Health psychology

This chapter looks at the field of health psychology This is done through the lens of the
biological, cognitive and sociocultural approaches.

Students may study any one of the following categories of health problems: stress, addiction,
obesity, chronic pain or sexual health. This chapter focuses on stress, addiction and
obesity. Supplementary materials will be available to address the other health problems.

Each chapter is divided into smaller sections with quizzes to test for mastery of key vocabulary
and "checking for understanding" questions with sample answers to check for broader conceptual
understanding.

I would like to thank Alžběta Kupková from the University of New York in Prague for her
contributions to this chapter.

Chapter 8.1 Determinants of health

This chapter looks at key concepts in health psychology. The key topi

• The biopsychosocial model of health and well-being

• Dispositional factors and health beliefs
• Risk and protective factors

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Chapter 8.2 Health problems

This chapter looks at biological, cognitive and sociocultural explanations

of why prevalence rates change over time. The key topics of study are:

• Stress and its effects on health

• Explanations of addiction
• Explanations of obesity
• Prevalence rates of health problems

Chapter 8.3 Health promotion

This final chapter looks at how psychologists attempt to change

health behaviours in communities.

The key topics of study are:

• Theories of health promotion

• Effectiveness of health promotion programs

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1. Determinants of health

ATL: Essential understandings

One's approach to health and well being is the result of biological, psychological and
sociocultural factors.

One's beliefs about health have a direct influence on health behaviours.

A combination of risk and protective factors influence one's health behaviours.

Today the focus on health is, to a large extent, on prevention because it is acknowledged that
many health problems are related to lifestyle. It is believed that if people can change their
lifestyle, their general health will improve. Many health psychologists are involved in research
on how to prevent illness, as well as how to promote health and reduce health risks. The goal of
health psychology is to find ways to help people to stay healthy as well as how to best treat
health problems - for example, in relation to alcoholism, stress, and obesity.

For the majority of the twentieth century, academics were members of a medical school of
thought today called biological reductionism. Biological reductionism is an approach to health
and medicine characterized by the assertion that all disease is determined exclusively by
physiological dysfunction. The goal of biological reductionists was to create clear categories of
these bodily dysfunctions and thus to be able to accurately predict who will become ill and
subsequently how to best treat the problem. However, some scientists would argue that such an
objective is unrealistic and even that such an approach to health and disease is just plain wrong.

One of these people was George Engel, an American psychiatrist who in 1977 wrote an article
titled The Need for a New Medical Model: A Challenge for Biomedicine. In this work, he argued
that it was ill-advised to only explain illness in terms of physiological dysfunction of the
individual. Instead, he proposed that health was influenced by many different systems, which in
turn also interacted with and influenced each other. Together, these systems - biological,
psychological and social - determined one’s health. Engel’s approach became known as the
biopsychosocial model. According to this model, none of these factors in isolation is sufficient
to lead definitively to health or illness—it is the deep interrelation of all three components that
leads to a given outcome

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Among the advantages of the biopsychosocial model (BPS) is that it looks at individuals
holistically - as systems - rather than passive responders to biological destiny. It believes that a
person can take control over their health behavior. The model also puts a focus on prevention
with the goal of avoiding health problems - or at least postponing them - as a result of promoting
positive behaviors such as a healthy diet, exercise and stress management. A growing amount of
research suggests that it is the combination of health status, beliefs about health, and
sociocultural barriers to accessing health care that influence the likelihood of an individual
engaging in health-promoting behaviors.

There are some limitations of such a model. First, it is not always clear how and to what extent
these factors interact. When carrying out research on one aspect of the model, it is often not
possible to isolate that variable from other factors. For example, when studying the cognitive
origins of stress, one cannot control for physiological factors. As a result, the model's predictive
validity is often questioned. Another limitation is simply its practical application. Being able to
diagnose or treat an individual patient with regard to biological, psychological and sociocultural
considerations is both time and resource consuming.

Research in psychology: Steptoe and Marmot 2003

Steptoe and Marmot conducted a survey on the interaction of social, psychological, and
physiological aspects of stress. The researchers used a sample of 227 British men and women,
aged 47–59. The aim of the study was to look at differences in physiological stress responses
to a number of stressors. They used seven questionnaires, each related to a different stressor.
Blood samples were also taken, in order to have a physiological measure for stress - for
example, levels of cortisol - that could indicate an elevated risk for heart problems.

The seven stressors in this investigation were: job stress; environmental stress, neighbourhood
and housing issues; economic problems; lack of social support from close relatives; loneliness;
lack of feelings of control over one’s own life; and lack of self-efficacy in relation to stressors.
Self-efficacy is defined as a person’s feeling of competence to deal with a specific task or
problem.

The researchers found that a person scoring high on one stressor did not necessarily have a
high score on another. However, participants who had a high mean score on all seven stressors
also had blood tests indicating that they were in the high-risk group for developing heart
problems. The same relationship was seen in terms of psychological effects of stress - for
example, depression, anxiety, and low quality of life. The researchers argue on the basis of
these results that stress research must focus on specific stressors in isolation, as well as

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 combinations of stressors, since the accumulated effect of several stressors may put
individuals at increased risk of heart disease. Since health research is, to a large extent, about
prevention of illness, knowing which stress factors are implicated in heart disease can help to
design interventions.

In this unit you will find several examples of how the biopsychosocial model can be used to
explain health issues. You should be able to explain one of those health issues from the lens of
each of the approaches in order to demonstrate understanding of the model.

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1.1 Disposition and health beliefs

Health psychologists argue that one's disposition - that is, personality - and their beliefs about
health play a significant role in their behaviour. One’s beliefs are relatively stable mental
schemas that are created throughout life through learning. One’s beliefs give meaning to
perceptions, they help one make sense of the world around them and ultimately guide behavior.
However, many beliefs are not very rational. Many people are not very willing to change their
beliefs and they approach situations with a preconceived opinion, which influences health
behaviors.

When we discuss health behaviours, we refer to health-impairing habits - which would include
smoking, drinking and a sedentary lifestyle - and health protective behaviours - which would
include a healthy diet, regular exercise and regular health check-ups. Psychologists assume that
human beings are rational information processors. It is assumed that if we are presented with a
good argument regarding the dangers of drinking two to three glasses of alcohol on a daily basis,
we would change our behaviour. This, however, is not the case for all behaviours. Later in this
chapter we will examine some of the theories for obesity, addiction and stress behaviours. In this
section we are going to look at health beliefs that may influence behaviour: risk perception and
self-efficacy.

Curriculum clarification

This section of the text will primarily focus on health beliefs and their effect on health
problems. Although personality will be discussed below, in order to address the learning goal of
"dispositions" - you should also study one of the health problems in this unit. Disposition can
include genetic predisposition, personality traits and gender.

Risk perception

Risk perception can be defined as the extent to which an individual feels that they are at risk of
developing a health problem. Risk perception is often related to family experience. If no one in
your family has ever had breast cancer, you may feel like you are at low risk to get it. If your
grandfather was overweight and never had any heart problems - and was a happy man! - you
may not be worried about the fact that you have put on a few kilos (or pounds) too many.

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Psychologists suggest that one of the reasons that we have this irrational perception of risk is due
to optimism bias. We tend to overestimate the number of our health-protective behaviours and
underestimate the significance of our health-impairing habits.

Research in psychology: Weinstein (1983)

Weinstein carried out a study of 88 undergraduates (32 males and 56 females) to test their
level of optimism bias.

He asked participants to fill out a questionnaire about eleven health and safety risks, ranging
from tooth decay and injury in a car accident to cancer and diabetes. The participants were
then asked to answer the following question: Compared to other people of your age and sex,
what are your chances of getting [the problem] – greater than, about the same, or less than
theirs? In addition, they were asked their level of worry about the chance of developing the
health problem.

The study was experimental. There were three conditions in which the participants answered
the questionnaire.

In the first condition (the control group), participants were simply asked to fill out the
questionnaires.

In the second condition (the "own-risk" group), the questionnaire included a list of risk
factors. But before filling in the questionnaire they were told, "In some cases these risk factors
are well-established; in other cases, it's not clear and they are only possible risk factors." They
were asked to assess the number of risk factors that pertained to them before filling in the rest
of the questionnaire.

In the third condition (the "informational" group), was shown the list of risk factors and told,
"Each of the questions about risk factors has a number which shows the response of a typical
Rutgers male or female based on data we gathered earlier this semester." They were then
asked to complete the rest of the questionnaire.

The results showed that the "own risk" group felt that they had least chance of developing the
health problem and were the least worried of the three groups. An unexpected finding was that
merely rating oneself on risk factors substantially increased optimistic biases. The results also
showed that when participants were given information about the risk status of their peers, the
optimistic bias was significantly reduced.

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 ATL: Inquiry

The following list includes some of the standard health and safety risks, many of which were
included in Weinstein's study.

• Lung cancer
• Type II diabetes
• Death by car accident
• Breast cancer
• Getting robbed
• HIV infection
• Heart attack
• Ulcers

First, try to put these health and safety risks in order from "biggest risk" to "lowest risk." Be
able to justify your decision.

Then it is time for some research. Try to find for each one of the health problems above, the
chance of developing the problem. When doing your research, which factors seem to make a
difference in one's level of risk?

In a study carried out by Hoppe and Ogden (1996), the researchers wanted to see if the level of
unrealistic optimism would be affected if participants focused on their health-impairing habits
rather than their health protective behaviour. In their study, the risk increasing behaviour was
"unsafe sex" and the risk decreasing behaviour was "safe sex." The sample consisted of
heterosexual participants only.

The participants were asked to complete a questionnaire under one of two conditions. In the "risk
increasing" condition, they were asked questions which would most likely be answered
negatively - for example, "since being sexually active how often have you asked about your
partners’ HIV status?". In the risk-decreasing condition, they were asked questions that would

8
most likely be answered positively - for example, "since being sexually active how often have
you tried to select your partners carefully?"

The results showed that when focused on risk-decreasing questions, their own sense of risk was
lower - that is, their level of optimism was higher.

Self-efficacy

Albert Bandura (1997) defined self-efficacy as one's belief in one's ability to succeed in specific
situations or accomplish a task.

Neupert et al (2009) studied the role of self-efficacy in exercise behaviour. The sample was made
up of a group of older adults, all committed to begin a strength-training program. Levels of self-
efficacy were measured before and six months into the program. The study found that the
participants who had higher self-efficacy at six months were more likely to be exercising twelve
months later. Findings indicate a correlation between self-efficacy and exercise behavior. One's
beliefs developed during an exercise program are important for commitment to continue. This
shows the potential importance of the feedback given by a trainer or coach

Based on the concept of self-efficacy, Ajzen (1985) proposed the theory of planned
behaviour. The theory outlines three factors that predict behavioural intentions, which are then
linked to behaviour.

• Attitude towards behaviour – it can be negative or positive, for example, “exercise will
make me feel better and be healthier” or “exercise is too much work and does not really
help”.
• Subjective norms – this means whether a behaviour will be executed depends also on
what one’s significant others’ (like friends and family) attitude towards the behaviour is.
Simply, if one’s parents exercise regularly and believe it is part of a healthy lifestyle, he
is more likely to exercise as well.
• Self-efficacy – This means the level to which someone believes he is able to execute the
behaviour and persevere. For instance, if one does not believe he will be able to make
time for exercise, or that it will be too uncomfortable or painful, then he won't exercise.

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ATL: Critical thinking

Scott et al (2007) wanted to test the theory of planned behaviour with regard to exercise habits.
In their study, 41 participants were selected to study the amount of walking that they did on a
daily basis. In order to avoid the problems of self-reported data, all participants were given a
New Lifestyles NL-2000 pedometer for one week. After the week, participants were asked to
complete a questionnaire that measured the dimensions of the TPB.

Overall, the recall of walking was poor, showing that self-report measurement is not highly
accurate. Although the TPB predicted intentions to walk well, it did not predict the actual
amount of walking, as assessed by pedometer.

Write a response to Scott et al to help him understand his results. What variables do you think
could account for the inability of the theory to predict the number of steps taken by the
participants?

The Theory of Planned Behaviour is a holistic theory that looks at several factors that influence
behaviour - so the role of self-efficacy alone is difficult to measure. Also, although the theory
seems to indicate causation, the research is correlational in nature and thus causation can only be
implied, not firmly established.

The theory also ignores environmental and cultural factors in explaining one's behaviour. Even if
one has a high sense of self-efficacy, fresh fruit and vegetables may not be readily available or
more expensive than they can afford. Or, one might have a very negative attitude towards
drinking and a high level of self-efficacy, but will drink because she is looking to be accepted by
a group.

Personality and health problems

When discussing personality, psychologists usually apply the Five Factor Model of personality.
The five factors are dimensions used to describe an individual's personality.

Openness to experience: One's level of intellectual curiosity and willingness to try new
things.

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 Conscientiousness: Characterized by impulse control. A person with a high level of
conscientiousness is goal directed, likes to plan, is able to delay gratification and follows
norms and rules.

Extraversion: One's level of engagement with the external world.

Agreeableness: One's level of concern for others over oneself as well as optimism with
regard to human nature.

Neuroticism: One's tendency to experience negative emotions, such as anger, anxiety, or

depression. Those with high levels of neuroticism are more prone to stress.

Health psychologists use the Five Factor Model to determine if specific personality traits may
play a greater role in the development of health impairing habits than others. Ingledew and
Ferguson (2006) investigated the role of personality in predicting safer sex in university students
by administering a standardized personality test as well as a questionnaire about their sexual
behaviours in the last year. The researchers concluded that the traits of agreeableness and
conscientiousness were the greatest predictors of safer sex practices.

ATL: Critical thinking

An addictive personality?

We tend to use the word "addiction" rather glibly. We say things like, "I started eating those
nachos chips and couldn't stop. I was totally addicted!" Or, "Have you seen Game of Thrones? I
am a total addict."

Psychologists are also not always in agreement with regard to what is an "addiction." The
recently released DSM V refused to include Internet addiction as an actual disorder.

Some argue that people have an "addictive personality" - a set of personality traits that make an
individual more prone to develop addictions to drugs, alcohol or other habit-forming behaviors.

Looking at the five factors above, what do you think would be the personality traits of an
addictive personality?

After making your prediction, read this Scientific American article on additive personality. How
would you respond to the author of this article?

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1.2 Risk and protective factors

There are several basic factors which influence one’s health; some of the most important ones
include nutrition, level of physical exercise, smoking and drinking behaviour, drug use, sleep
regimen and even such things as wearing a seatbelt. These factors have a direct influence on
many health problems. However, how a person behaves in these aspects of life is determined by
other overarching factors – some of them are protective while some increase health risks. We
decided to divide factors that influence our health behaviours into protective and risk factors.
These factors can be biological or environmental in nature.

This chapter will introduce some of the key social and dispositional factors that play a role in
health behaviours. More information relevant to specific health problems may be found in the
relevant chapters.

Social factors

One of the basic forms of learning is modeling or in other words imitating what other people
around us do. Every child and even every adult learns behavior in this way, mainly from one’s
parents and later in life from one’s peers. Consequently, it becomes a very important health
protective factor when one’s parents and peers have a healthy lifestyle; one is much more likely
to eat healthy food, exercise, drink alcohol moderately, sleep well and fulfill other rules of
healthy living once her parents and peers also behave in this way. Sadly, the same is true about
the opposite; if one’s parents and friends smoke or eat junk food, there is a relatively high
probability that one is also going to.

Mays et al (2014) carried out a study of 406 adolescents ages 12 to 17 to determine the effect of
parental smoking behaviour. Interviews were carried out both with the adolescents and their
parents. The adolescents then had follow-up interviews one and five years later. The parental
interviews focused on parental smoking history, current smoking, and nicotine dependence.

12
The researchers found that adolescents with parents who were nicotine-dependent smokers were
more likely to be early regular smokers and early experimenters with each additional year of
previous exposure to parental smoking. The researchers concluded that adolescents with
nicotine-dependent parents are susceptible to more intense smoking patterns and this risk
increases with longer duration of exposure.

Economic factors are extremely important as protective as well as risk factors in health
behaviour. Poverty is one of the major risk factors when it comes to health. People living in
poverty tend to have significantly higher levels of stress than financially secure individuals. Not
only that, they also have less access to appropriate health care. They often live in insufficient
housing conditions and are more likely to be malnourished and experience physical violence. As
a result of this, people living in poverty have statistically more health problems.

Haan et al (1987) looked at the mortality rate of residents in a poor neighbourhood in the US
over a period of nine years. All participants in the study were 35 years or older. The members
of the community were matched with the national averages based on several variables. These
included age, race, sex, income, employment status, access to medical care, health insurance
coverage, smoking, alcohol consumption, physical activity, body mass index, sleep patterns,
social isolation, marital status, and diagnosis of depression.

The findings were that the rate of mortality was 1.71 higher than the national average across all
variables. This means that the residents of the poor neighbourhood in Oakland, California were
almost twice as likely to die of health-related causes in the period of the study as residents of
non-poverty neighbourhoods. These results support the hypothesis that one's socioeconomic
environment may be an important risk factor for poor health and early mortality - and that this
may be independent of individual behaviours.

Research in psychology: Jessor, Turbin and Costa (1998)

Jessor, Turbin and Costa (1998) conducted a longitudinal questionnaire study on protective
and risk factors in adolescent health behaviour. The sample of 1493 students from three middle
schools and four high schools in the US with 42% Hispanic, 33% white non-Hispanic and 24%
African-American participants. 55% of participants were female and 45% were male.

The researchers first tested their sample on their level of healthy diet, adequate sleep, regular
exercise, good dental hygiene and seatbelt use.

13
From these factors, they created the “health-enhancing behaviour index” or HEBI. They found
that HEBI correlated positively with socioeconomic status and negatively with age. Moreover,
white non-Hispanic participants were also higher than the rest of the sample and children from
complete families than those from incomplete ones.

The researchers categorized factors influencing health into proximal risk factors, proximal
protective factors and distal protective factors. The proximal risk factors included friends as
models of sedentary behaviour, friends as models of eating junk food, parents smoking
cigarettes, environmental stress and susceptibility to peer pressure. The proximal protective
factors included parents as good models for health, school health programs and best friend as a
good model for health. Finally, the distal protective factors the researchers tested were
academic performance, religiosity, relationship with parents, positive relations to adults,
prosocial activities and church attendance.

The researchers found that all these variables had a significant relationship with health-related
behaviour in adolescents, therefore they are all to a certain extent valid predictors of health-
related behaviour.

This study, like all other studies, has some limitations. These include the fact that the data were
obtained through self-report, which is not a highly reliable technique. Additionally, the research
was conducted only in the United States of America; therefore, it cannot be generalized to a
global community. However, the researchers team up with researchers in the People’s Republic
of China to carry out a similar study and obtained the same results as the original study - thereby
increasing both the cross-cultural validity and the reliability of their study.

Dispositional factors

Personal factors are also crucial in one’s health-related behaviour. Many aspects of one’s
personality influence health such as risk-taking tendency or self-efficacy. One aspect of
personality aspect that appears to have a direct effect on health is one's locus of control - an
individual’s perception of personal agency. Some people tend to think they have control over
events in their life and they believe that they determine their own fate; these people would have
an internal locus of control. On the other end of the spectrum, there are people who believe
they have minimal influence over their own lives and it is rather luck or some other external
force that decides what is going to happen to them – these people have an external locus of
control.

As could be inferred, having an internal locus of control is a protective factor in health behaviour
while having an external one is a risk factor; individuals with an internal locus of control are
more likely to lead a healthy lifestyle as they believe that by doing so they can influence their
health situation. On the contrary, people with an external local of control tend to think whatever
they do, their health is predetermined and they cannot do anything about their situation, so “why
bother?” The same principles also work in case a person becomes seriously ill; if she has an
internal locus of control, she will work hard on trying to recover while if she has an external
locus of control, she will feel helpless and that she cannot change her fate. She may be passive
and demonstrate only limited health-promoting actions.

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Sangeeta et al (2015) researched the relationship between health-promoting behaviour and locus
of control. Their sample consisted of 200 college students (50% males, 50% females). They
found a significant positive relationship between internal locus of control and health
responsibility, physical activity, good nutrition, spiritual growth and even interpersonal
relationships and stress management. This study confirms the suggestion that internal locus of
control is a good predictor of a healthy lifestyle.

ATL: Critical thinking

When looking at risk and protective factors for obesity, could it be that a culture's attitudes
toward food and eating may play a role in one's risk of becoming obese?

Obesity rates in France are among the lowest in the OECD. About 1 in 10 people is obese in
France. The latest figures from the CDC show that more than one-third (34.9% or 78.6 million)
of U.S. adults are obese. What might account for this difference?

Some people have argued that the French have one of the healthiest eating cultures.

Take a look at the list of typical French eating behaviors. Which three do you think might be the
most significant in protecting the French from obesity? Be able to justify your choices.

1. People do not deprive themselves of the foods they love - they just eat smaller portions
of those foods.

2. The French spend time preparing their meals. Processed and packaged foods are often
avoided.

3. Meals are served in courses.

4. The French eat when they are hungry. There is a French saying, "Bon repas doit
commencer par la faim" - A good meal must begin with hunger.

5. Fresh fruit is often served as dessert.

6. The television is not on during meals. Dinner is a time when people talk about their
day and engage in friendly debate.

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2. Health problems

ATL: Essential understandings

The biopsychosocial model can be used to explain health problems.

Theory can be applied to prevent and treat health problems.

