Risk behaviour and stress
Psychology and health
Kay Govender & Inge Petersen; Basil Joseph Pillay
After studying this chapter you should be able to:
•demonstrate an ecological-systems understanding of the concepts of risk behaviour and resilience
•discuss how the health belief model helps to explain preventive health behaviours
•discuss how the stages of change model can be used as a framework for studying addictive behaviours
•identify the assumptions underlying the theory of reasoned action and the theory of planned behaviour
•identify the assumptions of the social-cognitive model
•explain how social networks mediate the capacity of people to respond to high-risk situations
•understand how cultural and structural factors influence risk behaviour
•describe what stimuli cause stress reactions
•explain the psychophysiology of stress
•describe the relationship between stress and illness
•be able to describe stress-reduction methods.
Xolani had always been a fairly cautious person who tried to weigh up his options carefully before he took a risk of any kind. He didn’t drink or smoke, and he tried to take care of his physical well-being. Sometimes, though, when he read magazine articles about the many different risks to his health, Xolani felt anxious. There seemed to be so much information and so many confusing rules about how to keep safe and fit these days. He also felt a bit guilty, as though if he got sick, it was his own fault for not taking proper care of himself. In spite of this information overload, Xolani did believe that it was important for people to have accurate information about some of the serious health risks they faced and what they could do to avoid the problems. HIV/AIDS was a good example of a disease that could be prevented if people knew the risks and took better care of themselves.
Xolani sometimes found it quite stressful trying to keep healthy! He and his friends often used the word ’stress’ to describe what they were feeling when things were getting them down in some way, but he hadn’t given much thought to what it really meant. However, as he learned about the concept in his psychology course, he was able to identify more clearly the ways in which his mind and body reacted to demanding circumstances. This was especially the case at exam time. On the day of an exam, Xolani often had sweaty palms and would feel his heart beating faster. He had found that it helped a little if he deliberately tried to slow down his breathing. By the end of the exam period, he would feel exhausted, almost like he had run a marathon. Then, just as he should be celebrating that the exams were all over, he would inevitably come down with a cold or flu. It always seemed so unfair! Xolani wished that he didn’t react so badly to exams. He had seen that other people seemed to cope better, while some worried about different issues, like money or relationships. People had to deal with a great deal of stress and pressure in their daily lives and Xolani wondered what sorts of long-term effects this might have on their emotional and physical health.
Smoking cigarettes, drinking large quantities of alcohol, overeating and having unsafe sex are a few of the common high-risk behaviours in which people engage. Other ’lifestyle’ risk factors include physical inactivity, eating the wrong kinds of foods and not accessing health-screening services where these are available. In this sense, we are often told that we live in a ’risk society’ (a term coined by Ulrich Beck, 1992). Experts frequently disagree about what is dangerous and what should be considered risky behaviour, and how we should manage risk. As an example, conflicting ideas about the cause, treatment and behavioural management of HIV/AIDS have interfered with combating this pandemic.
In a context of increasing social fragmentation and mistrust of expert systems, many people have a heightened awareness of the physical and social dangers that they are exposed to in everyday life. Increasingly, risk-management strategies (such as negotiating safe sex, managing our diet or exposure to harmful substances) position individuals as being ultimately responsible for monitoring and managing the risk in their lives (Rhodes & Cusick, 2000). But this can be problematic in situations where people do not have the freedom to control their lives. For example, it has been found that gender inequality and economic dependence make women less likely to be able to control whether they have safe sex or not (Jewkes, Levin & Penn-Kekana, 2003).
An ecological-systems approach to understanding risk behaviour
Risk is the possibility of harm, and to risk something (such as your health) means to put it in danger. Risk behaviours refer to specific forms of behaviour that are proven to be associated with increased susceptibility to a specific disease or ill-health. Vulnerability, or the susceptibility to negative outcomes, is determined by a number of risk factors. Risk factors refer to biological, psychological, social or economic behaviours or environments that are associated with, or cause increased susceptibility to, a specific disease, ill health or injury. They comprise processes, within or outside individuals, which predispose them to succumb to negative stressors.
Figure 21.1 Risky behaviour can be as simple as smoking, drinking too much alcohol and overeating
Figure 21.2 Bronfenbrenner’s four levels of influence
Why do people sometimes behave in ways that can be perceived as harmful or risky to their mental and physical health? An ecological-systems approach (Bronfenbrenner, 1986) understands vulnerability to risk behaviour as being influenced by multiple contexts. These contexts can be broadly categorised into four levels of influence, namely the individual or intrapersonal level, the interpersonal level, the community level and the societal level (see Figure 21.2). An ecological-systems approach to understanding a health problem emphasises the interdependence between the factors across all the levels.
When considering these four levels, we can see how they provide different strategies for reducing vulnerability to high-risk behaviour and promoting healthy behaviour. These strategies can generally be split into person-centred and situation-centred interventions:
•Person-centred interventions work with individuals and groups to promote health-protective behaviour and enhance resilience. Resilience is the successful adaptation to the environment despite exposure to risk.
•Situation-centred interventions are focused on creating environments with protective factors that enable individuals and groups to practise healthy behaviour. Protective factors are those influences that limit or reduce the likelihood of high-risk behaviour and play a moderating or buffering role.
Some theories of behaviour and behaviour-change determinants focus on an individual’s cognitive evaluation of their behaviour. Others broaden their focus by taking into account aspects of the social and structural environment in which people are located. These theories are briefly discussed below and are summarised in Table 21.1.
•People engage in a wide variety of high-risk behaviours; however, there is not complete agreement about what should be considered risky behaviour and how we should manage risk.
•Increasingly, risk management strategies are becoming an individual responsibility; however, individuals live in social and cultural contexts which may limit their control over aspects of their lives.
•The risk of harm is increased through risk behaviours; vulnerability to harm depends on various biological, psychological, social or economic risk factors.
•The ecological-systems approach understands vulnerability to risk behaviour and to harm as being influenced by multiple contexts. These contexts can be categorised into four levels of influence: individual, interpersonal, community and societal levels.
•The different levels indicate different strategies (e.g. person- or situation-centred) for reducing vulnerability to high-risk behaviour and promoting healthy behaviour.
•Resilience involves successful adaptation to the environment despite exposure to risk.
•Protective factors are those influences that limit or reduce the likelihood of high-risk behaviour and play a moderating or buffering role.
The individual level
At the individual (intrapersonal) level, the cognitive (mental) perspective is commonly used for understanding risky behaviour. Intrapersonal factors include knowledge, attitudes, beliefs, motivation, self-concept, developmental history, past experience and skills.
Two well-known models that try to understand individual factors that influence behaviour are the health belief model (Rosenstock, 1974) and the stages of change (transtheoretical) model (Prochaska & DiClemente, 1984). The theory of reasoned action and the theory of planned behaviour also provide insights at the individual level.
The health belief model
The health belief model (HBM) (see Figure 21.3) was one of the first models that adapted theory from the behavioural sciences to understand health problems. It was developed in the 1950s by psychologists working in the US Public Health Service and it remains one of the most widely recognised conceptual frameworks of health behaviour (National Cancer Institute, 2005). It was developed with the specific purpose of helping to understand why people did not participate in public health programmes that were on offer; in other words, it was interested in preventive health behaviours (Rosenstock, 1974 in DiMatteo & Martin, 2002).
