Health Psychology: Theory, Research and Practice - David F. Marks 2010


Welcome to Health Psychology: Theory, Research and Practice (Fifth Edition). This textbook provides an in-depth introduction to the field of health psychology. It is designed for all readers wishing to update their knowledge about psychology and health, especially undergraduates and postgraduates taking courses in health psychology, medicine, nursing, public health, and other subjects allied to medicine and health care. The authors strive to present a balanced view of the field and its theories, research and applications. We aim to present the mainstream ideas, theories and studies within health psychology and to examine the underlying theoretical assumptions and critically analyse methods, evidence and conclusions. This edition updates all content from previous editions and adds significant, core topics from the biological and clinical domains.

All mainstream domains and topics relevant to health psychology are included. A key feature of this textbook is the equal priority given to the three aspects of the biopsychosocial (BPS) approach: biologicical, social and psychological determinants of health, illness and health care. The authors argue that both social embeddedness and psychological influences are as important to health and illness as genes and ’germs’. In this book we attempt to locate health psychology within its global, social and political contexts. We attempt to provide a snapshot of the ’bigger picture’ using a wide-angle lens, as well as giving detailed, critical analyses of the ’nitty-gritty’ of theory, research and practice.

This textbook introduces readers to the field of health psychology, the major foundations and theoretical approaches, contemporary research on core topics, and how this theory and evidence is being applied in practice. In this fifth edition we have improved the structure, updated the text, enhanced the pedagogical features, and expanded the online resources.

Health psychology is still relatively young, having developed as a sub-discipline in the 1970s and 1980s. The primary mainstream focus has been theories and models about social-cognitive processes concerned with health beliefs and behaviours. This approach has yielded thousands of research publications of a mainly empirical nature to study issues, test theories and models about the causes of health behaviour change, and investigate interventions. The growth of interest in this subject has been truly amazing. Similar to psychology more generally, the primary focus of health psychology has been the behaviour, beliefs and experiences of individuals.

The book introduces alternative, critical approaches to health psychology which are not yet part of the mainstream. We advance the case that psychological issues are embedded in human social structures in which economics and social justice play crucial roles. The mainstream socio-cognitive framework appears to us to be of limited relevance in a world where issues of poverty, social injustice and conflict exist for millions of people, and psychological processes are conditioned by basic limitations of capability, freedom and power (Marks, 1996, 2002a, 2004; Murray and Campbell, 2003; Murray, 2014a, 2014b). We evaluate and critique contemporary psychological theories and models in that context.

In our view, to make a contribution to society, theory, research and practice in health psychology must engage with the real economy, develop approaches for industrial-scale behaviour change, and work with communities and the struggles of the dispossessed. An agenda for health psychology needs to include ’actionable understandings of the complex individual—society dialectic underlying social inequalities’ (Murray and Campbell, 2003: 236). Preliminary thoughts on ’actionable understandings’ and of the ’individual—society dialectic’ are presented in this book. By having access to mainstream and alternative perspectives in a single volume, lecturers and students can reach an assessment of the field and how it could make more progress in the future.

We explain the significance of the biological and social contexts, and review theory and methods (Part 1), analyse the complexity and diversity of health behaviour (Part 2), discuss health promotion and disease prevention (Part 3), and explicate the significance of clinical health psychology for some of the major afflictions of the age (Part 4).


Source: Adapted from Dahlgren and Whitehead (1991: 23)

The book uses a multi-level framework that takes into account both the biological determinants and the social context of health-related experience and behaviour. This multi-level framework, the ’Onion Model’, assumes different levels of influence and mechanisms for bringing about change (see Table P1 and Chapter 1 for details).

Health psychology is a potentially rich field but, if it is to become more than a ’tinker’, it is necessary to master an appreciation of the cultural, socio-political and economic roots of human behaviour. In this book, we aim to apply an international, cultural and interdisciplinary perspective. We wish to demonstrate the great significance of social, economic and political changes. As the gaps between the ’haves’ and the ’have-nots’ widen, and the world population grows larger, the impacts of learned helplessness, poverty and social isolation are increasingly salient features of contemporary living.

Those concerned with health promotion and disease prevention require in-depth understanding of the lived experience of health, illness and health care. By integrating research using quantitative, qualitative and action-oriented approaches, we take a step in that direction.