Prevalence rates of health-related problems change over time as a result of changes in social and
cultural norms.

For this part of the unit, you should be able to talk about the nature of one health problem. This
includes the biological, cognitive and social origins of the problem and potential prevention
and/or treatment of the problem.

The IB Psychology course allows you to choose from the following list of health issues:

• Addiction - This could be smoking, alcohol or any other drug. It should, however, be a
recognized addiction.
• Chronic pain
• Obesity
• Sexual health
• Stress

The guidance from the IB is that you should discuss "explanations" of health problems. This is
very broad. To make sure that you have a rich understanding of the problem, this text addresses
potential origins of the problem, ways to prevent the problem and current strategies to reduce the
problem. This then links to the next part of the unit which is dedicated to health promotion
campaigns.

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2.1 Health problem: Addiction

People have always used a range of substances in the hope of an effect, such as inducing self-
confidence, having fun, or relaxing. Most substances - even coffee - can produce dependence, as
well as withdrawal symptoms after long-term use.

The term addiction suggests that the individual cannot control his or her behaviour. An
addiction is characterized by behaviour and other responses that always include a compulsion to
use the substance continuously, in order to experience the psychological and physiological
effects and to avoid discomfort in its absence.

In the UK, the General Household Survey (GHS) found that in 2006, 23 percent of all men and
21 percent of all women were smokers. Of these British smokers, 59 per cent said it would be
difficult to go without smoking for a whole day, and 16 per cent said they had their first cigarette
within five minutes of waking up. This could indicate “addiction”.

Addiction is characterized by continued use of the substance, despite knowing about problems
associated with the substance; persistent desire and/or unsuccessful effort to control substance
use. Addiction can be psychological and/or physiological:

Psychological addiction relates to craving— that is, a strong desire to smoke. Situations
associated with smoking, as well as the smoker’s mood and psychological state, come to
serve as “triggers” for the craving - for example, after a meal, when talking on the phone,
during work or study breaks, and when feeling angry.

Physiological addiction relates to symptoms such as tolerance - that is, a person needs
more of the drug in order to achieve the same effect - and withdrawal symptoms if the
substance is not taken - for example, nausea, irritability, anxiety, difficulty concentrating,
and increased appetite.

The general increase in life expectancy over the past 150 years is considerably less for smokers
than for non-smokers. Already in the 1950s, evidence indicated that smoking was predictive of
lung cancer. Today, a substantial number of the adult population still smoke, even though most
of them are aware of the related health risks.

17
In order to understand why people begin to smoke, why they continue, and why they experience
difficulties giving up, researchers have investigated biological, psychological and social factors
that may promote smoking.

The biological approach can explain why smokers continue to smoke once they have started. The
active ingredient in tobacco is nicotine, a psychoactive drug. By inhaling tobacco smoke, the
average smoker takes in 1 - 2mg of nicotine per cigarette. Some of the effects of nicotine are as
follows.

It stimulates the release of adrenaline, which increases heart rate and blood pressure.

It stimulates the release of dopamine in the brain’s reward circuits, which results in a brief
feeling of pleasure. Within a few minutes, the acute effects of nicotine wear off. The
pleasant feeling causes the smoker to continue smoking to maintain the pleasurable effects
and prevent withdrawal symptoms.

It acts on acetylcholine receptors in the brain, as if it were the natural neurotransmitter.

With repeated smoking, the brain adapts to what it regards as normal levels of
acetylcholine in order to restore balance. One way to do this is to grow more acetylcholine
receptors.

Research suggests that nicotine may be as addictive as heroin and cocaine. Once smokers are
addicted to nicotine, they will experience withdrawal symptoms when the level of nicotine is not
constant in the body. A substantial number of smokers declare that they would like to quit
smoking - up to 70 per cent of current smokers in the US, according to figures from the Centers
for Disease Control and Prevention (CDC).

For WHO and national health boards around the world, a major concern is preventing children
from starting smoking. According to the American Lung Association, around 6000 adolescents
under the age of 18 start smoking every day. People who start smoking in childhood have an
increased chance of lung cancer, compared to smokers who begin later in life. They are also
more likely to become addicted because the young brain is particularly vulnerable to the
addictive effects of nicotine. This is a major reason why governments and health psychologists
try to prevent young people from starting to smoke in the first place.

Research in psychology: DiFranza et al 2006

Addicted after the first puff?

DiFranza et al. (2006) conducted a longitudinal study of 217 adolescents (mean age of 12) in
Massachusetts (US). Most of the children were European American, and they all reported having
inhaled a cigarette at least once. They completed psychological evaluations and reported their
history of tobacco use, as well as answering questions relating to attitudes and beliefs, and to the
social environment, such as family and community. Eleven of them were interviewed. Tobacco
dependence was assessed, based on reported cravings, changes in tolerance, time devoted to
smoking, and inability to quit.

18
The results indicated that the adolescents who had an immediate experience of relaxation after
the first puff were more likely to become addicted to cigarettes, with 67 per cent of those who
recalled a relaxation effect after their first inhale becoming dependent, compared to 29 per cent
of those who did not experience such an effect. According to the researchers, post-inhale
relaxation was also the biggest risk factor for being unable to stop later. Of the participants who
experienced the relaxation, 91 per cent said they were unable to quit, and 60 per cent of those
said it was as if they had lost control. The conclusion of this study seems to be that it takes far
less to become addicted than was previously thought—at least for some individuals. It is not
known why some are more sensitive to nicotine than others.

ATL: Inquiry

Carry out a bit of your own research. Develop a survey to see why your peers who are not taking
psychology believe that people begin smoking. When carrying out the survey, be sure to find out
from each participant whether he or she smokes. Keep all data anonymous.

• To what extent were the responses biological, cognitive or social in nature?

• Was there a difference in the types of responses received from smokers vs non-smokers?
• What does the data say about your participants' belief in the level of "choice" in starting
to smoke?

Going further - Compare your results to an IB school in a different country. Are there cultural
differences in your data?

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2.2 Factors affecting addiction

The origins of addiction are quite complex and not fully understood by psychologists. Addiction
occurs when people become physically dependent on a substance through repeated use.

There are two basic approaches to the origins of addiction. The disease model of addiction
argues that addiction has biological roots and is a problem with which the individual will
struggle throughout his/her life. The addiction is believed to have a genetic origin.

On the other hand, the social cognitive model of addiction (also called the social learning model
of addiction) argues that children learn addictive behaviours by observing role models (e.g.
parents, peers and media celebrities), and because they tend to see the positive consequences of
this behaviour, they begin to imitate it.

Most psychologists today combine the two approaches into what is referred to as a
Biopsychosocial approach. When using this approach, several factors may play a role in
substance abuse and/or addiction. These include:

• Genetic predisposition.
• Personality factors such as neuroticism and/or self-esteem
• Environmental factors such as availability of substances
• Cultural attitudes
• The media
• The nature of the substance - that is, whether it can lead to physical addiction.

Genetic vulnerability

Before looking at the role of genetics in addiction, first, let's look at what happens to the addicted
brain

Liga video: The chemistry of addiction https://www.youtube.com/watch?v=ukFjH9odsXw

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In order to develop a genetic argument for the origins of addiction, psychologists carry out
family and twin studies. If addiction has a genetic component, we should see addictive
behaviours running within families - and in cases of twins, identical twins (MZ) should have a
higher rate of both of them having addictive behaviour than fraternal twins (DZ).

The argument that addiction is potentially genetic is based on the argument that there are
physiological roots of addiction and that it is not solely a psychological phenomenon. The
sensitivity of the dopamine system is one biological explanation for addictive behaviours.
Research on rats carried out by James Olds in the 1950s showed that when the nucleus
accumbens - a part of the limbic system which is high in dopamine pathways - was stimulated,
rats continued to press a lever to get "a hit." This early research indicated that dopamine and the
nucleus accumbens may be the biological roots of addictive behaviour. The question, then, is if
there is a gene or set of genes that may make some people more prone to addiction than others?

Kendler & Prescott (1998) have examined the patterns of marijuana and cocaine use by female
twins and found that genetic factors play a major role in the progression from drug use to
dependence. The researchers interviewed 1,934 twins, ranging in age from 22 to 62. In the study,
drug "use" involved at least one nonprescribed use of a drug; "dependence" was based on the
DSM-IV definition and included characteristics such as physical symptoms of tolerance or
withdrawal, taking larger amounts of the drug or using it over a longer period than intended, or
spending large amounts of time seeking, obtaining, and recovering from the effects of the drug.

Their research indicated that family and social environmental factors are influential in
determining whether an individual begins using drugs, but the progression from the use of
cocaine or marijuana to abuse or dependence was due largely to genetic factors. The study found
that concordance rates - both twins using, abusing, or being dependent on drugs - were higher for
identical than fraternal twins. For example, for cocaine dependence concordance was 35 percent
in identical twins and zero for fraternal twins.

Tsuang (1998) found that in males, genetic influences are stronger for abuse of some drugs than
for others. Tsuang and his colleagues studied drug use in 1,874 identical male twin pairs and
1,498 fraternal male twin pairs. The researchers found evidence to suggest that genetic
influences contribute to a common vulnerability for abusing marijuana, sedatives, stimulants,
heroin or opiates, and psychedelics. The genetic influence for abuse was greater for heroin than
for any other drug.

21
One of the genes that researchers are focusing on is the DRD2 gene which codes for the number
of dopamine receptors available in the mesolimbic dopamine system. A person with fewer
dopamine receptors is unable to 'feel' the effect of dopamine as well as someone with a higher
number of dopamine receptors, and so needs higher levels of dopamine to produce the same
effect as a person with more dopamine receptors. People with the DRD2 A1 variation of the gene
have fewer dopamine receptors, and also seem more vulnerable to addictions.

In a study of 103 alcohol-dependent males, Ponce et al (2008) found that 39% carried the DRD2
A1 allele. He found that those with the allele had a higher prevalence of alcoholism in the family
and an early onset of alcohol abuse. However, the research on the DRD2 A1 gene has been
inconsistent.

Evaluation of genetics research

There are some methodological considerations when discussing biological research on the
factors that influence addiction. First, much of the research is reliant on self-reported data - that
is, the people that sign up for the studies report both the level of their own addiction and the
addictions of their twins or other family members. In addition, the results of the research are
inconsistent - that is, there is not a high level of reliability. Different drugs seem to have different
levels of concordance in twins. Is this the nature of the drugs or does this have something to do
with the way that the genes work?

In addition, there are also questions about the nature of the argument. When discussing the
origins of addiction, are we talking about the initiation of drug use - that is, why the person
started using the drug in the first place? Or are the genes responsible for the level of addiction? It
is difficult to separate out these issues. Although twin studies seem to indicate that there is a
some genetic component to addiction, it is not yet clear which genes are responsible and what
role they may play in addiction.

Finally, a genetic argument is both reductionist and deterministic. Although a genetic factor may
have to interact with the environment in order to produce a behaviour the argument still posits
that if an individual has the correct set of genes, then he is more likely to be addicted to the
substance.

ATL: Reflection

Do you think that it is helpful to know that you might have a gene that could lead to
addiction? Why or why not?

If you think that it is helpful, would you recommend that all teens get their DNA tested so that
they would better understand the risk of addiction?

22
The role of stress

Stress has an effect on our physiology. These effects may also have an
influence on the likelihood of addictive behaviour. Some people smoke or drink when they feel
stressed. They use smoking or alcohol as a way of coping, but this may lead to addictive
behaviour.

Morgan et al (2002) carried out a study in non-human primates to show how social factors can
influence the level of dopamine receptors and the propensity to self administer drugs. First,
dopamine levels were measured in monkeys that had been individually housed. Then, the
monkeys were housed in groups for 18 months. Those monkeys that were high in the social
hierarchy also experienced higher levels of dopamine receptors. The monkeys that were
submissive saw a decrease in their level of their dopamine. When self-administered cocaine was
made available to the monkeys, the subordinate animals took more cocaine than the dominant
monkeys. This suggests that environmental stressors can produce profound biological changes
that have important behavioral association, including vulnerability to cocaine addiction.

In humans there is a lot of research that shows a strong correlation between childhood abuse and
later development of drug & alcohol dependency. Cleck & Blendy (2008) found that the longer
the abuse continues the greater the later chances of dependency. But unlike the well-controlled
monkey study by Morgan et al, research on the role of abuse is solely correlational in nature and
it is not possible to isolate variables to determine a cause and effect relationship. However, if we
generalize the findings from animals, we can perhaps find an explanation for this correlational
data.

ATL: Inquiry

Many of the studies of addiction are done with animals. However, animal models for addiction
could be seen as problematic.

Read through the following article on the use of animal models in the study of addiction.

Create a graphic organizer that examines the pros and cons of using animals in research on
addiction.

23
Social cognitive learning theory

Much research on smoking focuses on individual factors—for

example, how attitudes or cognitions may predict smoking behaviour. According to Ogden
(2012), this is a problem because it takes individuals out of their social context, and a person’s
behaviour and beliefs are developed through interaction with the social world. Social cognitive
learning theory includes this aspect.

Social Cognitive Learning Theory argues that we learn behaviour by observing the behaviour of
others. It is important that we identify with the person modeling the behaviour and that we feel
that the model has received some positive outcome for the behaviour. This is the concept of
vicarious reinforcement.

One important set of role models is our parents. Bauman et al (1990) found that among
American adolescents, if the parents did not smoke, then their children were less likely to smoke.
80% of adolescents whose parents did not smoke had never tried smoking, whereas over 50% of
those with parents that smoke did. Murray et al. (1984) found that in families where the parents
were strongly against smoking, the children were up to seven times less likely to smoke.

Another very important factor in smoking is peer-group pressure. For adolescents, the peer group
is a source of social identity and learning social norms - and this may include smoking. Unger et
al. (2001) carried out a cross-cultural survey on adolescent smoking in a sample of 5143
Californian adolescents with a mean age of 13.

The study found that European American students who had close peers who smoked were more
likely to smoke than other students (e.g. Asian American and Hispanic students). The researchers
explained that in individualistic cultures, adolescents typically create their own youth culture,
characterized by rebellion, in order to set themselves apart from their parents. In collectivist
cultures, the bond between the teen and the parents is considered important. Rebellion is not
tolerated, so adolescents are more likely to conform to the roles and norms that parents prescribe
for them.

Peer influences have been found to be among the strongest predictors of drug use during
adolescence. It has been argued that peers initiate youth into drugs, provide drugs, model drug-
using behaviours, and shape attitudes about drugs.

However, Social Cognitive Learning Theory simply shows why individuals may initiate drug
use. It is not a predictor of which individuals will develop abuse or addiction. In addition, when
it comes to peer influence, it is important to remember that we have some level of choice of the

24
groups to which we belong. It is possible that the use of drugs among peers is not simply because
of the influence of others, but because of some common traits which attracted individuals to that
peer group.

2.3 Prevention strategies: Addiction

A number of strategies have been adopted by governments all over

the world to prevent smoking and its devastating consequences on health. Since the 1990's, most
European countries have put either a ban or restrictions on advertising, but most of the world’s
population is not protected by such restrictions. WHO wants a total ban on tobacco advertising,
tobacco promotion, and tobacco sponsorship (e.g. of sports and music venues). Tobacco
companies have always marketed their products where they can reach the youth audience, but
they are now targeting adolescents in the developing world because it has become increasingly
difficult to market their products in most western countries.

On No Tobacco Day, 31 May 2008, WHO targeted children and adolescents in an attempt to
prevent smoking. According to WHO figures, two out of three countries have no information
about tobacco use, so people do not even know the dangers of smoking.

Most smokers start as teenagers. Consumer research has shown that tobacco advertising has a
powerful effect on the smoking attitudes and behaviour of young people. This is partly because
of the use of imagery and positive association, and partly due to the fact that young people are
more brand-conscious than adults, and are therefore more likely to smoke the most popular and
well-advertised products. Tobacco sponsorship also promotes brand association, which makes it
easier to begin smoking.

Prevention strategies are designed to address potential problems in a target population before
they start or become highly problematic. At first, it was thought that teens just didn't know the
danger of drugs and alcohol. But attempts to educate young people did not make a significant
difference. They knew that smoking was bad for them and smoked anyway. Prevention
strategies then focused on scare tactics like the following video.

Liga Graphic anti-smokimng advet released in UK

https://www.youtube.com/watch?v=AIyqcST29wQ

25
Even though you might think that this might make a difference, scare tactic approaches do not
seem to work. According the American National Institute for Drug Abuse, "research and
experience have demonstrated that such ads are either counterproductive or ineffective; students
learn better with a low fear appeal message and with a credible communicator. (1997)." When
people see scare tactics, they often use defensive attribution in order to justify why bad things
happen to others, but won't happen to them. For example, Yes, I drink. But I would never drive
while drinking. Or, we don't have cancer in our family; I am at low risk, so I am no worried.

So, what are the strategies that work? Below you will find three strategies that are currently used
to reduce substance abuse and addition. You should choose two to prepare for assessment.

Social influence approaches: DARE

The Social Influence Approach (Evans, 1976) emphasizes the importance of social and
psychological factors in promoting the onset of drug use. Adolescent drug use is seen as the
result of social influences from peers and the media to smoke, drink alcoholic beverages, or use
illicit drugs. An assumption of this approach is that teens begin to use drugs largely because they
lack the confidence or skills to resist social influences to use drugs Special emphasis is often
placed on teaching students to identify the techniques used by advertisers to influence consumer
behavior. There are three components to social influence programs like D.A.R.E (Drug Abuse
Resistance Education):

• Teaching people to recognize high-risk situations and to learn to exclude themselves from
these situations.
• Increasing the awareness of media influences
• Refusal skills training - that is, learning how to say no.

One of the most famous campaigns based on this approach was sponsored by US first lady
Nancy Reagan - the Just Say No campaign. Here is a PSA from the 1980s.

Liga video “Just say No” anti-drug campaign (1985)

https://www.youtube.com/watch?v=hw8Ok-cC_6M

26
Research on the effectiveness of the program shows that groups showed a reduction of 30 - 45%
in smoking compared to control groups. The effect, however, is short-lived, with most studies
showing that the effect lasts less than two years - with only a few studies indicating that it may
last up to five years (Flay et al, 1989).

The D.A.R.E. program in the USA is usually taught by local police officers to younger children -
age 10 - 12. Some studies have shown a short-term positive impact on drug-related attitudes, or
behaviour. However, most studies that have used large samples, random assignment, and
longitudinal follow-up have shown that DARE has little or no impact on drug use (Clayton,
Cattarello, & Johnstone, 1996).

Competence enhancement: Life Skills Training

Botvin's Life Skills Training Progam is based on the concept of competence enhancement which
emphasizes the development of positive social and personal self-management skills in order to
prevent the initiation of drug use. Life skills training is an interactive course which focuses on
cognitive factors, rather than social factors. Developing self-esteem and self-efficacy is a big part
of the program, teaching students how to make decisions and set personal goals. In addition,
stress and anxiety management - today often through mindfulness programs - is an integral part
of the program.

Another aspect of this approach is normative education. Perkins & Berkowitz (1986) carried
out a study of the student population at a private university in upstate New York. Their findings
were that students generally believed the norm for the frequency and amount of drinking among
peers was much higher than the actual norm or average level of consumption, and they believed
their peers were much more permissive in personal attitude about substance use than was true. In
addition, they found that when people go to parties, they tend to remember those that were
"wasted" or "stoned", and do not remember the people who were not, thus believing that the
behaviour is more common than it is. Perkins has argued that such misperception is likely to
have substantial consequences on personal use. The strategy of the Life Skills Training Program
is to communicate the truth about peer norms by drawing credible data from the student
population that is the target.

How effective is this approach? Research shows a range of between a 40 - 80% reduction in
tobacco and drug use (Botvin et al, 1984). However, like with the Social Influence Approach, it
appears that the effect is not long-term. Therefore, a booster is given.

27
 The graph demonstrates the effect of a booster -
that is, a short revision of the course. The first bar shows the percentage of students in a control
group that are engaging in tobacco use on a weekly basis in grade 9. The second bar shows the
percentage of students that have finished the LST program in grade 7 who are engaging in
tobacco use on a weekly basis in grade 9. Finally, the last bar shows the percentage of students
who finished the LST program in grade 7 and then have a five-session booster in grade 8
engaging in tobacco use on a weekly basis in grade 9. The results indicate that a booster has a
significant effect in preventing drug use.

The banning of smoking in public places

One final strategy is to simply ban smoking in public spaces.

Since often drug use like alcohol and smoking occurs in social settings, the argument is that if we
ban smoking in restaurants, then teen smoking will decrease. But is this true?

Lemstra et al (2008) studied the effects of a smoking ban in Canada. The study found a decrease
in the number of people who smoked. However, when looking at the percent decrease, it was
only about 6%. It is clear that a smoking ban alone is not enough to change smoking behaviours.

A study by Siegel (2005) found that young people living in Massachusetts towns with strong
restaurant smoking regulations had significantly lower odds of progressing to regular smoking
compared to those living in towns with weak smoking regulations.

28
However, the research is inconsistent. In a meta-analysis by Callinan et al (2010) they reviewed
50 studies of smoking bans in the US and found no consistent evidence of a reduction in
smoking prevalence attributable to the ban.

ATL: Communication

In May 2017, the Czech Republic became one of the last states of
Europe to ban smoking in restaurants and other public places. Currently, there is a group of
parliamentarians who want to sue the government, arguing that the law is unconstitutional and
needs to be revoked.

