journal assignment

Got health? 31aat may sound like a simple question, but it isn't; health is a process, not something we just "get" Peo- ple who are healthy in their forties, fifties, sixties, and beyond aren't just lucky or the beneficiaries of hardy genes. In most cases, those who are healthy and thriving in later years set

the stage for good health by making it a priority in their early years. You've probably heard from your parents and

grandparents that your college years are some of the best of your life. Here the canvas is hung upon which you will

paint the story of your life. Whether your story is filled with good health, productive careers, happiness, special relation- ships, and fulfillment of life goals is largely dependent on the health choices you make--beginning right now.

OBJECTIVES * Describe the immediate and long-term re- wards of healthy behaviors and the effects that

U your health choices may have on others.

* Compare and contrast the medical model of health and the public health model, and discuss the six dimensions of health.

i °: ÿ=

Hear It!i : spend time, but also to peo- !ÿ Want ÿ1, study-p6ÿOoaÿr.th|8 pie you've never met and to ;ÿ-1eliÿfelÿ::Downlbad:Pÿliloting the well-being of the entire .'i H6a|tliqÿehÿVÿf g habgeÿoat planet, i 4wwÿtÿÿ atelle.

How does what you do . .: ÿ-iÿ: t

today influence you and those around you? Let's take a look at how your actions and inac-

tions matter.

Why should I be concerned about health conditions in other places?

How do other people influence my health behaviors?

How can I stay motivated to improve my health habits?

Explain how aspects of the social and physi- cal environment influence your health.

* Discuss the importance of a global perspec- tive on health, and explain how gender, racial, economic, and cultural factors influence health disparities.

Compare and contrast three models of behavior change.

Identify your own current risk behaviors, the factors that influence those behaviors, and the strategies you can use to change them.

t

o

j, /

!

Identify several personal factors that influ- ence your health and classify them as modifi- able or nonmodifiable.

, Why Health, Why Now? In addition to our desires to improve our health, constant/ messages via television, the Internet, and magazines remind us of health challenges facing the world, the nation, your community, and your campus. We can't run from these issues, and we can't ignore them. Even health issues occur-

ring in another part of the world affect us. In the twenty-first

century your health is connected, not only to the people you directly interact with and the environments where you

What is meant by quality of life?

Choose Health Now for Immediate Benefits Almost everyone knows that overeating leads to weight gain, or that drinking and driving increases the risk of motor vehicle

accidents. But other, subtler choices you make every day may be influencing your well-being in ways you're not aware of. For

instance, did you know that the amount of sleep you get each night could affect your body weight, your ability to ward off colds, your mood, and your driving? What's more, inadequate sleep is one of the most commonly reported impediments to academic success (Figure 1.1). Another example is smok- ing: It has many immediate health effects, including fatigue, throat irritation, and breathing problems. And like poor sleep, it increases your vulnerability to colds and other infections.

Stress

Sleep difficulties

Anxiety

Cold/flu/ sore throat

Work

Internet use/ computer games

Depression

Concern for friend/ family member

Relationship difficulties

Extracurricular activities

' 2'0 '0 ' 0 10 3 40

Percent

d d FIGURE / , / Top Ten Reported Impediments to Academic Performance--Past 12 Months In a recent survey by the National College Health Association, students indicated that stress, poor sleep, recurrent minor illnesses, and anxiety, among other things, had prevented them from performing at their academic best. Source: Data are from American College Health Association, American College Health Association--National College Health Assessment II (ACHA- NCHA II) Reference Group Data Report, Spring 2011 (Baltimore: ACHA, 2012).

CHAPTER 1 [ ACCESSING YOUR HEALTH I 3

TA B L EI d I I Leading Causes of Death in the United States, | | 12009, Overall and byAge Group (15 and older)

All Ages Number of Deaths

595,444

573,855

137,789

129,180

118,043

Diseases of the heart

Malignant neoplasms (cancer)

Chronic lower respiratory diseases

Cerebrovascular diseases

Accidents (unintentional injuries)

Aged 15-24

Unintentional injuries 12,015

Assault (homicide) 4,651

Suicide 4,559

Malignant neoplasms (cancer) 1,594

Diseases of the heart 984

Aged 25--44

Unintentional injuries 28,149

Malignant neoplasms 15,389

Diseases of the heart 13,447

Suicide 12,119

Homicide 6,674

Aged 45-64

Malignant neoplasms (cancer) 159,379

Diseases of the heart 103,812

Unintentional injuries 32,667

Chronic lower respiratory diseases 18,616

Chronic liver disease and cirrhosis 18,348

Aged 65+

Diseases of the heart 476,519

Malignant neoplasms 396,173

Chronic lower respiratory diseases 117,856

Cerebrovascular diseases 109,764

Alzheimer's disease 82,438

diate benefits. When you're well nourished, fit, rested, and free from the influence of nicotine, alcohol, and other drugs, you're more likely to avoid illness, succeed in

school, maintain supportive relationships, participate in meaningful work and community activities, and enjoy your leisure time.

Source: Sherry L. Murphy, Jiaquan Xu, and Kenneth D. Kochanek, "Deaths:

Preliminary Data for 2010," National Vital Statistics Reports 60, no. 4 (Hyattsville, MD: National Center for Health Statistics, 2012.)

and other harm or damage. ÿIhis is especially significant because for

people between the ages of 15 and 44, unintentional injury--whether related to alcohol use or any other factor--is the leading cause of death (Table 1.1).

It isn't an exaggeration to say that healthy choices have imme-

4 I PART ONE [ FINDING THE RIGHT BALANCE

mortality The proportion of deaths to population,

life expectancy Expected number of years of life remaining at a given age, such as at birth,

chronic disease A disease that typi- cally begins slowly, progresses, and persists, with a variety of signs and symptoms that can be treated but not cured by medication.

Similarly, drinking alcohol reduces your immediate health and your academic performance. It also sharply increases your risk of unintentional injuries--not only motor vehicle acci-

dents, but also falls, drownings,

Choose Health Now for Long-Term Rewards The choices you make today are like seeds: Planting good seeds means you're more likely to enjoy the fruits of good health, including not only a longer life, but also a higher quality of life. In contrast, poor choices increase the likeli- hood of a shorter life, as well as persistent illness, addiction, and other limitations on quality of life. In other words, suc- cessful aging starts now.

Personal Choices Influence Your Life Expec- tancy According to current mortality and death statistics-- which reflect the proportion of deaths within a population--the average life expectancy at birth in the United States is projected to be 78.5 years for a child born i "ÿ 2012.1 In other words, we can expect that Ameri-

can infants born today will live to an average age of over 78 years; much longer than the 47-year life expectancy for pet- -ÿ ple born in the early 1900s. That's because life expec- "Why ÿ' tancy 100 years ago was largely determined by our susceptibility to infectious disease.

In 1900, over 30 per- cent of all deaths oc- curred among chil-

dren under 5 years

old, and the leading

Should I Care?" Just as health problems can

create challenges for success, improving your health can lead to

better academics, career suc-

cess, increased relationship satisfaction, and more joy

in living overall. cause of death was infec-

tion.2 Even among adults, infectious diseases such as tuber-

culosis and pneumonia were the leading causes of death, and widespread epidemics of infectious diseases such as cholera and influenza crossed national boundaries to kill millions.

With the development of vaccines and antibiotics, life expec- tancy increased dramatically as premature deaths from infec- tious diseases decreased. As a result, the leading cause of death shifted to chronic diseases such as heart disease, cerebrovascu- lar disease (which leads to strokes), cancer, and chronic lower respiratory diseases. At the same time, advances in diagnostic

technologies, heart and brain surgery, radiation and other can- cer treatments, as well as new medications continued the trend of increasing life expectancy into the twenty-first century.

