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My Health Beliefs and Behavior

  • Categories: Healthy Lifestyle Self Assessment

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Published: Mar 3, 2020

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Introduction, works cited:.

  • Craveri, M. (2002). The culture of the Europeans. University of Chicago Press.
  • Di Napoli, R., & Paparcone, M. (2017). The Italian Cultural Experience: A journey through the arts, humanities, and everyday life. Routledge.
  • Gennari, D. J. (2019). The joy of writing about Italian-American food. In Pizza, Pasta, and Cannoli: Italian-American Food (pp. 3-22). Bloomsbury Publishing USA.
  • Giuffrè, L. (2017). School education in Italy: An overview. Italian Journal of Sociology of Education, 9(2), 41-55.
  • Ilardo, J. (2013). Culture and customs of Italy. ABC-CLIO.
  • Leaman, O. (Ed.). (2010). The future of philosophy. Wiley-Blackwell.
  • Lillich, M. (2019). How to eat like an Italian. National Geographic.
  • Nava, M. (2017). L’Italia del made in Italy. Società e politica, (2), 117-124.
  • Scuderi, A. (2018). Family ties and migration decisions: Italy in comparison with Europe. European Journal of Population, 34(4), 491-511.
  • UNESCO. (2019). Festivals in Italy. Retrieved from https://ich.unesco.org/en/lists.

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health behaviors essay

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Studying Health Psychology and Illness

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

health behaviors essay

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

health behaviors essay

  • Current Issues
  • Biosocial Model
  • In Practice

Health psychology is a specialty area that focuses on how biology, psychology, behavior, and social factors influence health and illness. Other terms such as medical psychology and behavioral medicine are sometimes used interchangeably with the term health psychology.

Health and illness are influenced by a wide variety of factors. While contagious and hereditary illnesses are common, many behavioral and psychological factors can impact overall physical well-being and various medical conditions.

An Overview of Health Psychology

Health psychology is a field of psychology focused on promoting health as well as the prevention and treatment of disease and illness. Health psychologists also focus on understanding how people react to, cope with, and recover from illness. Some health psychologists work to improve the health care system and the government's approach to health care policy.

Division 38 of the American Psychological Association is devoted to health psychology. According to the division, their focus is on a better understanding of health and illness, studying the psychological factors that impact health, and contributing to the health care system and health policy.

The field of health psychology emerged in the 1970s to address the rapidly changing field of healthcare. Today, life expectancy in the U.S. is around 80 years, and the leading causes of mortality are chronic diseases often linked to lifestyle.  Health psychology helps address these changes in health.

By looking at the patterns of behavior that underlie disease and death, health psychologists hope to help people live better, and healthier, lives.

How Is Health Psychology Unique?

Because health psychology emphasizes how behavior influences health, it is well-positioned to help people change the behaviors that contribute to health and well-being. Examples of health psychology in action would be researchers conducting applied research on how to prevent unhealthy behaviors such as smoking or to find new ways to encourage healthy actions such as exercising.

For example, while most people realize that eating a diet high in sugar is not good for their health, many people continue to engage in such behaviors regardless of the possible short-term and long-term consequences. Health psychologists look at the psychological factors that influence these health choices and explore ways to motivate people to make better health choices.

Importance of Health Psychology

The U.S. Centers for Disease Control's National Center for Health Statistics compiles data regarding death in the nation and its causes. Congruent with data trends throughout this century, nearly half of all deaths in the United States can be linked to behaviors or other risk factors that are mostly preventable.

In the CDC's 2012 report, the rate of death had declined for all leading causes except suicide. Life expectancy was also at an all-time high (78.8 years), yet about 83 Americans die from heart disease and stroke every hour. And more than a quarter of those deaths are preventable.

Cancer deaths were second, followed by chronic lower respiratory diseases—primarily chronic obstructive pulmonary diseases (COPD) such as emphysema and chronic bronchitis. COPD was followed by drug poisonings, including overdoses , then fatal falls among an increasingly elder population.

Current Issues in Health Psychology

Health psychologists work with individuals, groups, and communities to decrease risk factors, improve overall health, and reduce illness. They conduct research and provide services in areas including:

  • Stress reduction
  • Weight management
  • Smoking cessation
  • Improving daily nutrition
  • Reducing risky sexual behaviors
  • Hospice care and grief counseling
  • Preventing illness
  • Understanding the effects of illness
  • Improving recovery
  • Teaching coping skills

The Biosocial Model in Health Psychology

Today, the main approach used in health psychology is known as the biosocial model. According to this view, illness and health are the results of a combination of biological, psychological, and social factors.

  • Biological factors include inherited personality traits and genetic conditions.
  • Psychological factors involve lifestyle, personality characteristics, and stress levels.
  • Social factors include such things as social support systems , family relationships, and cultural beliefs.

Health Psychology in Practice

Health psychology is a rapidly growing field. As increasing numbers of people seek to take control of their own health, more and more people are seeking health-related information and resources. Health psychologists are focused on educating people about their own health and well-being, so they are perfectly suited to fill this rising demand.

Many health psychologists work specifically in the area of prevention, focusing on helping people stop health problems before they start.

This may include helping people maintain a healthy weight, avoid unhealthy or risky behaviors , and maintain a positive outlook that can combat stress, depression, and anxiety.

Another way that health psychologists can help is by educating and training other health professionals. By incorporating knowledge from health psychology, physicians, nurses, nutritionists, and other health practitioners can better incorporate psychological approaches into how they treat patients.

Branches of Health Psychology

Individuals who are interested in a health psychology career can choose to work in a specific branch of this field. Four main branches of health psychology are:

  • Clinical health psychology : This health psychology branch involves working with individuals, helping them make lifestyle changes for better health.
  • Community health psychology : Health psychology workers can also work with entire communities, such as studying diseases that are common in certain communities and the causes behind them.
  • Occupational health psychology : This branch of health psychology focuses on how a person's job can affect their health, in addition to finding ways to promote employee health within work environments.
  • Public health psychology : Another option for health psychology professionals is to work in a position that studies and/or is able to influence policies and programs designed to promote the health of the public as a whole.

A Word From Verywell

If you are struggling to make healthy changes in your life , dealing with the onset of illness, or facing some other type of health problem, seeing a health psychologist is one way to help start you off on the right foot. By consulting with one of these professionals, you can gain access to support and resources designed to help you cope with your illness and achieve your health goals.

American Psychological Association. Society for Health Psychology .

Centers for Disease Control and Prevention. Mortality in the United States, 2017 .

DeStasio KL, Clithero JA, Berkman ET. Neuroeconomics, health psychology, and the interdisciplinary study of preventative health behavior .  Soc Personal Psychol Compass . 2019;13(10):e12500. doi:10.1111/spc3.12500

Centers for Disease Control and Prevention. CDC National Health Report Highlights .

Mason PH, Roy A, Spillane J, Singh P. Social, historical and cultural dimensions of tuberculosis .  J Biosoc Sci . 2016;48(2):206–232. doi:10.1017/S0021932015000115

Baum A, Revenson TA, Singer JE. Handbook of Health Psychology. Second Edition . Psychology Press; 2012.

Brannon L, Updegraff JA, Feist J. Health Psychology: An Introduction to Behavior and Health . Cengage Learning; 2014.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Using these brief interventions, you can help your patients make healthy behavior changes.


Fam Pract Manag. 2018;25(2):31-36

Author disclosures: no relevant financial affiliations disclosed.

health behaviors essay

Effectively encouraging patients to change their health behavior is a critical skill for primary care physicians. Modifiable health behaviors contribute to an estimated 40 percent of deaths in the United States. 1 Tobacco use, poor diet, physical inactivity, poor sleep, poor adherence to medication, and similar behaviors are prevalent and can diminish the quality and length of patients' lives. Research has found an inverse relationship between the risk of all-cause mortality and the number of healthy lifestyle behaviors a patient follows. 2

Family physicians regularly encounter patients who engage in unhealthy behaviors; evidence-based interventions may help patients succeed in making lasting changes. This article will describe brief, evidence-based techniques that family physicians can use to help patients make selected health behavior changes. (See “ Brief evidence-based interventions for health behavior change .”)

Modifiable health behaviors, such as poor diet or smoking, are significant contributors to poor outcomes.

Family physicians can use brief, evidence-based techniques to encourage patients to change their unhealthy behaviors.

Working with patients to develop health goals, eliminate barriers, and track their own behavior can be beneficial.

Interventions that target specific behaviors, such as prescribing physical activity for patients who don't get enough exercise or providing patient education for better medication adherence, can help patients to improve their health.


Although many interventions target specific behaviors, three techniques can be useful across a variety of behavioral change endeavors.

“SMART” goal setting . Goal setting is a key intervention for patients looking to make behavioral changes. 3 Helping patients visualize what they need to do to reach their goals may make it more likely that they will succeed. The acronym SMART can be used to guide patients through the goal-setting process:

Specific. Encourage patients to get as specific as possible about their goals. If patients want to be more active or lose weight, how active do they want to be and how much weight do they want to lose?

Measurable. Ensure that the goal is measurable. For how many minutes will they exercise and how many times a week?

Attainable. Make sure patients can reasonably reach their goals. If patients commit to going to the gym daily, how realistic is this goal given their schedule? What would be a more attainable goal?

Relevant. Ensure that the goal is relevant to the patient. Why does the person want to make this change? How will this change improve his or her life?

Timely. Help patients define a specific timeline for the goal. When do they want to reach their goal? When will you follow-up with them? Proximal, rather than distal, goals are preferred. Helping patients set a goal to lose five pounds in the next month may feel less overwhelming than a goal of losing 50 pounds in the next year.

Problem-solving barriers . Physicians may eagerly talk with patients about making changes — only to become disillusioned when patients do not follow through. Both physicians and patients may grow frustrated and less motivated to work on the problem. One way to prevent this common phenomenon and set patients up for success is to brainstorm possible obstacles to behavior change during visits.

After offering a suggestion or co-creating a plan, physicians can ask simple, respectful questions such as, “What might get in the way of your [insert behavior change]?” or “What might make it hard to [insert specific step]?” Physicians may anticipate some common barriers raised by patients but be surprised by others. Once the barriers are defined, the physician and patient can develop potential solutions, or if a particular barrier cannot be overcome, reevaluate or change the goal. This approach can improve clinical outcomes for numerous medical conditions and for patients of various income levels. 4

For example, a patient wanting to lose weight may commit to regular short walks around the block. Upon further discussion, the patient shares that the cold Minnesota winters and the violence in her neighborhood make walking in her area difficult. The physician and patient may consider other options such as walking around a local mall or walking with a family member instead. Anticipating every barrier may be impossible, and the problem-solving process may unfold over several sessions; however, exploring potential challenges during the initial goal setting can be helpful.

Self-monitoring . Another effective strategy for facilitating a variety of behavioral changes involves self-monitoring, defined as regularly tracking some specific element of behavior (e.g., minutes of exercise, number of cigarettes smoked) or a more distal outcome (e.g., weight). Having patients keep diaries of their behavior over a short period rather than asking them to remember it at a visit can provide more accurate and valuable data, as well as provide a baseline from which to track change.

When patients agree to self-monitor their behavior, physicians can increase the chance of success by discussing the specifics of the plan. For example, at what time of day will the patient log his or her behavior? How will the patient remember to observe and record the behavior? What will the patient write on the log? Logging the behavior soon after it occurs will provide the most accurate data. Although patients may be tempted to omit unhealthy behaviors or exaggerate healthy ones, physicians should encourage patients to be completely honest to maximize their records' usefulness. For self-monitoring to be most effective, physicians should ask patients to bring their tracking forms to follow-up visits, review them together, celebrate successes, discuss challenges, and co-create plans for next steps. (Several diary forms are available in the Patient Handouts section of the FPM Toolbox .)