The Biopsychosocial Model

The dominance of the biomedical system has been challenged by figures in the the scientific establishment and by certain patient groups. These challenges are reflected in a call for more attention to the psychological and social aspects of health and, in particular, in the so-called ’biopsychosocial model(BPSM) proposed by Engel (1977, 1980). According to Engel (1980) all natural phenomena can be organized into a hierarchy of systems ranging from from the biosphere at one end of the hierarchy to society and the individual level of experience and behaviour towards the middle and then to the cellular and subatomic levels at the other end of the hierarchy. These different levels need to be considered if we are to fully understand health and illness. The BPSM has become the conceptual status quo of contemporary psychiatry (Ghaemi, 2009) and a banner for health psychology. Yet it is far from being established as a paradigm in medicine and health care where the biomedical model remains resiliently in force.

Long before Engel, William Osler (1849—1919) had stated: ’The good physician treats the disease; the great physician treats the patient who has the disease.’ He also stated: ’Listen to your patient, he is telling you the diagnosis.’ The traditional biomedical model remains the core of medical education, although there may have been a slight shift in the thinking of doctors in primary care and in liaison psychiatry towards a more holistic, BPS view of the patient (see Chapter 1). The BPSM remains a fertile idea for a transformed biomedical model by including the psychological and social aspects of illness along with the biological aspects. The BPSM has been influential, for example, in providing an account of the influence of racism on health outcomes (Clark et al., 1999) and in understanding adolescent conduct problems (Dodge and Pettit, 2003).

However, the BPSM has not been free of controversy — for example, when it has been extended as a cognitive behavioural theory of illness such as myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS) by asserting that cognitions and behaviours perpetuate the fatigue and impairment in individuals suffering from the condition(s) (Wessely et al., 1991; Chapter 24). In psychiatry Engel’s BPSM became associated with a particular socio-cognitive model for illness experience. We argue that the socio-cognitive formulation has tended to constrain theorizing within health psychology (Chapter 8) and narrowed thinking about clinical conditions and stigma to the presumption of incorrect beliefs and attitudes (Chapter 23). It is important to distance Engel’s generic BPSM as a schematic approach to health care from specific formulations of the socio-cognitive model. In truth, there is a multitude of biopsychosocial theories and models that should not be lumped together under a single umbrella, because the devil is in the detail. The adoption of the BPSM by general practitioners can meet with resistance or even hostility by patients either because they feel more comfortable with the traditional ’doctor knows best’ model of biomedicine or because they deem the BPSM is not a good fit for their illness (e.g. ME/CFS).

Seventy years ago the World Health Organization (WHO) proposed a definition of health as: ’a state of complete physical, mental and social well-being, not the mere absence of disease or infirmity’. This definition widened the scope of health care to consider well-being more holistically. The WHO definition has not been revised since its original publication in 1948. In Chapter 1 we suggest a wider definition, encompassing the economic, political and spiritual domains of daily living for these are also contributing conditions of well-being. Currently, some areas of health care are shifting from a concern with purely bodily processes to an awareness of broader concepts of quality of life and subjective well-being.

Another recent trend has been an ideological emphasis on patient choice and individual responsibility for health. Crawford (1980: 365) argued that ’in an increasingly “healthist” culture, healthy behaviour has become a moral duty and illness an individual moral failing’.

Human Rights and the Responsibility to ’Do No Harm’

The universal human rights of freedom of speech, thought and action within the law are an essential principle in health care. Health care is at the interface between policy and practice and as such must have a strong foundation in the rights of patients and populations as human beings. In recent years there has been a political shift wherein hate speech and divisive rhetoric by key political leaders have served to ’unleash the dark side of human nature’. This political shift has been the subject of a report by Amnesty International (2017), which has brought to stark attention the ’dark forces’ which are changing the geo-political environment ... wherein more and more politicians call themselves anti-establishment and wield politics of demonization that hounds, scapegoats and dehumanizes entire groups of people to win the support of voters.

This rhetoric will have an increasingly dangerous impact on actual policy. In 2016, governments turned a blind eye to war crimes, pushed through deals that undermine the right to claim asylum, passed laws that violate free expression, incited murder of people simply because they use drugs, legitimized mass surveillance, and extended draconian police powers. (Amnesty International, 2017:

The report also refers to the fact that some countries have implemented intrusive security measures, such as prolonged emergency powers in France and unprecedented surveillance laws in the UK. Another feature of ’strongman’ politics has been the rise of anti-feminist and anti-LGBTI rhetoric, such as efforts to roll back women’s rights in Poland (Amnesty International, 2017).