Regardless of the constitutionality of the law, is the law a good move for the Czech Republic?

Based on your understanding of smoking bans and other research which you may find online,
write a letter to the Czech government either in support of or challenging the anti-smoking
legislation.

Issues in prevention research

There are several concerns when looking at prevention research. For example, much of the
research in the US has been carried out on white, middle class and private schools. Although
there is some evidence that minorities also respond to these programs, there is a sampling bias to
the research which makes it difficult to generalize.

It is often difficult to compare the different conditions in different schools or cultures. Most of
the research uses cluster randomization - that is, whole schools are randomly allocated to the
conditions. Schools can have very different populations and different environments - including
access to drugs and attitudes toward drug use. The comparison between groups is problematic
and open to participant variability.

Many of the studies are short-term and thus do not determine the long-term effects of the
programs. Botvin has overseen several longitudinal studies, including one study where the
seventh graders are now in their mid-thirties. However, these longitudinal studies have the
problem of participant attrition - that is, people dropping out of the sample.

Finally, the studies are reliant on self-reported data. This means that the researchers have to trust
that the participants are accurately reporting their own drug use. In addition, they have to make

29
sure that ethical considerations are met and that all data is codified so that the surveys are
anonymous.

2.4 Treatments for addiction

Health psychologists do not only study the origin of a health

problem and ways to prevent it, but they also try to find ways to treat people who have the
problem. Two different treatments for addiction are outlined below: Nicotine replacement and
mindfulness. The final treatment that is examined is highly controversial - a program called
Alcoholics Anonymous.

Nicotine Replacement Therapy

There are four main nicotine replacement products on the market: nicotine gum, nicotine patches
(aka transdermal patches), nasal spray and nicotine inhalers. Recently there has been research on
the role of electronic cigarettes as a form of NRT. The goal of NRT is to first provide the
nicotine without the other negative ingredients of cigarettes, such as tar. Then the smoker
receives smaller and smaller doses over time until they are no longer dependent on nicotine. It
appears to be most helpful for people who smoke over 15 cigarettes a day. It has not been shown
to be effective in people who on average smoke fewer than 10 cigarettes per day.

Here is a good video by Dr Andrew Pipe on the use of NRT.

Liga video: NRT Nicotine replacement therapy.

https://www.youtube.com/watch?v=jK_dQRgGSIA

30
A meta-analysis by Hughes (2003) found that NRT is effective to help people to stop smoking. It
appears that NRT is twice as effective as simply "choosing to quit." However, the success rate
over all is still low. According to the American Cancer Society, with no program, the success
rate for quitting smoking is between 5 - 7%. With NRT the rate is 23%, but it drops to 15% after
only six months as often patients relapse. So, it appears that although the strategy is effective for
some, there are clearly factors that may effect whether the treatment is effective.

Another problem with NRT is that it has the same side effects as smoking, although it is not as
dangerous as smoking. NRT may lead to headaches, nausea and digestive problems, sleep
problems and high levels of cholesterol.

Even US President Barak Obama has struggled to give up smoking and used NRT (gum) in order
to kick the habit.

Liga video Obama´s Struggle to Quit smoking

https://www.youtube.com/watch?v=kaBGq734J0A

There is a debate about whether e-cigarettes will help to decrease smoking. Evidence strongly
suggests that e-cigarettes may be effective in helping smokers quit and preventing relapse, but
there have been few published studies to explain why this might be the case. A study by Bullen
et al (2013) found that e-cigarettes were about as effective as nicotine patches in helping people
in the study quit smoking. The study was made up of 657 smokers who wanted to quit. For six
months, 289 of the participants received e-cigarettes, 295 received nicotine patches, and 73
received placebo e-cigarettes, which contained no nicotine. They found that 7.3% of those in the
e-cigarette group had successfully quit smoking, compared with 5.8% in the nicotine patch group
and 4.1% in the placebo e-cigarette group. The differences in results are not statistically
significant, meaning each group had about an equal chance of quitting.

In a study by Brown et al (2014) they found that people who use e-cigarettes are 60% more
likely to quit than those that use willpower alone. The study was made up of 5,863 smokers who
had attempted to quit smoking without the aid of prescription medication or professional support.
20% of people trying to quit with the aid of e-cigarettes reported having stopped smoking
conventional cigarettes at the time of the survey.

31
One of the problems with studies of smoking cessation is that there is a sampling bias of people
who want to quit. Therefore, it is impossible to rule out the role of motivation in successful
treatment. In addition, relapse is rather common. If the addiction were only physiological, one
has to wonder why someone would start smoking again after having successfully overcoming the
physical withdrawal from nicotine. This implies that CBT (cognitive behavioural therapy) may
be helpful for clients to avoid relapse by developing strategies to avoid restarting their old
habit. This type of therapy is often provided in groups.

Mindfulness

Mindfulness - also known as MBSR - has been used as a way to stop

smoking. Unlike NRT which looks at addressing the physiological addiction (a problem-focused
approach), MBSR looks at using meditation in order to address the cognitive factors that trigger
the craving to smoke (a coping focus approach). Mindfulness has been shown to decrease both
stress and negative affect, both of which are correlated with smoking.

Davis et al (2007) carried out a study to test the effectiveness of MBSR on smoking cessation.
There were 18 participants, all who smoked an average of roughly 20 cigarettes per day for a
period of 26 years. The participants were given mindfulness training once a week for eight
weeks. The participants attempted to stop smoking in week 7 of the program. In order to test if
the participants had in fact stopped smoking, there were both self-report questionnaires and a
carbon monoxide breath test administered. In addition, the questionnaires asked about their level
of stress. After six weeks, 10 of 18 subjects (56%) showed that they had been smoke free.

Singh et al (2012) carried out a case study on 31-year-old man named "Paul" who had smoked
for 17 years and smoked on average between 15 and 20 cigarettes per day. He had been trying to
quit smoking for almost six years. Singh et al taught him three mindfulness techniques:

• Intention. Paul was taught to verbally state his intention to quit smoke. This included
statements like "I will not smoke today" and "I will not smoke anymore."
• Mindful observation of thoughts. He was taught that desires were simply "thoughts" and
should be "let go." In other words, he was to be aware of his thoughts, but not respond to
them.
• Meditation on the soles of his feet. If the desire thoughts were too strong and could not
be let go, he was taught to move his attention to the soles of his feet.

32
Within three months, Paul was no longer smoking, with the number of cigarettes smoked daily
decreasing incrementally over the three-month period. Paul is checked every three months to
determine whether he has been able to maintain his behaviour. After three years, he is still
smoke-free.

Critically thinking about Alcoholics Anonymous

One of the most famous ways to overcome alcoholism is a self-help

group called Alcoholics Anonymous.

Alcoholics Anonymous [AA] members meet in groups to help one another stop drinking and
then keep sober. The meetings, which are free and open to anyone serious about stopping
drinking, may include sharing stories, celebrating members’ sobriety, as well as discussing the
12 steps related to problem drinking. Members are supposed to correct all defects of character
and adopt a new way of life. They are to accomplish these difficult goals without professional
help. No therapists, psychologists or physicians can attend AA meetings unless they, too, have
drinking problems.

Most studies evaluating the efficacy of AA are not definitive; for the most part, they associate
the duration of participation with success in quitting drinking but do not show that the program
caused that outcome. Some of the problems stem from the nature of AA - for example, the fact
that what occurs during AA meetings can vary considerably. Further, about 40 percent of AA
members drop out during the first year, raising the possibility that the people who remain may be
the ones who are most motivated to improve.

A study called Project Match (Longabaugh and Wirtz, 2003) randomly assigned more than 900
problem drinkers to receive one of three treatments over 12 weeks. One was an Alcoholics
Anonymous based treatment. The other treatments were cognitive-behavioral therapy, which
teaches skills for coping better with situations that commonly trigger relapse, and motivational
enhancement therapy, which is designed to boost motivation to stop drinking. The results
showed a significant increase in the number of alcohol free days in all three cases – with about
19% of the participants giving up drinking altogether.

The Project Match study is, however, rather controversial. First, it did not have a control
group. Therefore, it is not possible to know the extent to which the therapies played a role in the
change of behavior. Secondly, there was no significant difference between the three types of
therapy. This could mean that there is another factor, such as foot-in-the-door compliance
techniques or simply motivation, which were more important than the actual type of therapy.

33
Moos & Moos (2006) carried out a 16-year study of problem drinkers who had tried to quit on
their own or who had sought help from AA, professional therapists or, in some cases, both. Of
those who attended at least 27 weeks of AA meetings during the first year, 67 percent were
abstinent at the 16-year follow-up, compared with 34 percent of those who did not participate in
AA. Of the subjects who got therapy for the same time period, 56 percent were abstinent versus
39 percent of those who did not see a therapist—an indication that seeing a professional is also
beneficial.

That all being said, the Cochrane Collaboration (Ferri et al, 2006) conducted a review of
studies conducted between 1966 and 2005 on the effects of AA and reached a stunning
conclusion: “No experimental studies unequivocally demonstrated the effectiveness of AA” in
treating alcoholism.

ATL: Thinking critically

Read the following article on the effectiveness of Alcoholics Anonymous.

What are the three strongest arguments against AA in this article? Why do you think so?

Which argument do you think is the weakest? How do you think you could possibly "prove the
author wrong?"

2.5 Health problem: Obesity

Currently, more than 1 billion adults are overweight - and at least

300 million of them are clinically obese. Current obesity levels range from below 5% in
China, Japan and certain African nations, to over 75% in urban Samoa. But even in
relatively low prevalence countries like China, rates are almost 20% in some cities.

Childhood obesity is already epidemic in some areas and on the rise in others. An estimated 22 million
children under five are estimated to be overweight worldwide. According to the US Surgeon General, in
the USA the number of overweight children has doubled and the number of overweight adolescents has
trebled since 1980. The prevalence of obese children aged 6-to-11 years has more than doubled since
the 1960's.

Obesity prevalence in youths aged 12-17 has increased dramatically from 5% to 13% in boys and from
5% to 9% in girls between 1966 - 70 and 1988 - 91 in the USA. The problem is global and increasingly
extends into the developing world; for example, in Thailand, the prevalence of obesity in 5-to-12-year-olds
rose from 12.2% to 15.6% in just two years.

34
Obesity accounts for 2 - 6% of total health care costs in several developed countries; some estimates put
the figure as high as 7%. The true costs are undoubtedly much greater as not all obesity-related
conditions are included in the calculations. (WHO Report, 2008.)

Definitions of obesity

Obesity is an excess of body fat that frequently results in a significant impairment of

health. Obesity results when the size or number of fat cells in a person's body
increases. A normal-sized person has between 30 and 35 billion fat cells. When a
person gains weight, these fat cells first increase in size and later in number. One
pound of body fat represents about 3500 calories.

When a person starts losing weight, the cells decrease in size, but the number of fat
cells generally stays the same. This is part of the reason that once you gain a significant
amount of weight, it is more difficult to lose it. However, some recent studies seem to
imply that fat cells can be destroyed as a result of certain medications and that a
decrease in fat cell number may occur if a lower body weight is maintained for a
prolonged period of time.

Each fat cell weighs a very small amount (about 0.4 to 0.6 micrograms but can be as
small as 0.1 micrograms to as large as 1.2 micrograms). In other words, it would take
about 5 million fat cells to get just 1 ounce of fat. However, the weight of billions and
billions of fat cells does add-up. Obviously, it is not practical to count the number of fat
cells in a person's body, so science has come up with easier methods to determine if a
person is overweight or obese.

Earlier methods involved tables of desirable weights at various heights that were
derived by life insurance companies. These tables were based on illnesses and death
rates.

A better method was developed that more closely correlates with body fat and the
metabolic complications of obesity. This is the Body Mass Index ("BMI") and it is
calculated as follows:

BMI = Weight (in kg.) / Height (in meters) Squared (ht. x ht).

For example, a man who is 5' 10"(1.78 meters) tall and weighs 285 lbs. (~130 kg.)
would have a BMI of 130/(1.78 x 1.78) = 41.

The following chart shows the relationship between BMI and obesity.

35
Although BMI can be used for most men and women, it does have some limitations. First, it may
overestimate body fat in athletes and others who have a muscular build. In addition, it may
underestimate body fat in older persons and others who have lost muscle.

As we look at the question of obesity, most of the research we will examine will use the BMI as
a determinant of obesity.

ATL: Inquiry

Start by taking a look at the map below. The data is from 2011 from the World Health
Organization. The darker red the country, the higher the rate of obesity. If the country is grey,
that means that no data is currently available.

Do a bit of research to find out what the rate of obesity is in the following countries:

• Denmark
• India
• Peru
• Samoa

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 • USA

How would you explain these differences in obesity rate?

2.6 Factors influencing obesity

There is a number of physiological theories of obesity. One of them is linked to

genetic predisposition. It seems that body size runs in families. Having one obese parent results
in a 40 per cent chance of becoming obese, and having two obese parents increases the
likelihood of becoming obese to 80 per cent. According to Garn et al. (1981), the chances of thin
parents having an overweight child is about 7 per cent. Since parents and children generally
share environment as well as genetic makeup, it could be that the former also plays a role.

In order to investigate the relative role of genes and the environment, researchers can carry out
twin studies. Stunkard et al (1990) studied 93 pairs of MZ twins who were raised apart. He
found a concordance rate of over 65% for BMI. This means that there may be a genetic
predisposition to obesity that is expressed through environmental stimuli. Changes in culture and
food availability - together with this genetic predisposition - may explain the steep increase in
obesity worldwide. Otherwise, genetics alone cannot account for the rapid growth in obesity.

Although results from twin studies indicate a genetic factor in obesity, the role of this factor is
not really clear. One suggestion relates to metabolism, which may be genetically determined, but
the evidence is still inconclusive. Another suggestion relates to the amount of fat cells in the
individual, which may also be genetically determined.

There is evidence that genes determine individual susceptibility to weight gain. However, the
obesity epidemic cannot be attributable to genetic factors alone, since the increase in the
prevalence of obesity has taken place over too short a period for the genetic make-up of the
population to have changed substantially.

One explanation of obesity relates to evolution. According to this hypothesis, humans are
genetically programmed to eat when food is available, in order to store fat for times when food is
scarce. This genetically determined behavioural programme has worked well during evolutionary

37
selection, but it is now inappropriate because food is abundant and people are no longer as
physically active.

ATL: Inquiry

Another important physiological origin of obesity may be the hormone "leptin." Watch the
following video which looks at the research on obesity by Jeffrey Friedman. Take notes on the
research on the OB mouse and the role of the hormone leptin.

Liga video Jeffrey Friedman (Rockefeller U./HHMI) The causes of obesity and the discovery
of leptin. https://www.youtube.com/watch?v=oN3woHJ7ZDY

Cognitive explanations of obesity

Cognitive theory can be used to explain why people choose to eat the foods that they do. This
scene from Supersize me looks at how television plays a role in a child's attitude toward food.

Liga Video Superzize me-american children being interrogated

https://www.youtube.com/watch?v=2oFpUW11RPs

38
Human beings are cognitive misers. Baumeister et al (1998) argued that making decisions
actually uses energy which we would rather not use. As human beings, we tend to apply the
following mantra to decision making: I don't know, I don't care and I don't have time.

In order to eat healthy food and thereby maintain a healthy weight, I would have to know what to
look for when reading the labels on food products. In addition, you have to care about healthy
eating. Finally, many of us feel that we don't have time to read all the labels in the grocery store
or to educate ourselves on healthy eating. That is why we use heuristics - that is, short-cuts to
decision making which are often irrational in nature. Heuristics are simple procedures that help
individuals find adequate, though often imperfect, answers to difficult questions.

One heuristic that seems to affect eating behaviour the representativeness heuristic.
When the children above see Ronald McDonald, they associate him with positive images.
Therefore, he represents a positive lifestyle - and thus good eating. When people make rapid
decisions they rely on heuristic devices, such as the appearance of objects, familiar pictures,
shapes, sizes, logos, brands and prices. Although relying on heuristic cues to guide eating usually
results in selections that are larger and have more calories, this automatic decision-making
mechanism allows people to function efficiently, and frees up limited attention and cognitive
capacity to address other demands.

Many food products use signs and symbols in their packaging that suggest a product is healthier
than it really is in order to promote sales. Tversky & Kahneman have shown that the
representativeness heuristic is often used to make decisions - that is, if there are cues that make it
look healthy, then it must be healthy. In his book, The Social Animal (pp 156 - 157) Elliot
Aronson writes about a consumer study done on the role of heuristics in food choice.

39
Parents were asked whether they would buy Lucky Charms (an American breakfast cereal) or
Quaker's 100% Natural for their children. Parents easily chose the Quaker's 100% Natural. Both
the name and the picture of fields of the wheat on the box told them that it was healthier. They
had used the representativeness heuristic to make the decision, rather than doing a bit of
research.

In 1981 the magazine Consumer Reports conducted a test of breakfast cereals. Their researchers
fed young rats, which have nutritional requirements very similar to humans, an exclusive diet of
water and one of thirty-two brands of breakfast cereal for a period of eighteen weeks. They
found that the rats grew and remained healthy on a diet of Lucky Charms. This was not the case
with a diet of Quaker's 100% natural. A careful look at the ingredients shows that Lucky Charms
is lower in calories and in saturated fats than 100% Natural. While it is also slightly higher in
sugar, this difference is of no dietary significance. In this case, judging the cereal by its box led
to a false assumption about the healthy nature of the cereal.

Wansink, Just, & Payne (2009), examined how irrational beliefs about eating affect behaviour.
One such belief is that people make is that they know how much they want to eat. In their study,
62 MBA students who sat through a 90–minute class explaining that if presented with a one–
gallon bowl of Chex Mix, they would serve and eat more than if presented with two half–gallon
bowls. Despite this lesson, the students who served themselves from the one–gallon bowl served
53% more and ate 59% more and did not believe the size of the serving bowls influenced their
behaviour.

Another eating myth is that people know when they are full, but a study of 150 Chicagoans and
Parisians showed that Americans are more likely to use external, environmental cues to
determine when they are done eating, rather than cues of internal satiety (Wansick et al, 2007).
The researchers asked a matched set of 150 Parisians and Chicagoans when they knew they were
through eating dinner. The Parisians said they knew they were through eating dinner when they
“were no longer hungry” or when the “food no longer tasted good”—both internal cues of
satiation. In contrast, the Chicagoans said they knew they were through eating dinner when their
“plate was empty” or when the TV show they were watching “was over”—external cues of
satiation. It appears that these irrational beliefs about food seem to lead to over-eating.

Sociocultural arguments

Watch the following video on countries that value obesity in women. Listen carefully to the
theories as to why this is true.

Liga video Top 5 Conutries that celebrate Female Obesity

https://www.youtube.com/watch?v=LMQYWm-Bs1o

40
Culture plays a significant role on how we eat. Food choices and combinations are learned very
early in life. Social events and family rituals are often centered around large meals. Today's
culture promotes eating habits that contribute to obesity. People may serve large portions and
foods that are most readily available instead of choosing foods that are most nutritious. Cooking
with butter, chocolate and other high-caloric foods is a normal part of the American diet. Also,
food is often used as a reward. Children are treated to sweets for cleaning their room, and the
team is taken for pizza or ice cream after the game. Seldom is eating only when hunger is
present.

Overweight people are usually less physically active than normal weight adults. Lakdawalla &
Philipson (2002) argue that obesity has more to do with lack of physical activity than with food
intake. The change to a more sedentary lifestyle is an important variable in the "obesity
epidemic."

The body uses energy during physical activity, and if one eats more than is burned, fat will be
stored. The increase in obese people has been linked to the sedentary lifestyle of modern
people—that is, the lack of physical activity. In the past, people used much more energy on work
and transportation than they do today. Television viewing has increased over the years, and so
has the use of videos and computer games. Prentice and Jebb (1995) studied changes in
physical activity in a UK sample. The researchers found a positive correlation between an
increase in obesity, and car ownership and television viewing. However, the data were
correlational, so a cause-and-effect relationship cannot be established.

The economists Lakdawalla and Philipson (2002) estimated, based on individual-level data from
1976–1994, that 60 per cent of the total growth in weight was due to a decrease in physical
activity, with 40 per cent due to an increase in calorie intake.

Research in psychology: Forslund et al (2005)

41
 Forslund et al. (2005) undertook a cross-sectional study in 22 medical centres in
Sweden, to investigate how snacking may influence weight. They used self-reports
(questionnaires) to compare the energy intake (estimated in kilocalories) of 4259 obese men and
women with 1095 controls. They were interested in how much of the energy came from meals
and how much came from snacking. Snacking was defined as eating between the main meals.
The participants had a physical exam and blood tests were taken.

The obese people ate on average six times a day, compared to five times in the non-obese group.
The obese were also more likely to eat later in the day than the non-obese. The researchers
noticed that, overall, obese participants reported a significantly higher energy intake than the
control group.

Snacking was more frequent in the obese group, and women were more frequent snackers than
men. The proportion of energy from fat was more pronounced in the obese group. Generally,
energy intake was more likely to come from sweet, fatty food choices in obese frequent snackers.
The non-obese ate more healthy snacks. The researchers found that obese participants exercised
less than the non-obese. The obese also had lower education levels than the non-obese.