A variety of digital tracking tools exist, including online programs, smart-phone apps, and smart-watch functions. Physicians can help patients select which method is most convenient for daily use. Most online programs can present data in charts or graphs, allowing patients and physicians to easily track change over time. SuperTracker , a free online program created by the U.S. Department of Agriculture, helps patients track nutrition and physical activity plans, set goals, and work with a group leader or coach. Apps like Lose It! or MyFitnessPal can also help.

The process of consistently tracking one's behavior is sometimes an intervention itself, with patients often sharing that it created self-reflection and resulted in some changes. Research shows self-monitoring is effective across several health behaviors, especially using food intake monitoring to produce weight loss. 5


The following evidence-based approaches can be useful in encouraging patients to adopt specific health behaviors.

Physical activity prescriptions . Many Americans do not engage in the recommended amounts of physical activity, which can affect their physical and psychological health. Physicians, however, rarely discuss physical activity with their patients. 6 Clinicians ought to act as guides and work with patients to develop personalized physical activity prescriptions, which have the potential to increase patients' activity levels. 7 These prescriptions should list creative options for exercise based on the patient's experiences, strengths, values, and goals and be adapted to a patient's condition and treatment goals over time. For example, a physician working with a patient who has asthma could prescribe tai chi to help the patient with breathing control as well as balance and anxiety.

In creating these prescriptions, physicians should help the patient recognize the personal benefits of physical activity; identify barriers to physical activity and how to overcome them; set small, achievable goals; and give patients the confidence to attempt their chosen activity. Physicians should also put the prescriptions in writing, give patients logs to track their activity, and ask them to bring those logs to follow-up appointments for further discussion and coaching. 8 More information about exercise prescriptions and sample forms are available online.

Healthy eating goals . Persuading patients to change their diets is daunting enough without unrealistic expectations and the constant bombardment of fad diets, cleanses, fasts, and other food trends that often leave both patients and physicians uncertain about which food options are actually healthy. Moreover, physicians in training receive little instruction on what constitutes sound eating advice and ideal nutrition. 9 This confusion can prevent physicians from broaching the topic with patients. Even if they identify healthy options, common setbacks can leave both patients and physicians less motivated to readdress the issue. However, physicians can help patients set realistic healthy eating goals using two simple methods:

Small steps. Studies have shown that one way to combat the inertia of unhealthy eating is to help patients commit to small, actionable, and measurable steps. 10 First, ask the patient what small change he or she would like to make — for example, decrease the number of desserts per week by one, eat one more fruit or vegetable serving per day, or swap one fast food meal per week with a homemade sandwich or salad. 11 Agree on these small changes to empower patients to take control of their diets.

The Plate Method. This model of meal design encourages patients to visualize their plates split into the following components: 50 percent fruits and non-starchy vegetables, 25 percent protein, and 25 percent grains or starchy foods. 12 Discuss healthy options that would fit in each of the categories, or combine this method with the small steps described above. By providing a standard approach that patients can adapt to many forms of cuisine, the model helps physicians empower their patients to assess their food options and adopt healthy eating behaviors.

Brief behavioral therapy for insomnia . Many adults struggle with insufficient or unrestful sleep, and approximately 18.8 percent of adults in the United States meet the criteria for an insomnia disorder. 13 The first-line treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I), which involves changing patients' behaviors and thoughts related to their sleep and is delivered by a trained mental health professional. A physician in a clinic visit can easily administer shorter versions of CBT-I, such as Brief Behavioral Therapy for Insomnia (BBT-I). 14 BBT-I is a structured therapy that includes restricting the amount of time spent in bed but not asleep and maintaining a regular sleep schedule from night to night. Here's how it works:

Sleep diary. Have patients maintain a sleep diary for two weeks before starting the treatment. Patients should track when they got in bed, how long it took to fall asleep, how frequently they woke up and for how long, what time they woke up for the day, and what time they got out of bed. Many different sleep diaries exist, but the American Academy of Sleep Medicine's version is especially user-friendly.

Education. In the next clinic appointment, briefly explain how the body regulates sleep. This includes the sleep drive (how the pressure to sleep is based on how long the person has been awake) and circadian rhythms (the 24-hour biological clock that regulates the sleep-wake cycle).

Set a wake-up time. Have patients pick a wake-up time that will work for them every day. Encourage them to set an alarm for that time and get up at that time every day, no matter how the previous night went.

Limit “total time in bed.” Review the patient's sleep diary and calculate the average number of hours per night the patient slept in the past two weeks. Add 30 minutes to that average and explain that the patient should be in bed only for that amount of time per night until your next appointment.

Set a target bedtime. Subtract the total time in bed from the chosen wake-up time, and encourage patients to go to bed at that “target” time only if they are sleepy and definitely not any earlier.

For example, if a patient brings in a sleep diary with an average of six hours of sleep per night for the past two weeks, her recommended total time in bed will be 6.5 hours. If she picks a wake-up time of 7 a.m., her target bedtime would be 12:30 a.m. It usually takes up to three weeks of regular sleep scheduling and sleep restriction for patients to start seeing improvements in their sleep. As patients' sleep routines become more solid (i.e., they are falling asleep quickly and sleeping more than 90 percent of the time they are in bed), slowly increase the total time in bed to possibly increase time asleep. Physicians should encourage patients to increase time in bed in increments of 15 to 30 minutes per week until the ideal amount of sleep is reached. This amount is different for each patient, but patients generally have reached their ideal amount of sleep when they are sleeping more than 85 percent of the time in bed and feel rested during the day.

Patient education to prevent medication nonadherence . Medication adherence can be challenging for many patients. In fact, approximately 20 percent to 30 percent of prescriptions are never picked up from the pharmacy, and 50 percent of medications for chronic diseases are not taken as prescribed. 15 Nonadherence is associated with poor therapeutic outcomes, further progression of disease, and decreased quality of life. To help patients improve medication adherence, physicians must determine the reason for nonadherence. The most common reasons are forgetfulness, fear of side effects, high drug costs, and a perceived lack of efficacy. To help patients change these beliefs, physicians can take several steps:

Educate patients on four key aspects of drug therapy — the reason for taking it (indication), what they should expect (efficacy), side effects and interactions (safety), and how it structurally and financially fits into their lifestyle (convenience). 16

Help patients make taking their medication a routine of their daily life. For example, if a patient needs to use a controller inhaler twice daily, recommend using the inhaler before brushing his or her teeth each morning and night. Ask patients to describe their day, including morning routines, work hours, and other responsibilities to find optimal opportunities to integrate this new behavior.

Ask patients, “Who can help you manage your medications?” Social networks, including family members or close friends, can help patients set up pillboxes or provide medication reminders.

The five Rs to quitting smoking . Despite the well-known consequences of smoking and nationwide efforts to reduce smoking rates, approximately 15 percent of U.S. adults still smoke cigarettes. 17 As with all kinds of behavioral change, patients present in different stages of readiness to quit smoking. Motivational interviewing techniques can be useful to explore a patient's ambivalence in a way that respects his or her autonomy and bolsters self-efficacy. Discussing the five Rs is a helpful approach for exploring ambivalence with patients: 18

Relevance. Explore why quitting smoking is personally relevant to the patient.

Risks. Advise the patient on negative consequences of continuing to smoke.

Rewards. Ask the patient to identify the benefits of quitting smoking.

Roadblocks. Help the patient determine obstacles he or she may face when quitting. Common barriers include weight gain, stress, fear of withdrawal, fear of failure, and having other smokers such as coworkers or family in close proximity.

Repeat. Incorporate these aspects into each clinical contact with the patient.

Many patients opt to cut back on the amount of tobacco they use before their quit date. However, research shows that cutting back on the number of cigarettes is no more effective than quitting abruptly, and setting a quit date is associated with greater long-term success. 19

Once the patient sets a quit date, repeated physician contact to reinforce smoking cessation messages is key. Physicians, care coordinators, or clinical staff should consider calling or seeing the patient within one to three days of the quit date to encourage continued efforts to quit, as this time period has the highest risk for relapse. Evidence shows that contacting the patient four or more times increases the success rate in staying abstinent. 18 Quitting for good may take multiple a empts, but continued encouragement and efforts such as setting new quit dates or offering other pharmacologic and behavioral therapies can be helpful.


Family physicians are uniquely positioned to provide encouragement and evidence-based advice to patients to change unhealthy behaviors. The proven techniques described in this article are brief enough to attempt during clinic visits. They can be used to encourage physical activity, healthy eating, better sleep, medication adherence, and smoking cessation, and they can help patients adjust their lifestyle, improve their quality of life, and, ultimately, lower their risk of early mortality.

Loef M, Walach H. The combined effects of healthy lifestyle behaviors on all-cause mortality: a systematic review and meta-analysis. Prev Med . 2012;55(3):163-170.

Bodenheimer T, Handley MA. Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns . 2009;76(2):174-180.

Lilly CL, Bryant LL, Leary JM, et al.; Evaluation of the effectiveness of a problem-solving intervention addressing barriers to cardiovascular disease prevention behaviors in three underserved populations: Colorado, North Carolina, West Virginia, 2009. Prev Chronic Dis . 2014;11:E32.

U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans (7th Ed). Washington, D.C: U.S. Government Printing Office; 2010.

Sreedhara M, Silfee VJ, Rosal MC, Waring ME, Lemon SC. Does provider advice to increase physical activity differ by activity level among U.S. adults with cardiovascular disease risk factors? Fam Pract . 2018;35(4):420-425.

Pinto BM, Lynn H, Marcus BH, DePue J, Goldstein MG. Physician-based activity counseling: intervention effects on mediators of motivational readiness for physical activity. Ann Behav Med . 2001;23(1):2-10.

Hechanova RL, Wegler JL, Forest CP. Exercise: a vitally important prescription. JAAPA . 2017;30(4):17-22.

Guo H, Pavek M, Loth K. Management of childhood obesity and overweight in primary care visits: gaps between recommended care and typical practice. Curr Nutr Rep . 2017;6(4):307-314.

Perkins-Porras L, Cappuccio FP, Rink E, Hilton S, McKay C, Steptoe A. Does the effect of behavioral counseling on fruit and vegetable intake vary with stage of readiness to change?. Prev Med . 2005;40(3):314-320.

Kahan S, Manson JE. Nutrition counseling in clinical practice: how clinicians can do better. JAMA . 2017;318(12):1101-1102.

Choose My Plate. U.S. Department of Agriculture website. https://www.choosemyplate.gov/ . Updated January 31, 2018. Accessed February 1, 2018.

Ford ES, Cunningham TJ, Giles WH, Croff JB. Trends in insomnia and excessive daytime sleepiness among U.S. adults from 2002 to 2012. Sleep Med . 2015;16(3):372-378.

Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep . 2003;26(2):177-182.

Viswanathan M, Golin CE, Jones CD, et al.; Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med . 2012;157(11):785-795.

Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the patient-centered approach to medication management services . 3rd ed. New York: McGraw-Hill; 2012.

Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, Graffunder CM. Current cigarette smoking among adults — United States, 2005–2015. MMWR Morb Mortal Wkly Rep . 2016;65(44):1205-1211.

Patients not ready to make a quit attempt now (the “5 Rs”). Agency for Healthcare Research and Quality website. http://bit.ly/2jVvpoY . Updated December 2012. Accessed February 2, 2018.

Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician . 2012;85(6):591-598.

