Conservation of Resources Theory

Abstract

Conservation of resources (COR) theory offers a framework within which to understand responses to stress and suggests that stress results from circumstances involving threatened or actual loss of valued resources. Furthermore, it is the desire to defend, conserve, and acquire these valued resources which motivates human behavior in the face of stress. According to COR theory, loss is more salient than gain, and loss begets loss. The theory has received much empirical support and is particularly helpful in understanding relationships between stress and physical health. It offers fundamental insights that have guided research on coping with chronic illness, medical consequences of natural disasters, and long-term effects of occupational burnout. It has implications for disaster intervention and for improving medical care – especially for those with histories of trauma. COR theory may prove especially useful in understanding health-related resource caravan passageways – that is, mechanisms by which risk and resilience factors cluster together and impact health.

Full text

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
27
Conservation of Resources Theory
Resource Caravans and Passageways in Health Contexts
Lucie Holmgreen, Vanessa Tirone, James Gerhart, and Stevan E. Hobfoll
Since 1988, conservation of resources (COR) theory (Hobfoll, 1988; 1989) has provided a
framework within which to understand the processes involved in experiencing, coping with,
and becoming resilient to chronic and traumatic stress. Its basic premises have been supported
by empirical work in areas ranging from natural disaster recovery (e.g., Blaze and Shwalb,
2009) to occupational burnout (Gorgievski and Hobfoll, 2008). COR theory acknowledges
that some circumstances – namely, those that threaten or deplete resources – are objectively
stressful. It is an ecological and multileveled theory that seeks to understand individuals nested
within their families, communities, and cultures (Hobfoll, 2001). This chapter outlines the
tenets of COR theory and explains the role of resources therein. Principles and corollaries
of the theory are delineated, and highlights of empirical support are provided for each. The
chapter next reviews how COR theory has been used to study health, and nally explores the
implications of the theory for health in both clinical and research contexts.
COR theory begins with the basic tenet that people are motivated to acquire, protect, and
foster the acquisition of those things which they value – their resources (Hobfoll, 1988; 1998).
Stress occurs as a response to any set of circumstances that results in the threatened or actual
depletion of resources. The stress response, then, comprises an attempt primarily to limit losses
and secondarily to maximize gains, with the loss aspect of the equation disproportionately
dominant. As such, behaviors exhibited in stressful contexts may vary markedly in form, yet
serve the common function of resource conservation. COR theory therefore emphasizes the
objective nature of stress and stress responding over the individual appraisal process empha-
sized by Lazarus and Folkman (1984). Simultaneously, it focuses on the shared cultural dimen-
sions of stress and resources, positing that although most resources are universally valued, their
relative worth is likely to vary cross-culturally (Hobfoll, 2001).
The Handbook of Stress and Health: A Guide to Research and Practice, First Edition.
Edited by Cary L. Cooper and James Campbell Quick.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
443

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
444 The Handbook of Stress and Health
The idea that resource loss is the crucial determinant of stress has been supported by a great
deal of research. In particular, resource loss is the strongest predictor (or among the strongest
predictors) of the severity and duration of psychological distress in the wake of natural disasters
(e.g., Blaze and Shwalb, 2009; Freedy, Saladin, Kilpatrick, Resnick, and Saunders, 1994; Paul
et al., 2014; Smith and Freedy, 2000). Similarly, resource loss robustly predicts psychological
distress – above and beyond trauma exposure – in the context of interpersonal disasters such
as ongoing armed conict (e.g., Hobfoll, Hall, and Canetti, 2012). It has also been shown
to predict psychological distress following more isolated incidents of extreme violence, even
after controlling for other variables such as prior trauma exposure (e.g., Hobfoll, Tracy, and
Galea, 2006). Finally, it is a crucial determinant of occupational burnout (Hobfoll and Shirom,
2000; Shirom, Toker, Melamed, Berliner, and Shapira, 2013).
Resources
COR theory begins with the assumption that much of human behavior and culture is organized
around the acquisition and preservation of valued resources. The value of any given resource
is determined by the interplay of both phylogenic and ontogenic contingencies. As a result,
some resources are essential for survival and are inherently reinforcing across humans, while
others are shaped through cultural and personal experiences and so vary cross-culturally,
as well as between and within individuals over time. Resources are characterized by
their external or internal locus relative to the individual. For example, vigor, hope, and
self-efcacy are located within the individual and are key as they provide the energy and
motivation to seek and maintain external resources such as stable employment and supportive
relationships.
The value of a resource can be explained on a basic level by its necessity for survival. Other
resources are less related to survival itself but to the protection of the individual and their status.
Hobfoll and Lilly (1993) identied 74 resources in the Conservation of Resources Evaluation
(COR-E). Primary resources such as food, health, housing, and clothing are directly related to
survival and are valued cross-culturally. Secondary resources such as social support, employ-
ment, and community environment gain their reinforcing value through their associations
with primary resources such as food and housing. Tertiary resources, such as accomplish-
ment, nancial credit, and social status, are culturally constructed and provide access to
primary and secondary resources (Hobfoll and Lilly, 1993).
Resource Caravans
Resources tend to be highly correlated and nested within individuals, families, communities,
and cultures. Observed correlations across distinct resources are referred to as resource cara-
vans because resources tend to be accumulated by individuals and groups and carried across the
life span (Hobfoll, 2001). The plausible sociocultural mechanisms that explain and facilitate
the nesting of resources are referred to as resource caravan passageways. Whereas resource
caravans and passageways explain the accumulation and preservation of resources, risk fac-
tor caravans refer to the constellations of hazards nested within individuals and communities
which preclude and drain resources (e.g., Layne et al., 2009). The positive association between
social support (external) and self-efcacy (internal) is an example of a resource caravan. Plau-
sible resource caravan passageways that explain this association include the environmental