Obese Non-obese Obese Non-obese

men men women women

n = 1891 n = 505 n = 2368 n = 587

Average BMI 37.1 25.8 38.7 24.7
Total energy (kcal) 3234 2766 2683 2223
% of time with no physical
31.5 9.5 32.3 11.0
activity

Evaluation of theories of obesity

It is clear that no one approach can explain the current obesity epidemic. Each approach has
different limitations.

The biological approach is highly reliant on animal models. As you can see with the OB mouse,
there are also serious ethical considerations when using animals for such research. Genetic
research is problematic because it cannot isolate genes as a variable; environmental factors must
always be factored in as playing a role in the behaviour.

42
Cognitive arguments are based on irrational thinking and heuristics. Although there is some
evidence that the way that we think may influence our choices of when, what and how much to
eat, many of the studies are done under artificial conditions. And it is not possible to actually
know the thinking processes that people engage in during the time of overeating. In the studies
that were explained above, although they showed faulty thinking with regard to eating, there was
not a direct link to obesity.

Finally, sociocultural research has the problem of not being able to establish a clear cause and
effect relationship. There are two many variables that are not controlled. And it is not clear why
in a culture where "thin-ness" is promoted, why some people will be obese - or vice versa.

2. 7 Prevention strategies: obesity

When discussing the prevention of obesity in society, it is clear that

there are several factors that need to be discussed: our modern day sedentary lifestyle,
availability of high fat and high caloric foods, sugary drinks and portion size. Those things seem
relatively easy to address, so why have we not been able to prevent a global obesity epidemic?

One of the reasons that it is difficult is because of cultural and socioeconomic norms. Watch the
video below on obesity around the world and then take a look at the research below that
examines the extent to which public health campaigns for a healthier diet are successful.

Liga video Obesity Around the world

https://www.youtube.com/watch?v=zZYoQoBvrBM

SLT & the Media Effects Model

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 On average, children in the United States view 15 television food
advertisements every day, 98% of which are low in nutritional value, averaging out to 5,500
messages per year. Another study has shown that only 2% of advertisements (out of the 10,000
food advertisements that a child watches on average yearly) are about fruits and vegetables.
Could media be used to a more positive effect to encourage healthy eating and fight the obesity
epidemic?

Social Cognitive Learning Theory has been applied in main stream television series in order to
change people's behaviour. The use of soap operas for this goal became known as the Sabido
Method. In a study by Valente et al (2007) the researchers measured the effect of a storyline on
a popular American television show, ER (Emergency Room) in which an obese, low-income
African American teenage boy is diagnosed with hypertension.

The show dedicated three episodes to integrating a discussion of teenage obesity, hypertension
and heart disease, as well as the doctor explaining the 5 A Day plan to the young teen. The 5 A
Day plan recommends five portions of fruit and vegetables per day. By a series of random phone
surveys, the researchers found that after watching those three episodes of ER, people gained
higher awareness and knowledge of 5 A Day, and were reported to engage in some change in
their eating behaviours.

Beaudoin et al (2007) studied the effects of the STEPS media campaign in New Orleans which
was targeted at African-American women aged 18 to 49. In order to develop the media
campaign, focus groups made up of African-American women who were overweight were used
to determine what type of message would be the most effective. The focus groups indicated that,
although cost was a factor in influencing fruit and vegetable consumption, time constraints
appeared to be more important. In addition, because time constraints were a barrier to physical
activity, it was important to incorporate physical activity into an existing daily routine instead of
approaching it as a separate task. The message of the campaign was tailored to fit the lifestyle of
the target population. For example, one television ad showed an African-American couple in
their 30's sitting at a kitchen table. The man says that it is hard and time consuming to eat healthy
foods. The woman provides him with a bag of pre-cut salad. Afterward, they happily eat the
salad. The setting is familiar, the language is straightforward and the accent is from New
Orleans. Eating healthy does not need to be laborious and time consuming.

Once again, using random-digit telephone dialling, interviews were conducted. The results
showed improvements in people’s attitudes related to healthy diet and physical activity.

Health Belief Model

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The Health Belief Model argues that when an individual perceives a threat from a disease
(measured by susceptibility to the disease and the severity of disease) and understands the
benefits of preventive action, then the individual is likely to take preventive action. The second
component of the model is that the individuals need to identify perceived barriers to a change in
their behaviour. The final important aspect of the HBM is self-efficacy - an individual's belief
that he or she is able to perform the advocated behaviour.

One implementation of the HBM was the Project Lean (Low-Fat Eating for
Americans Now) Campaign (Samuels 1993). The first step was to inform the target population
about the risks of high-fat diets. The poster on the left is an example of the type of media
campaign that was used to highlight these risks. As you can see on the poster, there was also a
hot-line which people could call to get more information about the effects of a high-fat diet and
to get a free brochure with suggestions for dietary change.

Researchers determined the barriers to change through a series of focus groups. One of the
perceived barriers to changing their diet was the fear that low-fat food was "inconvenient" and
"tasteless." In order to develop self-efficacy in the community, chefs and food journalists took
part in the campaign to demonstrate how to easily prepare tasty low-fat foods. The response was
very strong with over 300.000 calls coming through the hotline

ATL Inquiry: The debate about government control

Liga video FDA Trans Fats Ban May Target Your FAvoriote Food

https://www.youtube.com/watch?v=rNwjRJm20zI

Another way to deal with obesity is by having the government impose bans or higher
controls on what we eat. Recent new legislation around the globe includes:

45
 • Europe leads the world in eliminating trans fats
• Calories will be printed on all menus in restaurants and takeaways (Ireland)
• Sugary drinks banned from Texas schools
• A potential new nutritional label to simplify health information

What do you think? Do you think that the best way for society to tackle this is to have the
government take over and eliminate factors that have contributed to the obesity epidemic? Why
do you think so? See if you can find any evidence to support your opinion.

Evaluating prevention strategies

Prevention strategies are difficult to assess. Here are some of the key concerns.

• Many of the studies are short-term and thus do not determine the long-term effects of the
programs.
• The studies are reliant on self-reported data. This means that the researchers have to trust
that the participants are in fact being honest about their dietary habits. There is little to no
way to verify their claims. Because of the nature of the studies, social desirability effect
or other demand characteristics may affect the data.
• It is difficult to establish a cause and effect relationship between a campaign and a
change in eating behaviour.
• The outcomes for most campaigns are still relatively small (averaging around 8%). It is
not clear why the other 92% are not reacting to the campaigns.

2.8 Strategies for reducing obesity

Since prevention strategies are not 100% successful in reducing obesity,

psychologists have to study ways in which they can help those who are already obesity and need
to lose weight. As there are different approaches to explaining the origin of the problem, there
are different treatments that are used with the hope of helping the patient.

In this section was are going to look at three examples of treatments for obesity. The first
example is a drug-based treatment. The second treatment is mindfulness. The third strategy is
Cognitive Behavioural Therapy.

Drug treatments

Liga video FDA Approves first obesity drug in 13 years

46
https://www.youtube.com/watch?v=rnmxh7F21Tw

Doctors do not recommend drug treatments as the sole remedy for obesity, but recommend a
comprehensive program. They encourage drug treatments as an addition to change in eating
habits - particularly calorie intake - and an increase in activity.

Two different drugs

There are two types of drugs that are prescribed: appetite suppressants and lipase inhibitors.

Appetite-suppressant drugs (such as Belviq) promote weight loss by decreasing appetite or

increasing the feeling of being full because they increase the level of neurotransmitters that affect
mood and appetite. There is some evidence for the effectiveness of these drugs, although they
have some side effects, such as nausea, constipation, and dry mouth.

Lipase inhibitors (such as Orlistat or Xenical) act on the gastrointestinal system and reduce fat
absorption. There may be a range of unpleasant side effects, especially after eating a meal with
high fat content. This could probably have a preventive effect, since eating fat becomes
associated with unpleasant consequences. The following video demonstrates how this works.
Please note carefully when watching the video the side-effects of the drug.

Liga video Alli (Xenical, Orlistat) Weight loss

https://www.youtube.com/watch?v=vdhVVgR54KQ

Berkowitz et al. (2006) carried out a longitudinal study with a sample of 498 obese adolescents
(age range 12–16 years). The aim of the study was to investigate if an appetite-suppressant drug
(sibutramine) reduced weight more than a placebo. The participants were randomly allocated to
either receive the drug or to receive the placebo. In order to represent current practice in

47
medicine, the participants also received counseling about how to eat less food, increase physical
activity, reduce stress, and keep track of how much they ate.

Adolescents who took the appetite suppressant usually lost weight (6.4kg) during the first
months of the trial. Those who took the placebo usually gained weight (1.8kg). The weight loss
tended to be faster at the beginning of the study and then eventually their weight was maintained.

There are a few limitations of the study. First, there were side-effects of taking the drug. This
included increased heart-rate. In addition, even though this was a longitudinal study, there was
no follow-up study to determine if the participants were able to maintain their weight loss.

Jain et al (2011) carried out a study on the effectiveness of Orlistat in treating obesity. Their
sample included 80 obese patients who were randomly allocated to one of two conditions. The
first group received 120 mg of Orlistat three times a day; the second group received a placebo
three times a day. The groups were matched for BMI and cholesterol levels. In addition to the
drug treatment, participants were counseled in exercise, diet and stress management.

Compared to the placebo, Orlistat caused a significant reduction in weight, BMI and cholesterol
levels. The average weight loss was 4.65 kg vs. 2.5 kg in the placebo group. Notice that the
change in behaviour alone resulted in weight loss, but the drug treatment increased weight loss
over a shorter period of time. As with the Berkowitz study, the long-term maintenance of weight
loss was not studied, but it is argued that the comprehensive treatment will help to maintain the
weight loss.

Finally, Yanovski & Yanovski (2014) carried out a meta-analysis of placebo-controlled trials
for approved obesity medications. All studies had a sample of at least 50 participants and lasted
at least one year. They found that medications approved for long-term obesity treatment when
used as in addition to lifestyle intervention, lead to greater mean weight loss and an increased
likelihood of achieving clinically meaningful 1-year weight loss relative to placebo.

Mindfulness-based eating awareness training

Liga video Jean Kristeller, Ph.D “Mindfulness Based Eating”

https://www.youtube.com/watch?v=a_DyhhkYgME

Kristeller's work on Mindfulness-based eating awareness training focuses on the assumption that
if we can become more aware of our own physical state - that is, whether we are hungry, full,
bored, stressed, etc. - then we will respond to food in a more productive and healthy way. Part of

48
mindfulness is also to slow down and "live in the present." In our modern world, food is often
"functional" and quickly consumed during short breaks in our busy schedules. Kristeller argues
that by learning to focus on our food and enjoy it will cut down on the need to consume so many
calories.

This is linked to research on stress being carried out by Elissa Epel on the relationship between
stress and overeating.

Liga video Stress Eating and the Comnsequences

https://www.youtube.com/watch?v=DP7SC2ltMNM

Kristeller, Wolever & Sheets (2013) carried out a study to test the effectiveness of MB-EAT
(Mindfulness-Based Eating Awareness Training) compared to CBT. The study randomly
allocated 150 participants to one of three conditions: A 12-week MB-EAT program, a CBT
intervention, or a wait-list control. A wait-list control is a group that is willing to use the MB-
EAT and/or CBT treatments, but is not given treatment for the duration of the study. All of the
participants were obese, with 66% of them meeting the full DSM-IVR criteria for binge eating
disorder.

Compared to the wait-list condition, both MB-EAT and the CBT treatment showed
improvement. At four months after the MB-EAT treatment had completed, 95% of those
diagnosed with binge eating disorder no longer met the criteria for that diagnosis. This compared
to 76% of those who received the CBT treatment. Their conclusion was that the amount of
mindfulness practice predicted weight loss and a decrease in binge eating behaviours.

O'Reilly et al (2014) carried out a meta-analysis of research done on Mindfulness-based

interventions (MBIs) on treating obesity and eating behaviours. One of the problems with the
research was the lack of peer-reviewed research as this is still a very new field of study. The
researchers reviewed 21 studies and found that 86% of the studies reported improvements in
eating behaviours. However, as with the drug treatments discussed above, the research covered a
large range of intervention variables, including mixing MBI with CBT, exercise, medication and
other approaches to weight management.

Madsen et al (2009) argue that although mindfulness may have benefits, it also is competing
with a food environment which is related to socio-economic status. Children living in poverty
often live in high stress communities where affordable food is often high in fats and sugar. It is
in these communities where obesity levels are highest.

Mietus-Snyder taught mindfulness, as well as nutrition and healthy eating, to a group of inner-
city kids and their parents in Northern California to see what impact it would have on the kids’

49
levels of stress as well as their BMI. A control group was used that was given an exercise
regime, rather than mindfulness training.

Results from her study found that neither the mindfulness group nor the control group changed
their metabolic profile by much, though both groups did have overall reductions in anxiety and in
the kids’ body mass index scores. She argues that it is the food environment in which these
children live that provides an unhealthy diet. This has to change in order for mindfulness - or any
other program - to be effective.

Cognitive Behavioural Therapy

CBT aims to change how people think about eating as well as their eating behaviour. The
therapy targets those thoughts and beliefs that prevent the patient from losing weight when they
have decided to do so. The important thing is not why the patient is overeating, but dealing with
cognitions that lead directly to eating. CBT must focus on the patient’s permission-giving beliefs
that lead to overeating - for example, “It’s okay to eat now because I am upset.”

Stahre et al. (2007) conducted a randomized trial with a group of 42 obese women in Sweden.
16 of them participated in a program that included elements of CBT, and 20 participated in a
control group that included moderate-intensity physical activity. The treatment lasted for 10
weeks (two hours per week). The participants’ weight was controlled periodically over an 18-
month period.

In the cognitive program, the weight loss was 8.6kg at the end of the treatment and 5.9kg after
the 18-month follow-up. Participants in the control group had lost an average of 0.7kg, and after
the 18-month follow-up, they had gained 0.3kg on average. Although the difference between the
two groups is statistically significant, it is important to note two key limitations of the study.
First, it is a very limited sample size. Secondly, only women were tested. In addition, the mean
weight of the women was 100.3 kgs with a standard deviation of 14.8 kgs. This raises questions
as to the number of the women that lost enough weight to be considered in the healthy range of
BMI.

In spite of these two studies showing that CBT may have some effect on eating behaviours, the
vast majority of the research shows that CBT does not have a long-term effect on weight loss.
Cooper et al (2010) carried out a long-term study of 150 female participants with obesity who
were randomly allocated to either CBT for a period of 44 weeks or a guided self-help program
for 24 weeks. The CBT treatment resulted in an average weight loss of about ten percent of
initial weight, compared to minimal weight loss in the self-help program. The participants were
subsequently followed-up for three years post-treatment. The great majority regained almost all
the weight that they had lost with the CBT treatment. The researchers suggest that it is ethically
questionable to claim that psychological treatments for obesity “work” in the absence of data on
their longer-term effects.

One of the arguments against CBT is the idea that we have a set-point for our weight. Watch this
video to get a better understanding of what that might mean.

50
Liga video Why dieting doesn´t usuaññy work Sandra Aamodt

https://www.youtube.com/watch?v=jn0Ygp7pMbA

ATL: Critical thinking

After reading this chapter on strategies for reducing obesity, which of three strategies
described above would you recommend to a friend that was struggling with

obesity? Rank the three strategies in order of desirability. Be able to justify your
response.

2.9 Health problem: Stress

. University applications due Friday? Need to have a difficult

conversation with your parents about a situation in one of your classes? Does a recent text
message seem to indicate that the love of your life wants to break up after lunch today? Any of
these experiences may make you feel rather stressed - your heart races, you feel weak in the
knees, you have problems concentrating.

Any adverse or challenging event could be labelled a stressor. According to Professor of

Neurology Robert Sapolsky of Stanford University, humans are the only species that can imagine
stressors. People react in exactly the same way physiologically and psychologically if they think
that their boss will fire them as if they were actually facing the stressful situation of losing their
job. We can also experience stress about the future - for example, fear of global warming,
potential financial problems or fear of aging.

Types of stress

51
One of the difficulties of studying and managing stress is that "stress" is not a single
phenomenon. Stress management can be complicated and confusing because there are different
types of stress - acute stress, episodic acute stress, and chronic stress -- each with its own
characteristics, symptoms, duration and treatment approaches.

Acute Stress

Acute stress is the most common form of stress. It comes from demands and pressures of day to
day life. The demands can be actual or perceived. For example, there may be a deadline that you
have to meet for your EE to be submitted to the IB. That is an actual demand. You may also feel
that you need to get all 7's this semester in order to please your family. This is a perceived
demand. Acute stress is short-term and has a foreseeable end in sight.

Because it is short-term, acute stress doesn't cause the damage associated with long-term stress.
The most common symptoms are:

• emotional distress - some combination of anger or irritability, anxiety, and depression

• muscular problems including tension headache, back pain, jaw pain, and the muscular
tensions that lead to pulled muscles
• stomach, gut and bowel problems such as heartburn, acid stomach, flatulence, diarrhea,
constipation, and irritable bowel syndrome;
• Over-arousal leads to elevation in blood pressure, rapid heartbeat, sweaty palms, heart
palpitations, dizziness, migraine headaches, cold hands or feet, shortness of breath, or
chest pain.

We all experience acute stress at some time in our life. It is highly treatable and manageable, as
we will see later in this unit.

Episodic Acute Stress

There are those, however, who suffer acute stress frequently, whose
lives are so disordered that they are studies in chaos and crisis. They're always in a rush, but
always late.They take on too much and can't manage their time or meet all the commitments that
they have made. This is the "over-extended" person or the "over-achiever." Unlike acute stress,
episodic acute stress is a lifestyle choice.

It is common for people with acute stress reactions to be over aroused, short-tempered, irritable,
anxious, and tense. Often, they describe themselves as having "a lot of nervous energy." Always
in a hurry, they tend to be abrupt, and sometimes come across as hostile. Interpersonal
relationships suffer. Friedman and Rosenman labeled this pattern of behaviour as Type A
personality.

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ATL: Reflection

Watch the following video where Stanford professor Robert Sapolsky speaks about Type A
personality and toxic hostility.

Liga video Robert Sapolsky How a Chair revealed the type A personality Profyle

https://www.youtube.com/watch?v=JVxfcE4F9Xo

After watching the video, take the Type A personality test.

After you have received your results, consider the following questions:

• What types of behaviour was the test looking for? How do you think that this fits with the
description of Type A personality discussed in Sapolsky's video?
• What are the problems with such a test? (Especially after being primed by such a video).
• Why do you think that these behaviours are ultimately dangerous to our health?
• Why do you think that people develop this personality type?

Another form of episodic acute stress comes from ceaseless worry. Pessimists often see disaster
around every corner and forecast catastrophe in every situation. The world is a dangerous,
unrewarding, punitive place where something awful is always about to happen. This perception
of the world leads to hyperarousal that is characteristic of episodic stress.

The symptoms of episodic acute stress are the symptoms of extended over arousal: persistent
tension headaches, migraines, hypertension, chest pain, and heart disease.

Treating episodic acute stress requires intervention on a number of levels, generally requiring
professional help, which may take many months. Often, lifestyle and personality issues are so
ingrained and habitual that they see nothing wrong with the way they conduct their lives. They
also tend to attribute their stress to other people and external events. Frequently, they see their
lifestyle, their patterns of interacting with others, and their ways of perceiving the world as who
and what they are. They also often feel that this is the way that "the world works" and how they
are supposed to be in order to be successful. There is a strong argument that cultural norms may
actually encourage these behaviours in some people. Often people who experience episodic acute
stress resist treatment until a health problem forces them to confront reality.

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Chronic Stress

Chronic stress is the stress that wears people away day after day, year after year. Chronic stress
has a serious effect on our health - both physically and psychologically. It also takes its toll on
relationships. Chronic stress very often is a response to something that an individual cannot
change in his/her life. Chronic stressors include poverty, dysfunctional families, domestic
violence, chronic illness, institutionalized discrimination and war/conflict. As a result, the
problem-focused coping strategies that are often used in acute stress situations - that is, moving
away from a stressor or changing the nature of the stressor - is not possible. A person suffering
from chronic stress often feels a sense of hopelessness and despair.

Some chronic stresses stem from traumatic, early childhood experiences that become internalized
and remain forever painful. Some experiences profoundly affect personality. A view of the world
is created that causes unending stress for the individual.

Chronic stress kills through suicide, violence, heart attack, stroke, and, perhaps, even cancer. It
also has a negative effect on memory and attention. The symptoms of chronic stress are difficult
to treat and may require extended medical as well as behavioral treatment and stress
management.

ATL: Thinking critically

Is it possible that there are also some good sides to stress?

There is also something that is called eustress. This term was first used by Hans Selye. He
differentiated between distress - that is, negative stress - and eustress, which is the positive
response to stress that makes one feel a sense of pride and accomplishment. Eustress is not about
the stressor, but about how one perceives stress. The following Ted Talks with Kelly McGonical
looks at how stress can actually be a positive factor in one's life.

Liga video Kelly Mcgonigal How to make stress your friend

https://www.ted.com/talks/kelly_mcgonigal_how_to_make_stress_your_friend/up-
next?language=en

What do you think about McGonical's argument? Do you think that the research that she
describes is strong evidence that stress is not bad for you? Why or why not?

ATL: Reflection

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What are two stressors that you have encountered in the past year?

How did you react to each of these events, physiologically and psychologically?

Why did you think that you experienced these events as stressful?

How did you deal with the stressors? Did it work?