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Childhood obesity intervention plan, exploring health behaviors and awareness., annotated bibliography: inadequate public knowledge about the significance of mental health concerns, popular essay topics.

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  • Clin Interv Aging

Models and theories of health behavior and clinical interventions in aging: a contemporary, integrative approach

W jack rejeski.

1 Department of Health & Exercise Science, Wake Forest University, Winston-Salem, NC, 27109, USA

Jason Fanning

Background: Historically, influential models and theories of health behavior employed in aging research view human behavior as determined by conscious processes that involve intentional motives and beliefs. We examine the evolution, strengths, and weaknesses of this approach; then offer a contemporary definition of the mind, provide support for it, and discuss the implications it has for the design of behavioral interventions in research on aging.

Methods: A narrative review was conducted.

Results: Traditionally, models and theories used to either predict or change health behaviors in aging have not viewed the mind as encompassing embodied and relational processes nor have they given adequate attention to multi-level, in-the-moment determinants of health behavior.

Discussion: Future theory and research in aging would benefit from a broader integrative model of health behavior. The effects of adverse life experience and changes in biological systems with aging and chronic disease on health behavior warrant increased attention.


The health care of older adults is complex requiring varying degrees of commitment on the part of patients to follow prescribed regimens of treatment. These regimens include behaviors such as dietary intake, physical activity, prescription drug use, taking preventive health screenings, and adherence to behavior protocols for physical rehabilitation. As a field, Behavioral Medicine has come to recognize that health behaviors are determined by multiple levels of influence. 1 For example, significant others and interactions with health care providers play a powerful role in shaping the beliefs of older adults. Similarly, what older adults would “like to do” and what they are “able to do” in the realm of health behavior is often determined, in part, by environmental and policy decisions such as access to facilities and reimbursement from Medicare. Of critical importance is that, while theories often conceptualize health behaviors as intentional and under conscious control, this is often not true as is evident in the biological and environmental determinants of addictive behaviors. 2

We open this review by touching on several models and theories of health behavior and/or health behavior change, capturing evolving thought on the topic. Our goal is to demonstrate how models/theories of health behavior have evolved across time and gaps that exist. We then present a contemporary definition for the concept of mind and review support for an integrative model based on this perspective. We believe this model will help to advance intervention development in aging research and foster an interdisciplinary science of health behavior and health behavior change.

A progression in models/theories of health behavior and behavior change

Behavioral scientists have devoted considerable effort to the development and evaluation of models and theories designed to understand and/or influence health behavior. As theory has advanced, scientists have adopted increasing specificity in the conceptual definition and measurement of constructs while becoming more interested in behavior change over understanding why individuals engage in particular health behaviors. Additionally, there has been increased interest in affect as well as the physiological and environmental input to health behavior and health behavior change. To illustrate the evolution of extant models/theories and the current state-of-the-art, we discuss the health belief model, the Social Cognitive Theory, the relapse prevention model, self-determination theory, research on affect and a biological model of desire, along with the socio-ecological model.

Health belief model (HBM)

The HBM first appeared in the 1950s as a guide to research on tuberculosis screening. 3 , 4 It distilled concepts from an established body of psychological and behavioral research and set the stage for the theories that followed. HBM is an expectancy-value model. As an example, people take medication to control their cholesterol because they value avoiding cardiovascular disease. Core constructs include perceived threat of a given disease state, which is the product of perceived susceptibility to the disease and perceived disease severity. The model also emphasizes decisional balance: the relative weight of perceived benefits as compared to perceived barriers to engaging in a behavior. As shown in Figure 1 , health behavior results from the combined effect of perceived threat and decisional balance over anticipated outcomes. 4 The HBM acknowledges the input on health behavior from other factors such as psychosocial variables and environmental cues, but it conceptualizes these effects as acting through either perceived threat or decisional balance . Of note, HBM practitioners have long recognized the limited scope of the model. For instance, as Janz and Becker noted: 4 “It is clear that other forces influence health actions as well; for example…some behaviors (eg, cigarette smoking; tooth-brushing) have a strong habitual component obviating any ongoing psychosocial decision-making process”.

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The health belief model.

Note: Adapted from Janz NK, Becker MH. The health belief model - a decade later.  Health Ed Quart . 1984;11(1):1–47. Copyright 1984, with permission from SAGE Publications. 4

Social cognitive theory (SCT)

As a second approach to models/theories of health behavior, we focus on Bandura’s SCT. 5 As with HBM, SCT conceptualizes individuals as rational actors. While there is continued emphasis on the concept of expectancy-value, a chief advancement of SCT is its focus on personal agency and the importance of context as a determinant of health behavior. Moreover, while SCT has been useful in understanding why people perform a specific health behavior, it has also had a major effect on interventions for behavior change.

Self-efficacy, or one’s perceived ability to bring about a specific course of action in a particular context, is the core construct in SCT. Efficacy beliefs are dynamic, affecting and being affected by several downstream constructs highlighted in SCT (see Figure 2 ). These include outcome expectations and barriers/facilitators of behavior that arise from both social relations and cultural forces. Individuals with higher self-efficacy for a behavior are likely to have higher expectations for associated outcomes. They also perceive greater support from the social and physical environment and engage in more favorable self-regulatory behaviors than those with low self-efficacy. Success with the behavior fuels self-efficacy, especially when success occurs in the face of challenge. In addition, encouragement from others and observing relatable peers or those less skilled having success with a given behavior also enhances self-efficacy. Finally, one’s physiological state has an immediate influence on self-efficacy. For example, Bandura calls forth the image of preparing for a public speaking event. As anxiety mounts in preparing to deliver a talk, some individuals become hypersensitive to physical symptoms such as rising heart rate, increasingly sweaty palms, and a queasy stomach. The result is that they experience a sharp, in-the-moment decline in their speech-related self-efficacy.

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Social cognitive theory.

Note: Aadapted from Bandura A. Health promotion by social cognitive means.  Health Educ Behav.  2004;31(2):143–164, copyrught 2004 by permission of SAGE Publications. 6

In part, the appeal of SCT arises from its specificity. 7 Other contemporary theories, such as the theory of planned behavior, prioritize parsimony and do not address behavior change. 8 , 9 SCT also offers interventionists clear targets for improving efficacy beliefs, supporting self-regulation, minimizing external barriers, and bolstering positive outcome expectancies. Moreover, it explicitly models the interplay between underlying transient biological states, one’s sense of agency, and the influence of proximal socio-structural pressure. Unfortunately, these key considerations are typically lost in implementation, with the focus constrained to individual-level perceptions and the influence of proximal social connections. 7

Relapse prevention (RP)

The third model of health behavior that we chose for inclusion is RP for addictive behavior. 10 RP is a model targeted specifically to behavior change. As an outgrowth of SCT, the intent behind RP was to describe the process of relapse for addictive behavior, emphasizing the importance of early intervention. They conceptualized relapse as an expected and transitional process; a key aim is to avoid or to learn how to cope with high-risk situations.

RP identified two categories of factors that contribute to a risk for relapse: immediate determinants and covert antecedents. Akin to Bandura’s recognition that transient, in-the-moment physiological states can exert substantial influence on self-efficacy, RP proposes that high-risk situations serve a similar function. They are immediate (in-the-moment) determinants of addictive behavior. These range from social and physical environments, to internal states such as depression or negative affect. Another immediate determinant, coping, captures how an individual responds to a high-risk situation. Outcome expectancies are a third determinant, in that individuals who expect short-term benefits such as reduced anxiety from the behavior are more likely to relapse. The fourth immediate determinant is the abstinence violation effect, which refers to the feeling of guilt or lack of control accompanying a single lapse.

Covert antecedents of relapse are a partial determinant of whether an individual successfully negotiates immediate determinants. Here, lifestyle factors, including both positive and pleasurable activities alongside one’s responsibilities contribute to or alleviate stress, which in turn is related to the likelihood of a relapse. More recent iterations of the model 11 specify both trait-like—tonic — influences on relapse, which are thought to dictate initial susceptibility to a relapse, and more dynamic and transient influences—phasic. Phasic influences include momentary mood states, urges and cravings, and in-the-moment changes in self-efficacy or outcome expectations. These phasic influences represent the most proximal determinants of a relapse.

Although not explicitly stated in RP, an interesting feature is the awareness that conscious goals related to recovery often succumb to the physiological symptoms of withdrawal, negative affective states, and the emotional tipping point created by the abstinence violation effect. Thus, it is not surprising to find that recent research on mindfulness-based treatment techniques specific to RP (MBRP) have been successful in countering the influence of negative affective states on the likelihood of relapse, and enhancing individuals’ abilities to cope with distress. 12 , 13

Self-determination theory (SDT)

We believe it is important to briefly discuss Deci and Ryan’s SDT 14 because it unites concepts from SCT (eg, goal setting; mastery), RP (eg, one’s inner state affects motivated behavior), the motivational role of affect in behavior by way of enjoyment, and the importance of strong social ties. SDT posits that humans are driven by three core needs: the need to experience competence, meaningful social connection (ie, relatedness), and autonomy (ie, a sense of control over one’s behaviors). The core needs outlined in SDT are positioned to be innately valued, and as with other theories, Deci and Ryan underscore the importance of aligning the content of one’s goals with an individual’s core needs. 14 For instance, an exercise goal formed for the explicit purpose of looking better to one’s peers, an extrinsic personal goal, will lose salience more rapidly than an intrinsic exercise goal emanating from the value of human connection and formed for the purpose of being able to engage with one’s grandchildren or to foster a relationship with friends. 15

Moreover, the ways in which these goal-driven behaviors are regulated are given importance in SDT. An intrinsically motivated behavior is one that brings about feelings of interest, enjoyment, or satisfaction, and it is theorized that this produces self-motivated, or self-determined behavior that is likely to last. When the behavior is motivated by factors aside from the merits of the behavior itself, it is said to be externally regulated. These more “controlling” forms of motivation are expected to sometimes regulate short-term behavior, but have a low likelihood of facilitating behavioral maintenance. 15

There are several important conclusions to be drawn from research on SDT and health behavior. As with research on incentives and affective valence described below, SDT highlights the importance of maximizing behaviors that produce positive bodily states such as enjoyment. It also provides a useful framework for considering appropriate incentives. Namely, by emphasizing incentives that are intrinsic as opposed to extrinsic. Lastly, it underscores the value of leveraging the group as a tool of behavior change; a notion we will highlight in the final section of this manuscript.


Although the motivational significance of incentives and affective valence that people associate with particular outcomes of a health behavior are evident in the concept of expectancy-value, within contemporary theoretical frameworks it is frequently assumed that people value their health and the focus of most research has been on self-efficacy, outcomes expectation, and behavioral intention. 7 Researchers traditionally assumed that increases in self-efficacy are valued because they increase a sense of personal agency. 5 , 16 One exception is research on RP in which researchers clearly appreciate the role of physiological withdrawal on relapse and the fact that addictive substances are often valued as a means of coping with life stress. 11

There has been a surge of interest in the affective determinants of health behavior, including work on both reflective and reflexive affect. 17 Reflective affect is cognitive based and referred to as “subjective liking”, whereas reflexive affect has been characterized as “core liking”, the pure, abrupt, visceral experience that is a function of contextual stimuli and associations. 18 Reflexive affect can be an in-the-moment experience or anticipatory in nature. Rhodes and Gray 19 recently note that most research on affect and health behavior has focused on reflective as opposed to reflexive affect. Although not conducted on older adults, reviews of the exercise literature have shown that reflexive affect may be more important in predicting future exercise behavior than reflective affect or social cognitive variables. 20

Given the growing interest in reflexive affect 17 and the importance of incentives to health behavior, there are important lessons to be learned from work in the biology of addiction. In the “Biology of Desire”, Lewis 2 describes the neuroscience of how substances and behaviors of desire become habitual through activity in the reward network. The central axis for desire begins in the ventral tegmental area (VTA) of the midbrain. Activation of this region of interest provides the fuel for desire—dopamine! Other key areas of the brain involved in impulsive behavior—the initiation of an addictive behavior—include the ventral and dorsal striatum, amygdala, hippocampus, and prefrontal cortex (PFC). In the early stages of desire for a substance or behavior, both nonconscious and conscious processing are involved. The amygdala acquires and maintains emotional sensations and communicates with the hippocampus, a structure that stores explicit memories of experience. The ventral striatum is responsible for feelings of attraction, desire, and craving. It is the main driver for impulsivity, getting its fuel from the VTA. The PFC creates conscious, context-specific interpretations of highly motivating situations and is key to executive function, planning, bringing memories into consciousness, sorting and comparing memories, and making decisions.