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 445
conditioning of adaptive self-talk, modeled social problem solving, and emotion regulation
within family, school, and peer groups.
Resource caravans and passageways are evident across levels of social interactions, includ-
ing the individual, family, and community. The family is a particularly salient nexus where
cultural, economic, and public policy processes meet to create resource and risk factor car-
avans. Socioeconomic status is related to income and linked to an array of health outcomes
(Adler and Newman, 2002), and much wealth is nested within families. Families collect and
conserve nancial resources and share these resources through several mechanisms (Bowles,
Gintes, and Groves, 2005). Factors such as intelligence, thought to be highly heritable, only
explain a portion of variance in the transmission of wealth, and a multitude of factors may
bridge wealth across generations, including better schooling, healthy environments, and nan-
cial inheritances (Bowles et al., 2005). In addition to these nancial inheritances, families also
collect and conserve resources through inter vivos transfers in the form of socialization and
networking. Through the transmission of favors and the shaping of skills and traits, families
provide crucial access to economic opportunities (Corak, 2013). Still, many resources are nite
and economies are competitive, and so the same passageways that benet some families may
convey risk to others by consolidating wealth and opportunities among the few.
Risk factor caravans also occur at the level of the family unit in the form of intergen-
erational violence and trauma. Contextual theories of violence posit that some individuals
exposed to childhood abuse may be at risk of engaging in subsequent violent behavior within
the family system via behavioral modeling, potentiation of anger, substance abuse, and verbal
rules that support aggressive behaviors (Bell and Naugle, 2008; Gardner and Moore, 2008).
In turn, physical violence may co-occur with other aggressive characteristics, including hos-
tility, criticism, and emotional volatility, that lead to escalating cycles of conict and violence
(Langhinrichsen-Rohling, Hankla, and Stormberg, 2004).
The community neighborhood is another nexus where cultural, economic, and public policy
processes meet to create caravans and passageways. Whereas disparities in wealth and socioe-
conomic status may exist between families in the same neighborhood, social welfare benets
and other forms of public assistance may reduce disparities by providing equal opportunities in
the form of education, effective policing, public sanitation, and equal health-care access. How-
ever, disparities are also observed across neighborhoods, school districts, and police precincts
due to variability in the local tax base. Some low-income urban neighborhoods are marked
by limited opportunities and resources, thus decreasing the probability that community mem-
bers will obtain ample education and protable careers that will support the local tax base.
Through processes of modeling, chronic stress, and coercion these neighborhoods may also
become saturated with interpersonal violence and vicarious exposure to trauma that substan-
tially drain coping resources (Espino et al., 2015; Hobfoll et al., 2013). Escaping these risk
factor caravans can be a tremendous task for an individual as obstacles are encountered at
personal, family, and community levels.
COR Theory Principles and Corollaries
Principle 1
From the central tenet of COR theory (i.e., that humans are motivated to accrue and conserve
resources), several principles and corollaries follow. Principle 1 states that “resource loss is

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
446 The Handbook of Stress and Health
Predisposing
Resource Lack
Fragile
Environments
and Settings
Potentially
Stressful Events
Resource Losses
Resource Gains
Negative
Personal, Social,
and Material
Outcomes
Weak,
positive
impact
Strong
negative
impact
Pre-existing
Strengths
Figure 27.1 Disproportionate impact of lack and loss.
disproportionately more salient than is resource gain” (Hobfoll, 1998, p. 62), “in both degree
and speed of impact” (Hobfoll, 2011, p. 128). Thus, loss of a given resource will have a greater
psychological impact than will gain of the same resource (see Figure 27.1). This idea echoes
the work of Kahneman and Tversky (1979), whose prospect theory posits a cognitive bias
in favor of preventing loss as opposed to promoting an equal amount of gain. Principle 1 is
supported by research demonstrating that stress responses are most consistently generated by
major life events involving signicant loss and not by those involving gain or mere transition
(see Thoits, 1983, for a review; Hobfoll, 1988; 1989; 1991). In COR theory, a life event creates
stress to the extent that it entails or threatens a cascade of resource loss.
This rst principle has received a great deal of empirical support. Hobfoll and Lilly (1993)
followed groups of individuals over time and found that psychological distress was predicted
by resource loss and that resource gain was only important in predicting psychological dis-
tress in the context of resource loss. That is, gain by itself was not predictive of lower distress,
but it became important in predicting distress level in those individuals who also experienced
a signicant amount of loss. The same holds for pregnant women, in whom resource loss is
associated with psychological distress, and resource gains predict psychological distress only
in the context of resource loss (Wells, Hobfoll, and Lavin, 1999). Similarly, psychological
distress – including both probable posttraumatic stress disorder (PTSD) and probable depres-
sion – was predicted by resource loss but not by resource gain in New Yorkers following the
terrorist attacks of September 11, 2001 (Hobfoll et al., 2006).
Principle 2
The second principle of COR theory states that “people must invest resources to protect against
resource loss, recover from losses, and gain resources” (Hobfoll, 1998, p. 73). Principle 2
illustrates how the complex relationships among resource loss, gain, and distress impact a
wide variety of health behaviors. People invest resources in protecting against health resource
loss every time they promote healthy immune functioning by getting a good night’s sleep or

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 447
eating a balanced meal. They invest resources to recover from health resource loss when they
take time off of work to recover from an illness or spend money to visit the doctor. Finally,
they invest resources to gain further health resources when they spend time and money on
exercising to improve their cardiovascular health.
Empirical support for this second principle encompasses everything from studies on self-
regulation to the large body of work examining how we use social support and self-efcacy
to cope with stress. Consider the example of resource loss and distress in pregnant women.
Principles 1 and 2 suggest that a woman balancing multiple roles (e.g., expectant mother and
full-time employee) is investing more resources and therefore expecting greater returns than
is a woman in only one of these roles. To the extent that such gains do not materialize – that
is, to the extent that a resource loss occurs – the employed expectant mother will be more
vulnerable to experiencing psychological distress than will the other woman. In fact, Wells,
Hobfoll, and Lavin (1997) found exactly that. This is key given the detrimental health impacts
of psychological distress during pregnancy on mothers and babies (e.g., Schetter and Tanner,
2012). Other studies have found even more direct evidence of the negative health effects of
low reward in the context of high resource investment. Specically, Siegrist, Peter, Motz, and
Strauer (1992) found that such conditions, studied within an occupational framework, predict
heart attack and stroke as reliably as do the objective biomarkers of hypertension and left
ventricular hypertrophy.
Corollary 1
Several corollaries follow from COR theory’s basic principles The rst states that those with
greater resources are less vulnerable to resource loss and more capable of orchestrating resource
gain. Conversely, those with fewer resources are more vulnerable to resource loss and less capable
of achieving resource gain …Moreover, those who lack resources are more likely to experience
extreme consequences. (Hobfoll, 1998, p. 80)
This rst corollary is intricately connected with the ideas of resource caravans and caravan pas-
sageways as one must have available either a personal cache of resources or access to shared
resources in order to offset losses or potential losses. Crucially, lack of access creates vulner-
ability to further loss under stress. Corollary 1 predicts that those with lower social support,
less access to health care, longer working hours, and less time and money to prepare healthy
meals or exercise will be more vulnerable to the losses entailed by chronic diseases such as
diabetes.
This corollary also suggests that individuals who have more resources to begin with, includ-
ing cultural capital (e.g., Miller and McNamee, 1998) and privileged social status (white race,
male sex, greater income) are less vulnerable to psychological distress following chronic or
traumatic stress. Paul and colleagues (2014) recently found that not only did resource loss pre-
dict greater psychological distress in a sample of hurricane survivors, but that so did female
sex and racial minority status. Similarly, among survivors of Hurricane Katrina, predictors of
psychological distress included not only resource loss but also being black, being female, and
being elderly (e.g., Adeola, 2009). This corollary also affects important medical outcomes. For
example, storm-exposed black women were 1.45 times more likely than were white women
to give birth to infants in hypoxic distress following Hurricane Andrew (Zahran, Snodgrass,
Peek, and Weiler, 2010).