2.10 Physiological aspects of stress

The feelings that we experience when we are stressed are due

do the physiological changes in our bodies that occur in response to a stressor. When there is a
threat from our environment, our body immediately begins to prepare itself for either fighting the
threat - or running away from it - what is called the fight or flight response. The body does this
before we are even consciously aware of the threat.

The response is triggered by the hypothalamus which activates the sympathetic nervous system
and the adrenal-cortical system. The sympathetic nervous system "speeds up" the body's
systems and increases a sense of alertness. The adrenal glands release epinephrine (adrenaline)
and norepinephrine (noradrenaline) into the bloodstream.

The effects of the stimulation of the sympathetic nervous system include:

• An increase in heart rate and blood pressure

• Pupils dilate to take in as much light as possible
• Increased circulation to the major muscle groups
• Increased breathing rate
• Digestion, the reproductive system and the immune system are suppressed to allow more
energy for emergency functions

At the same time, the hypothalamus activates the adrenal-cortical system. As a result, over 30
hormones are released into the bloodstream, including cortisol. Glucose is released into the
blood to provide energy quickly and efficiently.

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The stress response

The goal of the Fight or Flight response is to get us ready to deal with a stressor. It is supposed
to be a "short-term response." In Robert Sapolsky's classic book Why Zebras Don't Get Ulcers,
he argues that the problem of modern day stress is that our fight or flight responses are activated
too often for situations that do not threaten our lives. When a zebra's sympathetic nervous
system kicks in, it is to flee a lion that it about to attack the herd. What is the rationale of getting
so stressed in a traffic jam? Or in the check-out counter at the grocery store? For humans, this

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theory alone does not explain stress, because our long-term stress is due to the perception of the
triggers. But regardless, the effects on our body are the same.

General Adaptation Syndrome

Hans Selye (1956) took our

understanding of the effects of stress on our physiological systems a step further with his
General Adaptation Syndrome model.

Selye's findings were accidental. As a young endocrinologist, he was trying to discover a new
hormone. In order to do this, he was injecting rats with ovarian extract. Over time, the rats
developed symptoms such as swollen lymph nodes, bleeding ulcers and enlarged adrenal glands.
Some of them died. Although he thought that he was onto something, he found that the control
group, which was being injected with a simple saline solution, also had these symptoms. It
appeared that the stress of the repeated injections - and not the substance being injected - was the
reason for the physiological response. Stress was the culprit.

According to Selye, there are three stages of the G.A.S. During the alarm stage the
hypothalamus responds to the stressor by activating the fight or flight response.

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In the resistance stage, the adrenal cortex continues to release glucocorticoids to help the body
react to the stressor until the stress is resolved or the body can no longer resist. Because one of
the results of the activation of the sympathetic nervous system is the suppression of the immune
system, the body is not able to fight off colds and flu during this time.

What follows is one of two stages. The negative outcome is the exhaustion stage. During this
phase, the stress has been persistent for a longer period. The body's ability to cope with the
stressor is depleted and the body is not able to maintain normal function. The immune system is
depleted. It is in this stage that major health effects may be seen.

The positive outcome is the recovery stage. This happens when the stressor is gone or coping
has been successful. Homeostasis of the physiological systems is restored.

Researchers are interested in how stress is related to health problems. They are now aware that
long-term stress causes an increase in cortisol, which can lead to depression or memory
problems. Cortisol also affects the immune system, thereby making the individual more
susceptible to infection, because of a decrease in the number of T-cells.

Cohen (1993) carried out a study to see if stress leads to colds. In his study he gave 276 healthy
participants a series of tests to determine their overall general health and their recent exposure to
stress. He then exposed 276 healthy participants to either a cold virus or to a simple saline
solution, which served as the placebo. Participants were then quarantined for five days. They
checked daily for any sign of illness. The researchers found that the duration and nature of stress
that an individual experiences is a strong predictor of who gets a cold. Those who had high levels
of stress for a month or more were over twice as likely to get ill as those who had no such stress.
The type of stress also seems to matter. Participants who were unemployed were three times
more likely to develop colds than those who didn’t have work-related problems. And those who
reported serious problems in their close relationships were 2.5 times more likely to contract
viruses than those without such problems.

This study is an interesting one, but it doesn't look at how stress actually leads to a decrease in
our body's ability to fight off disease. To get more information on that, we need to turn to a
classic study in psychology carried out by Kiecolt-Glaser et al (1984).

Kiecolt-Glaser et al. (1984) analysed blood samples from volunteer medical students one month
before and after students had completed the first two examinations. The participants were given
the Social Readjustment Rating Scale to account for life changes that occurred within the last
year that would raise their level of stress. As a result of this test, the participants were divided
into two groups: a high stress and a low stress group. Levels of loneliness were also measured
and the participants were also divided into two groups: high loneliness and low loneliness.

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Natural Killer cell (NK) activity was measured in the students' blood sample. NK cells are
lymphocytes which provide rapid responses to viral-infected cells. A low level of NK activity
indicates a poorly functioning immune system.

There was a significant decrease in NK cell activity between the first blood test and the second
blood test - which was given during the stress of examinations. Those participants in the "high
stress" group were more likely to have lower levels of NK than those in the "low stress" group.
This means that stress experienced previous to the exams played a role in their immune systems
ability to cope with the stress of examinations. In addition, those participants in the "high
loneliness" group had lower levels of NK than those in the "low loneliness" group. This confirms
the role of social support as a protective factor for better health.

The research seems to support the General Adaptation Model that is proposed by Selye. As our
body continues to cope with stressors, it eventually becomes "exhausted." In this exhausted
stage, this is when we are most likely to become ill. Up until Kiecolt-Glaser carried out this
study, much of the research carried out on stress's role on the immune system had been carried
out on animals.

Unlike Cohen's study, Kiecolt-Glaser actually used biological markers to determine the effect of
stress, rather than simply observing whether someone gets ill or not. But even with this, the
cause and effect relationship is still rather difficult to fully establish. As it was a natural
experiment, the controls over the experiment were not as good as would be in a laboratory
experiment. For example, it is not known how the participants cope with stress. Some of the
participants may have better coping strategies which would better regulate their stress response.
This may have affected the results. However, the study is naturalistic and has high ecological
validity. It also seems to reflect the personal experience that many students experience with
regard to illness during and immediately following exam experiences.

The link between cognitive factors - that is, coping with the problem - and the recovery stage is
not clear. Selye's model may be an oversimplification - in reality, the process is more complex.

Research in psychology: The Whitehall study

Marmot et al. (1991) analyzed data from over 7000 participants

in their classic Whitehall study. The sample was made up of both male and female civil servants,
aged 35 - 55, working in the London offices of 20 different Whitehall departments. Participants
were given an initial screening to make sure that all were free of heart problems prior to the
study. The aim was to then find out whether employees in the lower position jobs - that is, with

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less control over their work environment - would develop heart problems over the five year
period. This is an example of a prospective longitudinal study. Although it is still correlational,
it establishes that heart disease developed over the course of the study - eliminating pre-
conditions as a confounding variable.

In order to gather their data, the researchers used a series of questionnaires, as well as carried out
health screenings. The participants were invited to the research clinic and a questionnaire was
sent to their homes at five year intervals. Self-reported non-fatal heart problems, as well as cases
of cancer and diabetes, identified in the questionnaires, were verified by hospital records.

The final data showed an inverse correlation between one's position in the Whitehall civil service
and one's level of heart disease. The rate of heart problems in the lowest levels of the system
were 1.5 times the rate in the highest levels, even when matched for such factors as exercise, diet
and smoking. According to the researchers, the most significant factor was the degree of control
that participants felt they had.

It appears that there is a relationship between one’s sense of control in their working
environment and the health of the cardiovascular system. The study has been supported by
animal research carried out by Robert Salpolsky. Sapolsky studied the effect of social hierarchy
on stress levels in baboon troops. Dominant male baboons were shown to have much lower
levels of stress than subordinate baboons. Sapolsky observed the bigger, dominant males often
teasing the weaker ones, pushing them around and not letting them have a fair share of food or
mating privileges. In fact, the baboons that were most submissive to the dominant males revealed
brain activity similar to the kind found in clinically depressed humans.

The fact that this is a longitudinal prospective study is a key strength of the research. Also, since
everyone in Britain receives the same quality of healthcare, the level of health care cannot be
considered a confounding variable to the extent that it would be in the United States.

However, there are some limitations of the study. The study was based primarily on self-report
questionnaires. Social desirability effect could play a role in individual responses regarding risk
factors. In addition, not all participants may have been conscious of - or honest about - their
health over the five year period. Though hospital records were also used, access to these records
was not always available to the researchers.

In addition, the sample was taken from the British government’s civil servants. The hierarchy is
perhaps more rigid in the Civil Service than in other large employers. This is simultaneously a
strength and a weakness of the Whitehall study. The study may not be representative of
conditions experienced in the average workplace.

Finally, the researchers may have overly attributed the effects on health to the hierarchy, rather
than to dispositional factors. Although control within the system may be the root of stress-related
illness, one has to question whether there is a disposition toward a sense of control.

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The effects of stress on memory

As if the effects on heart disease and your immune system are not enough,
stress also has a negative effect on memory - specifically, on the hippocampus. Sustained
increased levels of cortisol lead to hippocampal cell death, which in turn leads to memory
impairment. Research on veterans with PTSD and victims of child abuse shows hippocampal
atrophy - that is, they have smaller hippocampi than average.

Newcomer et al (1999) carried out an experiment to test whether high levels of the stress
hormone cortisol interfere with verbal declarative memory.

All participants were employees or students at the Washington University Medical

Center. All participants were asked to listen to and recall parts of a prose paragraph.
This tested their verbal declarative memory. It is known that verbal declarative memory
is often affected during long-term stress and the researchers knew from previous
studies that cortisol could be involved in memory impairment.

In order to investigate a possible link between cortisol and memory the researchers
designed an experiment with three experimental conditions:

• Condition 1 – high level of cortisol: The participants in the high level cortisol
group were given a tablet containing 160 mg of cortisol on each day of the four-
day experiment. This dose of cortisol is similar to what is seen in people
experiencing a major stress event.

• Condition 2 – low level of cortisol: The participants in the low level of cortisol
group were given a tablet containing 40 mg of cortisol per day. This dose is
similar to the amount of cortisol circulating in the blood stream of people
undergoing a minor stress event.

• Condition 3 – placebo group: The participants in this condition were given

placebo tablets - that is, a tablet that looked like the other tablets but with no
active ingredient. This was done in order to have a control group.

The experiment was done under a double-blind control.

The results indicated that high cortisol levels impaired performance in the memory task
since the participants who received the highest level of cortisol also showed the worst
performance in verbal declarative memory. The effect was not permanent, however.

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The performance of participants in the high cortisol condition returned to normal after
they stopped taking the hormone tablet.

It appears that cortisol interferes with the transfer of short-term memory to long-term
memory that takes place in the hippocampus. This makes sense as there are several
cortisol receptor sites on the hippocampus.

Since this study was experimental, the researchers could establish a clear cause and effect
relationship between the IV and the DV. The experiment ran over several days and the
participants were not in the lab the whole time, so the researchers did not have full control over
extraneous variables. In spite of this, there was a clear relationship between the amount of
cortisol ingested and the performance on the memory test.

2.11 Psychological aspects of stress

The argument that it is the interaction of cognitive and physiological responses that lead to how
we experience stress is the basis of Lazarus & Folkman's (1984) Transactional Model of Stress
and Coping. The researchers define stress as neither a result of the disposition of an individual
nor the nature of the environmental stressor, but the "transaction" between the two. The theory
argues that it is the appraisal of the environmental stressor that leads to an emotional response -
or the lack thereof.

Cognitive appraisal is defined as one's personal interpretation of a situation. It is how an

individual views a situation in terms of expecting either a positive or negative outcome. The
transactional model defines stress as arising from the appraisal that a stressor in the environment
will threaten one's well-being. The theory argues that there are two types of cognitive appraisal.
In primary appraisal, a situation is perceived as being either irrelevant, beneficial or stressful.
In secondary appraisal, the individual considers "what can be done about this?" Cognitive
appraisal then leads to the stress response - or the lack thereof.

The theory is criticized because it doesn't really consider the physiological response to a stressor.
It simply argues that when we don't have the resources for coping with the stressor, we
experience stress. It does, however, explain individual differences when confronted with a
stressor - that is, why one IB student breaks down in anticipation of mock exams, while another
student sees it as a personal challenge and feels good about the experience - even though both
students have the same level of competence in their courses.

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Modern interpretations of this model also consider the role of optimism and pessimism as
schema through which we interpret a stressor. This has been the basis for positive psychology.
The theory is that those with an optimistic outlook on life are cognitively more likely to recall
positive strategies for resolving stressful situations and see that they have the ability to change
the situation if they want to. It could, however, have more to do with the lifestyle of an optimist.
Optimists tend to live healthier lifestyles that include more physical activity and a healthier diet.
This may also play a role in how stress plays a role in their lives.

A study by Jobin et al (2014) looked at the role of optimism on stress and health. Participants
reported the level of stress they perceived in their daily lives. They also took a test to measure
their level of optimism and pessimism. Researchers then measured cortisol levels over a 6 year
period in a sample of 135 adults. Jobin found that on days where the participants experienced
higher than average stress, that's when the pessimists' cortisol levels were elevated and those
levels of cortisol were sustained for a longer period of time than was observed in the optimists.

ATL: Reflection

Optimists have a general tendency to expect positive outcomes. They have a

hopeful view on life and tend to always find "the good side" in others and in situations.

Pessimists have a general tendency to expect negative outcomes. Pessimists like to hear what the
problems are, so they can correct them. Part of why pessimists generate negative thoughts is that
they believe it helps them perform better.

Do you consider yourself an optimist or a pessimist? What is your evidence for this?

How do you think that being an optimist or pessimist affects you in the IB program?

Longitudinal studies show that HIV-positive people who have more pessimistic expectations
develop HIV-related symptoms more quickly, and die of AIDS sooner (Reed et al. 1999)

Social self-preservation theory suggests that threats to one’s “social self”, or to social esteem
and status, are associated with specific negative cognitive and affective responses, such as shame
and humiliation. It seems that such threats can influence physical health—for example, via the
immune system or through increased levels of cortisol. According to Kemeny (2004), HIV
infection often occurs in stigmatized groups (e.g. gay and bisexual men or drug abusers) and is a
stigmatizing sexually transmitted disease itself. HIV-positive gay and bisexual men who are
particularly sensitive to rejection related to their sexuality show more rapid progression of the
disease than those who are less sensitive to such social-self threats. Social self-preservation
theory predicts that biological responses to stress are mediated by self-conscious emotions such
as shame and sensitivity to rejection.

The psychological aspects of stress are bidirectional - our cognition - that is, our processing of
information - can lead to stress, and stress can have a negative effect on our cognition.

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2.12 Social aspects of stress

Humans are dependent on other human beings. Group living is perhaps one of the most
significant aspects of humanity, and our well-being may be threatened if social relationships are
stressful. Experiencing abuse in the family or being bullied are social stressors. Living in a
violent neighbourhood is another example.

On the other hand, stress can be alleviated via social support—for example, having good friends
or a loving family. Warm and nurturing families teach children how to manage stress effectively.

Poverty and social hierarchy

Sapolsky's research on the physiological effects of stress in

baboon troops was ground-breaking. The idea that social hierarchies - and our place within a
social hierarchy - could affect our health challenged the idea that those at the top of the
hierarchies must be the most stressed. At least in baboons, it appeared that those at the bottom
were the most stressed - and had the most negative health effects.

Tung et al (2012) carried out research with female macaques that shows that one's place in the
hierarchy leads some genes to express themselves. They manipulated the hierarchy by using
middle-ranking female macaques and introducing them into a new group one at a time. Newly
introduced monkeys almost always adopt a role subordinate to existing group members. The
researchers took blood samples to determine the effect of the hierarchy on the genetic expression
in the monkeys.

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They found that the monkeys at the bottom of the hierarchy had more activity in genes associated
with the production of immune-related cells and inflammation. In humans, chronic inflammation
and stimulation of the immune system is a risk factor for many different diseases - ranging from
heart trouble to Alzheimer's disease.

They also found that low ranking monkeys had higher rates of glucocorticoids. It is believed that
this hormone may play a key role in the gene expression observed in the study. This research
goes a long way in explaining why a hierarchy may actually lead to health problems for those
lower down in the system.

Looking at the research on hierarchies, that leads us to the question - does poverty in and of itself
lead to poorer health? There are two different positions on this argument.

Evans & Kim (2007) argue that poverty exposes people to risk factors that lead to a higher
vulnerability to stress and, therefore, poorer health. Their vulnerability theory was tested by
evaluating the health of 207 thirteen-year-olds living in poverty in the US. Qualitative data was
also gathered regarding their exposure to risk factors such as domestic violence, crime in their
neighbourhood or lack of quality housing. The researchers found that the greater the number of
years spent living in poverty, the greater the number of health issues. Most significantly, children
who had lived in poverty for an extended period of time had higher overnight levels of cortisol
and showed early signs of poor cardiovascular health.

However, the argument about risk factors cannot account for the fact that in the poorest societies
on the planet, we still see the trend that those at the top of the hierarchy have better health than
those below. It has been found that among the wealthiest quarter of countries on earth, there is no
relation between a country’s wealth and the health of its people – in other words, living in a
wealthy country does not guarantee that you will be healthier than people living in a less wealthy
country. In fact, people in Greece on average earn half the income of Americans yet have a
longer life expectancy. How can this be true?

It appears that when we look at social aspects of stress, it is impossible to

separate those factors from biological and cognitive aspects of stress. Wilkinson (2001) has
argued that it is the level of income inequality that is the most predictive of one’s health – rather
than simply one’s socio-economic status.

This was demonstrated by a clever study carried out by Operario et al (2004). In their
study participants looked at a diagram of a ladder with 10 rungs and then were asked, “In
society, where on this ladder would you rank yourself in terms of how well you’re doing?” The
ladder was not labelled in any way to indicate income level – it was completely up to the

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participant to decide how they defined the rungs of the ladder. The researchers found that one’s
subjective assessment of his/her socioeconomic status was a predictor of one’s level of
cardiovascular health, obesity and stress hormones. It may be that upward comparison – that
is, comparing yourself to those who have more in society than you do, may be the root of poor
health, and not simply the risk factors in your community.

Social support as a protective factor

Social support is exceptionally important for maintaining good physical and mental health.
Remember the study by Cohen on common colds in the section on the biological aspects of
health?

Overall, it appears that positive social support of high quality can enhance resilience to stress. In
the Alameda County Study (Breslow and Brewslow, 1993) 6,928 participants completed
questionnaires regarding their health, social network and personal characteristics. Follow up
interviews and questionnaires took place at intervals for up to 20 years. The findings indicated
that men and women without ties to others were 1.9 to 3 times more likely to die from heart
disease, stroke, cancer, or a host of other diseases over the duration of the study compared to
individuals with many more social contacts.

Linking psychology to CAS

Schwarzer et al (1994 ) studied the role of social support on stress in

refugees. Refugees have to deal with a number of stressors, among them looking for work and
creating a new social network. Prolonged unemployment and lack of social support can result in
impaired health. A sample of 235 East Germans was interviewed three times during two years
following their move to West Berlin in 1989, after the fall of communist East Germany. The
majority found a job during this time transitioned well to their new home.

Those, however, who remained unemployed were worse off in terms of self-reported health.
However, those who had a network of social support had better health than those that did
not. During the final set of interviews, those who had neither a job nor social support reported
frequent physical symptoms of illness or chronic pain.

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Questions

1. Make a list of the stressors that you would personally experience if tomorrow you moved to a
new country. How does this list differ from the stressors you would assume that a refugee would
experience?

2. What could your school community do to help promote better health among refugees in your
community?

2.13 Strategies for coping with stress

Knowing that stress has so many negative effects on our health, it

is important that we find ways to manage our stress. In theory, we can just leave stress situations
and escape the stressor. If I am stressed by having too many after-school commitments, I can
drop out of a club or decide to only attend once a month. But often this is not an option - or it is
a difficult option. Simply "getting out of" a stressful relationship or a job is not always easy. In
cases of chronic stress caused by poverty or systemic discrimination in a society, it may be
impossible.

Self-help books are full of advice on how to cope with stress. What do psychologists think are
the best strategies for addressing this health problem?

Cognitive-appraisal model of coping

Folkman and Lazarus (1988) suggested two main coping strategies. The first one is problem-
focused coping, which is dealing with the stressor itself. The purpose is to change the
problematic situation - for example, quitting an impossible job or leaving an abusive partner. The
second strategy is called emotion-focused coping. The purpose is to handle the emotional
aspects of stress rather than changing the problematic situation. There are several ways that
people do this, such as going to the movies, relaxation exercises, seeking social support, or
taking medication to alleviate tension.

However, it is difficult to make a clear distinction between the two ways of coping. Problem-
focused coping is probably more likely to happen if the person feels they can control the stressor.
Emotion-focused coping is more likely in cases where people feel they have little control over
the stressor. Generally, a situation perceived as one that has to be endured - for example, in the
case of the death of a loved one - is more likely to result in emotion-focused coping. However, it

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should be noted that the two strategies influence each other. Problem-focused coping may result
in the reduction of unpleasant emotions. Likewise, emotion-focused coping (e.g. talking with
close friends) may reduce tension and eventually result in more effective problem-focused
coping.

Generally, if people believe they can manage stress, the stress is less intense and of shorter
duration. This has implications for reducing risk factors in health - for example, in terms of the
relationship between stress and heart disease.