Once a person has been repeatedly exposed to a desired substance or behavior, involvement of the PFC in the reward network weakens to the point where conscious processing is no longer involved—the dorsal lateral region of the striatum has led to addiction, a compulsive act. The substance or behavior is now a habit: stimuli lead to a response (S-R) in the absence of conscious thought. We believe this model describing the biology of desire is important for several reasons. First, desire—or the incentive value of a behavior—is applicable to both functional and dysfunctional health behaviors. Second, as this model illustrates, intervention development would benefit from integrating concepts from neuroscience into the study of health behavior change. Third, as we will see later, there may be important neural phenotypes that could assist in tailoring treatment. Fourth, we believe this model is applicable to understanding incentives or desire more generally; habits vary in their strength! If we hope to promote health behaviors among older adults, there is little question that we need to discover the motivational levers that operate for different people in varied contexts. Fifth, we believe a focus on desire has wide application to the design of behavioral interventions and should give pause to health scientists implementing aversive interventions such as highly popular high-intensity physical activity training regimens.

Socio-ecological models

Finally, it is important to note the growing popularity of ecological models of health behavior. Drawn from a biological sciences view of ecology, which is interested in capturing the interplay between an organism and its environment, socio-ecological models identify multiple levels of influence, typically ranging from individual factors such as one’s biological state to broader community, geopolitical, and policy influences. 21 – 23

A key assumption of these models is that researchers can study individuals at various levels of influence, including the individual, community, state, or national level. However, effective health behavior change likely needs to consider the individual as affected by these various levels of influence. For instance, the likelihood an individual sets a goal to eat better, engage in exercise, commute in an active manner, or reduce sitting will be influenced by their built (eg, are there bike paths and healthy food options?) and social (eg, do social norms support healthy behavior?) environments. Similarly, the extent to which the environment is low-stress and perceived as safe may help or hinder an individuals’ ability to adhere to behavioral goals. 24 , 25 They also recognize that environments and those existing within them are in a constant state of flux; thus, interventions should be flexible and adaptable. 23 Clearly, social-ecological approaches to behavior change require considerable resources and time relative to individual-level interventions; however, they also underscore the important role that social and physical environments have on health behaviors, a point we will come back to later.

Across the models/theories reviewed, there is general acceptance for the concept of expectancy-value. That is, people engage in health behaviors because of the belief that the behavior will yield outcomes of value. It is interesting to note that, with the emergence of SCT, the focus has been on self-efficacy even though it is one of the several core constructs alongside incentives and outcome expectations. Although the role of affect and physiological states on health behavior is apparent in SCT, the theory posits that self-efficacy mediates these effects. In addition, it is surprising that researchers have paid so little attention to the incentives underlying health behaviors, how incentives and goals benefit from being linked to core needs central to SCT, and how the affect associated with the incentive value of health behavior may be tempered by the sacrifices that older adults are often required to make when changing their behavior.

Of note is the fact that, as models and theories of health behavior have evolved, there has been an increasing conceptual focus on behavior change. In fact, RP identified the importance of phasic determinants of behavioral maintenance, emphasizing the role of reflexive affect. Peoples’ psychological and physiological states can change over relatively brief periods and cause dramatic shifts in behavioral intentions. Finally, as far back as 1984, Janz and Becker recognized that conscious, decision-based models such as HBM could not explain all health behaviors, specifically noting the habitual drive underlying behaviors such as cigarette smoking. Supported by recent trends in neuropsychology, future research in intervention development must consider the role played by nonconscious processes and, in particular, how to modify these processes.

The concept of mind: theory development and scientific inquiry

We believe there is merit in stepping back for a moment to reconsider the concept of “mind” in greater depth. The reason for this reflection is that how theoreticians/researchers think about the mind heavily influences what they believe to be the primary drivers of behavior. Traditionally separated from the body, behavioral science has conventionally viewed the mind as a faculty of being human that enables people to have an awareness of the world and of their experience; it is responsible for consciousness and gives humans the capacity to think and to feel. The role of the mind or lack thereof in theory development is perhaps most evident the classic work of B.F. Skinner. Skinner proposed that the mind was irrelevant to understanding human behavior; rather, he argued that people behave in response to operant conditioning to reinforcement and/or punishment; promoting the concept of environmental engineering as a means for shaping behavior. Even in contemporary thinking, concepts such as “nudging”, 26 popular in behavioral economics, have shown that some desired health behaviors can be achieved through positive incentives or indirect influence; reemphasizing the point that in some instances the mind, when defined by traditional criteria of awareness, thinking, and feeling, is irrelevant to human behavior. Alternatively, the cognitive revolution that followed Behaviorism and continues to be favored by many theoreticians, places an emphasis on conscious, cognitive processes as determinants of health behavior. 7

As we consider why older adults do or do not behave optimally within the context of medical research or health care, we will continue to reinforce the notion that the health behavior of older adults requires considering multiple levels of influence, some of which obviate the need for conscious decision-making. We will also emphasize that human behavior is not always rational, and that implicit memories and biased processing of information are more common than currently recognized. Most important, we believe that a more complete understanding of why older adults behave as they do within the context of medical research and health care would emerge from a broader, alternative view of the mind. Specifically, we adopt the position that the mind should be conceptualized as a process rather than as an outcome such as a thought or feeling, noting that this process is responsible for regulating energy and information flow, and that this process is both embodied and relational.

The Mind as a Process and Implications for Health Behavior

Paraphrasing Siegel, 27 the human mind is a process that regulates the flow of energy and information between the body, brain, and relationships—thus, it is both embodied and relational (see Figure 3 ). As we will soon demonstrate, defining the mind as a process is consistent with Hebb’s 28 concept of associative learning: neurons that fire together wire together. What begins as energy through activation of neurons eventually becomes information that then defines learning and the formation of memories. Furthermore, as Siegel pointed out, the flow of energy and information occurs not only in the brain, but in conjunction with the body and relationships as well. Conceptualizing the mind as embodied is critically important to understanding health behavior for two reasons. First, it positions various biological inputs that may be either stable or unstable as important determinants of subjective experience and behavior. And second, Glass and McAtee 29 argue that features of the social, built and natural environment become embodied and act as “risk-regulators” that effect health behavior via various biological pathways. In other words, toxic environments adversely affect biological regulatory systems. These systems then become “internal risk regulators” that can have powerful effects on health behavior.

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The mind as a process.

Note: Reprinted from Lucas AR, Klepin HD, Porges SW, Rejeski WJ. Mindfulness-based movement: a polyvagal perspective. Integrative Cancer Therapies. 2018;17(1):5–15. 30

This complex, co-dependency between molecules, the mind, and the environment has also been supported by McEwen 31 and is obvious in the area of drug addiction where toxic microenvironments influence exposure to drugs 32 that then lead to molecular and cellular adaptations in the body that result in drug abuse. 33 Drug abuse also leads to other behaviors that can compromise health such as exposure to violence and a rapid drop off in self-care.

When Siegel noted that the mind is relational, he emphasized that the human brain is engaged in a constant flow of energy and information with other people. In fact, as we have just described, micro-social environments serve as a “risk regulator” of drug use. The powerful role of social relationships on health behavior is not surprising. We all enter this world dependent on others for our survival; as one leading neuroscientist puts it, our brains are wired to connect with others. 34 It is important to note that Siegel’s focus on the relational mind emphasized the effect that attachment through close interpersonal relations in childhood has on behavior and well-being. We agree that early interpersonal attachment experience plays an important role in health behavior not only in infancy but also across the lifespan. However, as we note above and consistent with Glass and McAtee, 29 we would argue that the relational mind encompasses powerful influences from social, built, and natural environments that range from the micro to macro levels of analysis.

Figure 4 provides a conceptual model of health behavior that describes the interrelationships between the relational mind (box to the left) and the biological regulatory systems that embody relational experiences (the box to the right). Embodiment occurs when relational experiences alter biological regulatory systems (BRS) through their effects on genetic and biological substrates of these systems. Note the distinction between the body and brain in depicting the BRS. Activity within the BRS at the level of the body directly influences neural networks and neural networks affect functioning of the BRS at the level of the body. Neural networks in the brain give rise to both conscious and nonconscious levels of processing. Of particular importance to models/theories of behavior change is that, for the most part, they operate at the level of conscious processing and ignore the fact that neural networks below the level of consciousness are critically important to health behavior and health behavior change. We also want to emphasize that BRS of the body can effect behavior through both conscious and nonconscious processing. Because our relational experience alters biological regulatory structures of the body and brain, these experiences also affect health behavior through these same pathways. This is readily apparent in how social and physical environmental factors support obesogenic behavior, including physical inactivity. 35

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An embodied and relational model of health behavior.

The embodied mind

In addition to addiction, there is a large body of literature supporting the notion that biological regulatory systems influence health behavior either through their effects on conscious subjective experience or via nonconscious processes. An example of such nonconscious effects that comes to mind is the phenomenon termed “sickness behavior”, a cluster of behaviors including decreased movement and increased time spent sleeping, lack of appetite, and the propensity for social isolation. Specifically, what we now know is that the release of interleukin-1 from the immune system stimulates the vagus nerve and, independent of the specific illness, has effects on the central nervous system that fuel this cluster of behavior. 36 Perhaps an even more glaring reminder of the embodied mind is depression. Tiermeier, 37 underscoring the public health significance of this disease in late life, concluded that over 50% of those with severe depression have disturbed glucocorticoid feedback mechanisms. Depression is also common with increasing comorbid conditions associated with aging, a phenomenon that appears to be related to inflammation and cell-mediated immune activation. 38 Not surprisingly, researchers have investigated the adverse effects that depression has on expectations and motives to engage in desired health behavior. For example, it is well known that depression is related to obesity 39 and sedentary behavior. 40 Additionally, there is evidence that digestive health plays a role in affect and emotion 41 and that gut bacteria can motivate people to pursue the consumption of specific macronutrients. 42 Data suggest that inflammation is a correlate of inactivity. 43 – 45 Moreover, body fat is associated with increased inflammation, whereas intentional weight loss in older adults lowers body fat and reduces inflammation. 46

Equally important is an awareness and appreciation of the fact that dynamic changes in biological regulatory systems and their substrates across relatively brief periods can profoundly influence functional brain networks and subjective states. For example, in a study of obese older adults, we found that craving for favorite foods dramatically increased over a period of 3 hrs when restricted to consume water only versus ingesting a meal replacement. 47 Even more interesting was the fact that following this brief fasting period, functional imaging of the resting state brains in the water only condition looked similar to what you would see in other addictive behaviors, brain states that differed dramatically from resting states taken following consumption of a meal replacement.

