and in the amount he wishes. He cannot drink beer with his friends without raising his blood glucose levels. This was his main social life \u201cwith his boys,\u201d telling jokes and anecdotes, watching sports, and drinking beer. It is very important to him after a long week at work. He should monitor his glucose with self-administered blood tests, but he finds this inconvenient and annoying, and therefore, does it infrequently. He worries when his cuts and bruises heal slowly. Sometimes, he must urinate a lot, run to the bathroom \u201clike an old man\u201d as he says. He worries about his long-term health and that his life might be shortening. All of this gets him down.<\/em>\r\n\r\n<em>\u00a0<\/em>Tomas thinks he cannot make the changes he needs to recover from diabetes. If he were less depressed, he be might be more optimistic about caring for himself. He believes <em>if <\/em>he could make some changes, it <em>could<\/em> have positive outcomes, but he does not yet believe he can make such changes. He lacks self-efficacy about this.\r\n\r\nIs having diabetes contributing to his experience of depression? Is his experience of depression worsening his diabetic disease? His feelings of being \u201cblue\u201d or \u201cdown,\u201d have led to increased appetite, decreased level of activity, isolating himself, and gaining weight. All problems for someone with diabetes. Also, the experience of depression interferes with his self-care. Tomas also has a genetic predisposition to this disorder. Better diabetes management should help his energy and mood, but he also needs specific treatment for depression such as cognitive behavioral therapy or anti-depressant medication.\r\n\r\n<strong>Bob: Physiological Disorders Overlooked due to Psychiatric Symptoms<\/strong>\r\n\r\nPsychiatric symptoms such as auditory hallucinations, disordered thinking or emotion are often thought to be primarily caused by a psychiatric disorder. However, there is a common and little understood phenomenon seen among people with mental illnesses who experience an increase in psychiatric symptoms, including psychotic symptoms of delusions and hallucinations due to acute illnesses in body systems other than the nervous system. Unfortunately, these symptoms are often mistakenly attributed solely to a person\u2019s psychiatric disorder.\r\n\r\n<em>Bob kept complaining of stomach problems. He was very anxious often crying and shouting when seeking medical care and had difficulty explaining his symptoms. Some of his concerns seemed delusional, based on outrageous, unfounded beliefs, such as claiming that the government had been putting poison in his food. His medical records indicated <\/em>that <em>he had been hospitalized for psychiatric problems in the past, and that he was prescribed several psychiatric medications. Health personnel told Bob that he was exaggerating; it was all his psychiatric disorder, and his psychotropic medication was increased. He resisted the increase, saying that\u2019s not the problem, and continued to cycle in and out of the emergency room. Bob died suddenly after several months of stomach pain due to infections from intestinal blockages that had been untreated.<\/em>\r\n\r\nBob did have difficulty expressing himself verbally, sometimes his explanations sounded strange and overly abstract. But there is also a specific problem of diagnostic over-shadowing (Hallyburton, 2022). In the perspective of healthcare practitioners, the diagnosis of psychiatric disorders often takes precedence over other conditions. Clinicians tend to prioritize the treatment of psychiatric disorders, frequently attributing numerous physical symptoms to these mental health issues.\r\n\r\nIn summary, physiological disorders can worsen psychiatric symptoms because they affect the same systems that regulate mood and thinking in the brain and nervous system. Clinically, this is why worsening psychiatric symptoms should prompt attention not only to the psychiatric diagnosis but also to other bodily systems and possible medical conditions.\r\n\r\n<em>Something similar happened to Tanya, she reported a set of symptoms that should have related to considering the diagnosis of colon cancer including irregular bowl movements, very dark stool, et. But at these times her psychiatric symptoms were also very severe, indeed flaring up. Instead of addressing both sets of symptoms, there was a decision, more than once, to focus on resolving the psychiatric symptoms first, with little or no success. Finally, based on conversations between Tanya and a new doctor, they did the necessary tests for cancer. She did have colon cancer which had already progressed to a later stage, which necessitated very aggressive treatment. In retrospect, the cancer disease process aggravated the psychiatric symptoms.<\/em>\r\n\r\nThe presence of a mental disorder and its impact can be very important as seen in the case illustrations above. At the same time, it should not be over-emphasized. People with serious mental health conditions get other illnesses, like everyone else, which seems to have been forgotten in two of the scenarios discussed above.\r\n\r\nPsychological challenges including psychiatric disorders often interact in sometimes unexpected ways. It all happens in one body, the systems of which, including the brain and nervous system, interact all the time with each other.\r\n\r\n<strong>\u00a0<\/strong>\r\n<div class=\"textbox\">\r\n<p style=\"text-align: center\"><strong>Chapter Summary<\/strong><\/p>\r\n\r\n<\/div>\r\n&nbsp;\r\n\r\nThis chapter provided a general introduction to the role of psychological factors in all health. In subsequent chapters, you will learn more about the closely related <em>social <\/em>domain, which overlaps significantly with the psychological domain. Psychological factors, broadly defined as cognition (thought and problem-solving processes) and emotion (feelings, affect and mood) are essential components of mental health, but are also very significant when it comes to overall health.\u00a0 Their effect is in combination with physiological factors, social factors and many other variables as proposed in Engel\u2019s (1977, 1980) model. In this chapter you were asked to consider:\r\n<ul>\r\n \t<li>How are psychological factors a <em>contributor <\/em>or<em> determinant<\/em> of overall health?<\/li>\r\n \t<li>Are psychological processes a <em>consequence<\/em> of physiological factors and other determinants of overall health?<\/li>\r\n \t<li>Are some psychological processes and mental health both a <em>contributor<\/em> to and a <em>consequence<\/em> of health status?<\/li>\r\n \t<li>Are psychological processes a \u201c<em>correlate<\/em>\u201d of other health status? Not a cause, not an effect, just associated with other health variables and the result of a third factor, such as genetics or environmental variables.<\/li>\r\n<\/ul>\r\nThe short answer to all four questions is \u201cyes\u201d under specific circumstances, but it very much depends on the circumstances. The answer to all four questions is also \u201cmaybe,\u201d because in many circumstances the research evidence is unclear or more research needs to be done to better understand the inter-relationship of all these factors. The answer to these questions is rarely a \u201cno.\u201d\r\n\r\nIn summary, psychological factors should be considered as a contributor, consequence, or correlate of health processes depending on the specific circumstances. Even when physiological factors are the strongest determinants, there are often psychological dimensions that should be addressed. At the same time, psychological factors should not be over-emphasized when non-psychological factors are very important, and the primary mode of intervention is necessarily physiological.\r\n\r\n<strong>References<\/strong>\r\n<ul>\r\n \t<li>Agorastos, A., &amp; Chrousos, G. P. (2022). 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(1997).\u00a0 <em style=\"text-align: initial;font-size: 1em\">Self-efficacy: The exercise of control.<\/em><span style=\"text-align: initial;font-size: 1em\">\u00a0 W. H. Freeman.<\/span><\/li>\r\n \t<li>Bandura, A. (2004). Health promotion by social cognitive means.