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
448 The Handbook of Stress and Health
Consistent ndings have emerged in populations exposed to ongoing or isolated mass vio-
lence. Among Palestinians exposed to ongoing sociopolitical violence, psychosocial resource
loss more strongly predicted levels of psychological distress than did trauma exposure, bene-
t nding, or demographic variables (Heath, Hall, Canetti, and Hobfoll, 2013). Additionally,
however, being a woman or an older and less educated man was associated with greater dis-
tress, which in turn led to greater domestic violence among men (Heath et al., 2013). Simi-
larly, experiencing less resource loss, being of majority status (Jewish), being male, and having
greater income and social support predicted psychological resistance or resilience trajectories
in a nationally representative sample of Israelis during a particularly violent period (Hobfoll
et al., 2009).
COR theory also predicts distress following traumatic events not involving heavy physi-
cal loss. Littleton, Grills-Taquechel, and Axsom (2009) studied Virginia Tech students shortly
prior to the mass campus shooting that took place there in 2007, following up with them twice
following the event. Students incurring more post-event loss of psychosocial resources (e.g.,
feeling successful, counting on loyalty from friends) reported greater psychological distress.
Those who reported greater social resources prior to the shooting were less likely to incur
psychosocial resource loss in its aftermath, thus protecting them to some extent from psycho-
logical distress.
Corollaries 2 and 3
The second and third corollaries of COR theory are closely linked and state that “those who
lack resources are not only more vulnerable to resource loss, but that initial loss begets future
loss” (Hobfoll, 1998, p. 81) and “initial resource gain begets further gain” (Hobfoll, 1998,
p. 82), respectively. The best illustrations of the third corollary in COR theory are the resource
caravan and caravan passageway concepts explored above. Loss spirals, though, given their
crucial implications for physical and mental health, are explored in more detail here.
Loss spirals occur because stressors require coping in the form of resource investment. When
resources are insufcient to begin with, resource investment may be enough to put a person
over the edge, resulting in further losses (see Figure 27.2). Not surprisingly, loss spirals have
been observed in populations experiencing ongoing sociopolitical conict. Heath, Hall, Russ,
Canetti and Hobfoll (2012) conducted a four-time-point, 18-month longitudinal study of Pales-
tinians exposed to ongoing violence and conict. They found that not only did resource loss
predict psychological distress over time, but that psychological distress predicted resource loss
over time, suggesting that a transactional process took place, with ongoing loss and distress
perpetuating one another.
Traumatic events need not be ongoing to produce loss spirals, however; they have also been
observed following single-incident traumatic events, including the mass shooting at Virginia
Tech (Littleton et al., 2009). In particular, many students reported psychosocial resource
losses two months after the event in the form of decrements in intrapersonal resources (e.g.,
optimism, feelings of pride) as well as interpersonal resources (e.g., companionship). These
losses predicted not only posttraumatic symptomology four months later but also further psy-
chosocial resource loss, resulting in a subset of students who appeared “stuck” in a loss spiral
(Littleton et al., 2009). The inclusion of resource loss at two and six months after the trauma
(along with pre-trauma distress and support) yielded a model accounting for a full 55 percent of
the variance in posttraumatic symptomology at six months, illustrating ongoing psychosocial
resource loss as a powerful predictor of posttraumatic distress.

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 449
Resource-Poor Environment Resource-Rich Environment
5. Job loss increases
symptoms of
depression and PTSD;
loss spiral continues
3. Symptoms
of PTSD
compromise
job
performance
4. Social
support is
mobilized;
neighbors and
grandparents
help with child
care
1. Married
mother working
part-time is
mugged; she
loses credit cards
and sustains a
head injury
2. Ongoing
doctors’
appointments
threaten job
security
2. Ongoing
doctors’
appointments are
scheduled around
part-time work
4. Depression
and
withdrawal
strain
supportive
relationships
5. Treatment
progresses and
results in
recovery; job is
maintained; loss
spiral ceases
3. Symptoms
of depression
and PTSD are
treated in
psychotherapy
1. Single mother
working two jobs is
mugged; she loses
two months’ rent
and sustains a head
injury
Figure 27.2 Loss spirals in resource-poor and resource-rich environments.
Corollary 4
The fourth and nal corollary suggested by COR theory is that “those who lack resources are
likely to adopt a defensive posture to guard their resources” (Hobfoll, 1998, p. 83). Individ-
uals with few psychological resources may adopt a denial coping strategy (Breznitz, 1983)
to preserve their limited resources, despite this strategy’s appearing inefcient or irrational.
The long-term risk of defensive and avoidant coping is that while these behaviors are rein-
forced by limiting loss, they also decrease engagement with the broader environmental con-
text, including potential access to other valued resources (Hayes, Luoma, Bond, Masuda, and
Lillis, 2006). Thus, after a man receives a diagnosis of cancer, engaging in protective and
avoidant strategies (e.g., denial coping) may be benecial in the short term (e.g., by reducing
emotional distress). In the long term, however, emotional distress may persist because his dis-
engagement prevents him from perceiving that environmental contingencies have changed or
may change (e.g., treatment options may prolong life and alleviate pain and suffering; Gerhart
et al., 2015). In situations such as these, graded exposure can be introduced to increase the
odds that the individual will engage in adaptive coping, accrue resources, and obtain a sense
of mastery (Hayes et al., 2006).
Research Findings on COR Theory and Health
Stress and Medical Outcomes
Traumatic stress Two major lines of research have explored the effects of resources on
medical outcomes. The rst focuses on the intersection between traumatic stress and health.
Traumatic stress can be seen as a particularly rapid loss of highly valued resources (Hobfoll,