Figure 21.3 The health belief model
The HBM focuses on six constructs that influence how a person will act in a given situation. Before someone engages in any behaviour, he/she will consider the health risk of the situation in terms of these concepts and this accounts for that person’s readiness to act. In terms of the model, action is also moderated by a number of personal factors such as age, sex, personality, culture, education, etc. (Glanz, Lewis & Rimer, 2002, in Bostwick, 2014). The six constructs are as follows:
•perceived susceptibility (their opinion of the chances of getting the condition)
•perceived severity (their opinion of how serious a condition and its consequences are)
•perceived benefits (their opinion of the efficacy of the recommended action to reduce risk or seriousness of impact)
•perceived barriers (their opinion of the material and psychological costs of the advised action)
•self-efficacy (their confidence in being able to successfully perform a behaviour)
•cues to action (they are exposed to messages that activate their readiness to act).
The stages of change (transtheoretical) model
The stages of change (transtheoretical) model (SCM) was initially developed by Prochaska and DiClemente (1984) as a framework to study addictive behaviours including smoking, and alcohol and drug abuse. These authors believed that health behaviour change is a process rather than an event (National Cancer Institute, 2005). As individuals prepare to change their behaviour, it seems they move through a series of five stages (Prochaska & Norcross, 2010), each of which is associated with different attitudes, intentions and behaviour (Prochaska & Norcross, 2010):
1.During the precontemplation stage, people have no intention of changing their behaviour. They may even be unaware of the risk they are placing themselves in or that their behaviour represents a problem. At this stage there is considerable resistance to change.
2.Once they become aware of their problem behaviour and start to consider doing something about it, they are in the contemplation stage. Although they are aware that their behaviour represents a problem, they do not take any action to initiate change and they tend to struggle with indecision about changing their behaviour (Prochaska & Norcross, 2010).
3.In the preparation stage, people begin to take small steps towards changing their behaviour. They begin to formulate specific intentions to change their behaviour soon.
4.Once they take significant steps to change their behaviour, they are in the action stage. They invest considerable time and energy in their actions and persevere with the changes.
5.During the maintenance stage, people make every effort to prevent relapse and continue with successful strategies that helped them to successfully change their behaviour.
21.1A STUDY USING HBM CONCEPTS
Source: Ndabarora and Mchunu (2014)
This study examined the utilisation of HIV/AIDS prevention methods among university students at the University of KwaZulu-Natal. It was guided by the health belief model and studied health-seeking behaviours. The study considered perceived susceptibility, perceived severity and perceived benefit of condom use.
Although more than half of the students were aware of voluntary counselling and testing (VCT), only just over one-third of them had accessed these services. Almost half of the students used condoms and more than two-thirds had been tested for HIV. The students had a high perceived susceptibility; however, this did not correlate with their overall use of prevention methods. The study also found that the students had a good knowledge of HIV/AIDS, but they still had serious misconceptions about the disease.
There were a number of barriers to HIV testing identified by the study. As the HBM would predict, these included a low self-efficacy and low perceived susceptibility, although fear of testing positive and of stigmatisation were also found to be barriers. Knowledge of services was also important as this increased utilisation.
Although some HBM variables were confirmed by the study, others were not. The study found that a private venue for testing and greater advertising of services would assist in improving the student’s’ health-seeking behaviours.
Figure 21.4 The theory of reasoned action and the theory of planned behaviour
The model is circular in that people may enter the change process at any stage, relapse to an earlier stage, and begin the process once more (National Cancer Institute, 2005). They may cycle through this process repeatedly, and the process can also terminate at any point. This raises an important issue in behaviour change, that of relapse prevention. Prochaska and Norcross (2010) suggest that clients can be helped to understand that relapse is a process and that they can learn to identify situations that put them at risk for relapse as well as learn to cope with cravings.
The theory of reasoned action and the theory of planned behaviour
As depicted in Figure 21.4, both the theory of reasoned action (TRA) and the theory of planned behaviour (TPB) explore the relationship between behaviour and beliefs, attitudes, subjective norms and intentions. Behaviour results from an intention to carry out the behaviour (Ajzen & Fishbein, 1980), thus it is not seen as resulting from instincts or other impulses. According to the theory of reasoned action, a person’s intention to carry out a behaviour is determined by a combination of that person’s attitude towards the behaviour, together with his/her beliefs about what others whose opinions are valued think, as well as beliefs about whether key people approve or disapprove of that person’s behaviour (the person’s subjective norm). While the theory takes into account social normative influences, the model emphasises the subjective appraisal of these social influences by the individual.
Attitudes towards a behaviour are determined by people’s beliefs about the outcome of the behaviour, and their evaluation of that outcome. Their subjective norm is determined by what they think other people who are important to them want them to do, and their motivation to comply with these important people’s wishes. For example, Khanyi’s intention to complete her degree will be determined by her belief that completing the degree will lead to her being able to get a well-paying job (which she values) as well as the fact that her mother, whose opinion she values, will be proud of her. Similarly, Vuyisa’s intention to complete his degree will be determined by his belief that having a degree leads to peer respect (which he values), as well as the fact that his parents are not too concerned about his studies. In both these examples, Khanyi and Vuyisa’s intentions to complete their degree, which have been determined by their attitudes and beliefs, will be a strong determinant of whether or not they will complete.
To include influences at the community and societal level, the TRA was expanded into the theory of planned behaviour (TPB), which includes the element of perceived behavioural control (Ajzen, 1985). Perceived behavioural control is the extent to which people believe that they have control over their behaviour. This theory thus recognises societal influences but emphasises the individual’s subjective evaluation of these influences. For example, Jeff may believe that he is quite capable of remaining faithful to one partner. On the other hand, he may believe that society expects him to have multiple partners.
•At the individual (intrapersonal) level, risk-taking factors include knowledge, attitudes, beliefs, motivation, self-concept, developmental history, past experience and skills.
•The HBM was developed to help understand why people did not participate in available public health programmes.
•The HBM includes six constructs that influence how a person will act in a given health risk situation: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy and cues to action.
•In terms of the model, action is also moderated by personal factors such as age, sex, personality, culture, education, etc.
•The SCM was developed to study addictive behaviours including smoking, and alcohol and drug abuse.
•The SCM model argues that health behaviour change is a process rather than an event. In this change process, individuals move through a series of five stages: precon-templation, contemplation, preparation, action and maintenance.
•The SCM model is circular — a person may enter the change process at any stage, relapse to an earlier stage, and begin the process once more.
•The theory of reasoned action (TRA) and the theory of planned behaviour (TPB) explore the relationship between behaviour and beliefs, attitudes, subjective norms and intentions.
•According to the TRA and the TPB, behaviour results from an intention to carry out the behaviour; this is determined by a combination of attitude towards the behaviour and belief about what others think, as well as subjective norms.
•The TRA was expanded to include perceived behavioural control to lead to the TPB. Perceived behavioural control is the extent to which people believe that they have control over their behaviour.
•These cognitive models and theories of behaviour change have been criticised for being too individualistic and for assuming that people make rational decisions and are sufficiently educated about health and what constitutes healthy and risky behaviours.
Together with attitudes and subjective norms, perceived behavioural control is thought to influence intentions to perform a given behaviour.