\u00a0 <em style=\"text-align: initial;font-size: 1em\">Health Education &amp; Behavior<\/em><span style=\"text-align: initial;font-size: 1em\">,\u00a0 31, 143\u2013164. <\/span><a style=\"text-align: initial;font-size: 1em\" href=\"http:\/\/dx.doi.org\/10.1177\/1090198104263660\">http:\/\/dx.doi.org\/10.1177\/1090198104263660<\/a><\/li>\r\n \t<li>Barbek, R. M., Makowski, A. C., &amp; von dem Knesebeck, O. (2022). 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Goal setting outcomes. \u00a0<em style=\"text-align: initial;font-size: 1em\">Medical Care Research and Review<\/em><span style=\"text-align: initial;font-size: 1em\">, \u00a080(2), 145-164.<\/span><\/li>\r\n \t<li>Testa, A., et al. (2013). Psychiatric emergencies. \u00a0<em style=\"text-align: initial;font-size: 1em\">European Review for Medical and Pharmacological Sciences<\/em><span style=\"text-align: initial;font-size: 1em\">, \u00a017 Suppl 1, 86\u201399.<\/span><\/li>\r\n \t<li>Yu-Shiu L, et al. (2024). Health-promoting lifestyle. \u00a0<em style=\"text-align: initial;font-size: 1em\">European Journal of Cardiovascular Nursing<\/em><span style=\"text-align: initial;font-size: 1em\">, \u00a023<\/span><\/li>\r\n \t<li>Zechner, M. R., &amp; Gill, K. J. (2016). Predictors of physical activity in persons with mental illness: Testing a social cognitive model. <em style=\"text-align: initial;font-size: 1em\">Psychiatric Rehabilitation Journal<\/em><span style=\"text-align: initial;font-size: 1em\">, <\/span><em style=\"text-align: initial;font-size: 1em\">39<\/em><span style=\"text-align: initial;font-size: 1em\">(4), 321.<\/span><\/li>\r\n<\/ul>","rendered":"<p><strong>OVERALL OBJECTIVES<\/strong><\/p>\n<ol>\n<li>Describe psychological factors that influence physical health<\/li>\n<li>Discuss the influence of emotion on health behavior and physical health<\/li>\n<li>Assess the impact of individual some personality traits on health behavior and physical health<\/li>\n<li>Develop an introductory understanding of psychological contributors to health, including physical health<\/li>\n<li>Apply concepts of psychological determinants of health to case examples.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<div class=\"textbox\">\n<p style=\"text-align: center\"><strong>Psychological Determinants of Health<\/strong><\/p>\n<\/div>\n<p>&nbsp;<\/p>\n<p>Psychological factors, broadly defined as cognition (thought and problem-solving processes) and emotion (feelings, affect and mood), are essential components of mental health, but also are very significant when it comes to overall health, in combination with physiological factors, social factors, and many other variables, as explained in Engel\u2019s (1980) model. As you read this chapter and throughout this course, consider the following questions:<\/p>\n<ul>\n<li>How are psychological factors contributors or determinants of overall health?<\/li>\n<li>How does physical health influence psychological processes and mental health?<\/li>\n<li>Can psychological factors and emotional health conditions contribute to and be influenced by \u201cphysical\u201d health status?<\/li>\n<li>Are psychological factors a \u201ccorrelate\u201d of other health status? Not a cause, not an effect, just associated with other health variables and the result of a third factor, such as genetics or environmental variables.<\/li>\n<\/ul>\n<p><strong><em>The Influence of Emotions on Health<\/em><\/strong><\/p>\n<p><span style=\"text-align: initial;font-size: 1em\">Our emotional health strongly influences our physical health. Emotional health is regarded as an internal psychological factor, stemming from a person\u2019s emotions and thoughts. When someone experiences strong feelings related to their physical health, it can impact how frequently they seek medical care and how effectively they use healthcare services (Kikas, et al., 2026). Feeling anxious or worried about your health can interfere with getting medical care, following treatment recommendations, and other actions a person takes to prevent or treat health problems.<\/span><\/p>\n<p>People with more anxiety about their health are more likely to seek services from primary care and specialists. At the same time, they also experience more health-related disability than people who are not anxious about their health (Bobevski, et al., 2016).<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center\"><strong><em>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Psychological Health\u00a0 \u2194 <\/em>\u00a0<em>Physical Health<\/em><\/strong><\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Health Anxiety<\/em><\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>Health anxiety, also known as medical anxiety, is a person&#8217;s belief that they are currently experiencing or will develop a significant health condition (Rutter et al., 2018). Health anxiety is important to identify and address as it relates to worsened quality of life, social functioning, adherence to treatment, health outcomes, and higher healthcare costs (Romanazzo, et al., 2022).\u00a0 Treating health anxiety improves health outcomes for the person (Romanazzo, et al., 2022).<\/p>\n<p>&nbsp;<\/p>\n<p>People with significant health anxiety lasting more than six months may experience intense fears about their health that make it difficult to access health care. This can lead to a mental health condition known as <em>Illness Anxiety Disorder<\/em>, formerly referred to as hypochondriasis. This condition is characterized by excessive worrying about having or developing a serious, undiagnosed medical condition (French &amp; Hameed, 2023). People affected by this condition can be categorized into two groups: \u201ccare-seeking\u201d or \u201ccare-avoidant\u201d (Kikas et al., 2026). Care-seeking individuals frequently visit healthcare providers to try and alleviate their fears about undiagnosed illnesses, while care-avoidant individuals are likely to refuse medical services altogether (Kikas et al., 2026).<\/p>\n<p>&nbsp;<\/p>\n<p>Living with a chronic health condition can increase medical anxiety. People with these conditions can experience moderate to severe symptoms of anxiety related to:<\/p>\n<ul>\n<li>managing their illness<\/li>\n<li>fearing a recurrence of an illness<\/li>\n<li>interacting with healthcare providers.<\/li>\n<\/ul>\n<p>(Romanazzo, et al., 2022; Lebel et al., 2020).<\/p>\n<p>&nbsp;<\/p>\n<p>For example, up to 50% of people previously diagnosed with cancer experience an understandable fear of recurrence (Rutter et al., 2018). While the exact reasons for higher anxiety symptoms among people with chronic health conditions are not fully understood, it is suggested that the environment, genetic background, and socio-economic status contribute to the level of anxiety (Romanazzo, et al., 2022; Barbek et al., 2022).<\/p>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\">Important Point: Everyone may feel anxious or nervous about their health, but some people can develop unhealthy practices of over- using health care services or psychological barriers to seeking health care.<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p><strong><em>Stress, Vulnerability and Health<\/em><\/strong><\/p>\n<p>Stress is an external psychological factor that affects a person&#8217;s emotional well-being by influencing their psychological state, which, in turn, can impact their physical health.\u00a0 See Chapter 2 for an overview of the biological impact of prolonged stress on physical health. This was made most apparent in the Adverse Childhood Experiences (ACEs), a landmark public health study by insurance company Kaiser Permanente and the Center for Disease Control, which examined how childhood adversity is related to adult illnesses (Felitti et al. 1998). They surveyed 9,500 adults about their exposure to specific ACEs. These included childhood abuse, neglect, household dysfunction, physical, emotional, or sexual abuse; domestic violence; parental substance use; mental illness of a parent; incarceration of a family member; and the separation of family members from one another (Kendall-Tackett, 2020; SAMHSA, 2014). Many of these ACEs persist for several months through many years, perhaps an entire childhood.