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
450 The Handbook of Stress and Health
1991) and is associated with high levels of psychological distress, including PTSD. To the
extent that trauma entails resource loss, traumatic events and PTSD are likely to carry with
them crucial downstream physical health risks (Hobfoll, Vinokur, Pierce, and Lewandowski-
Romps, 2012), an idea borne up by research (e.g., Pacella, Hruska, and Delahanty, 2013).
Cook, Aten, Moore, Hook, and Davis (2013) studied university students affected by Hurricane
Katrina and found that resource loss predicted psychological distress and poorer self-reported
physical health. Similarly, ood victims reported greater psychological distress as well as
physical symptoms (e.g., headaches, indigestion) to the extent that they experienced loss
of psychosocial resources, such as time with loved ones and optimism (Smith and Freedy,
2000).
Perhaps most striking are studies employing specic biomarkers of health, illness, or
immune functioning. Ironson and colleagues (2014) studied survivors of Hurricane Andrew,
nding that resource loss (including damage to property) predicted both psychological distress
and poorer immune function as measured by objective biomarkers. Pregnant women exposed
to the same hurricane in their second or third trimester were 20–26 percent more likely to
give birth to infants with hypoxic distress than were nonexposed women (Zahran et al., 2010).
Similar observations have been made in populations exposed to sudden bereavement; Cankaya,
Chapman, Talbot, Moynihan, and Duberstein (2009) studied female primary care patients and
found that those who had experienced the sudden and unexpected loss of a loved one carried
biomarkers of inammatory immune responses.
Occupational burnout Another body of work has examined the effect of resources on med-
ical outcomes in an occupational context. A number of longitudinal studies have focused on
burnout, a result of chronic stress characterized by diminished resources in the form of emo-
tional exhaustion, physical fatigue, and cognitive weariness (e.g., Shirom, Westman, Shamai,
and Carel, 1997). For example, increases in employees’ burnout are marginally associated with
increased risk for hyperlipidemia, and increases in vigor (i.e., a stronghold of emotional, phys-
ical, and cognitive energy) are associated with decreased risk (Shirom et al., 2013). Burnout
is also associated with elevated risk for the development of type 2 diabetes and coronary heart
disease (Melamed, Shirom, Toker, and Shapira, 2006; Toker, Melamed, Berliner, Zeltser, and
Shapira, 2012). In a study of 3,368 employed individuals in Finland, burnout was associated
with both prevalence and severity of cardiovascular disease among men and musculoskeletal
problems among women as assessed by physicians (Honkonen et al., 2006). In a one-year lon-
gitudinal study of Swedish women, burnout predicted the presence of musculoskeletal pain and
related disability, controlling for other physical health, psychological health, and work-related
factors (Grossi, Thomt´
en, Fandi˜
no-Losada, Soares, and Sundin, 2009).
Researchers have also examined the stress-buffering effect of resources on medical out-
comes in an occupational context. In a 20-year follow-up study of healthy employees, vigor
was associated with signicantly decreased risk of mortality and diabetes (Shirom, Toker,
Jacobson, and Balicer, 2010). Having a stimulating and engaging work environment is neg-
atively associated with employees’ waist circumference over time (Fried et al., 2013). In a
ten-year follow-up study of rst-year law students, optimism and social resources prospec-
tively predicted better physical health (Segerstrom, 2007). Thus, jobs which chronically drain
internal resources create vulnerability to disease and mortality. Meanwhile, the extent to which
people are able to feel energized and stimulated in their occupation appears to have a protective
effect on physical health.

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 451
Although having a demanding job can erode health, lacking employment can also be
damaging. In a population-based study, recent and current unemployment was positively
associated with anxiety, depression, and somatic concerns, and negatively associated with
self-reported physical health (Kessler, Turner, and House, 1988). In the same study, internal
resources, receipt of public assistance, and social support were negatively associated with
deleterious outcomes of unemployment. Stressors had a stronger negative impact on physical
and mental health outcomes for unemployed people than for employed people. Consistent
with COR theory, the major stressor of losing a job most profoundly impacts people who
initially lack resources and diminishes individuals’ health functioning in the face of future
stressors.
Psychological Functioning in Medical Populations and Health
Risk Behaviors
COR theory has also been applied to biopsychosocial functioning in medical populations. Loss
spirals and resource caravans in particular have been observed to play critical roles in areas of
health functioning as diverse as postpartum transition, chronic illness management, and health
risk behavior. For example, resource loss predicts increases in anger and depression as women
transition from pregnancy to the postpartum period (Wells et al., 1999). The interrelatedness
of resources and their loss was further illustrated in a qualitative study of stroke survivors
and their families. Egbert, Koch, Coeling, and Ayers (2006) found that loss of mobility led to
difculties for stroke survivors in performing activities of daily life, including driving, which
led to social isolation. In this study, the social support networks of patients served as conduits
for community integration (Egbert et al., 2006), illustrating the ameliorating role of resource
caravans.
Lane and Hobfoll (1992) studied patients with chronic obstructive pulmonary disease and
found that losses incurred as a result of their chronic illness led to anger, which in turn led to
anger in their partners. This pattern is highly suggestive of a continuing loss spiral whereby
increasing loss may jeopardize supportive relationships, thus leading to further loss. Addi-
tionally, among women with chronic fatigue syndrome, resource loss and gain predict qual-
ity of life whereas fatigue and symptom severity do not (Taylor, Kulkarni, and Shiraishi,
2006). Resource loss is also associated with anxiety and depression among rheumatoid arthritis
patients (Dirik and Karanci, 2010).
Resource loss also has important implications for obstetric populations. Pregnant women
who have fewer material and psychosocial resources to begin with (less education, income,
optimism, self-esteem, etc.) experience more psychological distress, which predicts lower birth
weights and shorter gestational periods (Rini, Dunkel-Schetter, Wadhwa, and Sandman, 1999),
likely leading to further cascades of resource loss for the mothers.
COR theory also has implications for health risk behaviors. For example, individuals who
are experiencing resource loss may try to distract or distance themselves from stress by engag-
ing in poor health behaviors, which can contribute to ongoing loss (Hobfoll and Shirom, 2000).
Additionally, COR theory suggests that, in order for interventions with at-risk populations to
be successful, they must be perceived as strengthening existing resources and building new
resources. In fact, an AIDS prevention intervention based on this framework increased HIV-
related knowledge and safe-sex behaviors among single, pregnant, inner-city women (Hobfoll,
Jackson, Lavin, Britton, and Shepherd, 1994).