These cognitive models and theories of behaviour change have been criticised for being too individualistic; Campbell (2003, p. 8) argues that this is because of a lack of ’actionable understandings of the ways in which community and social contexts impact on health’. These are discussed in later sections. In addition, cognitive models have been criticised for assuming that people make rational decisions (Campbell, 2003). However, most adolescents, and some adults, do not approach risk taking from a logical perspective. Emotional and interpersonal factors, as well as economic and power relations in society, often play an important role in determining risk behaviour (Airhihenbuwa & Obregon, 2000; Campbell, 2003). Furthermore, the HBM assumes that people are sufficiently educated about health and what constitutes healthy and risky behaviours. It has been suggested that the HBM, for instance, is therefore more applicable to well-educated, upper socio-economic groups (Rice, 1998, in Ross & Deverell, 2004).
The interpersonal level
At the interpersonal level, behaviour is influenced by people’s interactions with other people in their social world (e.g. family members, friends, co-workers, health professionals and others) and by cognitive factors, as well as by the interaction between these factors. Lyons and Chamberlain (2006) note that cognitive factors have been extensively researched across a wide range of health-related be haviours. The social-cognitive model is useful for understanding behaviour at this level because it explores the reciprocal interactions of people and their environments, and the psychosocial determinants of health behaviour.
The key feature of the social-cognitive model (SCM) is the reciprocal determinism between thought, behaviour and the environment (Bandura, 1986). Rather than focusing on the automatic shaping of behaviour by environmental forces as was argued by behaviourists like B. F. Skinner (see Chapter 5), this approach emphasises the importance of intervening thought processes. These include aspects of cognition such as information acquisition, storage and retrieval. In addition, Bandura felt that self-efficacy was critical in the performance of behaviour.
The SCM maintains that behaviour is determined by cognitive expectations and incentives:
•Cognitive expectations are beliefs about the likely results of an action in terms of positive or negative outcomes. For example, you may study hard for your exams if you believe it will lead to good marks.
21.2A STUDY USING SCM CONCEPTS
Source: Harrison, Xaba, Kunene and Ntuli (2001)
A qualitative study was conducted to explore young women’s understanding of risk for HIV/AIDS and teen pregnancy. It used peer-group discussions with school-going girls in the rural Hlabisa district of KwaZulu-Natal.
Access to money and gifts played an important role in young women’s decisions to have sex with men. Risky sex was often driven by a desire for status and acquisition of luxuries, which young girls in poor communities could not afford. As one girl participant stated about her older boyfriend, who was a taxi driver: ’He is quite old, but it doesn’t matter, if he’s right and has got the style (wears fancy designer label clothes) it is okay, after all love has no age.’ Clearly these girls were entering into sexual relationships with older and economically well-off men because of the expected positive rewards of material wealth and status. Girls were modelling the sexual behaviour of their peer group. Girls were punished by being beaten up or abandoned if they refused sex. On the other hand, some girl participants indicated that they would delay having sex until they were adults. These girls seemed to have a different role model for success. They demonstrated high levels of self-efficacy in practising abstinence from sex during their teens. The expected outcome of abstaining from sex was that they would not contract HIV/AIDS or be burdened with the role of being teen mothers during their school years.
People model certain behaviours because of perceived expected material and psychological rewards.
•Incentives are anticipated rewards that encourage a particular behaviour. In the example above, the incentive may be a prize or monetary reward from your parents, school or university.
Most learning occurs through observing others (modelling), where people are likely to perform the behaviour they observe, particularly if the model is similar to themselves in age, gender or race, and when the behaviour results in desirable social, psychological or material consequences. Furthermore, high-status individuals have been found to exert a stronger influence on behaviour than low-status individuals (Bandura, 1971). For example, the behaviour of a matric leader is more likely to be copied as a model than that of a new Grade 8 learner in a school. However, self-efficacy is also important in the SCM. Self-efficacy is a person’s conviction that they can perform a particular behaviour successfully (see Box 21.2).
While individual and interpersonal factors are often taken into consideration in understanding high-risk behaviour, the role of broader issues occurring at a community and societal level is often neglected. Mary Douglas in her influential work Purity and danger (1969) is particularly critical of the dominant individualistic and interpersonal approaches taken by psychological researchers in risk-perception research because of their focus on processes of cognition and individual choice. The cognitive model in particular has treated risk as an objective fact independent of society.
•At the interpersonal level, behaviour is influenced by the person’s interactions with other people in their social world.
•The SCM explores the reciprocal interactions of people and their environments, and the psychosocial determinants of health behaviour.
•The key feature of the SCM is the reciprocal determinism between thought, behaviour and the environment.
•This approach emphasises the intervening thought processes, including information acquisition, storage and retrieval.
•According to the SCM, behaviour is determined by cognitive expectations and incentives.
•Most learning occurs through observing others (modelling); various characteristics of the model impact on this process.
•In addition, self-efficacy is critical in the performance of behaviour.
•The SCM has been criticised for neglecting issues occurring at a community and societal level.
The community level
Bickerstaff (2004) shows how social and cultural factors influence the ways in which people conceptualise and deal with risk. Rather than responding as autonomous agents to the risks they perceive, people act as members of social networks. Examples of social networks would be extended family, school peers, work colleagues, and so on. These networks positively or negatively influence the capacity of these individuals to respond to high-risk situations.
21.3CULTURE AND AFRICAN CONCEPTS OF HIV/AIDS PREVENTION, CARE AND SUPPORT
Source: Airhihenbuwa and DeWitt Webster (2004)
The PEN-3 model is presented as a framework for HIV/AIDS prevention, care and support in Africa.
Culture is an important factor in how HIV/AIDS has affected African populations. It has eroded cultural structures. In addition, culture and language are critical for providing appropriate health care. In the past, training of health care workers has assumed that universal models of learning and behaviour are acceptable. This neglects indigenous knowledge and strategies. As a result, health intervention strategies (especially those that are individually based) have failed Africans. The PEN-3 model has been used to guide cultural approaches to managing HIV/AIDS in Africa, as well as for planning health and child survival interventions. The model’s primary domains are cultural identity, relationships and expectations, and cultural empowerment.
In applying the model, sociocultural issues can be framed within the domains. This then allows for a collective decision to be made about where and how to intervene to achieve the best outcome in terms of prevention and control of the epidemic. It is essential to place culture at the centre of HIV/AIDS prevention, care and support in Africa.
Community social networks can act as a protective factor. Social capital, which refers to people’s memberships of social groups or networks (their degree of connectedness), gains certain interpersonal and/or material benefits for an individual (Petersen & Govender, 2010; Putnam, 1995). Trust and reciprocity between members of a social group allow members to call on favours, share socio-economic resources, circulate privileged information and gain better access to opportunities (Sacchetti & Campbell, 2014). Communities whose members have high levels of social capital are also better able to resist disruptive forces. They are more likely to identify external threats as a group problem and marginalised groups, as collectives, can sometimes mobilise effectively to pressure decision-makers to address their concerns.
Public policies (such as apartheid) that increase socioeconomic inequities, as well as disrupt the personal, domestic and community social networks of marginalised communities, make such communities particularly vulnerable to the development of high-risk behaviours (World Health Organization, 2012). This involves a variety of interrelated mechanisms including a failure to socialise adolescents properly, as well as compromising social controls that are used in most communities to minimise negative influences such as early sexual debut, teenage and/or unwanted pregnancy, sexual abuse, alcohol and drug abuse, and criminal violence. A South African study in an informal settlement in KwaZulu-Natal found that girls and women felt particularly vulnerable to sexual abuse given the lack of supportive community networks and controls in place to protect them (Petersen, Bhagwanjee, Bhana & Mzimela, 2003).