\u00a0 Members of ethnic, racial, and gender minorities are at increased risk, as are people of lower economic status (Trauma-Informed Care Implementation Resource Center, 2021).<\/p>\n<p>&nbsp;<\/p>\n<p>The more ACEs a person reported, the higher the person\u2019s risk for later problems such as depression, substance use, suicide attempts, smoking, heart disease, liver disease, chronic lung disease, and other major causes of illness and death. Since the original study there have been at least 25 additional studies with over 325,000 participants on the impact of childhood ACEs on illnesses in adulthood (Hughes et al., 2017). Eight studies provided sufficient data to assess the impact of each additional ACE in the lives of children (total participants = 197,981). Each additional exposure to Adverse Childhood Experiences (ACEs) was associated with a 13% increase in the odds of having two or more chronic illnesses, often referred to as <em>multi-morbidities (<\/em>Senaratne et al., 2024<em>)<\/em>. These multi-morbidities are defined as the co-occurrence of two or more long-term physical or mental health conditions that typically last for over one year.<\/p>\n<p>&nbsp;<\/p>\n<p>The ACEs Study showed that early adversity is not only a psychological issue but also a major health risk factor. Childhood trauma and household instability can have biological, psychological, and social consequences for health. This includes increased risk for mental illness, increased likelihood of engaging in health-risky behaviors such as substance misuse and sexual promiscuity, chronic diseases, and premature death (Kendall-Tackett, 2020). At the same time, these studies have also found that the impact of ACEs can be reduced by protective relationships, social support, therapy, stable environments, and community resources.<\/p>\n<p>ACEs impacts lifelong health in diverse ways.<\/p>\n<ul>\n<li>Stress from adverse childhood events can lead to increased levels of <strong>stress hormones and inflammation<\/strong>, both of which are linked to worse health outcomes (Cleveland Clinic, 2025; Kendall-Tackett, 2020). For example, elevated levels of cortisol are normally associated with adaptive short-term changes of the \u201cfight or flight\u201d response. When they are elevated over the long-term due to the prolonged stress due to an ACE, it harms many of the bodies\u2019 systems and organs, including the immune system.<\/li>\n<li>People who have experienced ACES are also more likely to <strong>engage in risky health behaviors<\/strong> that worsen health, such as substance use, overeating, or unsafe sexual practices (Kendall-Tackett, 2020).<\/li>\n<li>People exposed to more ACES are more likely to <strong>use substances<\/strong> (e.g., smoking, illicit drugs, and drink heavily), experience mental health issues, and self-directed harm (Hughes et al., 2017).<\/li>\n<li>More individual and different ACES of childhood are associated with more <strong>multi-morbidities<\/strong>, a term meaning multiple diseases (Senaratne et al., 2024).<\/li>\n<li>Higher risks of experiencing <strong>negative beliefs about their health<\/strong>, worsening health and increasing the risks of depression (Kendall-Tackett, 2020).<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>There are several treatments available for managing stress associated with exposure to ACEs. These include practicing stress management techniques, mental health treatment, engaging in cognitive behavioral therapy, and adopting healthy lifestyle behaviors. These actions can help reduce stress and improve overall health outcomes (Cleveland Clinic, 2025; Rutter et al., 2018). If individuals are never exposed to these very adverse experiences in childhood, it can reduce the risk of developing multiple health conditions as an adult<\/p>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\">Learn more about ACES here: <a href=\"https:\/\/www.cdc.gov\/aces\/about\/index.html\">https:\/\/www.cdc.gov\/aces\/about\/index.html<\/a><\/div>\n<\/div>\n<p><strong><em>Grief and Health Conditions\u00a0<\/em><\/strong><\/p>\n<p>Grief is the intense sadness that can arise from loss or significant changes in our lives, and it can negatively affect our health and increase the risk of mortality. This emotional response can result from internal events, like receiving a serious health diagnosis or experiencing a decline in physical abilities, as well as from external factors, like the death of a loved one. The health consequences of grief can include:<\/p>\n<ul>\n<li>an increased reliance on medication<\/li>\n<li>higher rates of hospital admissions<\/li>\n<li>noncompliance or non-adherence to medical treatments<\/li>\n<li>elevated symptoms of depression<\/li>\n<li>a greater risk of premature death<\/li>\n<\/ul>\n<p>(Stroebe et al., 2017; Carrillo-Alarc\u00f3n et al., 2015).<\/p>\n<p><em>Receiving news about a new health condition or disease can be challenging, often triggering a grieving process for many individuals.<\/em> For instance, people diagnosed with diabetes may experience profound grief as they come to terms with their condition and the potential serious health implications of uncontrolled blood sugar levels, such as vision loss and peripheral artery disease (Carrillo-Alarc\u00f3n et al., 2015). Additionally, individuals who have lost a limb due to diabetes-related complications may endure significant grief, which can lead to depression, increased pain, and slower healing and recovery (Spiess et al., 2014).<\/p>\n<p><em>Bereavement, or the grief experienced after the death of a partner, parent, or child, can lead to prolonged sadness that negatively affects both emotional and physical health<\/em> (Stroebe et al., 2007). It can disrupt appetite, sleep, and energy levels, increasing the risk of diseases and premature mortality (Stroebe et al., 2007). Healthcare costs for those who are grieving are higher than for others, and research suggests that grief can weaken the immune system, leading to changes in cardiovascular and endocrine health (Stroebe et al., 2007). Individuals who have lost their spouses, such as widows and widowers, are particularly vulnerable to premature death; however, this risk can be reduced through positive lifestyle choices, socioeconomic status, and social support (Ennis &amp; Majid, 2021).<\/p>\n<p>Grief and bereavement are important psychological determinants of health. To address grief and enhance both emotional and physical well-being, grief counseling and supportive therapy are recommended interventions (Stroebe et al., 2007; Carrillo-Alarc\u00f3n et al., 2015; Ennis &amp; Majid, 2021).<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center\"><strong>Habits and Goals: Foundations of Good Health<\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>An essential psychological factor influencing health is the daily habits and behaviors we actively choose to maintain our physical well-being. These practices are sometimes called \u201cself-regulatory capacities,\u201d or \u201cthe extent to which individuals possess skills or techniques that they can actively apply to alter or regulate their health behavior\u201d (Haggar, 2025, p.831).\u00a0 Self-regulation is important for good health outcomes because it moves a person into an active role in their health management.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Goal-Setting Practices<\/em><\/strong><\/p>\n<p><em>\u00a0<\/em><\/p>\n<p>Managing our health effectively requires consistent actions that enhance our well-being. Activities such as seeking preventative care and engaging in physical exercise require motivation. One effective strategy for improving and maintaining health behaviors is to set a large goal, break it down into smaller, more manageable goals, and then take small steps towards achieving them. Goal-setting practices are widely recognized for increasing physical activity (Swann et al., 2021). Research indicates that by establishing and accomplishing health-related goals, individuals can enhance various outcomes related to health, including \u201c[health-related] self-efficacy, quality of life, medication adherence, disease symptoms, depression, diet control, and HbA1c control\u201d (Tabaei-Aghdaei et al., 2023, p.157). Additionally, some evidence suggests that goal-setting can improve blood pressure, health anxiety, functioning, and body mass index (Tabaei-Aghdaei et al., 2023). By repeatedly setting health goals, we can positively transform our health behaviors.