Unfortunately, some researchers question :ÿ"ÿ ::: ÿ: ÿ:: ÿ

whether this trend of

increasing life expectancy will continue. In fact, a recent study projects that today's newborns will be the first gen- eration to have a lower life expectancy than that of their parents.3 One major contributor to future reductions in life

expectancy relates to obesity and sedentary lifestyle. A recent study led by researchers from the Harvard School of Pub- lic Health and the University of Washington indicates that smoking, high blood pressure, elevated blood glucose, and overweight/obesity currently reduce life expectancy in the United States by 4.9 years in men and 4.1 years in women.4

O7&fl are the healthy life expectancy ages of men and women, respectively, in the U.S., while the average

total life expectancy ages are 75.7 and 80.6.

Whereas lifestyle choices may be the biggest reason for

future declines in life expectancy, health care decisions may also have an impact. For example, a growing number of persons are opting out of vaccinations for their children, while there are increasing threats from resistant pathogens and new strains of diseases. Other individual choices, such

as tÿxting while driving or failing to properly dispose of toxic chemicals, also are part of life expectancy projections.

Personal Choices Influence Your Healthy Life Expectancy By now you're probably beginning to see how healthful choices, such as watching what you eat, enjoying

physical activity, and avoiding smoking and alcohol abuse, increase your life expectancy. But another benefit of these healthful choices is that they increase your healthy life ex-

pectancy; that is, the number of years of full health you en- joy, without disability, chronic pain, or significant illness.

Another dimension of healthy life expectancy is health-

related quality of life (HRQoL), a multidimensional con- cept that includes elements of physical, mental, emotional, and social function. HRQoL goes beyond mortality rates and life expectancy and focuses on the impact health status has on overall quality of life. Closely related to this is well-being, which assesses the positive aspects of a person's life, such as

positive emotions and life satisfaction,s

Choose Health Now to Benefit Others Our personal health choices don't affect only our own

lives. They affect the lives of others, because they contrib- ute to global health or the global burden of disease. For example, we've said that overeating and inadequate physi-

cal activity contribute to obe-

sity. But obesity isn't a problem only for the individual. Along with its associated health prob-

lems, obesity burdens the U.S. health care system and the U.S. economy overall. Direct medical

costs, including the costs of diag-

healthy life expectancy Expected number of years of full health remain- ing at a given age, such as at birth. health-related quality of life Assessment of impact of health status--including elements of physical, mental, emotional, and social function--on overall quality of life,

nosis and treatment, reached as high as $147 billion in

2008, and roughly half of those costs were paid by public programs (Medicaid and Medicare).e In addition, obe-

sity costs the public indirectly. These indirect costs include reduced tax revenues because of income lost from absen-

teeism and premature death, increased disability payments because of an inability to remain in the workforce, and increased health insurance rates as claims rise for treatment

of obesity itself as well as its associated diseases.

Health-related quality of life refers to a person's or group's perceived physical and mental health over time. Just because a person has an illness or disability doesn't mean his or her quality of life is necessarily low. Hawaiian surfer Bethany Hamilton lost her arm in a shark attack while surfing at age 13, but that hasn't prevented her from achieving her goals and a high quality of life. She returned to surfing just 1 month after the attack and has since traveled around the world competing as a professional surfer.

CHAPTER 1 [ ACCESSINGYOUR HEALTH [ 5

of excess in which small children learn behav-

iors early in life that are difficult to break. Should individuals be punished for choices that society influenced and the media promoted? Who is ulti-

mately responsible? Before you decide where you stand on this

issue, hold on: It's not as black and white as it may first appear, q-hat's because seemingly

personal choices that influence health are not always entirelywithin our personal control. We'll explain shortly, but first it's essential to under- stand what health actually is and which factors

we actually may be able to control.

What Is Health?

Unhealthy conditions in one location can have far-reaching impacts on the economy and health. When the 2011 earthquake and tsunami in Japan caused devastation in that country, productivity losses were felt as far away as Europe. The natural disaster also damaged the Fukushima Daiichi nuclear power plant, spreading radiation throughout the region and fear of potential nuclear fallout throughout the world.

health The ever-changing process of achieving individual potential in the physical, social, emotional, mental, spiritual, and environmental dimensions.

medical model A view of health in which health status focuses primarily on the individual and a biological or diseased organ perspective.

Direct and indirect costs are also associated with smoking,

excessive alcohol consumption, and illegal drug use. All of these choices place an economic bur- den on our communities and our society as a whole. ÿlae disease

burden goes beyond pure eco- nomics and includes social and

Today, health and wellness mean taking a positive, proactive attitude toward life

and living it to the fullest.For some, the word health simply means the antithesis of sickness. To others, it means being in good physical shape and able to resist illness. Still others use terms such as wellness or well-

being to include a wide array of factors that seem to lead to positive health status. Why are there all of these variations? In part, the differences are due to an increasingly enlightened way of view- ing health that has taken shape over time. As our

collective understanding of illness has improved, so has our

ability to understand the many nuances of health.

Models oflIealth Over the centuries, different ideals--or models--of human health have dominated. Our current model of health has

broadened from a focus on the individual physical body to an understanding of health as a reflection not only of our-

selves, but also of our communities.

what do you think? i Is obesity always a matter of

lacking willpower or discipline? • Since we tax cigarettes, is it rea-

sonable to tax high-calorie sodas? • What about taxing prepackaged, high-fat foods? • Who should decide? • Would you draw the line?

m

some cases, we already do.

We tax cigarettes and alco- hol, and a few communities are currently taxing sweet- ened soft drinks, which have been blamed for rising obe-

sity rates.7 On the other side of the argument are those who argue that smoking and drinking are addictions that require treatment, not punishment, and that obe-

sity is a product of a society

Medical Model Prior to the twentieth century, if you made it to your fiftieth birthday, you were regarded as lucky. Survivors were believed to be of hearty, healthy stock--hav- ing what we might refer to today as "good genes:' We didn't

have the means to delve into factors influencing risks, and as such, cleanliness, good behavior, and a bit of luck were part

of the good health formula. Throughout these years, perceptions of health were domi-

nated by the medical model, in which health status focused primarily on the individual and his or her tissues and organs. q-he surest way to bring about improved health was to cure the individual's disease, either with medication to treat the dis-

ease-causing agent or through surgery to remove the diseased body part. qlaus, government resources focused on initiatives that led to treatment, rather than prevention, of disease.

Public Health Model Not until the early decades of the 1900s did researchers begin to recognize that entire popula- tions of poor people, particularly those living in certain loca- tions, were victims of environmental factors over which they

6 { PART ONE I FINDING THE BIGHT BALANCE

emotional costs, such as those on families left without par- ents or on people who lose loved ones in their prime, qhe burden on caregivers who personally sacrifice to take care of

those disabled by diseases is another part of this problem. At the root of the concern that individual health choices

cost society is an ethical question causing considerable debate: To what extent should the public be held accountable for an individual's unhealthy choices? Should we require indi-

viduals to somehow pay for their poor choices? Of course, in

had little control: things such as polluted water, air, and food; poor housing; and unsafe work settings. As a result of this new

understanding, researchers began to focus on an ecological or public health model, which views diseases and other neg- ative health events more as a result of an individual's interac-

tion with his or her social and physical environment. Recognition of the public health model enabled health

officials to move to control contaminants in water, for exam-

ple, by building adequate sewers, and to control burning and other forms of air pollution. In the early 1900s colleges began offering courses in heakh and hygiene to teach stu- dents about these important factors. And over time, public health officials began to recognize and address many other forces affecting human health, including hazardous work conditions; negative influences in the home and social envi-

Public Hea Ith .y

° iovascular

deaths

d r-) FIGURE / ,/__ The Ten Greatest Public Health Achievements of the Twentieth Century Source: Adapted from Centers for Disease Control and Prevention, "Ten Great Public Health Achievements-- United States, 1900-1999," Morbidity and Mortal-

ity Weekly Report 48, no. 12 (April 1999): 241-43.

ronment; abuse of drugs and alcohol; stress; unsafe behavior; diet; sedentary lifestyle; and cost, quality, and access to health care.