Strategy 1: Social support

Psychologists have long known that having friends is important to mental well-being. A
longitudinal study of ageing found that regular personal and telephone contact with friends and
family increases life expectancy (Gilles et al. 2005). Social support also seems to be an important
factor in the way people cope with stress.

Social support can be defined as the experience of being part of a social network, with mutual
assistance and obligations, and that one is cared for by others. Social support can come from a
partner, relatives, friends, or various social support groups. Numerous studies have demonstrated
that having a network of supportive relationships contributes to psychological well-being. When
you have a social support network, you benefit in the following ways:

• Sense of belonging. Spending time with people helps ward off loneliness. Just knowing
you're not alone can go a long way toward coping with stress.
• Increased sense of self-worth. Having people who call you a friend reinforces the idea
that you're a good person to be around.
• Feeling of security. Your social network gives you access to information, advice,
guidance and other types of assistance should you need them. Since you feel you have
support, you may appraise potentially threatening situations as less stressful.

Research in psychology: Coan, Schaefer & Davidson's (2006)

Coan, Schaefer & Davidson's (2006) research shows how social

support may play a key role in stress reduction. In their study 16 married women were
threatened with an electric shock while holding their husband's hand, the hand of an
anonymous male experimenter or no hand at all while they were in a fMRI brain imaging
scanner. While in the fMRI the women were shown 12 non-threat indicating images
(safety cues) and 12 threatening images (threat cues) - that is, images that when
shown, indicated that an electrical shock was possible. The cues activated brain regions
associated with fear and anxiety.

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Results showed that the brain's "threat response" was lowest when holding their
husband's hand and strongest when no hand was held. Not only this, but there was a
negative correlation between the reported marital quality and the threat response - that
is, the higher the reported marital quality, the lower the brain's threat response. It
appears that social support is key to resilience.

Heinrichs et al (2003) argue that in addition to the fact that social support gives us
informational, emotional and practical support, it also increases our level of oxytocin, which is a
protective factor against stress. In their double-blind study, 37 healthy men were randomly
assigned to receive intranasal oxytocin or a placebo 50 min before carrying out a stressful
interview process. The participants were given five minutes to prepare a five-minute
presentation. In one condition, the participant received social support from their best friend
during this preparation time. In the other condition, the participants worked alone, without any
social support. The researchers found that the combination of oxytocin and social support
exhibited the lowest cortisol concentrations as well as decreased anxiety during stress. This study
indicates that there may be biological underpinnings of the role of social support on stress
reduction.

The following video demonstrates the study by Coan, Schaefer & Davidison (2006)

Liga video Jim Coan and the Hand Holding Experiment

https://www.youtube.com/watch?v=UCukN_8S124

Taylor (2002) has argued that there are gender differences when it comes to actively seeking out
social support during times of stress. Taylor's argument is that this is due to evolutionary-based
differences between men and women - where men activate the "flight or fight" response, whereas
women activate the "tend and befriend" response - that is, women tend to use social support
more as a coping mechanism than men do. Studies conducted by Repetti (1989) show that
women respond to highly stressful workdays by providing more nurturing behaviours towards
their children. In contrast, fathers who experienced stressful workdays were more likely to
withdraw from their families or display more interpersonal conflict.

Psychologists suggests that culture is a variable that may moderate how social support is
perceived. One dimension of culture is independence (western cultures) versus interdependence
(non-western cultures). In individualistic cultures, there is a strong emphasis on the self as
independent, whereas collectivist cultures perceive the individual as part of a social group—the

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self is interdependent. This has implications for seeking social support. Taylor et al. (2004)
explored cultural differences in the use of social support as a form of coping. European, US, and
Korean students were asked about their ways of coping with stress, including individual and
social coping strategies. They found that a significantly lower number of Korean students used
social support as a way of coping. They hypothesized that the Asian concern about disruption of
harmony in the group, social criticism, or losing face could be an explanation.

CAS: Social support in a digital world

The importance of Internet-based social support groups is rising. These groups can help people
who do not have a social network or may offer an additional source of support. Participating in
such groups provides people with a sense of belonging. Since they are so popular, it would seem
that such groups are quite efficient at helping people. But what does the research say?

Wenzelberg et al. (2003) carried out a randomized controlled experiment, which was aimed at
evaluating the beneficial effects of online support groups. The participants were 72 women
diagnosed with breast cancer. They were randomly assigned to a 12-week Web-based social
support group. The researchers found that the web-based program was effective in reducing
participants' scores on depression, perceived stress, and cancer-related trauma measures.

The researchers argue that Web-based support groups offer advantages, but that there are ethical
issues that need to be addressed. One is the privacy of the participants. According to the
researchers, securing participant confidentiality is important in groups like these. It is also
important that such support groups do not take the place of treatment.

Questions

1. If you were to undertake a CAS project on how to establish an online support group for IB
students suffering from exam stress, how would you go about it?

2. Use your knowledge of stress and suggest how you could provide informational and emotional
support. Would it be possible to provide practical support online?

3. What ethical guidelines would you have to put in place for your support group?

Evaluation of the strategy

• There are several studies that show that social support groups reduce stress
• Much of the research done is based on self-reports about how much support has been
received. It is difficult, therefore, to actually measure the level of actual support.
• It is difficult to isolate social support as a variable. Social support may also result in more
activity, a rise in self-esteem or practical information that helps the individual to solve a
problem. It may not actually be the presence of others alone, as suggested by Heinrichs et
al (2003), that alleviates the stress.
• It is not really clear how social support is related to coping. The relationship between
support and appraisal strategies has not been reliably demonstrated.

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 • There may be gender and culturally based differences in the likelihood to actively pursue
social support.

Strategy 2: Exercise

. Another way to reduce stress is to increase one's level of physical

activity. As we know, when the body is under threat, there is a biochemical response that takes
place: an increased secretion of glucocorticoids and noradrenaline, and the activation of the
sympathetic nervous system. Evidence supports the beneficial effects of regular exercise in
preventing or lessening the physiological effects of chronic stress.

Exercise increases your overall health and your sense of well-being. Physical activity also helps
increase the production of your brain's feel-good neurotransmitters, called endorphins. But the
effects are not all physical.

Exercise changes our focus and often allows us to stop thinking about the stressors that are
bothering us. Whether playing tennis or swimming laps in a pool, when exercising people
concentrate on their body's movements - a process that is very similar to mindfulness programs -
as we will see below.

Exercise also improves your mood. Regular exercise can increase self-confidence, it can relax
you, and it can lower the symptoms associated with mild depression and anxiety. Exercise can
also improve sleep, which is often disrupted by stress. All of these benefits can help to
counteract the negative effects of stress.

Brown & Siegel (1988) carried out a prospective longitudinal study of 384 female middle school
students. The researchers gave the students a "life events survey" to determine which stressors
they had experienced, as well as an activity questionnaire. The tests were given at the beginning
and at the end of the academic year. In addition, they carried out a medical health check-up.
They found that the negative impact of stressful life events on health declined as exercise levels
increased.

King et al (1993) carried out a 12-month study of adults aged 50 - 65. They were randomly
assigned a low or high-intensity exercise training program. The researchers found that regardless
of the exercise regime, an increase in exercise was related to lower levels of stress and
depression.

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Research in psychology: Hamer, Stamatakis and Steptoe

Hamer et al (2008) carried out a survey of 20,000 men and women in

Scotland to determine the effect of exercise and/or physical activity on their health.

The survey was carried out over two household visits. During the first visit, the participants
discussed their levels of physical activity, and their weight and height were measured. During the
second visit, they were asked about their general health and physical activity. They participants
took the General Health Questionnaire (GHQ-12), which measures psychological distress which
consists of 12 questions about participants’ general level of happiness, experience of depressive
and anxiety symptoms, and sleep disturbance over the last four weeks.

The researchers found that any form of daily physical activity was linked to a lower risk of
psychological distress. The more physical activity people engaged in, the less likely they were to
indicate psychological distress on their questionnaires. The research also showed that the
different activities, including domestic tasks (such as gardening), walking and sports, all showed
a reduced chance of psychological distress. The strongest effects were observed for those who
played sports.

The researchers concluded that stress reduction benefits were observed at a minimal level of at
least 20 minutes a week of any physical activity. In addition, there was a greater risk reduction
for activity that was undertaken for longer or at a higher intensity.

The study does suffer from bidirectional ambiguity - that is, there is the possibility that results
are actually showing that those who suffer from stress or anxiety are less likely to take part in
physical activity, instead of the other way around.

Here is a quick video on the positive effects of exercise on the brain. What can you learn from
this video that could help explain the benefits of exercise in coping with stress?

Liga video Exercise, Stress and the brain

https://www.youtube.com/watch?v=xpy_rAWSWkA

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Evaluation of the strategy

• There is clear biological evidence of the positive effects of exercise.

• Exercise may promote self-esteem, social activity and provide time away from stressors
such as work or family. Thus, it is difficult to determine the extent to which exercise
alone is effective against stress.
• Several studies on the effect of exercise use a very loose definition of stress. Often
"mood", "stress" and "health" are mixed - making it difficult to know to what extent
stress is actually being regulated.

Strategy 3: Mindfulness

One reason for stress is people worrying about the

past or the future, doing too many things at the same time, and not enjoying the moment because
they are thinking about what they have to do next. Since the mind is related to the body in a
complex way, learning to relax and concentrate on one thing at a time could be a way to reduce
stress. A large body of research has documented the beneficial effects of relaxation techniques in
stress reduction. One such technique is mindfulness-based stress reduction (MBSR).

Mindfulness aims to teach people how to respond to stressful situations "mindfully" - that is,
being able to appraise stressors realistically and step back from related thoughts and emotions. It
is believed that the positive or neutral appraisal of environmental stressors is what decreases the
stress response.

Shapiro et al. (1998) carried out a controlled study with a group of premedical students who were
offered the MBSR course at the University of Arizona. People who signed up for the course were
randomly assigned to the course (n = 37) or to a waiting list (n = 36). Participants in the MBSR

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group and the waiting-list group filled out a self-report questionnaire assessing stress before the
course and during exams after the course. The study was designed to coincide with exams, since
this is known to be a high-stress period. The participants also completed a questionnaire on
empathy.

The researchers found no difference between the two groups at the beginning of the term, but
they did identify differences around the time of the exams. People on the waiting list expressed
more anxiety compared to those who had participated in the MBSR class, who were, in fact, less
anxious than at the start. This suggests that the course had taught them to cope effectively with
the stress of exams.

Can these results be generalized to other people? The participants were medical students; they
were a self-selected sample; and they were offered course credits to participate, which probably
ensured the low drop-out numbers in this study. These are just some of the considerations that
may be included in any evaluation of this research.

Speca et al. (2000) performed a controlled test with a sample of cancer patients. They recruited
the participants by publishing the MBSR course in a cancer clinic in Calgary. Those who were
interested were randomly allocated to the experimental group or to a waiting list (the control).
The effectiveness of MBSR was assessed using a stress symptoms questionnaire. The
experimental group showed a reduction in total mood disturbance (anxiety, anger, depression) of
an impressive 65 per cent, and a reduction of 35 per cent in stress symptoms. The time spent
practicing meditation correlated positively with improvements in mood. There were no changes
in the average scores for the control group over the same period. The results provide evidence
that MBSR had a therapeutic effect. However, it may be that some of the effect was due to social
desirability effects, which could play a role in the patients’ self-reports on mood and stress
changes. Maybe they wanted to show that they had complied with the treatment and that it had
had an effect? This cannot be ruled out.

ATL: Thinking critically

Watch the following video on mindfulness.

Liga video All it takes is 10 mindful minutes /Andy Puddicombe

https://www.youtube.com/watch?v=qzR62JJCMBQ

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Many schools have started to incorporate mindfulness into the daily routine for their
students. The argument is that mindfulness will not only help improve their stress during exam
periods, but it will help with overall help and well-being.

Imagine that a group of students at your school wanted to begin a mindfulness program at your
school and that the school board intervenes and says that this is not an acceptable idea - seeing it
at least as unnecessary - at most, as religious propaganda. Design a presentation for the school
board in which you explain the benefits of a mindfulness program in your school. In addition, be
able to discuss the limitations of the program, but explain why these may not be a reason not to
have the program.

Evaluation of the strategy

• There is research that demonstrates that MSBR is a successful treatment method for
many people.
• It is not clear how meditation affects physiological processes with regard to stress.
• Mindfulness as a construct is not well defined. It is difficult to measure one's "level of
mindfulness" in order to determine its effect on stress.
• There is not enough research to account for placebo effects of the treatment. More
research is needed.

Evaluation of coping strategies - overview

When looking at these three strategies, you will see that there are some general issues that should
be discussed in a general discussion of how we can cope with stress.

• How do we measure stress? Many studies are reliant on self-reported data, rather than
biological markers of stress.
• It is difficult to control extraneous variables in longitudinal studies.
• Often the link between the strategy and the reduction in stress is not clear - that is, we
cannot really explain why it reduces stress.
• Personality, gender and culture may play a significant role in stress management.
• It is difficult to measure the effectiveness of strategies as people usually engage in more
than one. For example, a person practicing MSBR may join a group for meditation. It is
the social support then that alleviates the stress, or is it MSBR? Or it is a combination of
the two?
• Much of the research on stress is done on students. This leads to problems of
generalization of the findings

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2.14 Prevalence of health problems

. Why do health behaviours change over time? When we discuss

how common a problem is, we refer to its prevalence. Prevalence signifies what proportion of a
certain population engages in a certain behavior. As speaking about prevalence generally would
be too broad of a topic, we will concentrate on the prevalence of smoking and obesity because
both are commonly studied health problems. For instance, current prevalence of smoking in the
United States of America is 15.1% while for obesity it is 36.5% (CDC, 2016). However,
prevalence is not a stable variable; it changes over time and there are various factors which
influence it. We will concentrate on these factors in this chapter.

Definitions in psychology

Prevalence is usually expressed as a percentage (5%, or 5 people out of 100), or as the number of
cases per 10,000 or 100,000 people, depending on how common the illness or risk factor is in the
population.

There are several ways to measure and report prevalence, which vary according to the timeframe
for the estimate:

• Point prevalence is the proportion of a population that has the characteristic at a specific
point in time.
• Period prevalence is the proportion of a population that has the characteristic at any
point during a given time period of interest. “Past 12 months” is a commonly used
timeframe.
• Lifetime prevalence is the proportion of a population who, at some point in life up to the
time of assessment, has ever had the characteristics

The prevalence of smoking

In 1921 German scientists were the first to link smoking to lung cancer which led to anti-
smoking propaganda by the Nazis during the Second World War, together with the fact that
Hitler regarded smoking as a waste of money. After the war though, people returned to smoking
especially in the fifties and at the beginning of sixties; this may have been caused by the intense
marketing campaigns of tobacco producing companies. Cigarette brands sponsored television
shows, included film stars, singers and even athletes in their campaigns and produced catchy
slogans and colorful adverts. Additionally, they often targeted youth as a part of their marketing.

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In 1954, a study in the United Kingdom linked smoking to lung cancer again and this became
accepted by 1964 in the USA as well. By the 1980’s, much evidence had been gathered on the
health risks of smoking and consequently prevalence of smoking began declining in many
countries. Many countries also began implementing anti-smoking policies such as restricting
certain types of advertisements, prohibiting smoking in certain environments, additional taxation
and requiring proof of age when buying cigarettes. As a result of all these factors, smoking
prevalence in the United States, for example, decreased from 42% in 1965 to the current 15.1%.
Therefore, there is evidence that education and legislation were two of the most impactful factors
regarding smoking prevalence over the past century.

Furthermore, anti-smoking media campaigns can also be successful in reducing the number of
smokers. The Centers for Disease Control and Prevention, the official government health agency
in the United States, launched the anti-smoking campaign Tips from Former Smokers in 2012
and the results in 2017 show that between 2012 and 2015 around half a million smokers quit the
habit - and many more attempted to do so. It also stirred a public debate on smoking even
amongst non-smokers (CDC, 2017).

Research in smoking prevalence

Feigl et al (2015) conducted a study to determine whether a school smoking ban in Chile had
any effect on teenage smoking prevalence. The ban included schools as smoke-free zones and
also implemented a cigarette sale ban in an area of 300 meters around schools. This law went
into effect in 2006. The authors collected their data from 2001 to 2011 by carrying
out countrywide surveys of high school students, ages 14 - 18 years old. The surveys were
conducted every odd year, therefore there were six surveys in total. As a control group, the
researchers reviewed general population surveys for the 19 - 24 year old age group. Their sample
included 319 798 individuals.

The results were that smoking prevalence among Chilean teenagers was rising between years
2001 and 2005; however, once the ban came into effect, the prevalence of teenage smoking
decreased. In 2001, 41.9% of high school students had some experience with smoking while in
2011 it was only 25.7%. In the control group, 57.3% smoked in 2003 and 44.9% smoked in
2011. There was a more significant decline in smoking in the target group compared to the
control group.

However, looking a bit more closely at the statistics raises some questions. The data is the
prevalence of the whole sample. When divided by grade level, the researchers found that the
decline was apparent only in the lower school grades; the ban had no apparent effect on the
higher grades. Furthermore, the ban had an effect on the number of smokers but not the number
of cigarettes smoked per day by each smoker. Although the ban may have slowed the initiation
of smoking behaviour, it may not have had much effect on students who were already smoking.
The study lacks depth of information because the researchers had no contact with the subjects of
the study.

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Research in psychology: Park et al(2011)

The purpose of this study was to compare factors influencing

the prevalence of smoking among Korean and Chinese middle school students.

Data were collected from 12 schools in Korea and 6 schools in China. Students completed a
questionnaire in their classrooms under the supervision of the researchers. All participation was
voluntary and the data was anonymized. There were 10 002 questionnaires completed.

The smoking prevalence was higher in Chinese students than in Korean students. Risk factors,
such as father smoking, friends smoking, gender, grade, academic achievement, alcohol use, and
family income were associated with current smoking, and the differences in the two samples
were significant. Chinese students were more likely than Korean students to have friends who
smoked and a father who smoked. Smokers had a significantly higher rate of friends smoking,
father smoking, and alcohol use. Chinese male students were more than three times more likely
to smoke than Korean students. Korean students felt that smoking was less culturally acceptable
than the Chinese students.

Questions

1. If you could speak with the researchers, what questions would have you about how the
research was carried out?

2. Are there any variables that you believe should have been considered which do not appear in
the findings of the study? Why do you think that these variables may be important?

Another study on smoking was carried out by Evans, Farrelly and Montgomery (1999). The
researchers investigated the effect of smoking bans in the workplace on smoking prevalence. The
researchers used data retrieved from NHIS (national health interview survey) from two years –
1991 and 1993. These surveys asked not only about smoking habits but also about smoking
policies in the workplace. Altogether, the sample constituted of 18 090 subjects and was
nationally representative. The researchers found that in this timeframe smoking decreased by 5-
7% and the average cigarette consumption per smoker declined by 2.3 cigarettes a day. The
researchers concluded that the difference in smoking cessation could be attributed to workplace
smoking bans. However, there are many personal factors which motivate an individual to quit
smoking which are not accounted for in this study.

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Factors that increase the prevalence of smoking

• Permissive rules with regard to where people can smoke: restaurants, schools, cinemas,
clubs
• Inexpensive cigarettes
• Cultural norms that promote cigarette smoking
• Cigarette advertisements
• Lack of health education in schools
• Increased disposable income and economic security. In economic hard times, researchers
have found that smoking tends to decrease - for example, Iceland (McClure, 2012) and
Greece (Liaropoulos, 2012)

Prevalence of obesity

The current prevalence of obesity (2016) in the United States of

America is 36.5%, which is over a third of the population. Historically, this was not always the
case. Throughout most of history, obesity all around the world was rare and manifested
exclusively among the highest strata of the society as the majority of the population struggled to
get enough to eat. During the medieval times, obesity was seen as a sign of wealth and was
socially valued.

Yet after the industrial revolution, when production became mechanized, work became more
sedentary and society richer; obesity rates started to grow.

Today, obesity is no longer seen as a sign of prosperity but rather as a disadvantage and even as a
personal flaw. Still, obesity rates continue to grow in most western countries and in 2014, around
600 million individuals (13% of the population) were obese according to World Health
Organization (2017). This is most likely caused by the frequent consumption of calorie-dense
foods and a decrease in regular exercise due to urbanization, ways of transport and the nature of
work (WHO, 2017).

Research in obesity prevalence

She, King and Jacobson (2017) published a study which concentrated on the relationship
between public transport use and obesity. The authors gathered data on obesity from CDC’s
Behavioral Risk Factor Surveillance System (BRFSS) 2009 surveys and for public transport
usage data, they utilized the 2009 National Household Travel survey data. The data they
collected originated in 318 counties of 44 US states. They found that travelling by public

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transport was a good predictor of lower obesity prevalence. This is probably the case because
using public transport requires more exercise than driving an automobile and thus is effective in
reducing a sedentary lifestyle. This study is limited, as based on the methods used it cannot
establish a causal relationship or in other words it cannot say that using public transport actually
decreases obesity rates only that the more people travel by public transport, the lower the
prevalence of obesity.

TOK: Ethical thinking

China has a unique approach to fighting the obesity epidemic.

As China develops, its population is growing increasingly sedentary and in many cases adopting
a less nutritious diet, leading to concerns about public health.