<\/p>\n<p><strong><em>Habit Formation<\/em><\/strong><\/p>\n<p>A habit is an action that we take for our health without thinking about it.\u00a0 Positive examples of a health habit could be brushing your teeth or taking a shower in the morning, and negative examples of a health habit could be smoking or eating too much.\u00a0 These events do not have to be planned and occur on most days. Building a new habit, or changing an old one, takes time and practice, and the belief that you can do it (Haggar, 2025).\u00a0 Positive health habits can change our behaviors and can improve our overall health (Gardener, 2015). Building habits can also build our motivation to make additional changes for our health (Gardener, 2015).\u00a0 For example, someone who has improved their eating habits may feel more confident that they can start walking more.<\/p>\n<div class=\"textbox\">\n<p style=\"text-align: center\"><strong>Resilience, Coping and Personal Strengths Support Health<\/strong><\/p>\n<\/div>\n<p>&nbsp;<\/p>\n<p><strong><em>Use of Coping Strategies in Health<\/em><\/strong><\/p>\n<p><em>\u00a0<\/em>Stress, especially how a person perceives and manages it, influences physical health. Managing physical symptoms, treatments, and uncertainties can negatively affect our emotional well-being, which in turn impacts our ability to heal and recover from health issues problems over time.\u00a0 Coping strategies are the actions that help to manage stress, reduce distressing emotions, and navigate challenges.\u00a0 Healthy coping strategies can improve health outcomes, and longevity.\u00a0 Each person&#8217;s way of coping with difficulties is unique, and what proves most helpful varies from individual to individual. Coping often relies on sufficient sleep and rest, nutritious food, limiting alcohol, journaling, support from others, and physical activity (CDC, 2026).<\/p>\n<p>&nbsp;<\/p>\n<p>Four categories of <strong>adaptive coping strategies<\/strong> that support overall health include:<\/p>\n<ol>\n<li>Problem-focused: Efforts to address the problem directly through planning or time management<\/li>\n<li>Emotion-focused: Efforts to minimize distressing emotions by using positive reframing, humor or acceptance<\/li>\n<li>Meaning-focused: Efforts to change how one thinks about a situation through a lens of meaning and focus<\/li>\n<li>Social-focused: Strategies that focus on finding social support for a situation.<\/li>\n<\/ol>\n<p>(from Algorani, Gupta, 2023)<\/p>\n<p>&nbsp;<\/p>\n<p>Maladaptive coping strategies, such as avoidance or disengagement, can worsen mental health and physical health outcomes.<\/p>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\"><em>Cross-chapter link: See chapter 2 for a deeper dive into the biological impact of stress and how it influences physical health<\/em>.<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p><strong><em>Personal Strengths in Health Management<\/em><\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>Another perspective about improving health management and addressing chronic conditions is to identify and use personal strengths. Focusing on strengths can enhance health self-management and help identify the resources a person has to support their health (Kristjansdottir et al., 2018).<\/p>\n<p>Research suggests that people navigating chronic health conditions can identify their strengths, which can support emotional health and disease management. In one study, people with chronic health conditions suggested that focusing on strengths such as personal attributes (perseverance, curiosity, etc.), close relationships, and community supports would be helpful for their health (Aungst et al.,2019).\u00a0 A focus on strengths in chronic disease management may be particularly relevant to managing diabetes, addressing overuse of medical services, and building motivation in health conditions that require ongoing behavior change (Aungst et al., 2019).<\/p>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\">\n<p><em>Supplemental Activity<\/em>: Explore your personal strengths. Identify the strengths you possess that positively support your health.<\/p>\n<p><a href=\"https:\/\/www.viacharacter.org\/\">https:\/\/www.viacharacter.org\/<\/a><\/p>\n<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p><strong><em>Religion\u00a0and\u00a0Spirituality\u00a0<\/em><\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>Our self-perception, upbringing, and beliefs about meaning, purpose, and connection can also significantly influence our health. Furthermore, individuals who regularly practice religion and spirituality tend to experience lower levels of stress, live longer, and have a reduced risk of heart disease and hypertension (Koenig, 2012). In addition, involvement in religious and spiritual practices is associated with decreased pain and improved overall physical well-being (Kruk &amp; Aboul-Enein, 2024). Individuals with strong religious beliefs are more likely to engage in health-promoting behaviors. These behaviors include avoiding substances such as cigarettes and alcohol, participating in physical activity, and maintaining a balanced diet (Kruk &amp; Aboul-Enein, 2024; Koenig, 2012).<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Personality and Self-Efficacy<\/em><em>\u00a0<\/em><\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>This chapter has highlighted various external factors and actions that influence our emotions and their interaction with physical health. Another important aspect to consider is how we perceive our health. This section will briefly review some personality traits that affect our health and the cognitive perspectives that shape our understanding of it.<\/p>\n<p>&nbsp;<\/p>\n<p>Psychologists have studied personality traits to gain insights into their impact on physical health. Personality traits are defined as a consistent aspect of our identity and tend to remain stable over time (Hagger, 2024). Research has identified several traits that are commonly associated with positive health outcomes, including:<\/p>\n<ul>\n<li>Conscientiousness: paying attention to the minute details of health such as following up with medical care, engaging in preventative care and following directions<\/li>\n<li>Optimism: believing that one\u2019s actions for health will lead to positive changes.<\/li>\n<li>Extroversion: finding support from others to improve health and interest in engaging in new activities with others.<\/li>\n<\/ul>\n<p>(Haggar, 2024; Obara-Go\u0142\u0119biowska&amp; Micha\u0142ek-Kwiecie\u0144, 2020)<\/p>\n<p>&nbsp;<\/p>\n<p>These psychological traits influence our health, but people with other personality traits can also make positive changes to their health and well-being. Particularly when they consider how they <em>think <\/em>about their health.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Self-efficacy and Outcome\u00a0expectations\u00a0<\/em><\/strong><\/p>\n<p>One of the important theories about health behaviors is the Social Cognitive Theory by Bandura (2004).\u00a0 This theory has several components, but the most studied are <strong>self-efficacy<\/strong> and <strong>outcome expectations<\/strong>. Self-efficacy refers to a person&#8217;s belief in their ability to utilize their existing skills to overcome challenges (Bandura, 2004). It is essential for achieving health goals and making health behavior changes (Bandura, 1994).<\/p>\n<p>A strong belief in one&#8217;s ability to make changes in health\u2014known as self-efficacy\u2014is directly linked to improvements in health outcomes, such as increased physical activity and better management of blood sugar levels in individuals with diabetes (Baghbani et al., 2023; Jiang et al., 2019; Zechner &amp; Gill, 2016).