By the 1940s progressive thinkers began calling for policies, programs, and services to improve individual health and that of the population as a whole. In other words, their focus shifted from treatment of individual illness to disease prevention by reducing or eliminating the factors that cause illness and injury. For example, childhood vaccination pro- grams reduced the incidence and sever- ity of infectious disease; installation of safety features such as seatbelts and air- bags in motor vehicles reduced traffic

injuries and fatalities; and laws govern-

ing occupational safety reduced injuries to and deaths of American workers. In

1947 at an international conference focusing on global health issues, the World Health Organization (WHO) proposed a new definition of health: "Health is the state of complete physical, mental, and social well-being, not just the absence of disease or infirmity."a This new definition

definitively rejected the old medi- cal model.

Alongside prevention, the pub- lic health model began to empha- size health promotion, that is,

policies and programs that pro- mote behaviors known to support good health. Health-promotion

programs identify healthy people who are engaging in risk behav- iors (those that increase suscepti-

bility to negative health outcomes) and motivate them to change their

actions by changing aspects of the larger environment to increase an individual's chances of success.

Numerous policies, individual

ecological or public health model A view of health in which diseases and otheP negative health events are seen as a result of an individual's interaction with his or her social and physical environment.

disease prevention Actions or behaviors designed to keep people from getting sick. health promotion The combined educational, organizational, proce dural, environmental, social, and financial supports that help individuals and groups reduce negative health behaviors and promote positive change•

risk behaviors Actions that increase susceptibility to negative health out comes.

actions, and public services have worked to improve our

overall health status greatly in the past 100 years. (Figure 1.2 lists the ten greatest public health achievements of the twen- tieth century.)

Wellness and the Dimensions of Health In 1968, biologist, environmentalist, and philosopher Ren6 Dubos proposed an even broader definition of health. In his Pulitzer Prize-winning book, So Human an Animal, Dubos defined health as "a quality of life, involving social, emotional, mental, spiritual, and biological fitness on the part of the individual, which results from adaptations to the environment."9 This concept of adaptability, or the ability to

CHAPTER 1 ) ACCESSING YOUR HEALTH I 7

.GORE 1 ,3 The Wellness Continuum

Neutral point

cope successfully with life's ups and downs, became a key element in our overall understanding of health.

Eventually the word wellness wellness The achievement of the entered the popular voc'abu- highest level of health possible in each of several dimensions, lary. This word further enlarged

Dubos's definition of health by recognizing levels--or gradations--of health within each

category (Figure 1.3). To achieve high-level wellness, a person must move progressively higher on a continuum of positive health indicators. Those who fail to achieve these levels may

slip into illness, premature disability, or death. Today, the words health and wellness are

often used interchangeably to mean the dynamic, ever-changing pro-

cess of trying to achieve one's potential in each of six interre- lated dimensions (Figure 1.4):

• Physical health. ]his dimension includes characteristics such as body size and shape, sensory acuity and responsive- ness, susceptibility to disease and disorders, body functioning, physical fitness, and recuperative abilities. Newer definitions of physical health also include our ability to perform normal activities of daily living (ADLs), or those tasks that are neces- sary to normal existence in society, such as getting up out of a chair, bending over to tie your shoes, or writing a check. • Social health. ]he ability to have a broad social network and have satisfying interpersonal relationships with friends,

family members, and partners is a key part of overall

wellness. ]his implies being able to give and receive love and to be nurturing and supportive in social interactions. Successfully interacting and communicating with others, adapting to various social situations, and other daily behav- iors are all part of social health.

• Intellectual health. ]he ability to think clearly, reason objectively, analyze critically, and use brainpower effectively to meet life's challenges are all part of this dimension. ]his

includes learning from successes and mistakes and making sound, responsible decisions that consider all aspects of a situation. It also includes having a healthy curiosity about life and an interest in learning new things.

• Emotional health. ]his is the feeling component--being able to express emotions when appropriate, and to control them when not. Self-esteem, self-confidence, self-efficacy, trust, love, and many other emotional reactions and responses are all part of emotional health. • Spiritual health. ]his dimension involves having a sense of meaning and purpose in your life. ]his may involve a belief

in a supreme being or a specified way of living prescribed by a particular religion. It also may include the ability to under- stand and express one's purpose in life; to feel a part of a

greater spectrum of existence; to experience peace, content- ment, and wonder over life's experiences; and to care about

and respect all living things. • Environmental health. ]his dimension entails understand- ing how the health of the environments in which you live,

work, and play can positively or negatively affect you; pro- tectingyourself from hazards in your own environment; and working to preserve, protect, and improve environmental conditions for everyone.

there are flesh apples on sale at the neighborhood farmer's market; and a new bike trail opens along the river (and you have a bike!). If you're not so lucky, aspects of your world discourage health: Everyone in your family is over- weight and they eat high-fat diets; your peers urge you to keep up with their drinking; there are only cigarettes, alco- hol, and junk food for sale at the corner market; and you wouldn't dare walk or ride alongside the river for fear of

being mugged. This variety of influences explains why we said earlier that seemingly personal choices aren't totally within an individual's control.

Public health experts refer to the factors that influence health as determinants of health, a term the U.S. Surgeon General defines as "the range of personal, social, economic, and determinants of health The range environmental factors that infiu- of personal, social, economic, and

environmental factors that influence ence health status"1° ]he Surgeon health status. General's health promotion plan,

called Healthy People, has been published every 10 years since 1990 with the goal of improving the quality and years of life for all Americans. ]he overarching goals set out by the newest version, Healthy People 2020, are:

• Attain high-quality, longer lives free of preventable diseases • Achieve health equity, eliminate disparities, and improve health of all groups • Create social and physical environments that promote good health for all • Promote quality of life, healthy development, and healthy behaviors across all life stages

FIGURE 1,4 The Dimensions of Health 1ÿ1ÿ, ,,.ÿÿ When all dimensions are balanced and well developed, they support your active,

thriving lifestyle. Video Tutor', Dimensions of Health rÿ 1

0 ] PART ONE I FINDING THE RIGHT BALANCE

What Influences Your Health? If you're lucky, aspects of your world conspire to promote your health: Everyone in your family is slender and fit; your morn reminds you when it's time to see the dentist;

r Achieving wellness means attaining the optimal level of

well-being for your unique limitations and strengths. For example, a physically disabled person may function at his or

her optimal level of performance; enjoy satisfying interper- sonal relationships; work to maintain emotional, spiritual, and intellectual health; and have a strong interest in envi- ronmental concerns. In contrast, those who spend hours

lifting weights to perfect the size and shape of each muscle but pay little attention to their social or emotional health may look healthy but may not maintain a good balance in all dimensions.

Although we often consider physical attractiveness and athletic performance key measures of health, these external

trappings reveal very little about a person's overall heakh. ]he perspective we need is holistic, emphasizing the bal- anced integration of mind, body, and spirit.

Healthy People 2020 classifies health determinants into five large groupings: individual behavior, biology and genetics, social factors, policymaking, and health services (Figure 1.5).

' Determinants

Individuÿ. behavl

Health services

Biology and genetics .

Health outcomes

"1 FIGURE / , ÿJ Healthy People 2020 Determinants of Health The determinants of health often overlap with one another. Collectively, they impact health of individuals and communities.