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
452 The Handbook of Stress and Health
Health-Care Systems
As noted, COR theory explains how individuals nested within larger social networks experi-
ence stress when resources are lost or threatened. Thus, in addition to explaining individual
patterns of health-related risk and resilience, COR theory can be applied to the health-care
systems that serve individuals. Given the long hours and high stakes of loss within medical
care, it is not surprising that physicians are at increased risk of burnout compared to the general
population (Shanafelt et al., 2012).
COR theory also provides a framework for understanding research utilization by health-care
systems, which bear the burden of balancing cost-effectiveness with the need to integrate new
scientic ndings into patient care practices. A recent study (Alvaro et al., 2010) found support
for three key COR-consistent themes in the utilization of research in health-care settings by
conducting interviews with research team members, government decision-makers, and health
practitioners. First, organizational resources (e.g., availability of incentives to use research
evidence, training in how to use research evidence) are required for adaptation and change.
Second, the threat of loss leads to the protection of assets (e.g., fear of burnout contributes to
practitioners’ reluctance to commit time to research projects). Third, resources must be opti-
mized for adaptation (e.g., ongoing education and training after research funding ends creates
sustainable change). These ndings speak to the importance of considering the resources in
supporting research initiatives and providing state of the art patient care.
Implications
Research
We suggest several potentially fruitful lines of inquiry which use COR theory to enrich our
understanding of health-related processes.. First, further investigation is needed into the mul-
tileveled impacts of loss and trauma on both mental and physical health. For example, the
important observed risk factor caravan of multiple physical and mental health comorbidities,
may have its roots in the passageway (i.e., causal mechanism) of traumatic stress exposure
and subsequent inammatory processes and immune dysregulation (Canetti, Russ, Luborsky,
Gerhart, and Hobfoll, 2014). Additionally, COR theory and its principles of loss spirals make
explicit that stressors and stress responses can serve as both causes and effects of loss. Con-
ceptualizing serious medical events (e.g., diagnosis of terminal illness, coping with chronic
conditions, and acute incidents) as not only a result but also a cause of stress and loss can
help researchers delineate the ways in which interventions can more efciently interrupt these
chains of events.
Another timely avenue of research involves understanding the impact of access to health care
on physical and mental health outcomes. Research conducted in the state of Massachusetts,
where state-supported universal health care was implemented before similar legislation was
introduced on a federal level, suggests that accessible health-care coverage reduced all-cause
mortality rates by 2.9 percent (Sommers, Long, and Baicker, 2014). Large-scale analysis of
the impact of widespread availability of health-care resources on the United States population
remains to be done.
Ongoing advancements in statistical analysis have provided many opportunities to explore
complex data structures nested within individuals over time. Multilevel structural equation
models will enable the testing of bottom-up or emergent effects such as the impact of individual

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 453
trauma on higher-level constructs (Preacher, Zyphur, and Zhang, 2010). These may include
applications of COR theory to understanding how trauma faced by individuals emerges at
the community level to impact communal coping, school safety, neighborhood health-care
utilization, and regional political climate.
Practice
Extant research suggests practical uses of COR theory to impact health-related outcomes.
Trauma experts recommend that sense of safety, calming, senses of self- and community-
efcacy, and hope are key resources to foster in primary, secondary, and tertiary interventions
aimed at promoting positive psychological outcomes in the face of trauma (Hobfoll et al.,
2007). These are likely also prime targets for interventions seeking to promote psycholog-
ical and physical well-being in medical populations. Importantly, attempts to deliver these
ingredients to medical patients using traditional mental health paradigms (e.g., a psycholo-
gist delivering individual outpatient psychotherapy) may be ineffective or inaccessible as the
intervention is not delivered in the medical context. Rather, these resources can be taught and
bolstered by other components of health-care organizations. This design provides natural cues
to evoke coping strategies when they are needed most, leading to more effective reinforcement
of behavior (Hobfoll et al., 2013).
For example, Stevens, Hobfoll, Anaya, and Finigan (2014) recently piloted a multilevel
intervention for pregnant women with posttraumatic stress symptoms. Psychologists delivered
brief coping-based psychotherapy to patients and trained obstetricians to deliver trauma-
sensitive medical care to the same patients. The intervention led to moderate-to-large reduc-
tions in women’s posttraumatic stress and depression symptoms postpartum. The dual-delivery
nature of the intervention harnesses women’s repeated visits with obstetricians as oppor-
tunities to boost resources (self-esteem, coping abilities) while simultaneously minimizing
further resource depletion due to ongoing anxiety and avoidance of medical care. In this way,
treatment interrupts the loss cycle that trauma history and PTSD would otherwise perpetuate.
Patients with diverse medical needs will likely benet from similar psychosocial integration
of care.
Conclusions
COR theory offers a multileveled framework within which to understand responses to both
chronic and traumatic stress. In particular, it suggests that stress results from any set of circum-
stances involving threatened or actual loss of valued resources. Furthermore, it is the desire to
defend, conserve, and promote acquisition of these valued resources which motivates human
behavior in the face of stress. Resources encompass both survival-promoting commodities
and objects or conditions with shared cultural value. They do not tend to occur in isolation
but rather cluster together, creating resource caravans. According to COR theory, loss is more
salient than gain, and loss begets loss.
The theory has received a great deal of empirical support from a wide variety of research
domains and designs and has proven particularly helpful in understanding the relationships
between stress and physical health. In particular, it offers insights which have guided research
on areas such as coping with chronic illness, medical consequences of natural disasters, and
the long-term effects of occupational burnout. COR theory principles have implications not