To fight this, the Chinese government has implemented "mandatory callisthenics" - that is,
requiring that employers give employees two breaks a day - at 10 am and 3 pm - to do exercise to
a program on the Chinese state radio.

What do you think of such a program? Do you think that this an acceptable approach to
addressing the obesity epidemic? Why or why not?

What do you think your government could do to promote exercise?

A study conducted by Youlian et al. (2016) studied fourteen primarily African American
communities which took part in the Racial and Ethnic Approaches to Community Health across
the United States (REACH US) project. The goal of the project was to decrease obesity rates in
selected neighbourhoods, as the prevalence of obesity is higher among the African Americans in
the USA compared to the white population. The authors monitored these communities between
the years 2009 and 2012 and then compared the outcomes of the intervention to the general
population trends.

The intervention was community based - including health departments, universities, religious
communities and the local YMCA. These groups worked to minimize the construction of new
fast food restaurants in the area. They also tried to motivate stores to offer more healthy food
options in the community. They participated in the establishment of farmers' markets, produce
stands and community gardens and attempted to implement policies in favor of pedestrians,
cyclists, motorists and people using public transport. Furthermore, the coalition actively worked
to create physical activity opportunities such as outside wellness and exercise areas and also to

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decrease the costs of gyms and other such facilities. Also, classes and workshops on nutrition
and physical exercise were offered to the members of the communities. Finally, a campaign took
place promoting the intervention in the form of newsletters, radio ads and posters. The results
were positive, as the REACH US communities’ obesity rates overall decreased by 5.3% while
the obesity prevalence for the control population actually increased by 2.4%. These results show
that targeted interventions, which include the community, can be very effective in reducing
obesity and may be an appropriate approach to use in order for the population to become
heathier.

ATL: Critical thinking

There are several factors that we believe play a role in increasing obesity rates in a
population. This include, but are not limited to:

• Restaurant Dining. Restaurant dining and fast-food restaurant dining, in particular, have
been considered as major contributors to the obesity epidemic.
• Physical Education. Some argue that a reduction in the frequency of physical education
(PE) is a major contributor to obesity.
• Mandatory military service. Some argue that the end of compulsory military service has
led to higher rates of obesity in young men.
• Sidewalks and public transportation. Some have suggested that aspects of the ‘built
environment”, especially lack of sidewalks or a lack of public transportation decreases
walking which in turn increases obesity.
• High-Fructose Corn Syrup Consumption (HFCS). HFCS consumption has increased
substantially in the last several decades and has been speculated to be a contributor to the
obesity epidemic
• Vending Machines. Vending machines have been discussed as a threat to childhood
overweight and obesity and changes in school policy have been made to reflect this view.

Looking at the list above, first rank the six factors based on your opinion as to the importance
they play in the obesity epidemic.
Then, rank them again based on the "testability" of the hypothesis. Which of the six would be the
easiest to determine whether the claim is valid? How would you carry out research to test the
hypothesis?
Finally, do a bit of research. Which of these claims have been disproven?

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3. Health promotion

ATL: Essential understandings

Health psychologists employ different models to affect change in people's health related
behaviours.

There are difficulties in assessing the effectiveness of health promotion campaigns.

An important part of health psychology is to put theory into practice in health promotion.
Psychologists assume that one way to change unhealthy behaviours is to change attitudes and
beliefs. The main goal in prevention programs is to encourage people to change their health-
threatening behaviours, or to prevent people from developing health-threatening behaviours in
the first place. This is not as easy as it sounds because the exact link between beliefs and
behaviours is not known. Another problem is that at the time that health-threatening behaviours
develop, people often have little immediate incentive to change their behaviours. For example,
problems related to smoking occur many years after people have taken up smoking, not when
they start the habit.

There are several strategies to try to change the health behaviours of either an individual or a
whole population. As you can probably guess, these models do not work for everyone, but in
order to be effective, they should be able to produce a noticeable and enduring change in a
significant percentage of the population.

Health psychologists often base interventions on theories and empirical research related to
decision making, in order to understand what factors contribute to people’s decisions to change.
Two important theories on decision making that have guided interventions are the Health Belief
Model (HBM) and Social Cognitive Learning Theory.

ATL: Thinking critically

In the world of non-stop information it is difficult to believe that the average person does not
know that some behaviours are bad for their health. In most countries, for example, cigarettes

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 are clearly labeled with a warning that says that Cigarette Smoking Causes Cancer. In spite of
this, people continue to smoke. Why?

Such examples show that we human beings are very good at discounting the threats that their
behaviours cause to their health.

Watch the following video. What do you think? Will this change a smoker's behaviour? Why
or why not?

Liga video Thai Health Promotion Fpoundaion-Smokimng Kid

https://www.youtube.com/watch?v=aHrdy6qcumg

The Health Belief Model

The HBM and is one of the oldest social cognition models. The HBM predicts that individuals
will take a health-related action if they think that a negative health problem - for example,
developing lung cancer or type 2 diabetes - can be avoided by taking the recommended action,
and that they will be successful in doing so.

It is based on the assumption that for a behavioural change to succeed, individuals must have the
incentive to change, feel threatened by their current behaviour, and feel that a change will be beneficial
and be at acceptable cost. They must also feel competent to implement that change.

The HBM sees people as rational and suggests that the likelihood that a person will engage in
healthy behaviour depends on a number of factors, such as:

Evaluation of threat - for example, being overweight may result in developing a heart
condition; smoking may result in lung cancer. The person will probably recognize this as a
serious condition, but may also believe that it does not happen to people like them, for
example people their age. The model claims that people only act if they perceive a threat -
for example, a physical symptom like chest pains, death of somebody from heart disease or
lung cancer, or information from a mass media campaign.

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 Cost–benefit analysis - the person will evaluate whether the perceived benefits will be
higher than the perceived barriers - for example, if you have to buy healthy food, this is
more expensive than chips and burgers.

The HBM model also includes self-efficacy

beliefs - that is, the belief that you can perform adequately in a particular situation. This feeling
of competence will influence perception, motivation, and performance. Bandura (1977)
suggested that self-efficacy beliefs are important predictors of what people believe they are
capable of. People make judgments of self-efficacy primarily on the basis of previous
achievements. Other sources of judgment include:

• Observations of the performance of others - If he can do it, so can I!

• Social and self-persuasion - You can do it!
• Monitoring emotional states - for example, feeling anxious suggests low expectations of
efficacy.

Factors influencing change: The HBM

The Health Belief Model argues that a person's "readiness to change" is based on five factors. An
example of how these factors can be applied can be seen in campaigns to promote the use of
condoms to avoid HIV infection.

Perceived vulnerability: People have to believe that they can get HIV and know how one
contracts the disease.

Perceived severity: People need to believe that the consequences of getting HIV are significant
enough that they want to avoid contracting it. This is often accomplished through fear arousal.

Perceived benefits: People have to understand the benefit of using condoms to avoid HIV
infection.

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Perceived barriers: Barriers need to be explicitly identified and plans need to be developed to
overcome them. People may be embarrassed to ask a partner to use condom or they might not
want to pay to buy condoms. So, for example, practicing condom communication skills or
informing them about where they can get free condoms would potentially be successful
strategies.

Cues to action: People need to be reminded of safe sex practice in newsletters, a conversation
with a friend or receiving a pin that say "no glove, no love" or "respect wears a condom."

Research in psychology: Quist-Paulsen et al. (2003)

Quist-Paulsen et al. (2003) conducted a field experiment in which they

investigated patients who had been treated for heart problems in a Norwegian hospital. It is
known that mortality is reduced by 50 percent beyond three to five years if such patients stop
smoking. Normally, 30 - 45 percent of heart patients will stop spontaneously after treatment for
cardiovascular problems.

The researchers wanted to see if a longer intervention, including fear arousal, would get more
people to stop smoking and prevent relapse. They randomly assigned participants to a treatment
group and a control group. All patients were offered group counseling sessions. Patients in the
control group received no further counseling on how to stop smoking.

Patients in the treatment group had personal advice from trained nurses, and received material
that stressed the risks of continued smoking and the improved outcomes of cessation. Patients
were advised to stop, and nicotine replacement was offered to those with cravings. Spouses were
also advised to stop smoking.

The nurses contacted the patients nine times after they went home, to encourage them to stop
smoking. They stressed the negative aspects of smoking on their condition. Patients also had two
consultations in the year after leaving hospital. The researchers found that 57 percent of the
intervention group and 37 percent of the control group had stopped smoking. They concluded
that the program based on fear arousal and relapse prevention was effective for this group of
patients.

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ATL: Inquiry

When discussing health choices, it is not just about smoking. It is

about sex safe, drug and alcohol use, diet choices, exercise routines and stress management. For
this task, you are going to be asked to find out if there is a disconnect between health beliefs (or
knowledge) and actual behaviour.

To do this, we are going to create a short survey and then quantify and represent our data.

Step 1. Develop a survey with goal of finding out how much people exercise compared to what
they know about the health benefits of exercise.

Step 2. Carry out the surveys. If a participant reads your whole survey before answering, there
may be strong expectancy effects. Therefore, it would be best for you to carry out the survey
orally. Try to find five people to interview. If possible, avoid interviewing fellow students.

Step 3. Now it's time to graph your data as a class. There are many ways that you can do this
based on how you wrote your survey. For example, in the survey I designed, I asked how many
times they exercised per week on a regular basis and then asked them to name as many health
benefits of exercise that they knew. So, for my graph, I am going to make my x axis the number
of times that they exercise per week and the y axis the number of correct health benefits that
were identified.

To make my graph, I can use a simple online tool like "scatter plot generator." When I enter my
data and choose linear regression, it may look like this:

As you can see from the graph and the line of best fit, there is a
very minimal link between the two variables. In order to actually see the level of correlational,

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click on "correlational coefficient." This is a calculation of the Pearson's r test. When I do my
calculation, I find that the correlational coefficient for my data is r = -0.23. This means two
things. A value of 1.0 would mean a very strong correlation - that is, that those that know more
about exercise do more exercise. In this case, it is only .23. So there is only a very weak
correlation. Secondly, you can see the negative sign. This indicates the direction of the
correlation. In this case, it appears that there is a very slight correlation in the direction that those
that exercise more know less about the health benefits.

How does your data compare to mine?

A problem in the HBM is the focus on individual cognitions. It does not include emotional,
social, and economic factors, which are known to influence health behaviours as well. It seems
difficult to make standard measurements of many of the concepts - for example, perceived
vulnerability.

The HBM is also criticized for assuming that people are rational, which is not always the case.
Research has found that awareness of health risks alone does not necessarily inhibit people from
engaging in potentially risky behaviour. Studies have found that people are quite optimistic about
their health. Weinstein (1987) asked people to rate their risk of developing various disorders
compared to people like them. Individuals usually rate their chances of illness as lower than for
other people. This is the case in smokers, to a large extent. Weinstein suggested that the
following factors affect “unrealistic optimism”.

● People tend to believe that if a problem has not appeared yet, then it is unlikely to happen
in the future.

● People tend to think that personal action can prevent the problem.

● People believe that the problem is rare.

● People have little or no experience of the problem.

Evaluating the Health Belief Model

The Health Belief Model has been successfully applied in many cases to change behaviours from
as varied as smoking to safe sex to dietary change to prevent type II diabetes.

However, the HBM ignores the role of social and environmental factors on health, such as peer
pressure and cultural norms.

Finally, the model assumes that health behaviour change can happen simply by conscious choice.
This may not always be the case. People suffering from nicotine addiction often want to quit, but
simply cannot. Since health behaviour is seen solely as a choice, there is the temptation to
"blame the victim" rather than recognizing the complexities of changing behaviour.

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Social Cognitive Learning Theory

Social Cognitive Learning Theory suggests that health promoters act as ‘change agents’,
facilitating change through modification of the social environment and the development of skills
and capacities that enable individuals to make healthy changes. If you remember from the core,
there are several important components of Social Cognitive Learning Theory.

Observational learning is the ability to learn by observing the behaviour of others. For
example, people may be more likely to follow the example of people they see as role
models. Seeing someone you respect refuse to eat unhealthy foods may therefore change
your attitude about what you eat.

Expectations are the value an individual places on the outcomes resulting from different
behaviours. For example, if you believe that smoking will help you to lose weight and
place great value on weight loss, then you may be more likely to take up smoking.

Reciprocal determinism describes the way in which behaviour and the environment
continuously interact and influence one another. This is a key difference between this
theory and the Health Belief Model. Social Cognitive Learning Theory stresses the need
for addressing environmental influences in order to promote change. For example,
modifying social norms about smoking is considered to be one of the most powerful ways
of promoting cessation among adults.

Self-efficacy is an individual’s belief and level of confidence in her/his own ability to

successfully make a change or perform a behaviour. Social learning theory identifies self-
efficacy as the most important factor for successful change.

Health promotion campaigns that are based on Social Cognitive

Learning Theory include an informational component to increase perceptions of the risks and
benefits associated with a particular behavior, teaching social and cognitive skills that can be
used to initiate behavior change, building self-efficacy to promote behavior maintenance, and
building social support to sustain change.

One example is the Sabido Method. The Sabido Method is named after Miguel Sabido who was
Vice-President for Research at Televisa in Mexico. The goal is to change not just an individual’s
behavior, but to also improve the general society by changing attitudes and behavior. The
strategy originally was applied to soap operas – where viewers developed a “relationship” with
the characters in the serial. They then watch the characters evolve and change – and change for
the better.

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The first attempt at applying the Sabido Method was in a soap opera called Acompáñame
("Accompany Me"). The results of Acompáñame, as reported by the Mexican government's
national population council (CONAPO), were:

• Phone calls to the CONAPO requesting family planning information increased from zero
to an average of 500 a month. Many people calling mentioned that they were encouraged
to do so by the television soap opera.
• More than 2,000 women registered as voluntary workers in the national program of
family planning. This was an idea suggested in the television soap opera.
• Contraceptive sales increased 23 percent in one year, compared to a seven percent
increase the preceding year.
• More than 560,000 women enrolled in family planning clinics, an increase of 33 percent
(compared to a one percent decrease the previous year).

The Sabido method is based on several of the factors that promote social cognitive learning:

• Because viewers are committed to watching the show, they pay attention and retain the
plot.
• They observe both the rewards and punishments that are received by the characters for
the choices that they make – that is, vicarious reinforcement.
• They identify with the characters and feel connected to them. This serves as motivation to
replicate the behavior.
• The characters in the soap opera are “average people”- many viewers will see them as
part of their in-group.

The Sabido method has been successfully applied in other countries. For example, from 1993 to
1997 there was a serial in Tanzania to promote AIDS prevention behavior, ideal age of marriage
for women, and use of family planning. In order to test the effectiveness of the program, a
nationwide program was set up with the assistance of the University of New Mexico. The
experiment used an independent samples design. In the area near the capital city of Dodoma, a
music program was played. This was the control. The rest of the country heard the serial
broadcast by Radio Tanzania. The program ran for two years.

Nationwide surveys showed a significant increase in the percentage of listeners in the broadcast
areas who believed that they were vulnerable to HIV infection; an increase in the belief that
audience members, rather than their God or fate, can determine how many children they will
have; and an increase in the percentage of respondents who approve of family planning.
Importantly, the research showed a very significant increase in family planning use and a
reduction in fertility rate only where the program was broadcast (Vaughan et al, 2000).

Take a look at this video. In what ways does this campaign use Social Cognitive Learning
Theory to change behaviour?

Liga video #newfamilyrule

https://www.youtube.com/watch?v=QnYWV8yzmWs

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Evaluating Social Cognitive Learning Theory

Unlike the Health Belief Model, the Social Cognitive Learning Theory includes environmental
factors and seeks to change social norms. Programs such as the Sabido Method have been
effective in changing behaviour.

The theory does have limitations. It does not explain why some people choose to change while
others do not. It is difficult to measure levels of "self-efficacy." In many studies on the
effectiveness of social cultural learning theory, self-efficacy has not shown to be a valid
predictor of behavioural change.

3.1 Effectiveness of health promotion

programs

The goal of health promotion strategies is to enhance good health

and prevent illness. WHO (1986) defined health promotion as “the process of enabling people to
increase control over, and to improve their health”. However, it is not easy to get people to
behave in healthy ways because of the many factors that influence health habits, which include
such variables as social class, gender, education and culture. There are, of course, also individual
differences in approaching health; what motivates one to follow certain principles when it comes
to health depends on individual circumstances. For instance, a woman who wants to lose weight
may eat healthy food and exercise, but she may also smoke because she believes that it helps her
keep her stay slim. Likewise, one may decide to quit smoking and be successful for a year but
then relapse.

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ATL: Thinking critically

Below are two videos - each for a different campaign. One has the goal of making people more
active. The other is trying to raise awareness about child abduction.

Which of the two campaigns do you find more effective? Why do you think so?

Campaign 1. Get active

Liga video Get active: TV-campaogn to get out of the chair

https://www.youtube.com/watch?v=AY5AILaXDdA

Campaign 2. Child abduction

Liga video: Child abduction (social experiment) Child predator

https://www.youtube.com/watch?v=gGIDHrYKJ2s

Psychologists know that one-on-one contact is an effective way to change behavior in

individuals or small groups, but this approach is not possible when one wants to change habits of
whole populations. This has led psychologists and health workers to devise methods by which to
reach large numbers of people. Modern health promotion activities include:

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 • Public health campaigns that aim to change beliefs, attitudes, and motivations - for
example, informing smokers about the dangers of smoking and showing them how they
can stop.
• Changing the wider determinants of health - for example, changing the physical
environment; more stairs and fewer escalators.
• Public or private health services that can help people change their behavior - for example,
family doctors, pharmacies, or smoking cessation clinics.
• Political activities - for example, legislation raising tax or implementing bans on
smoking; reducing tax on healthy food and raising tax on sugar and fat.

Health campaigns

Health campaigns are often criticized for being ineffective. Some people
argue that they cannot make people change their habits and that they do not really help those
who need to change the most. According to Holm et al (2002), who conducted a survey on the
efficiency of health campaigns in relation to food habits in Denmark, health campaigns are
useful, but they cannot stand alone. They must be seen as an integral part of the entire health
promotion project. Holms states that a campaign can establish a norm for what is considered to
be healthy food and also create a general framework for the understanding of good practice in
losing weight but it needs to be based on people’s daily life (e.g. food culture) in order to be
effective.

A successful health campaign in Denmark in the 1990's aimed to decrease the use of butter on
the national rye bread sandwiches that constitute the Danes’ lunch. From 1985 to 2001, the
amount of people who said they did not use butter on the sandwich increased from seven percent
to forty percent. The use of low-fat milk has also increased in Denmark after health campaigns.
This shows that such campaigns can promote change.

It is difficult to make precise evaluations of the effect of a health campaign but according to
Holm, there is a long-term effect of various campaigns in Denmark. Each of them contributes to
increased knowledge and motivation to change unhealthy habits. One of the campaigns aimed at
increasing physical activity for adults—“30 minutes every day”—has probably contributed to the
rise in fitness center memberships. Furthermore, according to Holm, successful campaigns in
relation to obesity prevention must address three levels: what the individual can do, what can be
done in the community, and what should be done by the government.

What is more, in the modern world the media plays a decisive role in information spreading and
thus are one of the main means of health promotion and education. However, there are some
limitations to this approach; according to Sepstrup (1999), media campaigns can only be used to
convey simple messages. If the goal is to change attitudes and promote behavioral change, the
media campaign should be combined with other measures. Although media campaigns are

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excellent in bringing attention to and communicating knowledge about a specific topic, they may
not be enough on their own. People must have access to the necessary means to actually do
something. The simple message—such as “smoking kills” or “exercise 30 minutes every day”—
must be supported by activity options targeting people in their local area, so they can get the
necessary support to change their habits.

Still, it appears that media campaigns are certainly not ineffective. Huhman et al. (2005)
conducted a large-scale survey of children and parents to investigate the effectiveness of VERB
– a campaign in the US which used commercial marketing strategies to persuade the target
audience (children aged 9–13 years) to be physically active every day. They found that after one
year, 74 percent of the children were aware of the VERB campaign and there was also an
increase in sessions of free-time physical activity for children who were aware of the campaign
compared to those who were unaware of it. The researchers concluded that commercial
advertising in health promotion is promising.

The TRUTH campaign

Media campaigns might also be approached in a different and original

way, which may increase their influence. An instance of this was TRUTH anti-tobacco campaign
in Florida (US) in 1998–99. One of the aims of this campaign was to prevent teen smoking by
changing the attitudes of teenagers and encouraging them to form groups and spread the message
in the community. The campaign included a massive advertising drive, including 33 television
commercials, billboards, posters, the Internet (e.g. YouTube), program sponsorship,
merchandise, and local youth advocacy groups. The campaign also sponsored the YouCare video
contest at YouTube, where teenagers uploaded their own films.

However, what was extraordinary about this campaign was the active involvement of its target
audience - one of the core components of the campaign was young people confronting the
tobacco industry and accusing them of manipulating young people to encourage them to smoke.
The campaign leaders conducted focus-group interviews with teenagers to identify appropriate
ways of running the campaign. They found that teenagers were well aware of the dangers of
smoking, so this should not be the message of the campaign. Instead, the strategy of a youth
movement against the tobacco industry was decided by teen delegates at the Teen Tobacco
Summit in 1998: “Truth, a generation united against tobacco”. The campaign included the
formation of a new youth anti-tobacco advocacy group called SWAT (Students Working against
Tobacco), who worked at grass-roots levels.