CHAPTER 1 I ACCESSING YOUR HEALTH I 9

Individual Behavior Individual behaviors can help you attain, maintain, or regain good health, or they can deteriorate your health and pro- mote disease. From birth onward, your behaviors are shaped by a multitude of influences. Fortunately, most behaviors

are things you can change, so health experts refer to them as modifiable determinants. Modifiable determinants signifi- cantly influence your risk for chronic disease. Earlier, we said that chronic diseases are the leading causes of death and disability in the United States; indeed, they are responsible for 7 out of 10 deaths,n Incredibly, just four modifiable determi-

nants are responsible for most of the illness and early death related to chronic diseases (Figure 1.6). These are the following:12

• Lack of physical activity. Physical inactivity and over- weight/obesity are each responsible for nearly I in 10 deaths in U.S. adults.

• Poor nutrition. High dietary salt, low dietary omega-3 fatty acids, and high dietary trans fatty acids are the dietary risks with the largest mortality effects. • Excessive alcohol consumption. Alcohol causes 90,000

deaths in adults annually through cardiovascular disease, other medical conditions, traffic accidents, and violence. • Tobacco use. Tobacco smoking and the high blood pres- sure and cancer it causes are responsible for about i in 5

deaths in American adults.

fruits and vegetables, and don't smoke can

add up to 14 extra years to their lives.la

Other modifiable determinants include use of vitamins and other supplements, caffeine, over-the-counter medications,

and illegal drugs; sexual behaviors and use of contraceptives; sleep habits; and hand washing and other simple infection-

control measures.

Biology and Genetics Biological and genetic determinants are things you can't

typically change or modify. Health experts frequently refer to these factors as nonmodifiable determinants. They include genetically inherited traits, conditions, and predispositions to diseases such as sickle cell disease, hemophilia, cystic fibrosis, allergies and asthma, cardiovascular disease, diabe- tes, certain cancers, and other problems, lhey also refer to certain innate characteristics, such as your age, race, ethnic-

ity, metabolic rate, and body structure. Your gender is a key biological determinant: Women are at risk for low bone den-

sity, sexually transmitted infections, autoimmune diseases (in which the immune system attacks the body's own cells),

and depression. Your own history of illness and injury also classifies as biology; for instance, if you had a serious knee

injury in high school, it may cause pain with walking and exercise, which in turn may predispose you to weight gain.

d FIGURE | , ÿ_ÿ Four Leading Causes of Chronic Disease in the United States Lack of physical activity, poor nutrition, excessive alcohol consumption, and tobacco use--all modifiable health determinants--are the four most significant factors leading to chronic disease among Americans today.

110 I PART ONE I FINDING THE RIGHT BALANCE

On the flip side, studies show people who exercise regu- larly, drink alcohol in moderation, eat five daily servings of

Maybe you are already taking strides to live a more healthful life. How many of these healthy behaviors do you practice?

[] [] [] [] [] []

get a minimum of 7 hours of sleep every night.

maintain healthy eating habits and manage my weight.

regularly engage in physical activity.

practice safer sex.

limit my intake of alcohol and avoid tobacco products.

schedule regular self-exams and medical checkups.

Social Factors Social factors include both the social and physical condi- tions in the environment in which people are born or live.

Exposure to crime, violence, mass media, technology, and poverty, as well as availability of healthful foods, transpor- tation, living wages, social support, and educational or job opportunities are all examples. Physical conditions include the natural environment; conditions such as good lighting, trees, or benches; the state of buildings--homes, schools, or workplaces; exposure to toxic substances; and the pres-

ence of physical barriers, which can challenge people with disabilities.

Economic Factors Among the most powerful of all determinants of health are economic factors: Even in af- fluent nations such as the United States, people who are in lower socioeconomic brackets have substantially shorter

life expectancies and more illnesses than people who are wealtlly.14 Economic disadvantages exert their effects on

human health within nearly all domains of life. ÿhey include the following:

• Lacking access to quality education from early childhood through adulthood • Living in poor housing with potential exposure to asbes-

tos, lead, dust mites, rodents and other pests, inadequate sanitation, tap water that's not safe to drink, and high levels of crime

• Being unable to pay for nourishing food, warm clothes, and sturdy shoes; heat and other utilities; medications and

medical supplies; transportation; and counseling services, fitness classes, and other wellness measures • Having insecure employment or being stuck in a low-

paying job with few benefits • Having few assets to fall back on in case of illness or injury

As a student, you're likely to face economic challenges.

In a recent survey, 33 percent of college students reported that in the past year their finances had been "very difficult to handle:'is When you're injured or sick and the money

is tight, what can you do to get the best care for the lowest price? Read the Money & Health box on page 12 for ideas on maximizing care while minimizing costs.

Jhe Built Environment One part of the physical envi- ronment that is getting a fair amount of attention from pub- lic health officials these days is the built environment. As the name implies, the built environment includes anything cre- ated or modified by human beings, from buildings to roads that serve recreation areas and transportation systems to electric transmission lines and communications cables.

Researchers in public health have increasingly been promoting changes to the built environment that can improve the heakh of community members.16 For exam- ple, Walter Willett of the Harvard School of Public Health proposes that sidewalks and bike lanes be part of every federally funded road project.ÿ7 He asserts that when side-

walks are built in neighborhoods, people are more apt to start walking and slim down. Similarly, when a supermar- ket selling fresh produce replaces side-by-side fast-food outlets in an inner-city neighborhood, residents' dietary

choices improve. Simple changes in community environ- ments can make a difference by enabling you to make bet- ter choices.

Pollutants and Infectious Agents Physical condi- tions also include the quality of the air we breathe, our land, water, and foods. When individuals and communities are ex-

posed to toxins, radiation, irritants, and infectious agents via their environment, they can suffer significant harm.

These effects are not necessarily limited Io the local com- munity. With the rise of global travel and commerce, the

health status of people in one region can affect the health of people around the world. These environmental determinants are a grim reminder of the need for a proactive international response for disease prevention and climate change.

Policymaking Public policies and interventions can have a powerful and positive effect on the health of individuals and communi-

ties. Examples include policies banning smoking, laws man- dating seat belt use in motor vehicles and helmets for bikes

and motorcycles, vaccination programs, and public fund- ing for mental health services.1ÿ For example, in 2009 the

The built environment of your community

can promote positive health behaviors. The bike-friendly

nature of Amsterdam, Netherlands, with its wide bike paths and major thoroughfares closed to automobile traffic, encourages

residents to incorporate healthy physical activity

Into their daily lives.

CHAPTER 1 I ACCESSING YOUR HEALTH I 111

Money&Health MAXIMIZING CARE WHILE MINIMIZING COSTS

Preserve your health. Remember that four behaviors-- overeating, failing to exercise, smoking, and abusing alcohol-- account for the majority of preventable disease. Your most important cost-sparing strategy is to take care of your health in the first place.

Avoid unnecessary risks. Unintentional injuries aren't just the top cause of death in young adults, they're also a primary reason young adults seek emergency care. (For additional information, see Focus On: Reducing Your Risk of Unintentional Injury.)

Do your research. If you have health care insurance, read the Summary Plan Description (SPD). This explains what doc-

tor, emergency room, and hospital visits are covered and also specifies if vision, dental, or prescription benefits are included. The SPD also outlines any co-payments, annual deductibles, and in- and out-of-network rules for seeing specialists. When you know the answers to these questions, you're less likely to make decisions resulting in large bills.

Make sure you need health care, not self-care. The num- ber one reason behind doctor visits is the common cold--for which there's no treatment. For many conditions, rest, nutritious fluids, and the passage of time are the only healers. So think before you spend money on health care you don't need.

Try the least expensive health care options first. For instance, your student health center may be able to provide exactly the level of care you need for little or no cost. Or call the nurse hotline available on your insurance plan.