We do not want to create the impression that we are encouraging investigators to treat subjective experience as subordinate to objective biological influence in the study of health behavior. In this regard, we want to make two points. First, we believe that biological regulatory systems play a particularly potent role in certain health behaviors. This point has been made for addiction. 33 Yet, even in the case of addiction, it is clear that the precise embodiment of micro-social environments is not a given. "Medical researchers are correct that the brain changes with addiction. Nevertheless, the way it changes has to do with learning and development—not disease. Addiction can therefore be seen as a developmental cascade, often foreshadowed by difficulties in childhood” (page xiii). 2

Second, there is evidence that the role of biology in health behavior likely interacts with a person’s subjective sense of agency. For example, in a prospective study, we tracked 480 older men and women who had knee pain on most days of the week to examine how lower leg strength and baseline self-efficacy influence decline in stair climbing performance across 30 months. 48 What we observed was that older adults with low strength (estimated at the 25th percentile) and low self-efficacy (estimated at the 25th percentile) experienced a 4.15-s decrease in their stair climb performance that was statistically inferior in performance to any other subgroup. The other subgroups (high strength and low self-efficacy; low strength and high self-efficacy or high strength and low self-efficacy) lost about 1.30 s in their stair climb time and were not distinguishable from one another. In short, having high self-efficacy for the stair climb task buffered the effects that low strength was expected to have on decline in task performance.

Indeed, self-efficacy nicely illustrates the interplay between bodily states and the brain. The extent to which one’s self-efficacy beliefs are under the influence of fluctuations in biology differs depending on an individual’s experience in the behavior at hand. For a novice, efficacy beliefs are volatile and likely to change in response to shifting biological and psychosocial states, for example, momentary increases in muscle soreness and fatigue. Conversely, those with experience tend to display stability in their beliefs regarding their capability, and these beliefs are likely to persist despite momentary setbacks. 49

Whereas dynamic biological systems can influence the motivation to approach or desire specific substances or outcomes, equally important is how the body influences the motivation to avoid behavior. In fact, Porges 50 has argued that a major evolutional attribute of the human nervous system is the nonconscious motive to identify threat and thus to avoid harm to oneself. In fact, this probably explains why, when threatened even modestly as is true with many health events, people have a hard time thinking about anything but escaping the threat. Within the nervous system, the ventral root of the vagus nerve serves this function and one can estimate activity of this pathway linking body to brain via a biomarker known as respiratory sinus arrhythmia (RSA). 50 As a person is threatened and the threat exceeds resources, RSA decreases and there is a concomitant increase in sympathetic nervous system activity. A major consequence of a decrease in RSA is that the brain becomes less reflective and acts automatically as a means of neutralizing the threat—favoring neural pathways that result in a rapid response. This distinction between the capacities for slow, reflective cognitive processing of input versus a fast, automatic mode is a core principle of dual-processing models of social cognition. 51 , 52 Both low tonic levels of RSA (resting) and high phasic levels in response to withdrawal from stress are relevant to behavior change because they can promote behavioral and affective responses that can be inconsistent with consciously stated goals: “I know that I should stop eating snack food, but it helps me to get through the strain in my marriage.” Potential consequences of a dysfunctional vagal brake in aging might include outcomes such as a decrease in life space, social isolation, a lack of openness to adopting preventive health behaviors, increased likelihood of relapse, excessive sedentary behavior, dropping out of treatment, and the exacerbation of pain.

We want to end this section by pointing out that biological regulatory systems are likely to be useful in understanding individual differences in response to behavioral interventions. For example, Hendershot and colleagues 11 reviewed the growing literature of genetic influences on treatment response and relapse. They concluded that genetic polymorphisms moderate treatment effects for a variety of addictive behaviors including smoking, alcohol, and drug abuse through a range of metabolic and neurotransmitter pathways. Recently, research from our lab 53 used baseline dynamic brain networks from functional magnetic resonance imaging (fMRI) to identify older, obese, adults most likely to succeed in a behavioral weight loss intervention. We combined machine learning and functional brain networks to produce multivariate prediction models using baseline data to predict success with weight loss (a median split on percent weight lost) following 18 months of treatment. Older adults above the median lost on average 13.96% of the body weight, whereas it was 2.87% for those below the median. The prediction accuracy of our model was 95% as compared to static and random models that were either at or below 50%. Principal component analysis of the data suggested that effective self-regulation involved both nonconscious and conscious processes. 53

The relational mind: attachment

Having established the concept of the mind as an embodied process, we next examine why it is also important to consider the interpersonal, relational nature of the mind as an integral topic of theoretical inquiry into health behavior and aging. As infants come into the world, they directly connect with sources of energy and information flow communicated by significant others through physical proximity, nonverbal cues, and vocal tones. Cozolino 54 argues that just as neural synapses enable the flow of energy and information between neurons, people also exchange the flow of energy and information with others via social synapses. Shaw and colleagues, using a large national database, 55 found that a lack of emotional support from parents early in life was prospectively related to increased depression and chronic health conditions that persisted across the lifespan. Moreover, Mate 56 in a Canadian bestseller argued persuasively that early emotional disturbances steer people toward addiction. He is not alone in this promoting this thesis, and it would appear relevant to a range of health behavior including drugs, alcohol, smoking and even dietary choices. 57

Polyvagal theory provides a strong theoretical rationale for the fact that it is the ventral vagus nerve and its network of connectivity with other cranial nerves in the brainstem that serves as the main neural enabler of social connection in infancy and throughout the lifespan. Positive attachment, via this embodied network of connection with others, results in feelings of safety and security. Logically, polyvagal theory 50 posits that safety established through social connection is the primary need state of humans (note the overlap with core needs within SDT) and that failure to satisfy this need results in a variety of psychiatric complications. In fact, there is a substantial body of literature linking developmental dysfunction in RSA to psychopathology. 58 What we do not know at this point is whether developmental deficiencies in RSA lead to excessive health care utilization and accelerated rates of disability as people age.

The relational mind: micro- and macro-social/physical environments.

Because human relations extend well beyond primary caregivers, as discussed and depicted in Figure 4 , health behavior is profoundly affected by micro- and macro-relational effects. The effects are often due to “…constraints that limit choice and the role of normative structures that shape the social values attached to activities, identities and choices. It also engages themes of inequality and power in society” (pp. 79–80). 1 While one might typically conceive of these influences as exclusively social in nature, through experience, people become part of a relational fabric of existence with their physical and economic environments. For example, it is well known that physical features of neighborhoods, such as walkability 59 and safety 60 play a role in the physical activity behavior and social interactions of older populations.

Without question, a powerful social influence on health behavior of older adults, beyond early attachment, involves family members’ role in scheduling screening visits, managing medications, and noticing changes in function that warrant medical attention. 61 While these effects are generally favorable, family members can also have a negative impact on the health of older family members by being overprotective, and through various means restrict their life space and activity levels. These adverse consequences reflect the powerful role that ageism has on the health behavior of older adults. 62

Interestingly, there is evidence that as the complexity and size of social networks decline with aging, the effect of social forces on health behavior also decreases. 63 Perhaps this is one area where careful application of technology could be useful. Specifically, facilitating regular face-to-face communication (eg, via video telephony) with peers and with health care providers may be especially powerful on the well-being of individuals who are socially isolated. However, it is important that the use of technology is carefully considered, as increasing perceived isolation can be an adverse side-effect as well. For instance, the widespread use of automation in digital health interventions should be balanced with the cost and time burden of personal contacts, as automated programs may reduce meaningful face-to-face interactions with health care providers. In fact, there is emerging evidence that younger individuals who are the highest users of social media sites, which often maximize brief and effortless contacts instead of more effortful face-to-face communication, perceive greater isolation. 64 Still, with a careful approach to the design of digital health tools, robust social contacts can be extended to individuals who are at present socially and geographically isolated.

Also deserving attention is the topic of multiple exposures to toxic micro- and macro-relational environments. Lynch and colleagues 65 reported in the New England Journal of Medicine on how cumulative economic hardship affects the functional health of older adults. They defined economic hardship as an income <200% of the poverty level in 1965, 1974, and/or 1985. They found a strong-graded association between the number of times individuals were classified experiencing economic hardship (0, 1, 2, or 3) and the risk ratios for poor physical, cognitive, and psychological health. Others have reported a dose–response relationship between both the number and duration of toxic relational environments and disease risk. 66 , 67 Glass and McAtee 29 concluded that late life appears to be a period of increasing vulnerability to the cumulative effects of disadvantaged social and economic environments.

As aging research on health behavior advances, we want to emphasize our belief that researchers should pay more attention to micro-relational effects on health behavior, specifically, a focus on physician–patient interactions and the value of small group interactions on the health behavior of older adults. We base this position on the knowledge that attachment behavior is a lifespan need with peaks at both ends of the age spectrum. As espoused by polyvagal theory, 50 self-determination theory, 16 and advances in neuroscience, 34 we are wired for and need close human relationships. Epstein 68 has called upon medicine to rebuild a health care system that prioritizes attentive listening and compassion, a shift that would benefit the health of physicians and provide meaningful, close interpersonal experiences for patients. Illness, disease and the loss of function that occur with aging are major sources of threat to personal safety. In the midst of these threats, a powerful antidote can be active listening and compassion in the care of older adults.

Likewise, we believe there is opportunity in leveraging the social power of small group interactions between older adults. As an example, we have been promoting group-mediated behavioral interventions as a means of delivering movement-based and weight loss programs to older adults for close to 20 years. 69 – 72 Run in small groups of 8–15 participants, they use the group as an agent of change, that is, as a vehicle to promote self-regulatory skills, to enhance a sense of agency, and to increase commitment to change. Consistent with Epstein, 68 group leaders are taught to model and promote active listening and compassion among group members. Moreover, the group is used as a means of bringing awareness to what Neff 73 terms “community humanity”, that is, an appreciation for the fact that you are never alone in the struggle to make change or to deal with behavior change in the face of adversity.

In closing this section, one point we want to emphasize is that as one moves from micro- to macro-relational effects, level of personal control decreases. For example, there is no doubt that social programs and health policies influence the health behavior of older adults; however, the average individual has no control over how these programs or policies operate. Clearly, however, as we have observed with federal laws related to smoking, macro-level influences on health behavior warrant serious attention due to their potential effect on population health.

Summary and conclusions

There are several areas identified in this review that are important to aging research on health behavior. First, health behavior is highly influenced by dynamic in-the-moment processes that may originate in the environment, the body, and the brain 11 , 74 suggesting that the concept of awareness should be key to theories of behavior change. Awareness is a multidimensional concept, including in-the-mome n t awareness of (a) the target behavior, (b) the processes that lead to the behavior, and (c) action plans to interrupt these in-the-moment processes. To this end, we believe that emerging digital health tools, such as in-the-moment self-reports enabled via ecological momentary assessment and connected monitoring devices (eg, activity monitors, location sensors) offer tremendous resources for enhancing awareness of behaviors and factors that enhance or impede health behavior change. However, as with the application of technology for reducing social isolation, we would emphasize that digital health tools should be used in a manner that enhances awareness of one’s behavior without fostering negative psychosocial states that act against an individual’s ability to self-regulate. For instance, we would caution against delivering content on a social media platform alongside unregulated content that increases stress and results in ruminative thought processes. Clearly, additional research is needed in the area of aging and the role of technology in health behavior change.