<\/p>\n<p>Outcome expectations, which refer to a person&#8217;s belief that taking specific actions will result in a particular outcome, are a crucial factor in maintaining health (Bandura, 2004). For example, when someone believes that reducing their sugar intake or exercising more will help them lose weight, this belief can motivate them to engage in those activities. Research indicates that patients with various health conditions believe that taking proactive steps will enhance their health. For example, patients have seen improved treatment outcomes and overall health with conditions such as:<\/p>\n<ul>\n<li>Heart disease<\/li>\n<li>Stroke<\/li>\n<li>Serious injury<\/li>\n<li>Cancer<\/li>\n<li>Musculoskeletal conditions<\/li>\n<li>Recovery from surgical procedures<\/li>\n<li>Mental health recovery<\/li>\n<\/ul>\n<div>\n<p>(Bohlen et al., 2022; Laferton et al., 2022; Lafterton et al., 2017)<\/p>\n<\/div>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\">\n<p><em>Important Point: <\/em>Our personality and beliefs shape our health habits and outcomes. Regardless of personality traits, believing that we CAN make changes for our health (e.g., self-efficacy) and that the changes we make will make us feel better and lead to better health outcomes (e.g., outcome expectations) are critical to making health behavior changes.<\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<p><strong><em>Navigating Health Conditions with Grit<\/em><em>\u00a0and Perseverance<\/em><\/strong><\/p>\n<p>Living with health problems and chronic health conditions can be overwhelming.\u00a0 While some people experience grief with chronic health conditions, others use internal strengths and their determination and passion to help them successfully manage these conditions.<\/p>\n<p>Perseverance in managing health outcomes reflects a person&#8217;s strong belief that they can and will improve their health (Magon et al., 2024). Grit is defined as the combination of perseverance and passion for achieving long-term goals. It has been associated with the development of positive lifestyle habits, which can enhance overall quality of life for cardiac patients (Yu-Shiu et al., 2024). Additionally, grit plays a significant role in fostering healthy habits, reducing depression and anxiety, and preventing emotional distress in individuals with chronic conditions, as well as in supporting regular physical activity routines (Datu, 2021).<\/p>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\"><em>Important Point<\/em>: Having grit and perseverance helps people build healthy habits and manage chronic health conditions<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center\"><strong>Health Literacy and Theories about Psychological Factors in Health<\/strong><\/p>\n<p><strong>Health literacy is knowledge about and familiarity with health and health care, thus developing a level of comfort discussing and making decisions about<\/strong> these issues. It is foundational because people need to access, understand, and use health information to judge risk about themselves or loved ones, understand treatment options, and anticipate the benefits of treatment. With low health literacy, an individual might not fully understand health threats and may over- or under-emphasize their seriousness. This can affect motivation to engage in treatment and distort estimates of how much impact the self can have, also known as <strong>self-efficacy.<\/strong><\/p>\n<p>Various theories have been developed to understand psychological factors in health. Each considers health literacy to be critical. Together, these theories explain health behavior as a process that begins with understanding that leads to action.<\/p>\n<ul>\n<li>The <strong><em>Theory of Planned Behavior<\/em><\/strong><strong> (TPB:<\/strong> Ajzen 1971); explains behavior as the result of a person\u2019s <strong>intention<\/strong> to act, this applies to behaviors related to health and health promotion as well. Intention is shaped by 1) <strong>attitude<\/strong>, or whether the person views the planned behavior positively or negatively; 2) <strong>subjective norms<\/strong>, or whether family, members, peers and others are perceived as approving or disapproving of the behavior; and 3) <strong>perceived behavioral control<\/strong>, or whether the person believes they can perform the behavior.<\/li>\n<li><strong><em>Self-efficacy Theory<\/em><\/strong><strong> (Bandura, 1977) <\/strong>Already introduced above this theory emphasizes, \u201cCan I do this? If I can, will the outcome be positive?\u201d Thus, to change, an individual must both think they can bring the change but also believe it will result in desirable outcomes.<\/li>\n<li><strong><em>Transtheoretical Stages of Change Model<\/em><\/strong> developed by Prochaska and DiClemente (1982)<strong> has shaped many health interventions<\/strong>. At any given moment, people differ in readiness to address health conditions or change health behaviors and thus need distinct kinds of help. Someone in precontemplation may need basic awareness and health-literacy support, while someone in preparation may need a concrete plan. This approach looks at the bridge between intention and behavior by emphasizing different interventions: action planning, coping planning, self-monitoring, and relapse recovery depending on the individual\u2019s stage of readiness<\/li>\n<li>H<strong><em>ealth Action Process Approach<\/em><\/strong><strong> (HAPA) model<\/strong>, self-efficacy and the stages of change applied to health behavior expanded across the change process: confidence to start, confidence to maintain the behavior, and confidence to recover after setbacks.<\/li>\n<\/ul>\n<p><strong>\u00a0<em>Applying Health Theory to Health Behavior<\/em><\/strong><\/p>\n<ol>\n<li><em>Theory of Planned Behavior (TPB). <\/em><\/li>\n<\/ol>\n<p>In the context of health behavior, TPB can be used to plan interventions to help someone who intends to exercise regularly, eat healthier, quit smoking, engage in safe sex practices, take medication, or get vaccinated. Each of these takes a level of intention and advanced planning. \u00a0For example, a person might attend a smoking cessation program emphasizing the benefits of quitting. This is often in a group setting to develop positive attitudes towards smoking cessation and develop peer pressure and support for the intentions. This strengthens <strong>subjective norms and can increase<\/strong> peer and familial support. Personal c<strong>ontrol is enhanced<\/strong> by offering nicotine replacement, learning coping strategies, and phone support for when a person is tempted to resume smoking.<\/p>\n<ol start=\"2\">\n<li><em>Self-Efficacy and Social Cognitive Theory<\/em><\/li>\n<\/ol>\n<p>Self-efficacy theory holds that people are more likely to initiate and sustain health behaviors when they believe they can execute it successfully. For a change in health behavior, self-efficacy influences whether a person attempts a behavior, how much effort they invest, how they respond to setbacks, and whether they persist over time. For example, a person trying to make a health-related change such as: stopping smoking, increasing physical activity or following a medication regimen is more likely to succeed if they believe they can do it in \u201creal-life\u201d situations, including when stressed or experiencing temptation. Self-efficacy can be strengthened through mastery experiences, modeling of the behavior by others, encouragement from trusted people, and learning to overcome barriers. Many health self-management interventions build confidence gradually through achievable, incremental goals, skills training, feedback, problem solving, and relapse-prevention planning. Knowledge alone is often insufficient; people also need confidence that they can translate knowledge into action. A foundational reference is Bandura\u2019s <em>Self-Efficacy: The Exercise of Control<\/em> (1997), and a health-specific application is Bandura\u2019s \u201cHealth Promotion by Social Cognitive Means\u201d (2004).<\/p>\n<p>A more detailed example of\u00a0 health promotion by social cognitive means can be found in the development of a diabetes self-management program. Rather than simply giving information to participants, the program builds self-efficacy through incremental. achievable goals, practice, and modeling by peers to develop the conviction\u201d \u201cI can do it.