Go prepared. When you do visit your doctor, come with a list of symptoms, concerns, and questions. If you think you need a diagnostic test, request it and explain why. If you're sexually active, ask your doctor what tests you should have for sexually transmitted infections, even if you don't have symptoms.

Ask your doctor to help you get the lowest cost care. For instance, generic versions of most prescription medications are available, at a cost that may be 50 to 75 percent lower than that of the brand-name drug. So ask the doctor for the generic ver- sion of the drug, when possible.

Use the emergency room (ER) only for emergencies. Studies show that almost 70 percent of ER visits are not really emergencies at all--and care in an ER can cost ten times as much as the same care in a walk-in clinic.

When you get a bill from your provider, check it for ac- curacy. Medical-bill errors are common, especially duplicated charges and simple typos. Also review the statements you get from your plan to make sure that you received the care described and the right reimbursements.

Be aware that if your plan denies coverage for a test or treatment your physician says is necessary, you have the right to appeal the decision. Check your SPD for your plan's appeals process, which typically involves writing a letter explain- ing your grievance. Copy both your physician and your state insurance commissioner, and keep a copy for your own records.

Sources; American College Health Association. American College Health Association-National College Health Assessment I1: Reference Group Execu- tive Summary Fall 2010. (Linthicum, MD: American College Health Associa- tion, 2011), www.acha.org; U.S. Department of Labor. Top 10 Ways to Make

Your Health Benefits Work for You (September 29, 2010), www.dol.gov/ebsa/ publications/10working4you.html; Aetna. Six Ways to Save Money With Your Aetna Student Health Benefits, Aetnastudenthealth.com, www.aetna

studenthealth.com/schools/SavingMoneyFlyer.pdf; CalCPA. How to Minimize Health Care Costs (2007), American Institute of Certified Public Accountants, www.calcpa.org/Contentd25713.aspx.

112 I PART ONE FINDING THE RIGHT BALANCE

If you are uninsured or underinsured, ask your doctor for generic prescriptions to save on your costs.

NATIONAL HEALTH CARE REFORM

The United States saw four major politi- cal movements supporting national health insurance during the past century, but none had succeeded. The Obama admin- istration put health care reform at the top of its domestic agenda, and on March 23, 2010, the Patient Protection and Afford- able Care Act (ACA) became law. The main goal of the ACA is to provide access to health insurance for more than 30 mil- lion previously uninsured Americans and also to reform some insurance practices and policies deemed unfair or counter to the public good. The legislation is struc- tured to achieve its goals by expanding Medicaid eligibility to include an additional 17 million people. Although individual states could opt out of the expansion, it

aybe you're like the 6 percent of college students who reported in a 2010 survey that they had no health care insurance. Or maybe you're on your parents' plan or

one sponsored by your college or university, but there's a hefty deductible or co-payment, or the test or medication you need isn't covered. Whatever your situation, following a few strate- gies will help you get the best care for the lowest cost.

is largely funded by federal dollars, which few states are expected to refuse. The law also provides tax credits to small busi- nesses to help them pay for coverage for their employees.

One of the most contentious aspects of the ACA is the so-called individual mandate: All Americans will be required to carry health insurance by 2014 or face an annual (and progressively increasing) fine if they fail to do so. To help Americans find the most affordable plan for their needs, starting in 2014, they will be able to shop for and compare plans in state-based Affordable Insurance Exchanges. ACA supporters say that the individual mandate is necessary to push young, healthy Americans into the insurance pool and thereby dilute the cost of care overall. Op- ponents argue that compelling individuals to purchase an expensive product such as health insurance is an overreaching by the federal government and violates the Constitution's constraints on federal pow- ers. In June 2012 the U.S. Supreme Court ruled that Congress could enact the ACA under its authority to raise and collect taxes. Some critics immediately charged that a tax levied on an American who refuses to purchase a product or service is not comparable to a general income tax nor a tax incentive, such as for purchas- ing energy-saving devices for one's home.

Thus, the ACA is likely to face further chal- lenges.

Some reforms are already in effect. These include a provision allowing young adults to stay on their parents' health insurance plan up to age 26 if they do not have access to coverage through an employer. In addition, most employer- based and individual plans are now required to cover preventive services such as blood pressure screenings, certain cancer screenings, vaccinations, prenatal care, well-baby care, smoking-cessation

programs, and certain other services with no co-payment or deductible.

Other provisions now in effect ban or place restrictions on certain insurance industry practices such as the following:

Insurers are no longer allowed to deny coverage to children with preexisting conditions, and in 2014, this provision will be expanded to include adults.

Insurers are not allowed to cancel coverage because the insured made an honest mistake on his or her application.

Insurers now have to publicly justify rate hikes.

New health insurance plans cannot impose lifetime coverage limits.

More information and updates on health care reform can be found at www.healthcare.gov. ÿ

t!

residents of Albert Lea, Minnesota, signed on to an ambitious citywide initiative to improve the health of its residents. It man- dated that local restaurants make healthful changes to their

menus, that schools ban eating in hallways and selling candy for fundraisers, and that neighborhoods form "walking school

buses" to escort kids to school on foot. It also funded changes to the built environment, including laying new sidewalks and

digging plots for community gardens. The efforts appeared to pay off with noteworthy improvements in health care claims and other behavioral improvements in less than a year.19

Access to Quality Health Services The health of individuals and communities is also deter-

mined by access to quality health care, including not only services for physical and mental health, but also accurate and relevant health information and products such as eye-

glasses, medical supplies, and medications. In 2010, more

than 27 percent of young Americans (age 18 to 24) lacked health insurance.2° Individuals without health insurance

may delay going to the doctor for regular preventative care. If they are sick, their disease may not be diagnosed until it is advanced, reducing the chance of recovery and leading to higher rates of hospitalization, longer stays, and more costly health care than for those who have insurance and get pre- ventive screenings and prompt treatment.

In addition to the uninsured is the problem of the mil- lions of "underinsured"--those who have some coverage,

but not enough. These individuals cannot afford to pay the difference between what their insurance covers and what their providers and medications cost. Therefore, like the

uninsured, they tend to delay care or try other cost-saving measures such as taking only half of the prescribed dose of their medications.

CHAPTER 1 I ACCESSING YOUR HEALTH I 113

health disparities Differences in the incidence, prevalence, mortality, and burden of diseases and other health conditions among specific population groups,

belief Appraisal of the relationship between some object, action, or idea and some attribute of that object, action, or idea.

health belief model (HBM) Model for explaining how beliefs may influ- ence behaviors,

Access to health services is

affected by economics, pub- lic policies, and health insur- ance legislation. Early in 2010, President Obama signed into law a set of health care reforms intended to reduce the nation's health care costs while increas-

ing Americans' access to quality care. These reforms, which are

being implemented gradually over several years, are meeting

one category: your individual behaviors (or modifiable deter-

minants). Clearly, change is not always easy, Your chances of successfully changing negative habits improve when you iden-

O d"

In recognition of the changing demographics of the U.S. population and the vast differences in health status based

on racial or ethnic background, Healthy People 2020 includes strong language about the importance of reducing these health disparities.21 See the Health in a Diverse World box on

page 15 for examples of groups that often experience health

disparities.

We've just identified many factors critical to your health sta-

tus. However, you have the most control over factors in just

14 I PART ONE I FINDING THE RIGHT BALANCE

How Can You Improve Your Health Behaviors?

Health Disparities

significant legal challenges. For details on the new health

care legislation, see the accompanying Health Headlines box on

page 13.

tify a behavior that you want to change and then develop a plan for gradual transformation that allows you time to unlearn negative patterns and substitute positive ones. To

successfully change a behavior, you need to see change not as a singular euent but instead as a process that requires prep- aration, has several steps or stages, and takes time to occur.

Models of Behavior Change Over the years, social scientists and public health research- ers have developed a variety of models to reflect this mul- tifaceted process of behavior change. We explore three of those here.