In order to build relational ties, health promoters may promote self-help organisations. These organisations promote a sense of community and they empower group members to be able to give and receive help and share their problems (Arockiasamy, 2012).
Figure 21.5 Being a member of a social network is empowering
The societal level
At the societal level, theorists consider the role that society plays in determining risk; these approaches can be broadly categorised into cultural perspectives and structuralist perspectives.
Renowned anthropologist Mary Douglas (1985) contended that our cultural value systems are always relevant in the ways we judge risk or danger. So when people engage in activities they know to be labelled as risky (e.g. having sex without a condom when unsure of the HIV status of their sexual partner), this behaviour cannot only be attributed to a poor understanding of the dangers of contracting HIV/AIDS through unprotected sex. For instance, students have reported that they still engage in risky sexual practices, despite having a thorough understanding of HIV transmission (Petersen, Bhagwanjee & Makhaba, 2001). This is attributed to strong cultural beliefs that sex without a condom is more pleasurable. This notion is reinforced by shared cultural expectations of acceptable sexual behaviour and what constitutes risk. However, there has been some critique of Douglas’s theory (Oltedal, Moen, Klempe & Rundmo, 2004). Oltedal et al. (2004) found that cultural theory has a relatively low predictive power and argue that its success may be based on its simplicity and the intuitive sense that it makes.
An illustration of how cultural beliefs become influential to understanding HIV/AIDS is provided in Box 21.3.
Beck (1992) suggests that significant sectors of society are more affected than others by the various health risks, and that these differences are structured through inequalities such as class and position. At this societal level, risk is much more pervasive than at the community level because it involves systems of governance. The disadvantaged have fewer opportunities to avoid risks because of their lack of economic and political resources compared with the advantaged (World health Organization, 2012).
According to Wardle and Steptoe (2003), people who are socially and economically privileged tend to make healthier lifestyle choices in terms of nutrition and exercise; this may be due to differences in life opportunity and lifetime exposure to hardship. Thus, social class, gender, ethnicity and position in a person’s life are important structuring factors that may not allow some people the opportunity to have as much control over their actions as others. We have to ask: what chance does a young, single mother have to consider her behaviour? She may put herself at risk of contracting HIV because her promiscuous boyfriend is her only source of income. How much freedom from poverty does this mother have to self-construct her own life narrative?
In order to address power relations at a structural level, health promoters may facilitate the empowerment of groups to challenge structures through two processes: conscientisation (Freire, 1970) and social action (Alinsky, 1971, in Petersen & Govender, 2010). Conscientisation enables members to develop skills to analyse critically their problems and to recognise the roles they may take in changing their social conditions. Social action promotes community participation in efforts aimed at achieving common goals, such as improved quality of life, social justice and political efficacy. According to Petersen and Govender (2010), empowerment is achieved through bringing people together in social networks in order to develop social support and skills.
•Social and cultural factors influence the ways in which people conceptualise and deal with risk.
•Community social networks can act as a protective factor.
•Social capital refers to people’s memberships of social groups or networks; this gains interpersonal and/or material benefits for an individual. Also, such communities are better able to resist disruptive forces.
•Public policies that increase socio-economic inequities and disrupt community social networks make marginalised communities vulnerable to the development of high-risk behaviours.
•In order to build relational ties, health promoters may promote self-help organisations.
•Cultural perspectives argue that our cultural value systems are always relevant in the ways we judge risk, danger or acceptable behaviour.
•Cultural theory has been criticised for having a relatively low predictive power.
•Structural perspectives note that inequalities like class, gender, ethnicity and position affect health risks. The disadvantaged have fewer opportunities to avoid risks because of their lack of economic and political resources.
•To address structural inequality, health promoters may facilitate empowerment of groups through conscientisation and social action.
Table 21.1 Examples of theories of health risk behaviour at Bronfenbrenner’s four levels of influence
21.4SOCIAL ACTION: ’SERVICE DELIVERY’ PROTESTS
South Africa sees some 300 community protests a year. They have been considered to be ’rebellions of the poor’, stemming from historical inequality and a deep sense of social powerlessness. Other causes seem to be lack of accountability and oversight at local government level. In addition, some municipalities have outsourced service delivery with poor households being most affected by cutting off water and electricity, as well as evictions. In a context of widespread access to grants and state, it seems corruption and inaction on the part of political representatives play a role. Community members seek recognition — they want to be heard — and often violent protest seems the only way to try to achieve this. However, this approach is not always successful. (’Protests are a cry for political recognition’, Mail & Guardian, 29 August 2014).
Stress has become a common feature of modern living and is closely related to risk behaviours such as smoking, alcohol and drug abuse. The effects of stress directly affect our functioning and are responsible for many of the problems that we experience with our health.
Stress receives increasing attention in the popular media. There has also been a phenomenal increase in the availability of self-help books to assist both lay people and professionals to understand, manage and prevent this growing problem.
Stress has been studied for nearly a century; however, there is still little agreement about how to define this complex construct (Segerstrom & Miller, 2006). The term is often applied to a variety of negative feelings and reactions that accompany threatening or challenging situations. Hans Selye (1976), an early pioneer in stress research, based his understanding on the body’s physiological response to prolonged stressors. According to Selye, many different kinds of situations may produce the stress response. These include pain, fear, effort and fatigue. These different aspects have led to a variety of approaches to defining stress.
Defining stress in terms of physiological reactions and cognitive processes
Traditionally, stress research has defined stress either in terms of a stimulus or stressor (Segerstrom & Miller, 2006) or in terms of response. That response could have cognitive, physiological and behavioural aspects (Holt et al., 2012). Selye (1976) was particularly interested in the body’s reaction to stressors (see later in this chapter for more detail on this); later researchers focused more on the cognitive processes that influence the perception of stress. According to this definition, stress refers to physiological and psychological responses or reactions to certain demanding situations, events or circumstances. These stressors may be demanding life events (e.g. death, job loss, divorce or a motor vehicle accident), chronic situations (e.g. unemployment, poverty or illness) or catastrophic events (e.g. hijackings, assault or natural disasters).
Defining stress in terms of the interaction between the individual and the environment
Another approach to defining stress has been to focus on the relationship between individuals and their environment (Lazarus & Folkman, 1984). People experience psychological stress when they perceive that their environmental demands exceed their capacity to cope. This view is known as the transactional model, as a person responds to stress by making a cognitive appraisal of the stress. This takes place in two stages and involves a primary appraisal and a secondary appraisal.
In the primary appraisal, the event is evaluated as stressful or not stressful. If the event is appraised as stressful, the person must then evaluate if it is a harm, a loss, a threat or a challenge. In a harm or loss, the injury or damage has already occurred. A threat would be something that could lead to harm or loss. A challenge provides the opportunity for development or mastery. These categories are also associated with different emotional responses.
Secondary appraisal occurs after the event has been evaluated as a threat or a challenge. In this phase, the person considers his/her coping resources and possibilities.
An event is only appraised as a stressor if it is personally relevant and the person perceives that the demands of the situation exceed his/her resources to cope with it.