Additionally, the dynamic nature of health behavior casts doubt on the ability to adequately assess constructs using static study designs in which measures are taken at baseline, usually at a single time point during the day, and then again at one or two follow-up visits across the span of several weeks, months, or years. As we have shown, subjective states related to the regulation of health behavior can change in a matter of hours as a result of fluctuations in physiologic state. 47 This lack of attention to within-person variability compromises the goal of social science to understand mechanisms of health behavior change. This seems particularly important to the study of older adults given the variability created by aging biological systems, chronic health conditions, and the prevalence of physical symptoms such as pain and fatigue. This also holds implications for the design of health promotion interventions, which typically reply on a small number of weekly contacts between participants and their group members. This leaves individuals alone in their effort to overcome these powerful transient behavioral influences. Here again, mHealth tools may provide a bridge to social connection and to in-the-moment interventions during particularly challenging times.

Second, most theories of health behavior focus on conscious psychological processes, yet it is apparent that health behavior is highly influenced by nonconscious processes. 74 Indeed, health behavior is often under the control of stimuli from the environment and signals within the body—automatic responses resulting from brain networks that have been shaped through experience dependent learning across the lifespan. 75 Additionally, the digital age and advanced marketing strategies have accelerated the degree to which human behavior is subject to and controlled by environmental influence. With the nonconscious flow of energy and information empowered by fixated attention to internet-connected devices, powerful developmental experience, and rumination over multiple threats to the self, future theories and interventions on health behavior require expansion beyond conscious-derived constructs. In fact, one promising topic of influence in this area has been research on the role of implementation intentions in priming adaptive responses to contexts that normally short-circuit attempts to change behavior. 74

Third, it is clear that the relational nature of the human brain to the environment and to other people is central to health behaviors and attempts to change these behaviors. This was apparent in our discussion of the role that nonconscious processes play in health behavior. As noted previously, early life adversity created by impoverished social environments create “…constraints that limit choice and the role of normative structures that shape the social values attached to activities, identities and choices” (pp. 79–80). 1 While this adversity may stem from poverty and limited resources, the lack of trust and connection to others caused by developmental trauma constitutes an underappreciated influence on health behavior. As noted by Duffy and colleagues, 75 the negative impact of living in impoverished social environments and the existence of early attachment-related trauma on health behaviors are likely due to resultant dysfunction in brain networks that are critical to effective self-regulation as people age. The challenge these barriers create for behavior change are monumental and largely nonconscious.

Finally, in an attempt to understand and change health behavior, recent research suggests that greater attention should be devoted to the incentive value of health behaviors and affective processes that occur prior to, during and following the enactment of these behaviors. 17 How can we design behavioral interventions to optimize affective processes that facilitate the adoption and maintenance of positive health behaviors among older adults? As reviewed in this paper, answers to this question likely require intervention development targeting multiple levels of influence. It also requires paying close attention to the psychophysical state of older adults. Life transitions such as the onset or exacerbation of chronic disease, the death of a spouse, and coping with the biology of aging can drain the incentive value from either adopting new health behaviors or maintaining good health practices in the midst of emotional discord.


This paper was prepared for the keynote presentation at an NIA sponsored workshop for the Research Centers Collaborative Network (RCCN, December 2018) entitled “Achieving and Sustaining Behavior Change to Benefit Older Adults”. Partial support for this paper was provided through NIH/NIA funding: R56 AG051624.

The authors declare that there are no conflicts of interest in this work.

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Establishing healthy behaviors that stick

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By Mayo Clinic staff

Many people make healthy resolutions or set goals with the best intentions, only to see them fall short or break down completely over time. It's common to read about research and medical studies that promote a healthy lifestyle's psychological and physical benefits. Living a healthy lifestyle can even help prevent cancer . So why do you still fall short of your intentions to make healthy diet and lifestyle changes?

A few common reasons people tend to give up on changes to behaviors include:

  • Perceived dislike of exercise Studies show that people overestimate how difficult it is to exercise. As a result, you may tend to give up before you even begin a new exercise program or training regimen.
  • Toxic eating environment Quick, cheap and tempting food options are a constant pressure from a multibillion-dollar marketing industry. These highly targeted psychological messages may leave you wondering if you're in charge of your eating behaviors or, instead, are being conditioned to choose convenience over more nutritious options.
  • Setting too many goals or creating an all-or-nothing plan People tend to change too many behaviors or routines at a time. Creating restrictive changes that lead to feelings of deprivation or lower mood can result in an "on or off" or "all or nothing" plan that can't be maintained.
  • Consistency is complicated Whether you choose a lifelong goal or a temporary objective, staying motivated requires complex planning and follow-through. Establishing healthy behaviors that stick requires a different mindset and recognition that putting effort toward something important promotes an improved mood and well-being.

Tips to stay motivated

If you want to make your habits permanent, you need to:.

  • Alter your mindset and challenge negative thoughts and beliefs.
  • Anticipate lapses and recover quickly.
  • Remind yourself that you deserve to feel good and that your plan will get you there.
  • Start with one small change, celebrate success and add more changes over time.
  • Use positive self-talk such as "I'm an exerciser" and "I'm someone who eats healthy options," to embed identity shifts into your plan.

Your thoughts determine how you feel about yourself, which affects your behavior, mood, interactions with others and progress toward your goals. When you identify positive thoughts, make sure to practice them.

Consider using this path to help spur on your healthy behaviors:

  • Develop  positive and realistic goals  for yourself.
  • Find multiple ways to remind yourself of your goal.
  • Identify why you want to meet this goal.
  • List the behaviors you feel are unhealthy.
  • Select one of the identified behaviors that you would like to change.
  • Brainstorm ways to change this behavior and start small.
  • Devise a plan to promote this strategy.
  • Identify potential obstacles that could interfere with your goal.
  • Identify your options for support.
  • Set a date for when you want to achieve your goal.
  • Counter destructive thoughts with more constructive ones.
  • Consider what you must do to maintain change when you complete your goal.
  • Don't expect perfection; anticipate imperfection.
  • Evaluate your successes when you reach your goal.
  • Note how you feel now that you have worked to meet your goal.
  • Select another goal and restart the process when you're ready.

Don't let a lapse keep you from your goal

A lapse is a slight error, slip or pause in progress most people face at some point during the journey. Relapse occurs when lapses string together and a person returns to their former behavior. Remember that a lapse is normal and doesn't always lead to a relapse. Anticipate that a setback can and will occur. Then, figure out which triggers led to the lapse.

Common triggers include:

  • A certain time of day.
  • A challenging life event.
  • Negative emotions, boredom or a shift from your initial intentions.
  • Particular foods and visual cues.
  • People who have an influence on your life.
  • Social events, celebrations or your customs.

Remember, the danger is not the slip but how you react to that lapse. — Lisa Hardesty, Ph.D.,  is a clinical psychologist at Mayo Clinic Health System in Mankato , Minnesota.

Learn more about healthy behaviors that can help prevent cancer by reading these articles:

  • Cancer prevention: 7 tips to reduce your risk
  • Excess body weight, alcohol and tobacco: How lifestyle can affect your cancer risk
  • Is there a connection between ultraprocessed food and cancer?
  • Plant-based diet is encouraged for people with cancer
  • Reduce your risk of the 4 most common cancers

A version of this article was originally published on the Mayo Clinic Health System blog .

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Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness : A Systematic Review and Meta-Analysis

  • 1 Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 2 Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 3 Faculty of Social Work, University of Calgary, Calgary, Alberta, Canada
  • 4 Mathison Centre for Mental Health Research and Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 5 Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 6 Department of Electrical and Software Engineering, University of Calgary, Calgary, Alberta, Canada
  • 7 Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

Question   What is the prevalence of mental health disorders among people experiencing homelessness?

Findings   In this systematic review and meta-analysis, the prevalence of current and lifetime mental health disorders among people experiencing homelessness was high, with male individuals exhibiting a significantly higher lifetime prevalence of any mental health disorder compared to female individuals.

Meaning   These findings demonstrate that most people experiencing homelessness have mental health disorders, with current and lifetime prevalence generally much greater than that observed in general community samples.

Importance   Several factors may place people with mental health disorders, including substance use disorders, at increased risk of experiencing homelessness and experiencing homelessness may also increase the risk of developing mental health disorders. Meta-analyses examining the prevalence of mental health disorders among people experiencing homelessness globally are lacking.

Objective   To determine the current and lifetime prevalence of mental health disorders among people experiencing homelessness and identify associated factors.

Data Sources   A systematic search of electronic databases (PubMed, MEDLINE, PsycInfo, Embase, Cochrane, CINAHL, and AMED) was conducted from inception to May 1, 2021.

Study Selection   Studies investigating the prevalence of mental health disorders among people experiencing homelessness aged 18 years and older were included.

Data Extraction and Synthesis   Data extraction was completed using standardized forms in Covidence. All extracted data were reviewed for accuracy by consensus between 2 independent reviewers. Random-effects meta-analysis was used to estimate the prevalence (with 95% CIs) of mental health disorders in people experiencing homelessness. Subgroup analyses were performed by sex, study year, age group, region, risk of bias, and measurement method. Meta-regression was conducted to examine the association between mental health disorders and age, risk of bias, and study year.

Main Outcomes and Measures   Current and lifetime prevalence of mental health disorders among people experiencing homelessness.

Results   A total of 7729 citations were retrieved, with 291 undergoing full-text review and 85 included in the final review (N = 48 414 participants, 11 154 [23%] female and 37 260 [77%] male). The current prevalence of mental health disorders among people experiencing homelessness was 67% (95% CI, 55-77), and the lifetime prevalence was 77% (95% CI, 61-88). Male individuals exhibited a significantly higher lifetime prevalence of mental health disorders (86%; 95% CI, 74-92) compared to female individuals (69%; 95% CI, 48-84). The prevalence of several specific disorders were estimated, including any substance use disorder (44%), antisocial personality disorder (26%), major depression (19%), schizophrenia (7%), and bipolar disorder (8%).

Conclusions and Relevance   The findings demonstrate that most people experiencing homelessness have mental health disorders, with higher prevalences than those observed in general community samples. Specific interventions are needed to support the mental health needs of this population, including close coordination of mental health, social, and housing services and policies to support people experiencing homelessness with mental disorders.

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Barry R , Anderson J , Tran L, et al. Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness : A Systematic Review and Meta-Analysis . JAMA Psychiatry. Published online April 17, 2024. doi:10.1001/jamapsychiatry.2024.0426

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Guest Essay

What Martin Luther King Jr. Knew About Crime and Mental Illness

Blurred image of a white bird taking flight from a fence.

By Alvin L. Bragg Jr.

Mr. Bragg Jr. is the Manhattan district attorney.

In September 1958, the Rev. Dr. Martin Luther King Jr. was stabbed with a seven-inch steel letter opener. He had been autographing copies of his first book in Blumstein’s department store in Harlem. The woman who stabbed him was named Izola Ware Curry .

When Dr. King found out she was schizophrenic, he harbored no ill will toward her , saying instead, “I know that we want her to receive the necessary treatment so that she may become a constructive citizen in an integrated society where a disorganized personality need not become a menace to any man.”

Dated description aside, King recognized that people in crisis need mental health care to be healthy and safe. The many Izola Ware Currys in New York today are far more likely to find themselves in jail, or relegated to street corners and subway stations, than they are to receive comprehensive treatment. This disconnect can set the stage for people with mental illness to be both victims and perpetrators of real violence.

Mental illness isn’t a crime, and jail isn’t the answer for those experiencing it. We must meet the needs of people in crisis with treatment and support. In order to do so, we need more funding.

Lawmakers in Albany right now are in the final stages of negotiating our state budget. Gov. Kathy Hochul and the leaders of the Senate and Assembly must make good on their earlier support for significant investments in mental health care — especially for New Yorkers who have been struggling, posing potential dangers to themselves and others. Doing so now can reduce assaults in our city by people experiencing mental health crises. They can also ensure that when those people do commit crimes, they are held accountable in a manner that reduces recidivism.