Health Belief Model We often assume that when ra- tional people realize their behaviors put them at risk, they will change those behaviors and reduce that risk. However, it doesn't work that way for many of us. Consider the number of

health professionals who smoke, consume junk food, and act in other unhealthy ways. They surely know better, but their "knowing" is disconnected from their "doing:' One classic

model of behavior change proposes that our beliefs may help

to explain why this occurs. A belief is an appraisal of the relationship between some

object, action, or idea (e.g., smoking) and some attribute of that object, action, or idea (e.g., "Smoking is expensive, dirty, and causes cancer" or "Smoking is sociable and relaxing").

Psychologists studying the relationship between beliefs and health behaviors have determined that although beliefs may subtly influence behavior, they may or may not cause peo- ple to behave differently. In 1966, psychologist I. Rosen- stock developed a classic theory, the health belief model (HBM), to show when beliefs affect behavior change.22 The HBM holds that several factors must support a belief before

change is likely:

• Perceived seriousness of the health problem, The more seri- ous the perceived effects are, the more likely it is that action will be taken. • Perceived susceptibility to the health problem. What is the likelihood of developing the health problem? People who perceive themselves at high risk are more likely to take pre- ventive action.

• Cues to action. A person who is reminded or alerted about

a potential health problem is more likely to take action.

People follow the HBM many times every day. Take, for example, smokers. Older smokers are likely to know other smokers who have developed serious heart or lung prob- lems. They are thus more likely to perceive tobacco as a threat to their health than are teenagers who have just begun

O THE CHALLENGE OF HEALTH DISPARITIES The following factors can affect an indi- vidual's ability to attain optimal health:

:ÿ Race and ethnicity. Research indi- cates dramatic health disparities among people of certain racial and ethnic back- grounds. Socioeconomic differences, stigma based on "minority status," poor access to health care, cultural barriers and beliefs, discrimination, and limited education and employment opportuni- ties can all affect health status.

Inadequate health insurance. A large and growing number of people are uninsured or underinsured. Those with- out adequate insurance coverage may face high co-payments, high deducti- bles, or limited care in their area. :ÿ Sex and gender. At all ages and stages of life, men and women ex- perience major differences in rates of disease and disability. For instance, men smoke more than women, but women who smoke have higher rates of lung disease. And women are ten times more likely,than men to contract HIV (which causes AIDS) when having unprotected sex. In contrast, men have much higher

One of the ways public health officials attempt to address the problem of health dis- parities due to location, poverty, and lack of insurance is to organize Remote Area Medical (RAM) clinics. At a clinic like this, rural fami- lies, most with little or no insurance, wait in line for hours to receive free health care from hundreds of professional doctors, nurses, dentists, and other health workers.

death rates from both unintentional inju- ries and violence.

Economics. One's economic status can influence one's health. For example, persistent poverty may make it difficult to buy healthy food or to afford preven- tive medical visits or medication. Eco-

nomics also influences access to safe, affordable exercise.

Geographic location, Whether you live in an urban or rural area and have access to public transportation or your own vehicle can have a huge impact on what you choose to eat, the amount of physical activity you get, and your ability to visit the doctor or dentist. =k Sexual orientation. Gay, lesbian, bisexual, or transgender individuals may lack social support, are often denied health benefits due to unrecognized mari- tal status, and face unusually high stress levels and stigmatization by other groups. :ÿ Disability. Disproportionate numbers of disabled individuals lack access to health care services, social support, and community resources that would enhance their quality of life.

Source: Data from Centers for Disease Control and Prevention, "CDC Health Disparities and In- equalities Report," Morbidity and Mortality Weekly Report, Supplement 60 (January 14, 2011): 1-116. www.cdc.gov/mmwr/preview/ind201 l_su.html;

H. Mead, L. Cartwright-Smith, K. Jones, C. Ramos,

K. Woods, and B. Siegel, Racial and Ethnic Disparities in U.S. Health Care: A Chartbook (New York: The Commonwealth Fund, March 2008).

smoking. The greater the perceived threat of health problems

caused by smoking, the greater the chance a person will quit. However, many chronic smokers know the risks yet con-

tinue to smoke. Why do they miss these cues to action?

According to Rosenstock, some people do not believe they are susceptible to a severe problem--they act as though they are immune to it--and are unlikely to change their behavior.

They also may feel that the immediate pleasure outweighs the long-range cost.

Social Cognitive Model The social cognitive model developed from the work of several researchers over the

past several decades, but it is most closely associated with the work of psychologist Albert Bandura. Fundamentally, the model proposes that three factors interact in a recipro- cal fashion to promote and motivate change. These are the social environment in which we live, our thoughts or cog- nition (including our values, perceptions, beliefs, expecta-

tions, and sense of self-efficacy), and our behaviors (Figure

1.7 on page 16). We change our behavior in part by observing models in our environments--from childhood to the present moment--reflecting on our observations, and regulating ourselves accordingly.

For instance, if as a child we observed our mother suc-

cessfully quitting smoking, we are more apt to believe we can do it, too. In addition, when we succeed in changing ourselves, we change our thoughts about ourselves, and this in turn may promote further behavior change: After we've suc- social cognitive model Model 0t

behavior change emphasizing thecessfully quit smoking, we may role of social factors and thought pro-

feel empowered to increase our cesses (cognition) in behavior change,

level of physical activity. Moreo-

ver, as we change ourselves, we change our world; in our example, we become a model of successful smoking cessa- tion for others to observe. Thus, we are not just products of our environments, but producers.

CHAPTER 1 I ACCESSING YOUR HEALTH [ 15

r--

Behavior

toward making these changes a permanent part of his or her life. In this stage, it is important to be aware of the potential for relapses and to develop strategies for dealing with such challenges.

6. Termination. By this point, the behavior is so ingrained that constant vigilance may be unnecessary. The new behav-

ior has become an essential part of daily living.

: Tech

J vz""" &.Health SURFING FOR THE LATEST IN HEALTH

Transtheoretical Model Why do so many New Year's resolutions fail before Valentine's Day? According to Drs. James Prochaska and Carlos DiClemente, it's because we

are going about things in the wrong way; fewer than 20 per- cent of us are really prepared to take action. After consider- able research, Prochaska and DiClemente have concluded that behavior changes usually do not succeed if they start

with the change itself. Instead, transtheoretical model Model of

we must go through a series of behavior change that identifies six distinct stages people go through in stages to adequately prepare our- altering behavior patterns; also called selves for that eventual change.23 the stages of change model According to Prochaska and Di-

Clemente's transtheoretical model of behavior change (also

called the stages of change model), our chances of keeping those New Year's resolutions will be greatly enhanced if we

have proper reinforcement and help during each of the follow-

ing stages:

116 [ PART ONE j FINDING THE RIGHT BALANCE

1. Precontemplation. People in the precontemplation stage have no current intention of changing. They may have tried to change a behavior before and given up, or they may be in denial and unaware of any problem.

2. Contemplation. In this phase, people recognize that they have a problem and begin to contemplate the need to

change. Despite this acknowledgment, people can languish in this stage for years, realizing that they have a problem but lacking the time or energy to make the change. 3. Preparation, Most people at this point are close to tak- ing action. They've thought about what they might do and may even have come up with a plan. 4. Action. In this stage, people begin to follow their action

plans. Those who have prepared for change appropriately and made a plan of action are more ready for action than those who have given it little thought. 5. Maintenance. During the maintainance stage, a person continues the actions begun in the action stage and works

We don't necessarily go through these stages sequentially. They may overlap, or we may shuttle back and forth from one to another--say, contemplation to preparation, then back to contemplation--for a while before we become truly com- mitted to making the change. Still, it's useful to recognize "where we are" with a change, so that we can consider the

appropriate strategies to move us forward.