Defining stress in terms of a bio-psychosocial model of stress
Figure 21.6 The stress curve
A more integrative model that brings together various approaches to stress is the bio-psychosocial model of stress (Engel, 1977). This approach grew out of criticisms of the biomedical model, arguing that it is essential to include psychosocial aspects in understanding ill health. Thus, this model of stress involves three elements: the external component (social), the internal component (biological and psychological), and the interaction between these two components. The external component involves events in the person’s environment that can lead to a stress response. These events include a variety of psychosocial stimuli, commonly referred to as stressors (discussed below), that are either physiologically or psychologically threatening. The internal component of stress involves the psycho-physiological and cognitive reactions to stress. The interaction between the external and internal components involves the individual’s cognitive processes, as described in the transactional theory’s view of stress.
Not all stress reactions are negative. A certain amount of stress is essential to our health and performance, and there is a strong correlation between stress and performance (see the stress curve in Figure 21.6). While insufficient stress results in boredom and a lack of stimulation, a healthy level of stress is useful for optimal functioning. Too much stress is referred to as distress and this may result in ill health, poor performance and dysfunctional behaviour. Eustress is healthy, positive stress associated with happy events which can provide a sense of fulfilment.
•Stress is common in present-day society and is closely related to risk behaviours. Much attention is being paid to understanding and managing stress.
•There have been many definitions of stress:
”Selye focussed on the body’s physiological response to prolonged stressors. Later researchers focused more on the cognitive processes that influence the perception of stress.
”The transactional model focuses on the relationship between individuals and their environment; appraisal (primary and secondary) is an important part of this model.
”The bio-psychosocial model takes a more integrative view, looking at the internal and external components of stress as well as the interaction between these components.
•Positive stress (eustress) may be helpful to our health and performance.
The psychophysiology of stress
Whenever there is a perceived threat, the body reacts immediately in a sequence of psycho-physiological responses called the fight-or-flight response. This response occurs automatically, irrespective of whether the stressor is an actual threat (being held at gunpoint), being startled (hearing a balloon burst) or a new experience (taking a roller-coaster ride). Several systems and subsystems are activated to deal with the threat. These involve the autonomic nervous system and the endocrine system, which together produce the fight-or-flight response.
The autonomic nervous system
The autonomic nervous system is divided into two separate but interdependent systems — the sympathetic and parasympathetic systems, which generally have opposing functions.
The sympathetic system is responsible for arousal or a stimulated state, while the parasympathetic system brings the body back to its rested state (see Figures 21.8 and 21.9). The sympathetic system is responsible for arousing neural and glandular functions. This arousal involves an increase in heart rate, the dilation of the arteries of the muscles, including the heart, the constriction of the arteries of the skin and digestive organs, and the activation of certain endocrine glands. When there is no longer a need for an aroused state, the parasympathetic system acts to reverse the arousal, thus conserving and protecting the body’s resources (Holt et al., 2012). (See Chapter 7 for a more detailed discussion of the autonomic nervous system.)
The endocrine system
The endocrine system works in close association with the sympathetic system. This interaction is important in understanding how psychological events are translated into physiological reactions. The endocrine system is made up of the following glands: the pituitary gland, the thyroid, the parathyroids, the islets of Langerhans, the adrenal gland and the gonads (Figure 21.9). The endocrine system is slow-acting and controls body function and activity through chemicals called hormones. These hormones are secreted by the various endocrine glands into the blood stream, which transports them to different sites in the body (Holt et al., 2012).
The hypothalamus is connected to the pituitary gland, which controls the rest of the endocrine system. The hypothalamus signals to the pituitary gland to secrete two important hormones. One of these acts on the thyroid to produce thyroxine, which stimulates metabolism. High levels of thyroxine produce symptoms such as increased sweating, nervousness, shakiness and insomnia. However, should these hormones be produced over a prolonged period of time, the high level of hormones may harm internal organs and leave the organism vulnerable to disease.
The second hormone acts on the adrenal glands producing adrenalin (epinephrine) and noradrenalin (norepinephrine). Adrenalin interacts with organ receptor cells to increase the heart rate and blood pressure, and instruct the liver to release extra sugar. Noradrenalin increases the blood pressure and the heart rate. These changes prepare the body for action.
Figure 21.7 Functions of the autonomic nervous system (Atkinson, Atkinson, Smith & Hilgard, 1987)
These processes also lead to the release of hormones which are responsible for the body’s adjustment and response to emergency situations. These play a major role in the body’s immune responses. Stress has a negative effect in that it compromises the body’s immune system, which makes it susceptible to infections and illness.
The general adaptation syndrome
The general adaptation syndrome (GAS) describes the set of reactions that follow the organism’s exposure to an impending threat. Selye (1985) noted that a person who is subjected to prolonged stress goes through the following three phases: the alarm reaction, the stage of resistance, and the exhaustion stage.
Figure 21.8 The location of the endocrine glands in the body.
In the alarm reaction, the body mobilises its resources to respond to the threat. This reaction includes the various psychophysiological responses to a stressor. In this phase, the shock temporarily reduces the body’s resistance (Holt et al., 2012).
The resistance stage involves a continued state of arousal as the body’s response stabilises. The body secretes high levels of hormones to assist in the response to the stressor. If the stressful situation is prolonged, this high level of hormones may damage internal organs, making the organism vulnerable to disease. It is the resistance stage that seems to result in many of the diseases precipitated or caused by stress. Selye (1985) called these diseases of adaptation and they include infections, headaches, insomnia, high blood pressure and cardiovascular diseases.
21.5DOES STRESS EXIST?
Not all people believe that stress exists. Some believe that researchers, in trying to study the phenomenon, had to invent one word to represent hundreds of specific problems that affect us from time to time.
What do you think? Having read the chapter thus far, do you think that stress exists?
Ongoing stress leads to the exhaustion stage when the body’s resources are finally exhausted; this may be followed by a complete breakdown. In this stage, the person may show apathy or irritability, anxiety and self-destructive behaviour, and have frequent illnesses.
Types of stress
One of the things that can make stress management difficult is the fact that there are different types of stress (American Psychological Association, n.d.). Stress can be acute, intermittent/episodic or chronic.
Acute stress (short-term stress) is a reaction to an immediate threat, and results in the fight-or-flight response. It often involves a concrete threat that is readily identified as a stressor. The threat can be any situation, even those we are at first unaware of or falsely experience as a danger. Under most circumstances, once the acute threat has passed, the fight-or-flight response becomes inactivated and levels of stress hormones return to normal. They are stressors of relatively short duration and are generally not considered to be a health risk because they are limited by time. Acute stress is indicated by various symptoms, including emotional distress, muscular tension, digestive system problems and autonomic system arousal (American Psychological Association, n.d.).
Intermittent stress refers to responses to stressors that vary in duration, alternating between periods of stress and calm. It is also known as episodic acute stress. This kind of stress is almost a personality type as it typifies people who worry constantly or who take on too much in their lives (American Psychological Association, n.d.). Because of this, it is ’ingrained and habitual’ and very difficult to treat.
Chronic stress (long-term stress) is typical of modern life, which poses ongoing stressful situations that are not short-lived; in these situations, the fight-or-flight response is not helpful and has to be suppressed. This results in stress that is chronic. Common chronic stressors include: ongoing highly-pressured work, long-term relationship problems, loneliness and persistent financial worries. These stressors are of relatively long duration and can pose a serious health risk owing to their prolonged activation of the body’s stress response. Being a regular part of modern life, chronic stressors may be taken for granted and can therefore pose a serious health risk if they are not recognised and appropriately managed (American Psychological Association, n.d.).
•Whenever there is a perceived threat, the body reacts immediately in a sequence of psychophysiological responses called the fight-or-flight response.