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
454 The Handbook of Stress and Health
only for intervention in disasters entailing rapid and massive loss of personal and community
resources but also for improving medical care – especially for those with histories of trau-
matic stress exposure. COR theory may prove especially useful in informing future research
expanding our understanding of health-related resource caravan passageways – that is, the
mechanisms by which risk and resilience factors cluster together and impact health.
References
Adeola, F. O. (2009). Mental health and psychosocial distress sequelae of Katrina: An empirical study of survivors.
Research in Human Ecology,16(2), 195–210.
Adler, N. E., and Newman, K. (2002). Socioeconomic disparities in health: Pathways and policies. Health Affairs,21,
60–76. doi:10.1377/hlthaff.21.2.60
Alvaro, C., Lyons, R. F., Warner, G., Hobfoll, S. E., Martens, P. J., Labont´
e, R., and Brown, R. E. (2010). Conservation
of resources theory and research use in health systems. Implementation Science,5(79), 1–20. doi:10.1186/1748-
5908-5-79
Bell, K. M., and Naugle, A. E. (2008). Intimate partner violence theoretical considerations: Moving towards a con-
textual framework. Clinical Psychology Review,28, 1096–1107. doi:10.1016/j.cpr.2008.03.003
Blaze, J. T., and Shwalb, D. W. (2009). Resource loss and relocation: A follow-up study of adolescents two years
after Hurricane Katrina. Psychological Trauma: Theory, Research, Practice, and Policy,1, 312–322. doi:10.1037/
a0017834
Bowles, S., Gintes, H., and Groves, M. O. (2005). Unequal Changes: Family Background and Economic Success.
Princeton: Princeton University Press.
Breznitz, S. (1983). The Denial of Stress. Madison, CT: International Universities Press.
Canetti, D., Russ, E., Luborsky, J., Gerhart, J. I., and Hobfoll, S. E. (2014). Inamed by the ames? The impact of
terrorism and war on immunity. Journal of Traumatic Stress,27, 345–352. doi:10.1002/jts.21920
Cankaya, B., Chapman, B. P., Talbot, N. L., Moynihan, J., and Duberstein, P. R. (2009). History of sudden unexpected
loss is associated with elevated interleukin-6 and decreased insulin-like growth factor-1 in women in an urban
primary care setting. Psychosomatic Medicine,71, 914–919. doi:10.1097/psy.0b013e3181be7aa8
Cook, S. W., Aten, J. D., Moore, M., Hook, J. N., and Davis, D. E. (2013). Resource loss, religiousness, health, and
posttraumatic growth following Hurricane Katrina. Mental Health, Religion and Culture,16,352–366. doi:10.1037/
e700912007-001
Corak, M. (2013). Income inequality, equality of opportunity, and intergenerational mobility. Journal of Economic
Perspectives,27, 79–102. doi:10.1257/jep.27.3.79
Dirik, G., and Karanci, A. N. (2010). Psychological distress in rheumatoid arthritis patients: An evaluation within the
conservation of resources theory. Psychology and Health,25, 617–632. doi:10.1080/08870440902721818
Egbert, N., Koch, L., Coeling, H., and Ayers, D. (2006). The role of social support in the family and community inte-
gration of right-hemisphere stroke survivors. Health Communication,20, 45–55. doi:10.1207/s15327027hc2001_5
Espino, S. R., Fletcher, J., Gonzalez, M., Precht, A., Xavier, J., and Matoff-Stepp, S. (2015). Violence screening
and viral load suppression among HIV-positive women of color. AIDS Patient Care and STDs,29(S1), S36–S41.
doi:doi:10.1089/apc.2014.0275
Freedy, J. R., Saladin, M. E., Kilpatrick, D. G., Resnick, H. S., and Saunders, B. E. (1994). Understanding acute
psychological distress following natural disaster. Journal of Traumatic Stress,7, 257–273. doi:10.1007/bf02102947
Fried, Y., Laurence, G. A., Shirom, A., Melamed, S., Toker, S., Berliner, S., and Shapira, I. (2013). The relation-
ship between job enrichment and abdominal obesity: A longitudinal eld study of apparently healthy individuals.
Journal of Occupational Health Psychology,18, 458–468. doi:10.1037/a0033730
Gardner, F. L., and Moore, Z. E. (2008). Understanding clinical anger and violence: The anger avoidance model.
Behavior Modication,32, 897–912. doi:10.1177/0145445508319282
Gerhart, J., Asvat, Y., Lattie, E., O’Mahony, S., Duberstein, P., and Hoerger, M. (2015). Distress, delay of gratication
and preference for palliative care in men with prostate cancer. Psycho-Oncology. Epub ahead of print. doi:10.1002/
pon.3822
Gorgievski, M. J., and Hobfoll, S. E. (2008). Work can burn us out or re us up: Conservation of resources in burnout
and engagement. In J. R. B. Halbesleben (Ed.), Handbook of Stress and Burnout in Health Care, 3rd edn. (pp. 7–22).
Hauppauge, NY: Nova Science.