Step One: Increase Your Awareness Before you can decide what you might want to change, you need to learn what researchers know about the behaviors that contribute to and detract from your health. Each chapter in this book provides a foundation of information focused on these factors. Check out the Table of Contents at the front of the book

to locate chapters with the information you're looking for. This is also a good time to take stock of the health deter-

minants in your life: What aspects of your biology and behavior support your health, and which are obstacles to overcome? What elements of your social and physical envi-

ronment could you tap into to help you change, and what elements might hold you back? Making a list of all of the health determinants that affect you--both positively and

negatively--should greatly increase your understanding of what you might want to change, and what you might need to do to make that change happen.

Step Two: Contemplate Change Now that you've increased your awareness of the behaviors that contribute to wellness in populations, and the specific

health determinants affecting you, you may find yourself contemplating change. In this stage, the following strategies may be helpful.

Examine Your Current Health Habits and Patterns Do you routinely stop at Dunkin' Donuts for break- fast? Smoke when you're feeling stressed? Party too much on the weekends? Get to bed way past 2 AM? When considering

behavior you may want to change, ask yourself the following:

• How long and how frequently has this been going on? • How serious are the consequences of the habit or pattern in the short and long term? • What are some of your reasons for continuing this prob- lematic behavior?

• What kinds of situations trigger the behavior? • Are other people involved in this behavior? If so, in what way?

FIGURE 1 , 7 Social Cognitive Model We constantly change our behavior in response to factors in our social environment and our thoughts and feelings. In a reciprocal fashion, our behaviors change our environments as well as our thoughts and feelings--including our sense of our ability to make positive change.

thorn Social and feelings environment (cognition)

he Internet can be a wonder- ful resource for quickly finding nswers to your questions, but it

can also be a source of much misinfor- mation. If you're not careful, you could end up feeling frazzled, confused, and-- worst of all--misinformed. To ensure that the sites you visit are reliable and trust- worthy, follow these tips.

* Look for websites sponsored by an official government agency, a university or college, or a hospital/medical center. Government sites are easily identi- fied by their .gov extensions (e.g., the National Institute of Mental Health's website is www.nimh.nih.g0v). College and university sites typically have .edu extensions (e.g., Johns Hopkins University's website is www.jhu.edu). Hospitals often have an extension of .org (e.g., the Mayo Clinic's website is www mayoclinic.0rg). Major philanthropic foundations, such as the Robert Wood Johnson Foundation, the Kellogg Foun- dation, and others, often provide infor- mation about selected health topics. In addition, national nonprofit organi- zations, such as the American Heart Association and the American Cancer Society, are often good, authoritative sources of information. Foundations and nonprofits usually have URLs end- ing with a .org extension.

Find reliable health information at your fingertips!

Search for well-established, profes- sionally peer-reviewed journals such as the New England Journal of Medicine (httP://content.nejm.0rg) or the Journal of the American Medical Association (JAMA; http://jama.ama-assn.org). Although some of these sites require a fee for access, you can often locate concise abstracts and information, such as a weekly table of contents, that can help you conduct a search. Other times, you can pay a basic fee for a certain number of hours of un- limited searching. Your college may have Internet access to these journals that they make available to students for no cost.

Consult the Centers for Disease Control and Prevention (www.cdc.gov) for consumer news, updates, and ,ÿlerts.

For a global perspective on health is- sues, visit the World Health Organization (www.who.int/en).

There are many government- and education-based sites that are indepen- dently sponsored and reliable. The following is just a sample. We provide more in each chapter as we cover specific topics:

1 . Aetna Intelihealth: www.intelihealth.com 2. FamilyDoctor.org: familydoctor.0rg 3, MedlinePlus: www.nlm.oih.gov/medlineptus 4. Go Ask Alice!: www.g0askalice.columbia.edu

5. WebMD Health: webmd.c0m

* The nonprofit health care accrediting organization Utilization Accreditation

Review Commission (URAC; www.urac.org) has devised more than 50 criteria that health sites must satisfy to display its seal. Look for the "URAC Accredited Health Web Site" seal on websites you visit. =k And, finally, don't believe everything you read. Cross-check information against reliable sources to see whether facts and figures are consistent. Be espe- cially wary of websites that try to sell you something. When in doubt, check with your own health care provider, health education professor, or state health division website.

As we've explored throughout this chapter, health behav- iors involve elements of personal choice, but they are also influenced by other determinants that make them more or

less likely. Some are predisposing factors--for instance, if your parents smoke, you're 90 percent more likely to start smoking than someone whose parents don't smoke. Some are enabling factors--for example, if your peers smoke, you are 80 percent

more likely to smoke. Identifying the factors that encourage or discourage a habit is part of contemplating behavior change.

Various reinforcing factors can also contribute to your current habits. If you decide to stop smoking, but your fam-

ily and friends all smoke, you may lose your resolve. In such cases, it can be helpful to employ the social cognitive model and deliberately change aspects of your social environment.

For instance, you could spend more time with nonsmoking friends to give yourself a chance to observe people modeling the positive behavior you want to emulate.

Identify a Target Behavior To clarify your think- ing about the various behaviors you might like to target, ask yourself these questions:

• What do I want? What is your ultimate goal: To lose weight, exercise more, reduce stress, have a lasting relation- ship? You need a clear picture of your target outcome.

• Which change is the greatest priority at this time? People often decide to change several things at once. Suppose you are gaining unwanted weight. Rather than saying, "I need to

CHAPTER 1 [ ACCESSING YOUR I 17'

!

eat less and start exercising," identify one specific behavior

that contributes significantly to your greatest problem, and

tackle that first. • Why is this important to me? Think through why you want to change. Are you doing it because of your health? To improve your academic performance? To look better? To win someone else's approval? It's best to target a behavior

because it's right for you rather than because you think it

will help you win others' approval.

Another aspect of targeting is filling in the details. Iden-

tifying the specific behavior you would like to change--in contrast to the general problem--will allow you to set clear

goals.

Learn More about the Target Behavior Once you've clarified exactly what behavior you'd like to change, you're ready to learn more about that behavior. Again, the

information in this textbook will motivation A social, cognitive, and help. In addition, this is a great emotional force that directs human time to learn how to gain access behavior.

to accurate and reliable health

information on the Internet (see the Tech & Health box on

page 17). As you conduct your research, don't limit your focus to the

behavior and its effects. Also think about what aspects of your world might pose obstacles to your success, and learn all you can about those. For instance, let's say you decide you want to meditate for 15 minutes a day. You face a big ramp-up just

in learning what meditation is, how it's

practiced, and what benefits you might expect from it. But in addition, what might pose an obstacle to meditation?

Do you think of yourself as hyper? Do you live in a super-noisy dorm? Are you afraid your friends might think meditating is weird? In short, learn everything you can--positive and negative--about your target behavior now, and you'll be better prepared for

change.

is the number of times most people will attempt to

change an unhealthy behavior before succeeding.

a moment to two models of change discussed earlier: the

health belief model and the social cognitive model. Remember that, according to the HBM, your beliefs

affect your ability to change. For example, when reaching for another cigarette, smokers sometimes tell themselves, "I'll

stop tomorrow;' or %hey'll have a cure for lung cancer before I get it:' 3hese beliefs allow them to continue what they're

doing. To put it another way, they dampen motivation. So as you contemplate change, take some time to think about your beliefs and consider whether they are likely to motivate you

to achieve lasting change. Ask yourself the following. Do you believe that your current pattern could lead you

to a serious problem? The more severe the consequences are, the more motivated you'll be to change the behavior.

