Stress, Coping, and

Health Behavior
PHC 6410
Health behavior and Public Health
Importance to Public Health
• Stress can contribute to illness
– Directly - physiological effects
– Indirectly – bad health behaviors

• How the ill or at-risk for illness, cope.

• Influence of friends, family, and health care
providers on stress and outcomes
Why study stress and coping in
public health
• The psychosocial aspects of a situation
affect the determinants and consequences
of health behaviors

• Need to understand theories and concepts

to develop effective strategies and
intervention programs
Historical Concepts

• Stressors
– Demands made by the internal or external
environment that upset balance, thus
affecting physical and psychological well-
being and requiring action to restore balance
 History Concepts cont.
• 30’s – 50’s: Research focused on
physiological reactions to stressful stimuli
– General Adaptation Syndrome – 3 stages
(alarm reaction→ resistance →exhaustion)
with each evoking both physiological and
behavioral responses
 History Concepts cont.
• 60’s – 70’s: Research focused on
identifying and quantifying potential
stressors called stressful life events
– Social Readjustment Rating Scale (SRRS)
• High scores had more illness episodes
 History Concepts cont.
• Also 60’s and 70’s: Models with central
concept of ‘events are perceived in
different ways by various individuals and
these perceptions – rather than the
objective stressors – are main
determinants of effects on behavior and
health
History cont.

ƒ Biology and Epidemiology suggests that:

ƒ Some personalities and psychological states (i.e.
fatalism, hostility, emotional suppression) are linked
to disease endpoints
ƒ Chronic stressors and responses affect biology and
thus occurrence and progression of problems such as
cancers, infectious diseases
ƒ Difficult to separate causal factors in health status
and behavior as responses are different for everyone
ƒ ex. Stress causes headaches in some, acid-reflux in others
Transactional Model of
Stress and Coping
Purpose of Model: Framework for
evaluating processes of coping with
stressful events

BASIC SEQUENCE OF MODEL

• Appraisals→Coping Efforts→Coping
Outcomes
 Diagram of Transactional Model of Stress and Coping

Mediating Processes Outcomes

Primary
Poor Appraisal
Materials
•Perceived susceptibility Coping Effort Adaptation
•Emotional well-being
•Perceived severity •Problem Management
•Functional status
•Motivational relevance
Bad Design •Emotional Regulation
•Health behaviors
•Causal focus

Stressor
Meaning-Based Coping
•Positive reappraisal
•Revised goals
Secondary Appraisal •Spiritual beliefs
•Perceived control •Positive events
over outcomes
•Perceived control
over emotions
•Self-efficacy
Moderators

•Dispositional coping style

•Social support
Appraisals

• Primary appraisal – evaluate potential

threat

• Secondary appraisal – evaluate ability to

alter situation and manage negative
emotional reactions
Transactional Model cont.
Actual coping efforts (negative and positive
strategies used to mediate primary and
secondary appraisals) are aimed at problem
management and emotional regulation and
give rise to the outcomes of the coping
process (e.g. psychological well-being)
*During stress event need to take positive
psychological states into account as they
may:
ƒ Facilitate processing of self-relevant info
ƒ Serve as a buffer against adverse physiological
events
ƒ Protect against depression
Primary Appraisal
• Definition – a person’s judgment of the
significance of an event as stressful,
positive, controllable, challenging, benign,
or irrelevant
– Health problems usually seen initially as
threatening or as negative stressors
Primary Appraisal
• Two basic PA’s – perceptions of susceptibility to
and severity of a threat
– Prompt efforts to cope with the stressor
– Ex. Woman who perceives risk of breast cancer may
be motivated to obtain mammogram (problem-
focused coping/ problem-management strategies)
and may seek social support to cope with threat
(emotion-focused coping/emotional regulation)
• But…high risk perception may lead to distress and escape-
avoidance behaviors – leads to less adherence (i.e. not
getting screened as much)
Possible factors involved with a
Primary Appraisal
Appraisal Bias - when significance of threat is
minimized (e.g when health threat is
ambiguous or uncertain)
Motivational relevance - when a stressor is
appraised as having a major impact on a
person’s goals or concerns
Causal focus - If a person perceives themselves
as the cause of the stressor they may generate
more guilt and depression than anxiety
Secondary Appraisal
Definition – evaluation of the controllability of
the stressor and a person’s coping resources
– Examples
• Perceived ability to change the situation
• Perceived ability to manage one’s emotional reactions
• Expectations about the effectiveness of one’s coping
resources (i.e. coping self-efficacy)
Secondary Appraisal
Definition – evaluation of the controllability of
the stressor and a person’s coping resources
– Perceived control over health outcomes may
improve health as it increases likelihood of
adopting health behavior recommendations (i.e.
safe-sex behavior)
• But in situations with low control (severe or
fatal disease) high levels of perceived control
may actually increase distress and dysfunction
and thus negatively affect health
Coping Efforts