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 455
Grossi, G., Thomt´
en, J., Fandi˜
no-Losada, A., Soares, J. J., and Sundin, ¨
O. (2009). Does burnout predict changes in pain
experiences among women living in Sweden? A longitudinal study. Stress and Health,25, 297–311. doi:10.1002/
smi.1281
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., and Lillis, J. (2006). Acceptance and commitment therapy:
Model, processes and outcomes. Behaviour Research and Therapy,44, 1–25. doi:10.1016/j.brat.2005.06.006
Heath, N. M., Hall, B. J., Canetti, D., and Hobfoll, S. E. (2013). Exposure to political violence, psychological distress,
resource loss, and benet nding as predictors of domestic violence among Palestinians. Psychological Trauma:
Theory, Research, Practice, and Policy,5, 366–376. doi:10.1037/a0028367
Heath, N. M., Hall, B. J., Russ, E. U., Canetti, D., and Hobfoll, S. E. (2012). Reciprocal relationships between resource
loss and psychological distress following exposure to political violence: An empirical investigation of COR theory’s
loss spirals. Anxiety, Stress and Coping,25, 679–695. doi:10.1080/10615806.2011.628988
Hobfoll, S. E. (1988). The Ecology of Stress. Washington, DC: Hemisphere.
Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist,
44, 513–524. doi:10.1037/0003-066x.44.3.513
Hobfoll, S. E. (1991). Traumatic stress: A theory based on rapid loss of resources. Anxiety Research,4, 187–197.
doi:10.1080/08917779108248773
Hobfoll, S. E. (1998). Stress, Culture, and Community: The Psychology and Physiology of Stress. New York: Plenum
Press.
Hobfoll, S. E. (2001). The inuence of culture, community, and the nested-self in the stress process: Advancing
conservation of resources theory. Applied Psychology,50, 337–421. doi:10.1111/1464-0597.00062
Hobfoll, S. E. (2011). Conservation of resources theory: Its implication for stress, health, and resilience. In S. Folkman
(Ed.), The Oxford Handbook of Stress, Health, And Coping (pp. 127–147). New York: Oxford University Press.
Hobfoll, S. E., Hall, B. J., and Canetti, D. (2012). Political violence, psychological distress, and perceived health:
A longitudinal investigation in the Palestinian authority. Psychological Trauma: Theory, Research, Practice, and
Policy,4, 9–21. doi:10.1037/a0018743
Hobfoll, S. E., Jackson, A. P., Lavin, J., Britton, P. J., and Shepherd, J. B. (1994). Reducing inner-city women’s
AIDS risk activities: A study of single, pregnant women. Health Psychology,13, 397–403. doi:10.1037/0735-
7028.38.5.518
Hobfoll, S. E., and Lilly, R. S. (1993). Resource conservation as a strategy for community psychology. Journal of Com-
munity Psychology,21, 128–148. doi:10.1002/1520- 6629(199304)21:2<128::AID-JCOP2290210206>3.0.CO;2-5
Hobfoll, S. E., Palmieri, P. A., Johnson, R. J., Canetti-Nisim, D., Hall, B. J., and Galea, S. (2009). Trajectories of
resilience, resistance, and distress during ongoing terrorism: The case of Jews and Arabs in Israel. Journal of
Consulting and Clinical Psychology,77, 138–148. doi:10.1037/a0014360
Hobfoll, S. E., and Shirom, A. (2000). Conservation of resources theory: Applications to stress and management in
the workplace. In R.T. Golembiewski (Ed.), Handbook of Organization Behavior, 2nd rev. edn. (pp. 57–81). New
York: Dekker.
Hobfoll S. E., Stevens N. R., Gerhart J. I., Clift, A. T., Vechiu, C. V., Verela, V., …Fung, H. (2013). Traumatic stress,
health, and strategies for multi-level bio-psycho-social interventions. In K. Moore, K. Kaniasty, P. Buchwald, and
A. Ses´
e(Eds.),Stress and Anxiety: Applications to Health and Well-Being, Work Stressors, and Assessment (pp. 7–
16). Berlin: Logos.
Hobfoll, S. E., Tracy, M., and Galea, S. (2006). The impact of resource loss and traumatic growth on probable PTSD
and depression following terrorist attacks. Journal of Traumatic Stress,19, 867–878. doi:10.1002/jts.20166
Hobfoll, S. E., Vinokur, A. D., Pierce, P. F., and Lewandowski-Romps, L. (2012). The combined stress of family life,
work, and war in Air Force men and women: A test of conservation of resources theory. International Journal of
Stress Management,19, 217–237. doi:10.1037/a0029247
Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., …Ursano, R. J. (2007). Five
essential elements of immediate and mid–term mass trauma intervention: Empirical evidence. Psychiatry,70, 283–
315. doi:10.1521/psyc.2007.70.4.283
Honkonen, T.,Ahola, K., Pertovaara, M., Isomets ¨
a, E., Kalimo, R., Nykyri, E., …L¨
onnqvist, J. (2006). The association
between burnout and physical illness in the general population: Results from the Finnish Health 2000 study. Journal
of Psychosomatic Research,61, 59–66. doi:10.1016/j.jpsychores.2005.10.002
Ironson, G., Kumar, M., Greenwood, D., Schneiderman, N., Cruess, D., Kelsch, C. B., …Baum, A. (2014). Post-
traumatic stress symptoms, intrusive thoughts, and disruption are longitudinally related to elevated cortisol and
catecholamines following a major hurricane. Journal of Applied Biobehavioral Research,19, 24–52. doi:10.1111/
jabr.12014