•This happens automatically and involves the autonomic nervous system and the endocrine system.
•The autonomic nervous system is divided into two separate but interdependent systems — the sympathetic and parasympathetic systems, which generally have opposing functions.
•The sympathetic system is responsible for arousal and the parasympathetic system acts to reverse the arousal.
•The endocrine system works in close association with the sympathetic system. It consists of a number of glands which secrete hormones which are involved in the fight-or-flight response.
•If these hormones are produced over a prolonged period of time, the high level of hormones may harm internal organs and leave the organism vulnerable to disease.
•Hans Selye’s general adaptation syndrome (GAS) describes the stages that a person who is subjected to prolonged stress goes through:
”The alarm reaction involves the body’s psychophysiological responses to a stressor.
”The resistance stage involves a continued state of arousal; high levels of hormones may eventually damage internal organs and cause disease.
”The exhaustion stage is reached after prolonged resistance and breakdown then occurs.
•The GAS shows how mental and physical illnesses often follow the inability to adapt to stress. Stress is implicated in depression and other severe psychiatric disorders; in memory, concentration and learning difficulties; in heart and vascular disease; a compromised immune response and increased risk of infections.
Stressors are stimuli that cause stress reactions. These stimuli can arise from physiological, psychological, socio-cultural or environmental factors, or a combination of these. People may be exposed to a variety of stressors which may lead to different reactions in different people. Researchers are interested in which stimuli cause stress reactions. This field has been approached in several ways; some researchers (Holmes & Rahe, 1967) have considered the impact of life events (such as bereavement) while others (Kanner, Coyne, Schaefer & Lazarus, 1981) have focussed more on the role played by daily hassles (such as traffic jams and minor financial worries).
Life changes or events
According to Holmes and Rahe (1967), extremely intense life changes or events are life stressors that can cause acute or chronic stress reactions, including physical illness. These may be positive (a family wedding) or negative events or changes that create uncertainty and demand adjustment behaviours. Holmes and Rahe developed the Social Readjustment Rating Scale (SRRS), which is a method for measuring cumulative stress that a person is exposed to over a period of time.
The scale measures stress in life-change units (LCU) that are associated with specific stressful events. Table 21.2 depicts the 20 most stressful events as measured by Miller and Rahe (1997).
Table 21.2 The Social Readjustment Rating Scale Source: Bergh & Theron (2006), adapted from Miller & Rahe (1997)
Stress is such a fashionable topic that we often find popular magazine or online questionnaires for readers to measure their levels of stress, as well as stress management tips. Another stress measurement device is the BIODOTTM. Because there is a correlation between stress and skin temperature, the BIODOTTM is like a miniature thermometer that measures the change in temperature at the surface of the skin (http://www.cliving.org/stress.htm). Although popular, these tests should be viewed with caution. To accurately diagnose stress, a trained health professional would usually take a comprehensive clinical history, undertake a mental status examination, and may also use one or more stress measures.
Figure 21.9 Even happy events like getting married can be stressful
Interestingly, these researchers found that 80 per cent of people who had a cumulative score of 300 or more on the SRRS in recent months had a very high risk of developing a major illness within the next two years. Of course, we cannot be sure that these people would not have become ill for other reasons, but the high percentage and elevated risk suggests negative effects from experiencing stressful life events (Bergh & Theron, 2006).
Daily hassles and uplifts
Kanner et al. (1981) suggest that the stress that arises from daily hassles may be more significant for health. Hassles are ’the irritating, frustrating and distressing demands’ common to everyday life (Kanner et al., 1981, p. 3). Hassles are balanced by uplifts which are the small positive aspects of life like good communication with a spouse or lover and getting along well with friends (in Bergh & Theron, 2006). These researchers believe that daily stressors provide better explanations for a person’s state of well-being (both physical and psychological) than life stressors that only occur occasionally in an individual’s life. However, in understanding a person’s stress experience it is important to consider the overall pattern of hassles and uplifts (Kanner et al., 1981). Jones and Bright (2001) note the role of appraisal in hassles and uplifts, suggesting that if hassles are perceived as harmful or challenging, this is more likely to lead to ill health.
Three sources of internal and external stressors
Other sources of stressors have also been proposed. These are frustration, conflict, pressure and self-imposed stress (Misra & Castillo, 2004).
Frustration occurs when people are prevented from attaining their objectives. The frustration—aggression hypothesis proposes that people who experience frustration will react with aggression and anger. However, the ability to tolerate frustration, which is largely determined by how people have learned to satisfy their needs, differs considerably from person to person.
Conflict occurs when people want to satisfy a number of needs at the same time. Because they are unlikely to be able to do this, they are faced with difficult choices resulting in choice anxiety. This type of anxiety occurs when they have strong positive and negative emotions about the needs (known as approach—avoidance conflict), when they have to choose between two equally appealing needs (known as approach—approach conflict) or two equally unappealing needs (known as avoidance—avoidance conflict) (in Bergh & Theron, 2006).
Social expectations put pressure on people to perform (or conform to) certain expected behaviours. Sometimes people can become stressed in the face of these expectations, particularly if they are contrary to their own expectations or perceived to be beyond their abilities. An aspect of this kind of pressure is self-imposed stress. This is stress that arises out of individual differences in the desire to compete and win or succeed.
•There are several different types of stress:
”Acute stress (short-term stress) is a reaction to an immediate threat, and results in the fight-or-flight response.
”Intermittent stress involves repeated responses to stressors that vary in duration, alternating between periods of stress and calm.
”Chronic stress (long-term stress) involves ongoing stressful situations which can pose a serious health risk owing to their prolonged activation of the body’s stress response.
•Stressors are stimuli that cause stress reactions; these stimuli can arise from physiological, psychological, sociocultural or environmental factors, or a combination of these.
•Researchers are interested in which stimuli cause stress reactions; life events and daily hassles have been studied.
•Intense life events (positive or negative) can cause acute or chronic stress reactions, often leading to physical illness.
•Holmes and Rahe developed the Social Readjustment Rating Scale (SRRS) to measure cumulative stress that a person is exposed to over a period of time.
•An alternative approach suggests that stress arises from daily hassles and is moderated by uplifts. If hassles are appraised as harmful, they are more likely to lead to ill health.
•Other sources of stress are frustration, conflict, pressure and self-imposed stress.
Stress and illness
There is compelling evidence that an inability to adapt to stress is associated with a number of mental and physical illnesses. Experimental and clinical evidence implicates stress as a major predisposing factor in depression and other severe psychiatric disorders (Leonard, 2002). The repeated release of stress hormones disrupts normal levels of serotonin, the neurochemical involved in feelings of well-being. Low serotonin levels are associated with depression (Lee, Ogle & Sapolsky, 2002; Paykel, 2002). Stress also has significant effects on brain functioning, particularly on memory, concentration and learning.
Stress has also been implicated in heart disease through activation of the sympathetic nervous system which leads to:
•constriction of arteries (may block blood flow to the heart)
•blood becoming stickier (may lead to artery clogging or blood clot)
•release of fat into the bloodstream (raising blood-cholesterol levels)
•altered heart rhythms (risk of serious arrhythmias)
•sudden increases in blood pressure (may damage the inner lining of blood vessels; damage to the vascular system also increases the likelihood of a stroke).
Chronic stress compromises the immune response and increases the risk of infections. Some research has found that HIV-infected men with high stress levels progress more rapidly to AIDS compared to those with lower stress levels.