\u201d A modest walking goal might be set due to its achievability. There would be the opportunity to observe peers with diabetes and hear how they manage barriers, practice meal-planning, and track blood glucose. It is also important to address 1) outcome expectations\u2014improved self-management will improve energy and lessen symptoms\u2014and 2) environmental and social supports, family involvement, access to healthy foods, reminders, and follow-up contacts.<\/p>\n<ol start=\"3\">\n<li><em>Planning for Health &amp; Readiness to Change Health Behaviors<\/em><\/li>\n<\/ol>\n<p>There are many aspects of planning that are essential for promoting one\u2019s health. For example, regular exercise must consider factors such as inclement weather, work schedules, and family responsibilities. Managing illnesses, including mental health conditions, cardiac disorders, and cancer, requires careful scheduling of appointments, remembering to take multiple medications regularly, self-monitoring of symptoms, and implementing other self-care strategies. Conditions like diabetes involve strict medication adherence, which may include taking both pills and injections as prescribed. Additionally, it requires nutritional planning, purchasing and preparing the appropriate foods in the right quantities, monitoring glucose levels, and engaging in regular exercise. All these activities necessitate thoughtful planning in advance.<\/p>\n<p>Having good intentions is rarely enough, which is why are they so hard to implement. Another theory called the Transtheoretical <strong>Stages of Change Model<\/strong> (Stages of Change) sheds light on how health behavior change is a process proceeding through stages, rather than a single decision. It proposes that people move through stages: <strong><em>precontemplation<\/em><\/strong>, when they are not yet considering change; <strong><em>contemplation<\/em><\/strong>, when they are thinking about change; <strong><em>preparation<\/em><\/strong>, when they are getting ready to act; <strong><em>action<\/em><\/strong>, when they actively change the behavior; and <strong><em>maintenance<\/em><\/strong><em>,<\/em> when they work to sustain the new behavior and prevent relapse.<\/p>\n<p>Stages of Change is useful in health changes because motivation strategies can be matched to a person\u2019s readiness. For example, someone in precontemplation may benefit from hearing about smoking risks or even just the raising of doubt \u201cI notice you cough a lot,\u201d \u201cyou seem to get shortness of breath easily.\u201d A person in the contemplation phase might consider using a decisional balance, to weigh the pros and cons of smoking. Meanwhile someone in preparation phase may need a concrete plan to quit or assistance with nicotine replacement.<\/p>\n<p>Regardless of the stage, social support and encouragement are important, but they are particularly essential during the maintenance phase. Relapse, or returning to the old, unwanted behavior often happens, it is best to develop a plan for what to do before it happens.<\/p>\n<p>To motivate change, health professionals can assess a person\u2019s stage of readiness to change health behavior and use stage-appropriate strategies rather than giving the same advice to everyone. In the context of diet, exercise, medication adherence, smoking cessation, or substance use, early-stage interventions often focus on creating doubt, providing education, encouraging emotional reflection, and discussing the pros and cons of change. In contrast, later-stage interventions tend to emphasize goal setting, skill building, self-monitoring, coping strategies, rewards, and relapse prevention.<\/p>\n<p>This model is particularly useful because it acknowledges that ambivalence and relapse are normal parts of the change process. Resistance to change is not seen as denial or a lack of commitment; instead, it is recognized as a natural element of behavior change. Practitioners are encouraged to &#8220;roll with resistance,&#8221; viewing it as an expected aspect of the journey toward change. These techniques stem from motivational interviewing. A key references is Prochaska and DiClemente (1982). Other papers authored by Prochaska and DiClemente on motivational interviewing are included in the reference list.<\/p>\n<p>&nbsp;<\/p>\n<p style=\"padding-left: 80px\"><em>Resistance to Change<\/em><\/p>\n<p>From the perspective of the stages of change model, the focus is on helping the person help themselves. Hopefully, the individual comes to identify the change they want and will develop ideas about how to change. This can include identifying an inconsistency between a stated goal and an unhealthy behavior that potentially needs to be changed. Here are some examples:<\/p>\n<ul>\n<li>Ted claims to highly value his relationship with his daughter and wife, yet his habitual drinking keeps him away from them, out of his home, and worsens these relationships.<\/li>\n<li>Amanda very much wants to see her young grandchildren grow up but persists in smoking heavily.<\/li>\n<li>Miguel wants to live a full life, he has diabetes and his glucose levels are out of control, he does little to control them, leading to substantial changes in his levels of \u201cenergy\u201d sleepiness, and even more inactivity.<\/li>\n<\/ul>\n<p>Are Ted, Amanda, &amp; Miguel simply resistant to change, \u201cin denial,\u201d being difficult, or self-destructive? Perhaps. But within the Stages of Change framework, their resistance to change derives from the fact they are not yet ready for change. Just because someone needs care, does not mean they are ready to receive it, let alone participate in it actively. The practitioner\u2019s role is to help them become ready and consider changes.<\/p>\n<div class=\"textbox textbox--examples\">\n<div class=\"textbox__content\"><em>Important Point: <\/em>Stages of Change Theory suggests that people change their health behavior in stages, including precontemplation, contemplation, preparation, action, and maintenance.\u00a0 Because changing health is challenging, people often revert to old habits (relapse), and the process begins again.<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<ol start=\"4\">\n<li><em>Health Action Process Approach<\/em><\/li>\n<\/ol>\n<p>An application of the Stages of Change model to health and healthcare the Health Action Process Approach (HAPA). HAPA is a health behavior-change model developed by Schwarzer that explains how people move from thinking about change to starting and maintaining the desired behavior (Schwarzer, 2008). It has two broad phases: an <em>intentional<\/em> phase, where the individual develops an intention based on risk awareness, expected outcomes, and action self-efficacy; and a <em>volitional<\/em> phase, where intention is translated into behavior through planning, action control, maintenance self-efficacy, and recovery self-efficacy (Schwarzer, 2008, 2016). For example, a person may know they are at risk for diabetes, believe exercise will help, and feel capable of starting; HAPA then emphasizes making a daily exercise plan, monitoring progress, identifying and overcoming barriers, and recovering after setbacks that are experienced (Schwarzer &amp; Luszczynska, 2008).<\/p>\n<p>HAPA is related to the Theory of Planned Behavior because both models view intention as important, but HAPA goes further by explaining the intention\u2013behavior gap: why people may intend to change but fail to act (Schwarzer, Lippke, &amp; Luszczynska, 2011). It is also related to the Stages of Change Model because both recognize that behavior change unfolds over time with readiness varying. HAPA focuses less on stages and more on the psychological processes that move someone from inaction to action (Schwarzer, 2008, 2016). For health promotion, HAPA is useful for designing self-management of illnesses, sustained self-regulation (Schwarzer, Lippke, &amp; Luszczynska, 2011; Zhang et al., 2019). Together, these theories explain health behavior as a process that begins with understanding, moves through motivation, and depends on confidence, planning, and support to become action (Schwarzer &amp; Luszczynska, 2008; Zhang et al., 2019).