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
456 The Handbook of Stress and Health
Kahneman D., and Tversky A. (1979). Prospect theory: An analysis of decision under risk. Econometrica,47, 263–
291. doi:10.2307/1914185
Kessler, R. C., Turner, J. B., and House, J. S. (1988). Effects of unemployment on health in a community survey: Main,
modifying, and mediating effects. Journal of Social Issues, 44(4), 69–85. doi:10.1111/j.1540-4560.1988.tb02092.x
Lane, C., and Hobfoll, S. E. (1992). How loss affects anger and alienates potential supporters. Journal of Consulting
and Clinical Psychology, 60, 935–942. doi:10.1037/0022-006x.60.6.935
Langhinrichsen-Rohling, J., Hankla, M., and Stormberg, C. D. (2004). The relationship behavior networks of young
adults: A test of the intergenerational transmission of violence hypothesis. Journal of Family Violence,19, 139–151.
doi:10.1023/b:jofv.0000028074.35688.4f
Layne, C. M., Beck, C., Rimmasch, H., Southwick, J., Moreno, M., and Hobfoll, S. (2009). Promoting “resilient”
posttraumatic adjustment in childhood and beyond. In D. Brom, R. Pat-Horenczyk, and J. Ford (Eds.), Treating
Traumatized Children: Risk, Resilience, and Recovery (pp. 13–47). London: Routledge.
Lazarus, R. S., and Folkman, S. (1984). Stress, Appraisal, and Coping. New York: Springer.
Littleton, H., Grills-Taquechel, A., and Axsom, D. (2009). Impaired and incapacitated rape victims: Assault charac-
teristics and post-assault experiences. Violence and Victims,24, 439–457. doi:10.1891/0886-6708.24.4.439
Melamed, S., Shirom, A., Toker, S., and Shapira, I. (2006). Burnout and risk of type 2 diabetes: A prospective study
of apparently healthy employed persons. Psychosomatic Medicine,68, 863–869. doi:10.1097/01.psy.0000242860.
24009.f0
Miller, R. K., and McNamee, S. J. (1998). Inheritance and Wealth in America. New York: Springer.
Pacella, M. L., Hruska, B., and Delahanty, D. L. (2013). The physical health consequences of PTSD and PTSD
symptoms: A meta-analytic review. Journal of Anxiety Disorders,27, 33–46. doi:10.1016/j.janxdis.2012.08.004
Paul, L. A., Price, M., Gros, D. F., Gros, K. S., McCauley, J. L., Resnick, H. S., …Ruggiero, K. J. (2014). The
associations between loss and posttraumatic stress and depressive symptoms following Hurricane Ike. Journal of
Clinical Psychology,70, 322–332. doi:10.1002/jclp.22026
Preacher, K. J., Zyphur, M. J., and Zhang, Z. (2010). A general multilevel SEM framework for assessing multilevel
mediation. Psychological Methods,15, 209–233. doi:10.1037/a0020141
Rini, C. K., Dunkel-Schetter, C., Wadhwa, P. D., and Sandman, C. A. (1999). Psychological adaptation and birth
outcomes: The role of personal resources, stress, and sociocultural context in pregnancy. Health Psychology,18,
333–345. doi:10.1037/0278-6133.18.4.333
Schetter, C. D., and Tanner, L. (2012). Anxiety, depression and stress in pregnancy: Implications for mothers, children,
research, and practice. Current Opinion in Psychiatry,25, 141–148. doi:10.1097/yco.0b013e3283503680
Segerstrom, S. C. (2007). Optimism and resources: Effects on each other and on health over 10 years. Journal of
Research in Personality,41, 772–786. doi:10.1016/j.jrp.2006.09.004
Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D.,…Oreskovich, M. R. (2012). Burnout and
satisfaction with work–life balance among US physicians relative to the general US population. Archives of Internal
Medicine,172, 1377–1385. doi:10.1001/archinternmed.2012.3199
Shirom, A., Toker, S., Jacobson, O., and Balicer, R. D. (2010). Feeling vigorous and the risks of all-cause mortality,
ischemic heart disease, and diabetes: A 20-year follow-up of healthy employees. Psychosomatic Medicine,72,
727–733. doi:10.1097/psy.0b013e3181eeb643
Shirom, A., Toker, S., Melamed, S., Berliner, S., and Shapira, I. (2013). Burnout and vigor as predictors of the
incidence of hyperlipidemia among healthy employees. Applied Psychology: Health and Well-Being,5, 79–98.
doi:10.1111/j.1758-0854.2012.01071.x
Shirom, A., Westman, M., Shamai, O., and Carel, R. S. (1997). Effects of work overload and burnout on cholesterol
and triglycerides levels: The moderating effects of emotional reactivity among male and female employees. Journal
of Occupational Health Psychology,2, 275–288. doi:10.1037/1076-8998.2.4.275
Siegrist, J., Peter, R., Motz, W., and Strauer, B. E. (1992). The role of hypertension, left ventricular hypertrophy and
psychosocial risks in cardiovascular disease: Prospective evidence from blue-collar men. European Heart Journal,
13(suppl. D), 89–95. doi:10.1093/eurheartj/13.suppl_d.89
Smith, B. W., and Freedy, J. R. (2000). Psychosocial resource loss as a mediator of the effects of ood exposure
on psychological distress and physical symptoms. Journal of Traumatic Stress, 13(2), 349–357. doi:10.1023/
a:1007745920466
Sommers, B. D., Long, S. K., and Baicker, K. (2014). Changes in mortality after Massachusetts health care reform:
A quasi-experimental study. Annals of Internal Medicine,160, 585–593. doi:10.7326/m13-2275
Stevens, N. R., Hobfoll, S. E., Anaya, H. A., and Finigan, M. (2014). Improving pregnancy outcomes for survivors
of abuse using trauma-sensitive obstetric care. Symposium conducted at the annual meeting of the International
Society for Traumatic Stress Studies, Miami, Nov.

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
Conservation of Resources Theory 457
Taylor, R. R., Kulkarni, S., and Shiraishi, Y. (2006). Conservation of resources and quality of life in individuals with
chronic fatigue syndrome. Journal of Chronic Fatigue Syndrome, 13(4), 3–15. doi:10.1300/j092v13n04_02
Thoits, P. A. (1983). Multiple identities and psychological well-being: A reformulation and test of the social isolation
hypothesis. American Sociological Review,48, 174–187. doi:10.2307/2095103
Toker, S., Melamed, S., Berliner, S., Zeltser, D., and Shapira, I. (2012). Burnout and risk of coronary heart disease: A
prospective study of 8,838 employees. Psychosomatic Medicine,74, 840–847. doi:10.1097/psy.0b013e31826c3174
Wells, J. D., Hobfoll, S. E., and Lavin, J. (1997). Resource loss, resource gain, and communal coping during preg-
nancy among women with multiple roles. Psychology of Women Quarterly,21, 645–662. doi:10.1111/j.1471-6402.
1997.tb00136.x
Wells, J. D., Hobfoll, S. E., and Lavin, J. (1999). When it rains, it pours: The greater impact of resource loss com-
pared to gain on psychological distress. Personality and Social Psychology Bulletin,25, 1172–1182. doi:10.1177/
01461672992512010
Zahran, S., Snodgrass, J. G., Peek, L., and Weiler, S. (2010). Maternal hurricane exposure and fetal distress risk. Risk
Analysis,30, 1590–1601. doi:10.1111/j.1539-6924.2010.01453.x

JWST753-c27 JWST753-Cooper September 29, 2016 8:43 Printer Name: Trim: 244mm ×170mm
UNCORRECTED PROOFS
458