Stress has also been linked to gastrointestinal problems, such as irritable bowel syndrome and peptic ulcers. Other illnesses associated with stress include muscular and joint pain, headaches, sexual and reproductive dysfunction, skin disorders and allergies (Rice, 1998).
Coping and stress reduction
Lazarus and Folkman (1984, p. 141) define coping as the ’constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as … exceeding the resources of the person’. People utilise a variety of mechanisms to cope with, manage or reduce the stress produced from daily hassles or life changes and events.
Figure 21.10 One way to cope with, manage or reduce stress
Adaptive reactions refer to behaviours designed to manage the daily hassles that people encounter through, for example, exercising, meditating, talking to others, crying and going on holiday. Adaptive reactions can also be classified as problem focused, emotion focused or avoidance-withdrawal, among other styles (Laureano, Grobbelaar & Nienaber, 2014). With problem-focused coping, people will typically identify what is causing them to feel stressed, confront it, and plan the best way to manage their stress. These reactions require rational thinking and self-control. On the other hand, emotion-focused coping is directed at efforts to avert negative emotions and boost self-control. Avoidance-withdrawal coping involves either social withdrawal and isolation or psychological withdrawal.
There has been some criticism of the coping research. Coyne and Racioppo (2000) argue that the several decades of descriptive research based on various checklists and other instruments has yielded disappointing results. They argue that the checklists are often too general and abstract in their questions. Because of this, and also because situations requiring coping are often diverse and complex, the research results are confusing and unclear (Coyne & Racioppo, 2000). There has also been criticism of the distinction between emotion- and problem-focused coping. Coyne and Racioppo (2000) point out that seeking social support may be either one or the other, depending on the timing of the action and who is approached. Because of this, the power of the research to drive intervention strategies is limited (Coyne & Racioppo, 2000). Lastly, people may be taught coping skills, but this is no guarantee that they will actually apply them when the time comes.
There are a number of practical things that we can do to reduce stress; if such changes do not contain the stress, then professional help should be sought:
•A sound knowledge of stress helps us identify our sources of stress.
•Healthy lifestyle changes should be considered. These include regular exercise, restructuring priorities, increasing leisure and developing good social networks. Also important is a healthy diet (rich in a variety of whole grains, vegetables and fruits, low in fat and free of excessive alcohol, caffeine and tobacco).
•It is helpful to engage in healthy psychological behaviours such as discussing and expressing feelings of anger and frustration, being optimistic and keeping a balanced perspective on life.
•Learning relaxation techniques. Relaxation lowers blood pressure, respiration and pulse rates, releases muscle tension and eases emotional strains. A combination of progressive relaxation and imagery seems most beneficial.
Social and cultural influences on an individual’s experience of stress
Stress has been extensively researched in psychology, suggesting that it is a predominantly Western notion. Wong, Wong and Scott (2006) critique traditional Western theories of stress, saying that they typically ignore contextual factors, and cultural contexts in particular. However, the lack of an equivalent term in African languages makes the understanding of this concept in these cultures difficult. Generally, the words used among African-language speakers to describe stress are words employed to refer to general negative emotional problems, such as depression or abuse. But, among younger African people, the hybrid word istress is being increasingly used (Ngcobo & Pillay, 2008). Whatever term is used, it is essential to consider construct equivalence, as it is clear that how stress, as well as other psychological constructs, reflect ’our cultural values, worldviews, and hidden ideologies’ (Wong et al., 2006, p. 6).
Sociocultural contexts certainly influence stress reaction and perception (Ahmad-Nia, 2002; Cuellar, 2002). We need a better understanding of how various social and cultural structures influence and shape the individual’s experience of stress, and research should also focus on what events are perceived as stressful and what coping strategies are acceptable to use in a particular society (Pedersen, 2006). Answers to these questions would aid in the understanding, recognition and management of stress in multicultural contexts.
•Coping involves cognitive and behavioural efforts to manage demands that are appear to exceed our resources.
•People cope in various ways: problem-focused, emotion-focused and avoidance-withdrawal coping.
•People can also manage their stress through improved diet, increased exercise and relaxation, developing good social networks and maintaining a positive and balanced perspective on life.
•In a multicultural context it is essential to consider the social and cultural context in which stress is experienced.
•There is no certainty of the equivalence of psychological constructs between people from diverse cultures.
There is a clear link between risk behaviours and stress. While the different levels of influence on risk behaviour have been explored separately, a fundamental principle of the ecological-systems approach is that there is a reciprocal relationship between the individual, interpersonal, community and societal levels of influence. Any intervention aimed at behaviour change should thus ideally address the influences maintaining the high-risk behaviour at each level.
Stress is difficult to define because of the variety of meanings associated with the concept. While traditionally, stress research involved the body’s reaction to stressors and the cognitive processes that influence the perception of stress, theories such as the transaction theory of stress and the bio-psychosocial model of stress are more comprehensive and allow a better understanding of stress. Because stress has important implications for human functioning, there is a growing concern about how the pressures of modern living may severely impact on our health. Based on theory and research, there are a number of practical things that can be done to reduce stress. These include: gaining a sound knowledge of stress, adopting healthy lifestyle changes, engaging in healthy psychological behaviours, learning relaxation techniques and knowing when to seek professional help and advice.