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In order to measure the effect and awareness of the campaign, as well as changes in attitude
among adolescents, the campaign organizers carried out a number of telephone surveys of its
target audience. One of the findings was that teenagers’ negative attitude to smoking had risen.
Follow-up surveys indicated that non-smoking teens, who refrained from smoking because of the
campaign, were more likely to say that they had been influenced by the campaign. The Florida
Youth Tobacco Survey (FYTS), conducted in February 1999, found that the number of middle-
and high-school teenagers defined as “current smokers” went down by 19.4 percent and 8
percent respectively. During this time period, 29 000 teenagers from Florida made the decision
not to smoke, which was at the time one of the largest annual declines observed in the US since
1980.

Sly et al. (2002) carried out a survey 22 months after the campaign to investigate if the anti-
tobacco advertisements had had an effect on attitude changes such that the non-smokers would
remain non-smokers. They found that amount of exposure to the ads with the key message
theme—that is, that the tobacco industry manipulates teenagers’ attitudes to smoking—during
the campaign predicted that the subject had remained a non-smoker.

The findings from this campaign indicate that it is possible to change people’s attitudes and
behavior if the campaign is clear and focused on a target group. Furthermore, this demonstrates
that a campaign may be more successful if it directly involves its target group in its development
and creation.

An effective campaign: TRUTH

Overall, smoking decreased as a result of the TRUTH anti-tobacco campaign in Florida in 1998-
99. One of the aims of this campaign was to prevent teen smoking by changing their attitudes
and encourage them to form groups and spread the message in the community.

The campaign included a massive advertising including 33 television commercials, billboards,

posters, the Internet, program sponsorships, merchandise and the local youth advocacy groups.
The campaign also sponsored the YouCare video contest at YouTube where teens uploaded their
own films.

Here is an example of a Truth video from that campaign.

Liga video: “Truth” Ad

https://www.youtube.com/watch?v=7abIkin2mA8

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Do you find the PSA effective? Why or why not?

Finally, McVey and Stapleton (2000) demonstrated that anti-smoking television advertising
was successful in motivating people to give up smoking and preventing those who had stopped
from starting again. They chose four different TV regions of the United Kingdom and created
four intervention groups – a control group, two groups which received an intervention in the
form of anti-smoking TV spots and one group which received an intervention in the form of anti-
smoking TV spots and also locally organized anti-tobacco campaigning. From the selected
regions, they randomly picked 5468 participants, out of which 2997 were smokers and 2471
were ex-smokers. They interviewed these people before the intervention, then interviewed them
again after six months and finally after eighteen months. Some of the subjects quit the study
before the final follow-up, thus the end sample was comprised of 2381 participants.

The results showed that after eighteen months, 9.8% of smoker participants stopped smoking
while 4.3% of the ex-smokers started smoking again. The group, which was also additionally
subjected to locally organized anti-tobacco campaigning, did not show significantly different
results to the groups with the TV spots alone. All in all, the intervention was successful – the TV
campaign managed to reduce smoking in the tested population by 1.2% overall. Interestingly, the
campaign did not show as effective after six months, even though in the end it demonstrated to
be effective after the final check-up.

Still, this study may be limited by its cultural relevance; would these same advertisements work
as well in a different population? Effectiveness may also vary from advert to advert – there are
many different aspects which make a marketing campaign impactful and it is essential to also
consider these when evaluating the usefulness of TV advertising in changing a certain behavior.
It is quite vague to say that TV advertising either works or it does not – this decision should
possibly be more nuanced and should consider more variables.

The principles described above can be applied to health campaigns overall; it is difficult to
generally state whether they are effective or not. However, there are plenty of specific campaigns
which has been shown as impactful in specific populations. This is why academic studies are
very important in this area – it may be beneficial to clinically test campaigns before they are
implemented in the first place and to consider general rules of marketing in creation of these
campaigns in order for them to be attractive and influential. In the end, in principle they really
are no different to commercial marketing campaigns and perhaps just as commercial campaigns,

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some will be successful and some will fail. However, this does not mean they should be
abandoned overall.

ATL: Communication

Obesity is a problem in most developed countries. You have been hired as part
of a team to help your country address this issue by creating a video that would help to change
individual behaviour and reduce the level of obesity. Your team has to put together a proposal
for your statewide campaign.

As a team, you should write a proposal for how you think that they could address the problem.
As part of your proposal you should:

• Identify which health promotion model they are going to use. It may be one of the two
outlined in the previous lesson, or it may be one of the ones listed as areas of inquiry.
• Justify the choice of this model and note its limitations.
• Develop a visual for the campaign - e.g. a poster, a film, a slide show - that could be used
to try to affect the desired change. The visualization must reflect the health promotion
model that has been chosen.

Each team should then present their idea to the class. After all of the presentations have been
shown, the following three questions should be discussed:

• Which campaign do you think will be the most successful? Why?

• What factors do you think a country or company would look for in order to make a
decision about which campaign to choose?
• To what extent is it truly possible to predict the success of a campaign?

Evaluating effectiveness of health promotion strategies

In order to find whether or not health promotion is a good investment, the World Health
Organization [WHO] commissioned a group to provide guidance on the appropriate methods to
evaluate health promotion and to increase their quality (WHO, 1998).

Their recommendations were:

• Evaluations should draw on a variety of disciplines and employ a broad range of

information gathering procedures - in other words, data, researcher and method
triangulation should be used.

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 • Those who have a direct interest in a health promotion initiative should have the
opportunity to participate in all stages of its planning and evaluation.
• Health promotion initiatives should be evaluated in terms of their processes as well as
their outcomes.
• The use of randomized controlled trials to evaluate health promotion is, in most cases, not
an appropriate strategy for evaluating public campaigns.

The final point is rather interesting as often we believe that experimental data is the most
helpful. The problem is that experimental data relies on "outcome." Health promotion
campaigns, very similarly to therapy in abnormal psychology, need to look at how behaviour
changes over time. This may mean that there is a short-term change that is not sustained. If you
only look at the outcome, then you may judge the campaign a failure. If, however, the campaign
leads to positive results even in the short-term, this could be seen as having been effective. For
example, Gobins et al (2013) looked at the effectiveness of a Social Cognitive Theory based
multimedia campaign in the UK to promote STD testing. While the campaign was in the media,
the number of young people being tested for STDs increased significantly. However, once the
campaign was off the air, the number of people being tested returned to the previous
baseline. Would you consider this a total failure because the final outcome was not a sustained
increase in testing?

Difficulties in evaluating effectiveness of campaigns

Even though it appears that the TRUTH campaign was a success, we have to note that there are
several difficulties in evaluating the effectiveness of a public health campaign. Here is a list of
just a few problems.

• It is not possible to isolate variables when studying a large population being exposed to
public media. Therefore, although a correlation between exposure to the campaign and
change in behaviour can be observed, cause and effect cannot be determined.
• Levels of exposure to the media can only be measured through self-reported data. It is
unlikely that the average person can accurately determine the number of times that they
have been exposed, either directly or indirectly, to the campaign.
• Sampling is often problematic, so the results may not reflect the diversity of the
population.
• Even if a public health campaign is judged to be effective, often the findings are not
transferable to other populations.
• As noted above, it is difficult to measure the effectiveness over a large period of time to
determine if the results are simply short-term change or a durable, long-lasting change in
behaviour.
• Simply measuring health outcomes through hospital or work-related data is not enough to
determine that the campaign itself made a difference.
• Even if a campaign fails, it is difficult to know whether it failed because of the actual
campaign or the way that it was delivered.
• Much of the data obtained is self-reported, leading to potential demand characteristics
influencing the final outcome.

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 • Who is doing the research is very important. Often those that design the program play an
integral role in its evaluation, potentially leading to a lack of objectivity and researcher
bias.
• Strong evaluation requires triangulation. This is time-consuming and expensive.

Key studies: health

1. Kiecolt-Glaser (1984)
• Kiecolt-Glaser (1984)

Many of us have had our vacations ruined by colds and flu. We manage to get through all of the
things that we have to do before vacation - major projects, oral presentations and mock exams -
only to find ourselves spending our holidays in bed with fever, cough and a general feeling of not
being well. Is this just the gods punishing us for procrastination or can health psychology explain
why this happens to us? More importantly, if we know why this may happen, is there a way to
prevent it?

Background

Cohen (1993) carried out a study to see if stress leads to colds. In his study he gave 276 healthy
participants a series of tests to determine their overall general health and their recent exposure to
stress. He then exposed 276 healthy participants to either a cold virus or to a simple saline
solution, which served as the placebo. Participants were then quarantined for five days. They
checked daily for any sign of illness. The researchers found that the duration and nature of stress
that an individual experiences is a strong predictor of who gets a cold. Those who had high levels
of stress for a month or more were over twice as likely to get ill as those who had no such stress.
The type of stress also seems to matter. Participants who were unemployed were three times
more likely to develop colds than those who didn’t have work-related problems. And those who
reported serious problems in their close relationships were 2.5 times more likely to contract
viruses than those without such problems.

This study is an interesting one, but it doesn't look at how stress actually leads to a decrease in
our body's ability to fight off disease. To get more information on that, we need to turn to a
classic study in psychology carried out by Kiecolt-Glaser et al (1984).

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Procedure

The aim of the research was to see if the stress of important exams could lead to a decrease in
immune function. The sample was made up of 26 female and 49 male first-year medical students
from the Ohio State University College of Medicine. The sample was a self-selected (volunteer)
sample. All participants had to be free of any health problems in order to participate. The study
was a natural experiment in that the independent variable - the stress of examinations - was
"naturally" occurring and was not manipulated by the researcher.

The participants were tested for their level of stress before the experiment began. One month
prior to exams, the participants were given the Social Readjustment Rating Scale to account for
life changes that occurred within the last year that would raise their level of stress.

As a result of this test, the participants were divided into two groups: a high stress and a low
stress group. Levels of loneliness were also measured and the participants were also divided into
two groups: high loneliness and low loneliness.

A blood sample was then taken. A second blood sample was taken after students had completed
the first two examinations.

Natural Killer cell (NK) activity was measured in the students' blood sample. NK cells are
lymphocytes which provide rapid responses to viral-infected cells. A low level of NK activity
indicates a poorly functioning immune system.

Results
There was a significant decrease in NK cell activity between the first blood test and the second
blood test - which was taken during the stress of examinations. Those participants in the "high
stress" group were more likely to have lower levels of NK than those in the "low stress" group.
This means that stress experienced previous to the exams played a role in their immune systems'
ability to cope with the stress of examinations. In addition, those participants in the "high

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loneliness" group had lower levels of NK than those in the "low loneliness" group. This confirms
the role of social support as a protective factor for better health.

Kiecolt-Glaser concluded that stress has a direct effect on the immune system by suppressing NK
cell activity.

Discussion
The research seems to support the General Adaptation Model proposed by Selye. As our body
continues to cope with stressors, it eventually becomes "exhausted." In this exhausted stage, this
is when we are most likely to become ill. Up until Kiecolt-Glaser carried out this study, much of
the research carried out on stress's role on the immune system had been carried out on animals.
For example, Rasmussen (1957) demonstrated that stress could increase susceptibility to herpes
simplex virus in mice. It is a strength that the study was carried out on humans in a way that was
ethically sound.

Another strength of the study is that it was a repeated measures design - that is, an individual's
NK cell count was compared before and after the stress of examinations. This eliminated the
problem of participant variability, as each person's "post-stress" NK cell count was compared to
their "low-stress" baseline NK cell count.

Unlike Cohen's study, Kiecolt-Glaser actually used biological markers to determine the effect of
stress, rather than simply observing whether someone gets ill or not. But even with this, the
cause and effect relationship is still rather difficult to fully establish. As it was a natural
experiment, the controls over the experiment were not as good as would be in a laboratory
experiment. For example, it is not known how the participants cope with stress. Some of the
participants may have better coping strategies which would better regulate their stress response.
This may have affected the results. However, the study is naturalistic and has high ecological
validity. It also seems to reflect the personal experience that many students experience with
regard to illness during and immediately following exam experiences.

Finally, one of the problems of the experiment is the age of the participants. Students are often
used in psychological research because they are easy to find and usually willing to participant in
research studies. However, younger people usually have stronger immune systems than older
people. Therefore, it is difficult to generalize the findings to older people. In addition, the
stress of exams is an acute stressor. It is not like poverty or constant noise pollution. More
research needs to be done on the extent to which the nature of the stressor itself may - or may not
- have an effect on the immune system.

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2. Marmot et al (1997)

Marmot et al (1997) - also known as the "Whitehall Study" - is perhaps one of the most well-
known studies in health psychology. This study may be used to discuss the following learning
objectives:

Effect of sociocultural factors on health

Explanations of health problems

Research approaches in health psychology

Background

Since the 1960's, a long-term study has been running on the relationship between workplace
stress, health, and various individual and social risk factors. Participants were taken from
London-based Government civil servants. In the first study - Whitehall I - the researchers found
that workers in lower level positions suffered twice the rate of heart problems as the workers at
the highest levels. The focus of the Whitehall study was on an individual’s sense of control in his
or her work environment. The degree of control a person has over their workload has been
shown to affect directly the level of stress experienced. High levels of control lead to lower
levels of stress, while low levels of control – typically experienced by workers lower down the
organization hierarchy – can increase stress levels.

But this initial study simply set up correlational data without adequately establishing the health
of the individuals before they began gathering data. That is why the second study was done - and
continues to collect data.

Procedure

Marmot et al. (1997) analyzed data from over 7000 participants in the Whitehall II study. The
sample was made up of both male and female civil servants, aged 35 - 55, working in the London
offices of 20 different Whitehall departments. Participants were given an initial screening to
make sure that all were free of heart problems prior to the study. The aim was to then find out
whether they those in the lower position jobs - that is, with less control over their work
environment - would develop heart problems over the five year period. This is an example of a

101
prospective longitudinal study. Though it still is correlational, it establishes that in fact heart
disease developed over the course of the study - eliminating pre-conditions as a confounding
variable.

In order to gather their data, the researchers used a series of questionnaires, as well as carried out
health screenings. The participants were invited to the research clinic and a questionnaire was
sent to their homes at five-year intervals. Self-reported non-fatal heart problems, as well as cases
of cancer and diabetes, identified in the questionnaires were verified by hospital records.

Results

The final data showed a similar correlation between heart disease and status as found in the first
Whitehall study. The rate of heart problems in the lowest levels of the system were 1.5 times the
rate in the highest levels.

When the researchers analyzed the data in detail they found that risk factors such as smoking,
obesity and hypertension could account for some of the increase in lower grades, but the most
significant factor was the degree of control that participants felt they had. Lack of control had a
significant effect, independent of socio-economic and other risk factors. The graph on the next
page shows the “physical functioning score” of men and women in relation to their level within
the bureaucracy.

102
Discussion

It appears that there is a relationship between one’s sense of control in the work environment and
the health of one's cardiovascular system. The study has been supported by animal research
carried out by Robert Sapolsky. Sapolsky studied the effect of social hierarchy on stress levels.
Dominant male baboons were shown to have much lower levels of stress than subordinate
baboons. Sapolsky observed the bigger, dominant males often teased the weaker ones, pushing
them around and not letting them have a fair share of food or mating privileges. In fact, the
baboons that were most submissive to the dominant males revealed brain activity similar to the
kind found in clinically depressed humans.

The findings are also supported by other studies that have demonstrated a clear relationship
between stress at work and lack of control. Johannson et al. (1978) found higher levels of stress
hormones and stress-related illness in a group of highly skilled saw-mill employees whose work
was machine-paced, giving them little or no control over their work-rate.

The fact that this is a longitudinal prospective study is a key strength of the research. Also,
since everyone in Britain receives the same quality healthcare, the level of health care cannot be
considered a confounding variable to the extent that it would be in the United States.

However, there are some limitations of the study. The study was based primarily on self-report
questionnaires. Social desirability effect could play a role in individual responses regarding risk
factors. In addition, not all participants may have been conscious of - or honest about - their
health over the five year period. Although hospital records were also used, access to these
records was not always available to the researchers.

In addition, the sample was taken from the British government’s civil servants. The hierarchy is
perhaps more rigid in the Civil Service than in other large employers. This is simultaneously a
strength and a weakness of the Whitehall II study. The study may not be representative of
conditions experienced in the average workplace.

Finally, the researchers may have overly attributed the effects on health to the hierarchy, rather
than to dispositional factors. Although control within the system may be the root of stress-related
illness, one has to question whether there is a disposition toward sense of control. The research
does not account for differences within each level of the system, only between them.

103
3. Newcomer et al (1999)

Newcomer et al (1999) studied the effects of stress on verbal declarative memory. You can use
this study for the following content in the biological approach:

Research methods used in the biological approach.

The function of hormones in human behaviour.

It could also be used in the health option to address the following content:

Explanation of health problems.

The original study is available here.

Procedure

The aim of the research was to investigate whether high levels of the stress hormone
cortisol interfere with verbal declarative memory.

All participants were employees or students at the Washington University Medical

Center. All participants were given a clinical interview with a physician. They were
excluded from the sample if they were pregnant, had a history of mental illness, had
suffered head trauma, or had suffered from an illness that had been treated with
corticosteroids. In addition, participants not routinely sleeping during the night hours
were excluded to standardized circadian rhythms.

The researchers carried out a double blind laboratory experiment in which the participants were
matched for age and gender to one of three conditions:

• Condition 1 – high level of cortisol: The participants in the high-level cortisol

group were given a tablet containing 160 mg of cortisol on each day of the four-

104
 day experiment. This dose of cortisol produces blood levels similar to those seen
in people experiencing a major stress event.

• Condition 2 – low level of cortisol: The participants in the low level of cortisol
group were given a tablet containing 40 mg of cortisol per day. This dose is
similar to the amount of cortisol circulating in the bloodstream of people
undergoing minor surgical procedures such as having stitches removed.

• Condition 3 – placebo group: The participants in this condition were given

placebo tablets - that is, a tablet that looked like the other tablets but with no
active ingredient. This was done in order to have a control group.

All participants were asked to listen to and recall parts of a prose paragraph. This tested their
verbal declarative memory over a period of four days.

Results

The results indicated that high cortisol levels impaired performance in the memory task since the
participants who received the highest level of cortisol also showed the worst performance in
verbal declarative memory. However, the effect was not permanent. The performance of
participants in the high cortisol condition returned to normal after they stopped taking the
hormone tablet. According to the researchers, these results demonstrate a clear link between
levels of cortisol and remembering. It appears that high levels of cortisol interfered with the
recall of the prose passage, whereas moderate levels of cortisol may have actually assisted in the
recall of the passage. This makes sense as there are cortisol receptor sites on the hippocampus,
which is responsible for the transfer of information from STM to LTM and vice versa.

Evaluation

• Since this study was experimental, the researchers could establish a clear cause and effect
relationship between the IV and the DV.

105
• The experiment ran over several days and the participants were not in the lab the whole
time, so the researchers did not have full control over extraneous variables. In spite of
this, there was a clear relationship between the amount of cortisol ingested and the
performance on the memory test.
• Memorizing a piece of prose is perhaps not the most authentic memory experience.
Although it may explain student exam stress, the ability to generalize the results to other
situations may be limited.
• There are ethical considerations in the study. The participants ingested cortisol which
affected their memory negatively. However, the participants had signed an informed
consent form and the damage was not permanent.

106
Writing samples: Health

The following section includes annotated samples of responses to exam

questions - as well as strategies for answering questions based on the command terms. The
responses are not from the IB. They are based on work done in-class by students, or they are
created specifically for the site. Often the sample is designed to provide examples of common
mistakes or in order to show something that should be done for higher marks.

There is no definitive list of questions for this curriculum - so the list of potential questions
below is not exhaustive. However, I do believe that most of the questions will fall within the list
that has been provided below. Remember that there are no SAQs on Paper 2.

For the ERQ responses, students will need to include two or more pieces of research.

Potential exam questions: Determinants of health

All of these learning outcomes are written as "discuss" questions, but they could also be asked as
contrast, evaluate and to what extent questions.

Combining topic and guidance

• Discuss ethical considerations in the study of determinants of health.

• Discuss approaches to research used to study determinants of health.

Content only

• Discuss the biopsychosocial model of well being.

• Discuss the role of dispositional factors in health behaviour.
• Discuss the role of health beliefs in health behaviour.
• Discuss the role of protective and risk factors in health.
• Discuss research on the role of protective (or risk) factors in health.

Potential exam questions: Health problems

All of these learning outcomes are written as "discuss" questions, but they could also be asked as
contrast, evaluate and to what extent questions.

Combining topic and guidance

• Discuss a biological approach to understanding one health problem.

107
 • Discuss a cognitive approach to understanding one health problem.
• Discuss a sociocultural approach to understanding one health problem.
• Discuss ethical considerations in the study of one health problem.
• Discuss approaches to research used to understand one health problem.

Content only

• Discuss one explanation of one health problem.

• Discuss the prevalence of rates of health problems.

Potential exam questions: Health promotion

All of these learning outcomes are written as "discuss" questions, but they could also be asked as
contrast, evaluate and to what extent questions.

Combining topic and guidance

• Discuss a cognitive approach to promoting health.

• Discuss a sociocultural approach to promoting health.
• Discuss ethical considerations to promoting health.
• Discuss approaches to research used to understand the promotion of health.

Content only

• Discuss one theory of health promotion.

• Discuss the effectiveness of one health promotion program.
• Discuss the effectiveness of health promotion programs.

108
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