Around half of people in New York City jails — some 3,000 men and women — have been diagnosed with some degree of mental illness. On any given day, hundreds await evaluations or beds at dwindling and overwhelmed state psychiatric hospitals . On a typical day at Manhattan Criminal Court, you’ll witness the churn of people struggling with mental illness, caught up in a cycle of recidivism and incarceration instead of receiving the therapy, medication and other services that would help them lead healthy, productive lives.

And it’s not only New York. According to the Vera Institute of Justice, in the United States, people with serious mental illness are more likely to encounter law enforcement than they are to receive treatment . Since the 1950s, around the time King barely dodged death, the number of state hospital psychiatric beds has decreased by around 94 percent. In many cases, jails and prisons filled the void. While large-scale psychiatric institutionalization was far from perfect — to say the very least — meaningful community-based alternatives never materialized.

Today, corrections facilities double as de facto mental health hospitals across the nation — and about 63 percent of those with a history of mental illness do not receive treatment while incarcerated in state and federal prison.

But it is in New York City where the failed mental health system seems to be on starkest display.

Desperate scenes of people in clear distress on subway platforms, in city parks and on bustling street corners, are commonplace. And although overall crime is down , the city has witnessed terrifying acts of violence and alarming incidents of disorder. Innocent people shoved in front of oncoming trains is a citywide nightmare. Women fear being randomly punched while walking down the street. This is a humanitarian disaster, and a public health and safety crisis.

We must do better — for those with real and complex mental health needs, and for all New Yorkers who currently fear for their safety. But attaining a comprehensive mental health system won’t happen overnight.

In the past few years, I’ve committed $9 million to two programs, Neighborhood Navigators and Court Navigators . In both programs, individuals with lived experience — designated “navigators”— help guide our struggling neighbors through the complex landscape of social services. It’s a start, but so much more is needed.

This year’s state budget is another opportunity to continue to build New York’s mental health infrastructure. My office submitted a detailed proposal to Albany leaders outlining mental health investments that are urgently needed this year. If we fail to take systemic action, New Yorkers will continue to confront daily scenes of desperation, and risk falling victim to shocking — but not surprising — acts of arbitrary violence.

Most directly related to the work of the Manhattan district attorney’s office, I’ve asked Albany to invest at least $25 million to expand and strengthen New York’s problem-solving courts. Such courts provide precisely the kind of treatment options that King may have wanted for his attacker, but that did not exist then. In exchange for pleading guilty, participants are offered court-supervised treatment instead of incarceration.

If they comply with their treatment plan and avoid rearrest (typically for 18 to 24 months), their felony plea can be reduced to a misdemeanor or dismissed. One mental health court found that it reduced the likelihood of rearrest by 46 percent.

I also urged Albany leaders to fund community-based mental health treatment, investing $16.3 million to fund 20 new teams to provide support to justice-involved individuals with serious mental illness. Similar initiatives have been shown to reduce overall recidivism .

For those who cannot be safely diverted from incarceration to treatment in the community, Hope House , which recently broke ground in the Bronx, will soon offer a safe and humane alternative to the Rikers Island jail complex, with 24-hour security and therapeutic treatment. The state should commit $30 million in capital funding to scale up the Hope House model.

Supportive housing provides essential stability to those with mental illness who have been justice-involved. Thousands of individuals returning to New York City from state prison go straight to shelters. Homelessness increases the risk of incarceration, which in turn increases the risk of homelessness. To break this vicious cycle, Albany should invest in building 500 new re-entry apartments over the next three years, and should expand an existing housing program for people leaving city jails.

Since I took office, we have made substantial progress in driving down murders and shootings in Manhattan, but the rise in felony assaults remains a persistent challenge. To reverse the post-Covid rise in random assaults of and by people with untreated mental illness, prevention-oriented investments are critical; enforcement has little deterrence value for crimes committed by those experiencing a mental health crisis.

Following his brush with death at the hands of Izola Ware Curry, King recognized treatment as the best path to keep those with mental illness, and those around them, safe. With assaults like the one King suffered becoming more common, our leaders in Albany must heed his call today and invest in a comprehensive mental health network.

Now is the time for action to address our mental health emergency.

Alvin L. Bragg Jr. is the Manhattan district attorney.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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New Research Will Provide Insights into the Behavioral Health Workforce and the Services They Provide

AcademyHealth is highlighting four new projects at the UNC Behavioral Health Workforce Research Center to address the strategic aims of the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Behavioral health practitioners play an increasingly important role within the U.S. health care workforce as the incidence of mental health and substance use disorders (SUD) continue to rise nationally. Recent data from the Substance Abuse and Mental Health Services Administration (SAMHSA) reveal that in 2022, almost a quarter of all US adults (23.1 percent) reported having a mental illness in the past year, while 17.3 percent of people aged 12 or older reported having a substance use disorder in the same timeframe. Despite the increase in need for behavioral health services, individuals continue to face many different barriers in accessing the care they need, such as cost, insurance coverage, and provider availability. 

It is critical that state and federal policymakers have a full, nuanced understanding of the behavioral health practitioner workforce as it seeks to meet the growing need for care. With funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) the University of North Carolina at Chapel Hill Behavioral Health Workforce Research Center ( UNC-BHWRC ) undertook 10 projects in 2023 that address national-level planning and policy-relevant research questions. Now, in the second year of this effort, UNC-BHWRC will focus on an additional eight projects whose findings on the behavioral health workforce will inform SAMHSA and HRSA’s strategic aims. AcademyHealth is supporting the dissemination of UNC-BHWRC’s findings to the health services research community for the following projects:

Understanding the Continuum of Behavioral Health Professionals Working in Substance Use and Addiction Services in the United States

Within the behavioral health workforce, there exists a broad range of professionals known as addiction counselors. These professionals vary widely in terms of their training, education, certification, licensure requirements, and reimbursement allowances, all of which have the potential to differ widely from state to state. To better understand the diversity within this workforce and between states, this UNC-BHWRC project aims to determine how addiction counselors are identified within each state and describe the proportion of states that permit addiction counselors and other behavioral health professionals to be reimbursed for substance use treatment and service delivery. Identifying these differences across states and programs will provide important details and context for policymakers looking to improve their states’ behavioral health services.

Inclusion of Perinatal Services at Mental Health and Substance Use Treatment Facilities in the U.S.

An estimated one in five pregnant-capable people will experience a behavioral health disorder during the perinatal period (during pregnancy and the postpartum period of up to 12 months after delivery). Furthermore, the risk of developing SUD is highest for birthing people aged 18 to 29 years old, increasing throughout the reproductive years, and co-occurring SUDs are common among those with any SUD in pregnancy. Left untreated, these behavioral health disorders worsen maternal mortality rates and increase the likelihood of poor outcomes for both baby and birth parent. 

Recent efforts at the federal and state level emphasize the importance of increasing access to behavioral health treatment for pregnant and post-partum individuals. This UNC-BHWRC project will use the National Substance Use and Mental Health Services Survey (N-SUMHSS) to understand the inclusion of perinatal service delivery at mental health and substance use treatment facilities in the U.S. The information gleaned from this project will help inform current efforts to strengthen parental health and behavioral health systems. 

Educational Pathways to Professional-level Behavioral Health Degree Programs

Many individuals in need of behavioral health services are unable to access this care, particularly those in rural areas and those from communities of color . Researchers and policymakers broadly agree that bolstering the behavioral health workforce is necessary to alleviate these disparities in care access, particularly in areas identified as mental health care professional shortage areas. There is also broad acknowledgement that increasing diversity within the behavioral health workforce can improve the delivery of culturally and linguistically appropriate services. 

In support of the goal to increase supply, geographic distribution, and diversity of the behavioral health workforce, this UNC-BHWRC’s project will identify common pathways for individuals to enter full-time behavioral health professions in the U.S. This study will leverage nationally representative data to identify distinct educational pathways into graduate-level behavioral health professions and assess associations between particular pathways and individual and employment characteristics.

Advanced Behavioral Health Training in Geriatric Fellowships

Researchers estimate that the number of Americans aged 65 years and older will reach 80 million in 2040, one in five Americans. As this population increases, so will the number of individuals in need of behavioral health services. Indeed, SAMHSA notes that 15 percent of older adults are impacted by behavioral health problems; if this statistic holds true, roughly 12 million older adults will be impacted by behavioral health problems in 2040.

There are unique factors to consider when responding to the needs of older adults with behavioral health needs, such as the loss of friends, relationships, jobs, and identity that occur with age, acute and chronic physical health conditions that are common among older adults, and the growing diversity of the older adult population. As such, geriatric fellowships may be an opportunity to advance behavioral health training for physicians who provide this care to older adults, thus increasing access to behavioral health care. In this project, UNC-BHWRC will explore the distribution of geriatric fellowships by physician specialty (family medicine, internal medicine, and psychiatry) using data from the Accreditation Council for Graduate Medical Education (ACGME) and surveying geriatric fellowship program directors. 

Together with SAMHSA and HRSA, AcademyHealth will support the researchers at UNC-BHWRC as they conduct their studies and share findings as soon as they are available. Information about the UNC-BHWRC and previous studies is available here .

Stress and Its Effects on Health Essay

Introduction, physical effects, psychological effects, behavioral effects.

Stress is the emotional strain or tension experienced by an individual due to a reaction toward various demanding and influential situations. The challenging or compelling situations are termed stressors. Stressors can be internal or external and include life changes such as losing a significant figure, low socioeconomic status, relationship problems, occupational challenges, and familial or environmental factors. An individual’s response to stressors influences the outcome of their life. Health is a state of complete social, emotional, and physical well-being and not merely the absence of disease. Stress is a common risk factor for negative health status secondary to negative adaptation and coping with the stressors. Stressors can create a strain on one’s physical, psychological and behavioral well-being, leading to lasting effects that are detrimental to one’s health.

Stress is associated with various physical health impacts on an individual. In an online cross-sectional survey by Keech et al. (2020) to determine the association between stress and the physical and psychological health of police officers, the findings illustrate that stress negatively impacts physical and psychological well-being. One hundred and thirty-four police officers were involved in the study (Keech et al., 2020). The findings demonstrate that stress resulted in various short and long-term physical effects that included increased heart rates, sweating, high blood pressure, and long-term development of the cardiac condition. In addition, stress resulted in the development of gastrointestinal disorders such as peptic ulcer and irritable bowel syndrome. Keech et al. (2020) note that stress’s associated physical health effects are explained by various mechanisms that include overstimulation of the sympathetic nervous system and the hypothalamic-pituitary-adrenocortical axis.

Overstimulation of the sympathetic nervous system results in increased sympathetic actions on the peripheral body organs leading to increased sweat production, heart rate, respiration rate, and urinary and bowel elimination. The study notes that chronic stress without positive adaptation measures results in the progressive development of hypertension, peptic ulcers, and irritable bowel syndrome as long-term effects (Keech et al., 2020). Within the gastrointestinal tract, chronic stress activity on the sympathetic nervous system results in increased parietal cell action. Overactivity of the parietal cells results in excessive gastric acid production, gradually eroding the mucosa, and ulceration occurs.

The effects of stress on the cardiovascular system are explained in a review by Kivimäki & Steptoe (2017) to determine the impact of stress on the development and progression of cardiovascular diseases. In the review, stress is identified to cause cardiovascular conditions secondary to the effects of sustained sympathetic action on heart contractility and peripheral vascular resistance (Kivimäki & Steptoe, 2017). The sympathetic nervous system contributes to normal heart and blood vessel contractility. However, when the system is overstimulated, a surge in contractility above the normal limits ensues, leading to the progressive development of heart conditions.