action stage: the fourth stage in the stages-of-change model, during which people take significant steps to change their behaviour
acute stress (short-term stress): the reaction to an immediate threat, which results in the fight-or-flight response
adaptive reactions: behaviours designed to manage the daily hassles that people encounter
alarm reaction: according to the general adaptation syndrome, the first stage of psycho-physiological responses to a stressor (equivalent to the fight-or-flight response)
autonomic nervous system: a nervous system that is divided into two separate but interdependent systems — the sympathetic and parasympathetic systems, which generally have opposing functions
avoidance-withdrawal coping: reactions to stressors that involve avoiding the stressor by social and/or psychological withdrawal
BIODOTTM: a device much like a miniature thermometer that can measure the change in temperature at the surface of the skin
bio-psychosocial model of stress: a comprehensive model of stress that involves three elements: internal components, external components and the interaction between internal and external components
choice anxiety: a type of anxiety that occurs when people have strong positive and negative emotions about their needs (approach—avoidance conflict), or when they have to choose between two equally appealing needs (approach—approach conflict) or two equally unappealing needs (avoidance— avoidance conflict)
chronic stress (long-term stress): chronic stress is typical of modern life, which poses ongoing stressful situations that are not short-lived so that the fight-or-flight reaction has to be suppressed
cognitive expectations: beliefs about the likely results of an action in terms of rewards or punishments
conflict: a source of stress when people want to satisfy a number of needs at the same time
conscientisation: a process that enables members to develop skills to critically analyse their problems and to recognise the roles they may take in changing their social conditions
contemplation stage: the second stage in the stages-of-change model during which people become aware of their problem behaviour, and start to consider doing something about it
cues to action: factors that activate a readiness to change
cultural perspectives: explanations of risk behaviours that take into account the influence of the cultural context within which they occur
distress: too much stress, resulting in ill health, poor performance and dysfunctional behaviour
ecological-systems approach: an approach that understands vulnerability to risk behaviour as being influenced by multiple contexts, which can be broadly categorised into four levels of influence, namely the individual level, interpersonal level, community level and societal level
emotion-focused coping: reactions to stressors that are directed at efforts to avert negative emotions and boost self-control
endocrine system: a slow-acting system that controls body function and activity through chemicals called hormones
eustress: the optimal level of stress, which is necessary for optimal functioning, health and performance
exhaustion stage: according to the general adaptation syndrome, the final stage of psychophysiological responses to a stressor that occurs after a prolonged state of arousal
external component: according to the bio-psychosocial model of stress, a component of stress that involves environmental events that precede the recognition of stress and can elicit a stress response
fight-or-flight response: a response to a perceived threat whereby the body reacts immediately in a sequence of psycho-physiological responses
frustration: a source of stress caused by people being unable to attain their objectives
frustration—aggression hypothesis: a hypothesis that proposes that people who experience frustration will react with aggression and anger
general adaptation syndrome (GAS): a set of reactions that mobilise the organism’s resources to deal with an impending threat
hassles: minor negative events
health belief model (HBM): an early model developed to understand preventive health behaviours
incentives: positive reinforcements that encourage a particular behaviour
interaction between the external and internal components: according to the bio-psychosocial model of stress, a component of stress that involves the individual’s cognitive processes
intermittent stress: responses to stressors that vary in duration, alternating between periods of stress and calm
internal component: according to the bio-psychosocial model of stress, a component of stress that involves the psychophysiological reactions to stress
maintenance stage: the final stage in the stages-of-change model, during which people make every effort to continue with successful strategies that helped them change their behaviour
parasympathetic system: a part of the autonomic nervous system that brings the body back to its rested state
person-centred interventions: work with individuals and groups to promote health-protective behaviour (also referred to as a resilience-enhancing process)
precontemplation stage: the first stage in the stages-of-change model, during which people have no intention of changing their behaviour and may be unaware of the risk they are placing themselves at
preparation stage: the third stage in the stages-of-change model, during which people begin to take small steps towards changing their behaviour and begin to formulate specific intentions to change their behaviour soon
pressure: an individual’s sense that he/she needs to conform to, or perform according to, other people’s expectations
primary appraisal: an individual’s evaluation of an event as stressful, and the categorisation of this event as a harm, a loss, a threat or a challenge
problem-focused coping: reactions to stressors whereby people will typically identify what is causing them to feel stressed, confront it, and plan the best way to manage their stress
protective factors: influences that limit or reduce the likelihood of high-risk behaviour and play a moderating or buffering role
resilience: successful adaptation to the environment despite exposure to risk
resistance stage: according to the general adaptation syndrome, the second stage of psycho-physiological responses to a stressor that is a continued state of arousal
risk: the possibility of harm; the action of putting something in danger
risk behaviours: specific forms of behaviour that are proven to be associated with increased susceptibility to a specific disease or ill-health
risk factors: those bio-psychosocial behaviours or environments that increase susceptibility to a specific disease or illness
secondary appraisal: an individual’s evaluation of his/her coping resources and options after an event has been categorised as a threat or a challenge
self-efficacy: the belief that one has the ability to act to achieve certain goals or to manage a situation
self-imposed stress: stress that arises out a person’s desire to win or succeed
situation-centred interventions: interventions that are focused on creating more protective environments which enable individuals and groups to practise healthy behaviour
social action: a process that encourages people to take part in community efforts towards a common goal
social capital: a protective factor provided by community social networks, wherein membership of a social group or network secures certain benefits for an individual
social-cognitive model (SCM): a theory that emphasises the importance of the intervening thought processes, self-efficacy, expectancies and incentives in the performance of a behaviour
Social Readjustment Rating Scale (SRRS): a method for measuring cumulative stress that a person is exposed to over a period of time
stages-of-change model (SCM): a model with various stages explaining how people give up addictive behaviours
stress: a set of physiological, psychological and behavioural reactions that serve an adaptive function
stressors: stimuli that cause stress reactions, arising from physiological, psychological, sociocultural and/or environmental factors
structuralist perspectives: explanations of risk behaviours that take into account the influence of the structural environment within which they occur
sympathetic system: a part of the autonomic nervous system that is responsible for arousal or a stimulated state
theory of planned behaviour (TPB): an extension of the theory of reasoned action that, through its concept of perceived behavioural control, takes into account structural constraints or facilitators in behavioural intentions
theory of reasoned action (TRA): a theory that proposes that people’s behaviour results from an intention to carry out the behaviour, which in turn is determined by a combination of their attitude towards the behaviour, together with their beliefs about what others, whose opinions are valued, want them to do
transaction theory of stress: the theory that proposes that if individuals make a two-part cognitive appraisal of an element of their environment and perceive a mismatch between the demands of a situation and their resources to cope with it, the situation will be appraised as a stressor
uplifts: minor positive events
vulnerability: susceptibility to negative outcomes under certain conditions
Multiple choice questions
1.Risk behaviour refers to specific forms of behaviour that are proven to be associated with:
a)increased susceptibility to protective factors
b)increased susceptibility to a specific disease or ill health
c)decreased susceptibility to a specific disease or ill health
d)both a and b are correct.
2.Vulnerability is defined as susceptibility to:
a)positive outcomes under conditions of resilience
b)positive outcomes under conditions of risk
c)negative outcomes under conditions of risk
d)negative outcomes under conditions of resilience.
3.Locate the appropriate categorisation:
a)individual (health belief model), interpersonal (social-cognitive model), community (social capital model), societal (cultural model)
b)individual (health belief model), interpersonal (social-cognitive model), community (cultural model), societal (social capital model)
c)individual (social cognitive model), interpersonal (health belief model), community (cultural model), societal (social capital model)
d)none of the above is correct.
4.Which statement is associated with the concept of perceived benefit?
a)Using a condom will protect me from contracting HIV/AIDS.
b)I feel confident in using a condom.
c)I find it difficult to talk to my sexual partner about using a condom.
d)I currently use a condom.
5.Social capital refers to:
a)membership of a social group or network that secures certain benefits for the member
b)membership of a social group or network that marginalises the member from certain benefits
c)membership of a social group or network that allows the member to act more independently
d)none of the above is correct.
6.Stress may be seen as:
a)a variety of negative feelings and reactions that accompany threatening or challenging situations
b)a set of physiological, psychological and behavioural reactions that serve an adaptive function
c)the body’s reaction to stressors and the cognitive processes that influence the perception of stress
d)all of the above are correct.
7.The transactional theory of stress focuses on:
a)the relationship or interaction between the individual and the environment that places excessive demands on the individual’s resources
b)the cognitive appraisal of stress
c)both a and b
8.Cognitive appraisal involves:
a)the evaluation of an event as stressful and an assessment of the coping resources and options
b)rational assessment of a situation that may or may not be stressful
9.The fight-or-flight response involves:
a)the body’s delayed reaction to psycho-physiological responses
b)the body’s automatic response to a situation
c)the autonomic nervous system and the endocrine system.
d)both b and c.
10.The general adaptation syndrome (GAS) refers to:
a)a set of reactions that mobilise the organism’s resources to deal with an impending threat
b)the alarm reaction, the stage of resistance and the stage of exhaustion
c)both a and b
d)the fight-or-flight response.
1.What are risk factors and risk behaviours?
2.What is resilience?
3.What do resilience-enhancing interventions attempt to do?
4.What are the main criticisms of the models of understanding risk behaviour at the individual and interpersonal levels?
5.Why is it important to consider culture in understanding risk behaviour?
6.What is stress?
7.Explain the different categories of stress.
8.How does stress impact on a person’s health and functioning?