<\/p>\n<p><strong><em>Summary on Theories<\/em><\/strong><\/p>\n<p>Psychological and physiological disorders interact all the time. In fact, the distinction psychological from physiological is often artificial. Where else are thinking and emotion processed but in the brain, the nervous system, and to some extent the rest of the body? This does not mean that an effective intervention needs to be physiological, such as medication. Alternatively, it could be psychological or social in nature, such as different types of therapy or social support.<\/p>\n<p>&nbsp;<\/p>\n<div class=\"textbox\">\n<p style=\"text-align: center\"><strong>Case Illustrations<\/strong><\/p>\n<\/div>\n<p>&nbsp;<\/p>\n<p>In this next section we will consider several case studies based upon the real-life stories to illustrate the inter-connectedness of physical and emotional well-being<\/p>\n<p><strong><em>Kevin \u2013 An Example of a Physiological Disorder\u2019s First Sign being Cognitive<\/em><\/strong><\/p>\n<p>Why should some physical health conditions result in psychiatric symptoms? It is not fully understood; many disorders are associated with inflammation, which can harm the nervous system. Others result in neurohormonal changes, the release of hormones that affect the nervous system and how the person thinks and feels. For persons with and without psychiatric disorders, an infection or disorder in any bodily system can cause psychiatric symptoms. For example, one of the most common examples of this includes urinary tract infections (UTI) in both men and women, especially older adults. UTIs \u00a0can be associated with cognitive and affective (emotional) symptoms. Some even develop symptoms of psychosis, losing touch with reality. Kevin\u2019s symptoms were noticeable, but not so extreme.<\/p>\n<p><em>Kevin, a 55-year-old male, had several urinary tract infections in his life. Early warning symptoms of a UTI is that he became lethargic and a bit pessimistic, but hardly noticeable. He had another unusual early warning sign. Before he experienced the typical UTI symptoms of irregular urination, difficulty starting, excessive volume, persistent urgency, urine smelling like ammonia, he noticed that his thinking would become confused and he had trouble solving problems that he could normally work out. After that it happened more than once. he later realized that his \u201cthinking problem\u201d was an early symptom of\u00a0 UTI.<\/em><\/p>\n<p><strong><em>Anna \u2013 Experiences of Anxiety &amp; Panic<\/em><\/strong><\/p>\n<p>For many conditions, the origin is not known, whether it is primarily psychological or physiological, and it is an oversimplification to say it is one or the other.<\/p>\n<p><em>Anna has often experienced panic attacks when she leaves the house. In the past, she narrowly avoided a few car accidents and once witnessed a violent crime. As she prepares to go to work, she rushes around the house, which causes her heart rate to increase slightly, her breathing to quicken, and she begins to sweat a little. These modest changes often occur when people are getting ready to leave home, and most people may or may not notice them. It&#8217;s typical for someone who is hurrying to leave for work. However, as Anna becomes aware of these changes, her heart starts pounding, she experiences shortness of breath, and she feels a sense of impending doom. When she finally steps outside, panic sets in, but this feeling dissipates when she returns indoors. <\/em><\/p>\n<p><em>Over time, she developed a fear of going outside and tries to stay indoors as much as possible. She has sought help for her panic attacks throughout the years. She learned to use positive self-talk, a technique she began practicing on her own even before a therapist suggested it. She also mastered controlled breathing to help calm her breathing back to normal. Both methods have been effective in reducing her anxiety and preventing panic, although not entirely. <\/em><\/p>\n<p><em>As she got older, Anna underwent a routine cardiac evaluation, which revealed a mitral valve prolapse\u2014a minor anomaly in the heart valve&#8217;s functioning that can cause sensations like an increased heart rate. Sometimes, she mistakenly attributed these sensations to external factors. She was prescribed medication that improved the function of her heart valve, and for the first time, her panic attacks completely stopped.<\/em><\/p>\n<p>&nbsp;<\/p>\n<p>Were these psychological symptoms completely caused by this specific physiological cause?\u00a0 Research has established that some portion of panic attacks are caused by this heart valve anomaly. But why, if it was a physiological cause, did the psychological interventions help even before the medication? That might seem illogical, but it\u2019s not. Often, the treatment that works is not the reversal of the cause but brings relief through another mechanism. Sometimes there is the interaction of physiological and psychological functions that causes this type of anxiety disorder. Other times it may be one or the other.<\/p>\n<p><strong><em>John \u2013 Maintaining Positive Change for Cardiac Health<\/em><\/strong><\/p>\n<p>John, who is 63, has had more than two dozen cardiac procedures since his 30s. While these have been successful, in that he has survived and has had a normal work life and a full family life, intermittently he becomes fatalistic, giving up on his self-care. He has made successful lifestyle changes, successfully managed his weight and quit smoking, He has the experiences of self-efficacy having achieved these goals, but he is disappointed in the outcomes, He had high expectations for feeling much better.<\/p>\n<p><em>John resumed smoking but later quit again. He had lost weight; he regained a significant amount after intentionally abandoning his diet and regular exercise. During his recent visit to the cardiologist, he loudly claims he does not care about the risk, he will eat as much as he wants, and that exercise is a waste of time, at least the food isn\u2019t as bad as smoking. His cardiologist frowns a bit and shakes his head.<\/em><\/p>\n<p>He is tempted to confront John, and take issue with his thinking, taking on his resistance and denial head on. Instead, he decides to roll with it. He asks him, \u201cHow are you feeling?\u201d John says he has some shortness of breath and less energy than usual and had to leave his daughter\u2019s party early which upset him. He missed another social gathering due to not feeling well.<\/p>\n<p><strong>\u00a0<\/strong>John\u2019s doctor, for example, knows that the survival of his cardiology patients is affected by psychological factors, even when the cardiac techniques have been successful, death or disability are more likely among persons who are depressed or very anxious.\u00a0 He understands the stages of change approach and that readiness for change varies. He noticed that John had been in the maintenance phase of change successfully controlling his weight through adoption of\u00a0 a long-term diet and regular exercise but has now relapsed. Tempted to simply tell him he is going down a dangerous path, and he must lose weight again, he knows from experience with John and other patients that he is likely to react negatively, become stubborn, and resistant to change. The doctor has developed sufficient rapport with John to help him identify the discrepancy between his values and his behaviors. For example, John very much values his family life with his adult children and the driving trips with his wife on weekends away from home. When not feeling well, secondary to his weight gain and worsened cardiac symptoms, he remains home and isolated. This is a discrepancy between what he wants to do, what he values, and his current behavior of being indifferent to his weight. John\u2019s doctor will point this out to him and develop a plan for resolving this discrepancy between what John wants and how his behavior hurts those pursuits.