Psychological well-being incorporates a positive mental health status evidenced by an individual’s satisfaction with life, happiness, rational thinking and decision-making, and positive mood patterns. Stress has been associated with alterations in an individual’s psychological wellness. An explanation for alteration in an individual’s psychological well-being secondary to stress is negative adaptation. Keech et al. (2020) note that an individual’s response to a stressor determines whether stress results in positive or negative effects. In the online cross-sectional survey by Keech et al. (2020), the findings illustrate that pressure resulted in the development of anxiety, depression, and bipolar disorders as long-term effects among the participants. Exposure to stressful situations resulted in progressively developing anxiety among the individual secondary to persistent worry over the issue. The anxiety results in other physical manifestations, including increased heart rate, palpitations, sweating, and altered mobility. Depression and bipolar conditions were also associated with chronic stress secondary to the impacts of stress on neurotransmitter function and nerves.

Similar findings are noted in a cross-sectional study by Zhang et al. (2020) to compare the prevalence and severity of stress-associated mental health symptoms, including anxiety, depression, and insomnia among healthcare workers during the COVID pandemic. Five hundred and twenty-four healthcare workers were involved in the study. The study findings illustrate that 31.3% of the participants developed depression secondary to the stressful working environment, 41.2% reported anxiety, and 39.3% reported sleep disturbances (Zhang et al., 2020). The scientific explanation for the relationship between stress and depression was attributed to the effects of stressful periods on neurotransmitter homeostasis. Chronic stress results in the altered regulation of neurotransmitters in the central nervous system. Alterations in serotonin, norepinephrine, and dopamine resulted in the progressive development of depression and anxiety. Sleep disturbances reported by the participants are attributed to alterations in cortisol hormone homeostasis secondary to overstimulation of the hypothalamic-pituitary-adrenocortical axis.

Stressful situations can also lead to alterations in the behavioral patterns of an individual. The most common behavioral effects secondary to stress include the development of eating disorders, altered sleeping patterns, impaired concentration, and drug abuse especially alcohol. Alterations in sleep and eating patterns are linked to stress’s effects on the hypothalamic-pituitary-adrenocortical axis (HPA). Exposure to stressful events leads to increased activation of the HPA axis with a net effect of increased catecholamine production (adrenaline and noradrenaline) (Moustafa et al., 2018). Increased adrenaline and noradrenaline production results in dysregulation in the eating and sleeping patterns. Sustained high levels of cortisol results in difficulty falling asleep and increased metabolic processes. The biological clock regulates the typical sleeping pattern that relies on producing the sleep hormone melatonin. Melatonin production by the pineal gland is regulated indirectly by the concentration of serum cortisol levels and directly by light perception. Imbalances in the serum concentration cycle secondary to stress results in imbalanced melatonin production and concentration with a net effect of sleeping difficulties.

The emotional strain caused by stress increases the risk of alcohol and other illicit drug use and dependence. Moustafa et al. (2018) conducted an integrative literature review to determine the relationship between childhood trauma, early-life stress, alcohol and drug use, addiction, and abuse. The review findings illustrate that stress increases the risk of alcohol and drug use, addiction, and abuse among the victims. An explanation for the increased risk is the individuals’ lack of identification and implementation of effective coping strategies (Moustafa et al., 2018). Lack of effective coping strategies results in maladaptive measures such as illicit drug use and alcohol consumption. Extensive use of the maladaptive measures results in progressive addiction and drug abuse among individuals with an increased predisposition to other health effects. Alcohol consumption and other illicit drug use over time increase the risk of developing cardiac, respiratory, and liver conditions.

Stress is the emotional strain or tension experienced by an individual due to a reaction toward various demanding and influential situations. Individual response to stressors influences their health. Maladaptive response to stress results in various physical, psychological, and behavioral negative effects. Negative effects of stress on physical health include increased heart rates, sweating, high blood pressure, and long-term development of the cardiac condition. Psychological effects include the development of anxiety, depression, and bipolar disorders. The behavioral effects of stress on an individual include the development of eating disorders, altered sleeping patterns, impaired concentration, and abuse of alcohol and other drugs. Based on the research findings, it is essential for healthcare providers to identify strategic measures and health initiatives to educate and sensitize the community members on effective stress management approaches in all settings to aid in combating the health effects.

Keech, J. J., Cole, K. L., Hagger, M. S., & Hamilton, K. (2020). The association between stress mindset and physical and psychological well being: Testing a stress beliefs model in police officers . Psychology & Health , 35 (11), 1306-1325. Web.

Kivimäki, M., & Steptoe, A. (2017). Effects of stress on the development and progression of cardiovascular disease . Nature Reviews Cardiology , 15 (4), 215–229. Web.

Moustafa, A. A., Parkes, D., Fitzgerald, L., Underhill, D., Garami, J., Levy-Gigi, E., Stramecki, F., Valikhani, A., Frydecka, D., & Misiak, B. (2018). The relationship between childhood trauma, early-life stress, and alcohol and drug use, abuse, and addiction: An integrative review . Current Psychology , 40 (2), 579–584. Web.

Zhang, X., Zhao, K., Zhang, G., Feng, R., Chen, J., Xu, D., Liu, X., Ngoubene-Italy, A. J., Huang, H., Liu, Y., Chen, L., & Wang, W. (2020). Occupational Stress and Mental Health: A comparison between frontline medical staff and non-frontline medical staff during the 2019 novel Coronavirus Disease outbreak . Frontiers in Psychiatry , 11 . Web.

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Francis Collins: Why I’m going public with my prostate cancer diagnosis

I served medical research. now it’s serving me. and i don’t want to waste time..

Over my 40 years as a physician-scientist, I’ve had the privilege of advising many patients facing serious medical diagnoses. I’ve seen them go through the excruciating experience of waiting for the results of a critical blood test, biopsy or scan that could dramatically affect their future hopes and dreams.

But this time, I was the one lying in the PET scanner as it searched for possible evidence of spread of my aggressive prostate cancer . I spent those 30 minutes in quiet prayer. If that cancer had already spread to my lymph nodes, bones, lungs or brain, it could still be treated — but it would no longer be curable.

Why am I going public about this cancer that many men are uncomfortable talking about? Because I want to lift the veil and share lifesaving information, and I want all men to benefit from the medical research to which I’ve devoted my career and that is now guiding my care.

Five years before that fateful PET scan, my doctor had noted a slow rise in my PSA, the blood test for prostate-specific antigen. To contribute to knowledge and receive expert care, I enrolled in a clinical trial at the National Institutes of Health, the agency I led from 2009 through late 2021.

At first, there wasn’t much to worry about — targeted biopsies identified a slow-growing grade of prostate cancer that doesn’t require treatment and can be tracked via regular checkups, referred to as “active surveillance.” This initial diagnosis was not particularly surprising. Prostate cancer is the most commonly diagnosed cancer in men in the United States, and about 40 percent of men over age 65 — I’m 73 — have low-grade prostate cancer . Many of them never know it, and very few of them develop advanced disease.

Why am I going public about this cancer that many men are uncomfortable talking about? Because I want to lift the veil and share lifesaving information.

But in my case, things took a turn about a month ago when my PSA rose sharply to 22 — normal at my age is less than 5. An MRI scan showed that the tumor had significantly enlarged and might have even breached the capsule that surrounds the prostate, posing a significant risk that the cancer cells might have spread to other parts of the body.

New biopsies taken from the mass showed transformation into a much more aggressive cancer. When I heard the diagnosis was now a 9 on a cancer-grading scale that goes only to 10, I knew that everything had changed.

Thus, that PET scan, which was ordered to determine if the cancer had spread beyond the prostate, carried high significance. Would a cure still be possible, or would it be time to get my affairs in order? A few hours later, when my doctors showed me the scan results, I felt a rush of profound relief and gratitude. There was no detectable evidence of cancer outside of the primary tumor.

Later this month, I will undergo a radical prostatectomy — a procedure that will remove my entire prostate gland. This will be part of the same NIH research protocol — I want as much information as possible to be learned from my case, to help others in the future.

While there are no guarantees, my doctors believe I have a high likelihood of being cured by the surgery.

My situation is far better than my father’s when he was diagnosed with prostate cancer four decades ago. He was about the same age that I am now, but it wasn’t possible back then to assess how advanced the cancer might be. He was treated with a hormonal therapy that might not have been necessary and had a significant negative impact on his quality of life.

Because of research supported by NIH, along with highly effective collaborations with the private sector, prostate cancer can now be treated with individualized precision and improved outcomes.

As in my case, high-resolution MRI scans can now be used to delineate the precise location of a tumor. When combined with real-time ultrasound, this allows pinpoint targeting of the prostate biopsies. My surgeon will be assisted by a sophisticated robot named for Leonardo da Vinci that employs a less invasive surgical approach than previous techniques, requiring just a few small incisions.

Advances in clinical treatments have been informed by large-scale, rigorously designed trials that have assessed the risks and benefits and were possible because of the willingness of cancer patients to enroll in such trials.

I feel compelled to tell this story openly. I hope it helps someone. I don’t want to waste time.

If my cancer recurs, the DNA analysis that has been carried out on my tumor will guide the precise choice of therapies. As a researcher who had the privilege of leading the Human Genome Project , it is truly gratifying to see how these advances in genomics have transformed the diagnosis and treatment of cancer.

I want all men to have the same opportunity that I did. Prostate cancer is still the No. 2 cancer killer among men. I want the goals of the Cancer Moonshot to be met — to end cancer as we know it. Early detection really matters, and when combined with active surveillance can identify the risky cancers like mine, and leave the rest alone. The five-year relative survival rate for prostate cancer is 97 percent, according to the American Cancer Society , but it’s only 34 percent if the cancer has spread to distant areas of the body.

But lack of information and confusion about the best approach to prostate cancer screening have impeded progress. Currently, the U.S. Preventive Services Task Force recommends that all men age 55 to 69 discuss PSA screening with their primary-care physician, but it recommends against starting PSA screening after age 70.

Other groups, like the American Urological Association , suggest that screening should start earlier, especially for men with a family history — like me — and for African American men, who have a higher risk of prostate cancer. But these recommendations are not consistently being followed.

Our health-care system is afflicted with health inequities. For example, the image-guided biopsies are not available everywhere and to everyone. Finally, many men are fearful of the surgical approach to prostate cancer because of the risk of incontinence and impotence, but advances in surgical techniques have made those outcomes considerably less troublesome than in the past. Similarly, the alternative therapeutic approaches of radiation and hormonal therapy have seen significant advances.

A little over a year ago, while I was praying for a dying friend, I had the experience of receiving a clear and unmistakable message. This has almost never happened to me. It was just this: “Don’t waste your time, you may not have much left.” Gulp.

Having now received a diagnosis of aggressive prostate cancer and feeling grateful for all the ways I have benefited from research advances, I feel compelled to tell this story openly. I hope it helps someone. I don’t want to waste time.

Francis S. Collins served as director of the National Institutes of Health from 2009 to 2021 and as director of the National Human Genome Research Institute at NIH from 1993 to 2008. He is a physician-geneticist and leads a White House initiative to eliminate hepatitis C in the United States, while also continuing to pursue his research interests as a distinguished NIH investigator.

An earlier version of this article said prostate cancer is the No. 2 killer of men. It is the No. 2 cause of cancer death among men. The article has been updated.

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health behaviors essay


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  28. New Research Will Provide Insights into the Behavioral Health Workforce

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