• Emotional and functional effects of primary and

secondary appraisals are mediated by actual
coping strategies (positive and negative)
– Emotional regulation – directed at changing the way
one thinks or feels about a stressful situation
• Ex. – seeking social support, venting of feelings,
avoidance, and denial
• Best for stressors that are unchangeable or when
after all problem-management strategies have
been taken
Coping Efforts

• Emotional and functional effects of

primary and secondary appraisals are
mediated by actual coping strategies
(positive and negative)
– Problem-management strategies – directed at
changing the stressful situation
• Ex. – active coping, problem solving, and
information seeking
• Best for stressors that are changeable
Coping Efforts cont.

• Disengaging strategies – shifts attention away

from stressor
– Person more likely to use when stressor is
perceived as highly threatening or
uncontrollable
– Ex. Distancing, cognitive and behavioral
avoidance, distraction, denial
– May minimize initial distress but can lead to
increased distress over time
Coping Efforts cont.

• Engaging strategies
– Person more likely to use when stressor
appraised as controllable and a person has
high self-efficacy about problem
– Ex. Active coping, planning problem solving,
information seeking, and using social support
Coping Efforts cont.

• Meaning-based coping - can induce

positive emotion
– Ex. Positive reinterpretation, acceptance, use
of religion or spirituality
Coping Outcomes
• Represent a person’s adaptation to a stressor
following their appraisal of the situation
(primary) and resources (secondary) and is
influenced by coping strategies
– Because a problem or stressor may change over time,
outcomes may occur at different time frames
– Three main outcomes are:
• Emotional well-being
• Functional status (or health status, disease progression, etc.)
• Health behaviors
Theoretical Extensions
• Difference between coping efforts and coping styles
– Coping styles are dispositional or stable characteristics of an
individual
– Coping styles can be generalized while coping efforts are
situation-specific
*Coping styles are enduring traits and thus drive appraisal
and coping efforts
*Coping styles are moderators of the impact of stress on
coping processes and outcomes; coping efforts are
mediators of the effects of stress and appraisals on
emotional and functional outcomes – that is they
attempt to resolve problem
Theoretical Extensions cont.

• Dispositional coping styles – generalized

ways of behaving that can affect a
person’s emotional or functional reaction
to a stressor; are relatively stable over
time
– Two types of influential styles
• Optimism
• Information Seeking
Optimism

• Dispositional optimism – tendency to

have positive (optimistic) rather than
negative (pessimistic) generalized
expectancies for outcomes
• Optimists have better psychological
adjustments and have been shown to
have fewer physical symptoms during life
stresses and faster recovery
Information seeking
• Monitoring – seeking info
– Can contribute to heightened perceived risk and
excessive worry about health
– Can reduce worry and stress also if ways to reduce
problem are found
• Blunting – avoiding info

* Both monitoring and blunting can produce

positive and negative outcomes
Social Support

*Substantial evidence of beneficial effects

on psychological and physical well-being

ƒ Direct effects – extent of social network

ƒ Indirect or stress buffering effects – perceived

availability of support
 Stress Management Interventions
• Directed at emotional regulation
– Biofeedback - treatment technique in which people are
trained to improve their health by using signals from
their own bodies
– Relaxation techniques such as relaxation training,
hypnosis, yoga
• Problem management approaches based on
cognitive behavioral approaches similar to
Transactional Model
– Teaching individuals to achieve accurate primary
appraisals and evaluate and possibly enhance coping
resources
– Involves information seeking, direct action, inhibition of
action, intrapsychic processes, and use of social support