Changes to the geo-political framework towards an openly political agenda that supports division, inequality, discrimination, scapegoating and stigma are likely to ripple across into health and social care. All who work in health care face everyday difficult decisions that profoundly impact upon people’s lives. The embedding of such decisions in a human rights-based ethical foundation of ’do no harm’ becomes ever more relevant if the current climate continues.

Making the Best Use of This Book

This fifth edition has been completely revised and updated, with many additional chapters and with a significant share of references from the three years 2015—2017. Lecturers may recommend the chapters in any order, according to the requirements of any particular course and their personal interests and preferences. Chapters are written as free-standing documents. No prior reading of other chapters is assumed.

Each chapter begins with an Outline and ends with a detailed Summary of key ideas and suggestions for Future Research. Each chapter contains tables, figures and boxes, and recent examples of key studies to guide student understanding. International studies present works by key people living in different parts of the world, showing how context, culture and the environment affect health and behaviour.

Key terms are identified by bold and defined in the Glossary at the end of the book.

A useful companion reader to this textbook is The Health Psychology Reader (Marks, 2002b), which reprints and discusses 25 key articles, accompanied by introductions to the main themes. Readers can also refer to the 85 key articles in New Directions in Health Psychology (Murray and Chamberlain, 2015).

Online resources


The fifth edition of Health Pyschology is supported by a wealth of online resources for both students and lecturers to aid study and support teaching, which are available at

For students

· Learning objectives for each chapter to reinforce the most important material.

· Mobile-friendly eFlashcards which strengthen understanding of key terms and concepts.

· Mobile-friendly interactive quizzes that allow you to access your understanding of key chapter concepts.

· Links to videos that offer a new perspective on the material covered in the book.

· An action plan helping you to see how you progress through the course and materials.

For lecturers

· PowerPoint slides featuring figures, tables, and key topics from the book can be downloaded and customized for use in your own presentations.

· A Testbank that provides a range of multiple choice and short answer answers which can be edited and used access student progress and understanding.

· A Course Cartridge containing all the student and instructor resources in one place accompanies this book. The Course Cartridge allows you to easily upload these resources into your institution’s learning management system (e.g. your Blackboard or Moodle), and customise course content to suit your teaching needs. Visit the online resources or contact your local sales rep to find out more.


DFM: Over a period of 20 years, many talented people have helped to create this textbook and here I wish to acknowledge and give thanks for their contribution. To Michael and Emee, my co-authors, for friendship and collaboration over many years; specifically, to MM for his unstinting support and lively humour, in spite of a heavy administrative burden; to EVE for cake, songs and smiles. To Brian Evans, co-author of four previous editions, for pleasant walks, talks and lunches over heath and by river. To Ziyad Marar for his enthusiastic skills of persuasion that drew me into the SAGE fold two decades ago. To many colleagues at SAGE, especially: Michael Carmichael, the original commissioning editor, for his enthusiastic skills of persuasion (must be a SAGE thing), Luke Block as editor of the previous edition and Amy Jarrold, the editor of this fifth edition, with the capable assistance of Katie Rabot, and the complete editorial team for this new edition. To Toni Karic for her able assistance in developing the online resources. To Catherine Sykes for friendship and inspiration as a co-author of the second edition. To Carla Willig for friendship, as a co-author of the first two editions. To Cailine Woodall for contributing to and co-authoring the second edition. To generations of students and academic colleagues at universities, from Otago in the Deep South and Tromsø in the Arctic North, from Hokkaido, Hamamatsu, and Kyushu in the Far East and Oregon, Washington and Stanford in the Far West, and, closer to home at Sheffield, UCL, LSE, Cambridge and Middlesex Universities. To my father, Victor, for providing the quiet refuge I still call ’home’, away from the hustle and bustle of London. To Alice Vallat, for love, friendship and a happy home in Arles, Provence. Thank you all warmly and sincerely — this book couldn’t and wouldn’t have happened without you.

MM: Thanks, as always, to Anne for her continuing love, kindness and inspiration.

EVE: To my parents for life, to my Andy for love, to my mentor, DFM for guidance, and to my son, Vas for purpose — thanks!