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Tomas \u2013 A Dangerous Co-morbidity<\/em><\/strong><\/p>\n<p>Tomas has Type II diabetes and is experiencing depression at the same time, a co-morbidity, two medical disorders at once, including a psychiatric disorder. His trouble seemed to begin with when he did not have much personal energy for a few months. He felt down and pessimistic. He started becoming more sedentary, just moved around less, sometimes isolating himself from others.<\/p>\n<p><em>Tomas went to the doctor who diagnosed diabetes. The doctor also noted a certain pessimism and negative outlook by Tomas. He was beginning to show the signs of depression. He is very unhappy most of the time. He can no longer eat his favorite foods as often as he would like and in the amount he wishes. He cannot drink beer with his friends without raising his blood glucose levels. This was his main social life \u201cwith his boys,\u201d telling jokes and anecdotes, watching sports, and drinking beer. It is very important to him after a long week at work. He should monitor his glucose with self-administered blood tests, but he finds this inconvenient and annoying, and therefore, does it infrequently. He worries when his cuts and bruises heal slowly. Sometimes, he must urinate a lot, run to the bathroom \u201clike an old man\u201d as he says. He worries about his long-term health and that his life might be shortening. All of this gets him down.<\/em><\/p>\n<p><em>\u00a0<\/em>Tomas thinks he cannot make the changes he needs to recover from diabetes. If he were less depressed, he be might be more optimistic about caring for himself. He believes <em>if <\/em>he could make some changes, it <em>could<\/em> have positive outcomes, but he does not yet believe he can make such changes. He lacks self-efficacy about this.<\/p>\n<p>Is having diabetes contributing to his experience of depression? Is his experience of depression worsening his diabetic disease? His feelings of being \u201cblue\u201d or \u201cdown,\u201d have led to increased appetite, decreased level of activity, isolating himself, and gaining weight. All problems for someone with diabetes. Also, the experience of depression interferes with his self-care. Tomas also has a genetic predisposition to this disorder. Better diabetes management should help his energy and mood, but he also needs specific treatment for depression such as cognitive behavioral therapy or anti-depressant medication.<\/p>\n<p><strong>Bob: Physiological Disorders Overlooked due to Psychiatric Symptoms<\/strong><\/p>\n<p>Psychiatric symptoms such as auditory hallucinations, disordered thinking or emotion are often thought to be primarily caused by a psychiatric disorder. However, there is a common and little understood phenomenon seen among people with mental illnesses who experience an increase in psychiatric symptoms, including psychotic symptoms of delusions and hallucinations due to acute illnesses in body systems other than the nervous system. Unfortunately, these symptoms are often mistakenly attributed solely to a person\u2019s psychiatric disorder.<\/p>\n<p><em>Bob kept complaining of stomach problems. He was very anxious often crying and shouting when seeking medical care and had difficulty explaining his symptoms. Some of his concerns seemed delusional, based on outrageous, unfounded beliefs, such as claiming that the government had been putting poison in his food. His medical records indicated <\/em>that <em>he had been hospitalized for psychiatric problems in the past, and that he was prescribed several psychiatric medications. Health personnel told Bob that he was exaggerating; it was all his psychiatric disorder, and his psychotropic medication was increased. He resisted the increase, saying that\u2019s not the problem, and continued to cycle in and out of the emergency room. Bob died suddenly after several months of stomach pain due to infections from intestinal blockages that had been untreated.<\/em><\/p>\n<p>Bob did have difficulty expressing himself verbally, sometimes his explanations sounded strange and overly abstract. But there is also a specific problem of diagnostic over-shadowing (Hallyburton, 2022). In the perspective of healthcare practitioners, the diagnosis of psychiatric disorders often takes precedence over other conditions. Clinicians tend to prioritize the treatment of psychiatric disorders, frequently attributing numerous physical symptoms to these mental health issues.<\/p>\n<p>In summary, physiological disorders can worsen psychiatric symptoms because they affect the same systems that regulate mood and thinking in the brain and nervous system. Clinically, this is why worsening psychiatric symptoms should prompt attention not only to the psychiatric diagnosis but also to other bodily systems and possible medical conditions.<\/p>\n<p><em>Something similar happened to Tanya, she reported a set of symptoms that should have related to considering the diagnosis of colon cancer including irregular bowl movements, very dark stool, et. But at these times her psychiatric symptoms were also very severe, indeed flaring up. Instead of addressing both sets of symptoms, there was a decision, more than once, to focus on resolving the psychiatric symptoms first, with little or no success. Finally, based on conversations between Tanya and a new doctor, they did the necessary tests for cancer. She did have colon cancer which had already progressed to a later stage, which necessitated very aggressive treatment. In retrospect, the cancer disease process aggravated the psychiatric symptoms.<\/em><\/p>\n<p>The presence of a mental disorder and its impact can be very important as seen in the case illustrations above. At the same time, it should not be over-emphasized. People with serious mental health conditions get other illnesses, like everyone else, which seems to have been forgotten in two of the scenarios discussed above.<\/p>\n<p>Psychological challenges including psychiatric disorders often interact in sometimes unexpected ways. It all happens in one body, the systems of which, including the brain and nervous system, interact all the time with each other.<\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<div class=\"textbox\">\n<p style=\"text-align: center\"><strong>Chapter Summary<\/strong><\/p>\n<\/div>\n<p>&nbsp;<\/p>\n<p>This chapter provided a general introduction to the role of psychological factors in all health. In subsequent chapters, you will learn more about the closely related <em>social <\/em>domain, which overlaps significantly with the psychological domain. Psychological factors, broadly defined as cognition (thought and problem-solving processes) and emotion (feelings, affect and mood) are essential components of mental health, but are also very significant when it comes to overall health.\u00a0 Their effect is in combination with physiological factors, social factors and many other variables as proposed in Engel\u2019s (1977, 1980) model. In this chapter you were asked to consider:<\/p>\n<ul>\n<li>How are psychological factors a <em>contributor <\/em>or<em> determinant<\/em> of overall health?<\/li>\n<li>Are psychological processes a <em>consequence<\/em> of physiological factors and other determinants of overall health?<\/li>\n<li>Are some psychological processes and mental health both a <em>contributor<\/em> to and a <em>consequence<\/em> of health status?<\/li>\n<li>Are psychological processes a \u201c<em>correlate<\/em>\u201d of other health status? Not a cause, not an effect, just associated with other health variables and the result of a third factor, such as genetics or environmental variables.<\/li>\n<\/ul>\n<p>The short answer to all four questions is \u201cyes\u201d under specific circumstances, but it very much depends on the circumstances. The answer to all four questions is also \u201cmaybe,\u201d because in many circumstances the research evidence is unclear or more research needs to be done to better understand the inter-relationship of all these factors. The answer to these questions is rarely a \u201cno.\u201d<\/p>\n<p>In summary, psychological factors should be considered as a contributor, consequence, or correlate of health processes depending on the specific circumstances. Even when physiological factors are the strongest determinants, there are often psychological dimensions that should be addressed. 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