For example, smoking can cause cancer, emphysema, and other deadly diseases. The fear of developing those diseases

can help you stop smoking. But what if cancer and emphy- sema were just words to you? In that case, you could study up on these disorders and the tissue destruction, pain, loss

of function, and emotional suffering they cause. Doing so might increase your motivation: In Canada, a recent law

Assess Your Motivation and Your Readiness to Change On any given morning, many of us get out of bed and resolve to change a giv- en behavior that day. However, most of us soon return to our old behavior

patterns.

Wanting to change is an essential

prerequisite of the change process, but to achieve change, you need more than desire. You need real motiva- tion, which isn't just a feeling, but a social and cognitive force that directs your behavior. To understand what goes into motivation, let's return for

m

what do you think? Do you have an internal or an --

external locus of control?

• Can you think of some friends whom you'd describe as more

internally or externally controlled? • How do people with the different views deal w th similar situations?

m

requires that graphic images of gangrenous limbs, diseased organs, and chests sawed open for autopsy cover at least half of cigarette packages. The year after the law took effect, 38 percent of smokers who tried to quit cited the images as a motivating factor.24

Do you believe that you are personally likely to experi- ence the consequences of your behavior? For example, los- ing a loved one to lung cancer could motivate you to work harder to stop smoking. If you really couldn't convince your-

self that your behavior will affect you personally, you might ask your health care provider to give you an honest assess- ment of your risk.

Let's say you're still struggling to perceive the behavior as serious or the consequences as personal. If that's true, try employing the social cognitive model to help change those beliefs. For instance, you could interview people struggling with the consequences of the behavior you want to change. Ask them what their life is like, and if, when they were engag- ing in the behavior, they believed that it would harm them.

Your health care provider may be able to put you in touch with patients who would be happy to support your behav- ior change plan in this way. And don't ignore the motivat- ing potential of positive role models. Do you know people

who have successfully lost weight, stopped drinking, or quit

smoking? Hang out with them! Finding ways to stay motivated is a key pur- pose behind many of the behavior change steps and processes we have been

describing throughout this section. The Skills for Behav-

ior Change box summarizes some of these tips for main- taining motivation.

Even though motivation is powerful, by itself it's not enough to achieve change. Moti-

vation has to be combined with common sense, commitment, and a realistic understanding of how best to move from point A to point B. Readiness is the state of being that precedes behav-

ior change. People who are ready to change possess the knowl- edge, skills, and external and internal resources that make change possible.25

Maintain Your Motivation

Many people find it easiest to Stay m+otlVated by planning small incremental changes, work- ing toward a goal, and rewardlngCthemselves along the way. Friends can also help you stay motivated by modeling heatthÿ;behaVlors, offering support, joining you in your change efforts, and providing relnforcementÿ°ÿ ÿ;=

18 I PART ONE I FINDING THE RIGHT BALANCE

Develop Self-Efficacy Self-efficacy--an individual's belief that he or she is capable of achieving certain goals or of performing at a level that may influence events in life--is one of the most important factors that influences our health status. Prior success will lead to expectations of success in the future. In general, people who exhibit high self-efficacy are confident that they can succeed, and they approach chal- lenges with a positive attitude. In turn, they may be more mo- tivated to change and more likely to succeed.

Conversely, someone with low self-efficacy or with self-

doubts may give up easily or never even try to change a behav- ior. These people tend to shy away from difficult challenges. They may have failed before, and when the going gets tough,

]1 Pick one specific behavior you want to change.+l'rying to change too many things at once can be overwhelming. ) AsseSs the One behavior you wish te change; Figure Out Why it is important to change. If it doesn't feel important, then you'll have a hard time finding motivation, and it proIoably isn't abehavior you should address at this - time.

) Set achievable and incremental goals. By developing both short- and long-term goals, you improve your chances of accomplishing them and staying motivatedto move- forward.

) Give yourself rewards. Create a list of things you would find rewarding and plan for giving yourself specific rewards once you reach specific goals ....

) Avoid or anticipate barriers and temptation. By controlling or eliminating the environmentaicues that provoke the ÿ behavior you want to change, you'll make it easier for yourself to succeed at lasting change. ) Remind yourself why you are trying to change. Prepare a list ofbenefits you'll realize from making this change, both now and down the roadÿ youcan also prepare a list of the risks you face if you don't make this change. Post the lists where you will see them dally.

. | Enlist the help and support of others. Other people can be major motivators for positive change--either as role models, a cheering squad, or partners in change. Let the people youoare about know about your plans for change and ask them for help.+ .... | Don't be discouraged by lapses. Everyone experiences temporary setbacks, and a brief lapse doesn't meanthe

.... entire cause is Jost. Reexamine your plan+ ook for new strategies to motivate you, set some new short-term goals, and get i'ight back On the horse. .....

they are more likely to give up or self-efficacy Belief in one's ability to revert to old patterns of behavior, perform a task successfully,

If you suspect you have low

self-efficacy, the contemplation stage is a great time to get to work developing it! A technique of cognitive-behavioral

therapy called cognitive restructuring can help. (See Chapter 3 for information on cognitive restructuring.) Find out more by visiting your campus student counseling services.

Cultivate an Internal Locus of Control The con- viction thatyou have the power and ability to change is a pow- erful motivator. Individuals who feel they have limited control over their lives often find it more difficult to initiate positive changesY If they believe that someone or something else controls a situation or that they dare not act in a particular

CHAPTER 1 ] ACCESSING YOUR HEALTH [ 19

I j,

locus of control The location, exter- nal (outside oneself) or internal (within oneself), that an individual perceives as the source and underlying cause of events in his or her life. shaping Using a series of small steps to gradually achieve a particular goal.

way because of peer repercussions, they may become easily frustrated and give up. People with these characteristics have an external lo-

cus of control. In contrast, people who have a stronger internal locus of control believe that they have

power over their own actions. They are more driven by their own thoughts and are more likely to state their opinions and

be true to their own beliefs. Having an internal or external locus of control can vary

according to circumstance. For instance, someone who finds out that diabetes runs in his family may resign himself to fac- ing the disease one day instead of taking an active role in modi- fying his lifestyle to minimize his risk of developing diabetes. On this front, he would be demonstrating an external locus of control. However, the same individual might exhibit an inter-

nal locus of control when resisting a friend's pressure to smoke.

can help you achieve your goal. Suppose you want to start

jogging 3 miles every other day, but right now you get tired and winded after half a mile. Shaping would dictate a process

of slow, progressive steps, such as walking 1 hour every other day at a slow, relaxed pace for the first week; walking for an hour every other day, but at a faster pace that covers more distance the second week; and speeding up to a slow run the

third week. Regardless of the change you plan, remember that current

habits didn't develop overnight, and they won't change over-

night, either. Start changes slowly to avoid hurtingyourself or

causing undue stress. Keep the steps of your program small. Be flexible and willing to change the original plan if it proves too uncomfortable, and master one step before moving on to

the rest.

Use the SMART System Un- successful goals are vague and open- ended: for instance, "Get into shape by exercising more:' In contrast, suc- cessful goals are SMART--specific, measur-

able, action-oriented, realistic, and time-ori-

ented. Examples of SMART goals are:

• Specific. "Attend a Tuesday/Thursday aero- bics class at the YMCA." • Measurable. "Reduce my alcohol intake on Sat-

urday nights from three drinks to two." • Action-oriented. "Volunteer at the animal shel-

ter on Friday afternoons:' • Realistic. "Increase my daily walk from 15 to 20 minutes:' • Time-oriented. "Stayin my strength-training class for the full 10-week session, then reassessY

Use Shaping A stepwise pro- cess of making a series of small

changes known as shaping

To reach your behavior

change goals, you need to take things

one step at a time.

€=0 I PART ONE I FINDING THE RIGHT BALANCE

Set a Realistic Goal A realistic goal is one that you truly can achieve within the circum-

stances of your life right now. Knowing that your goal is attainable increases your motivation. This, in turn, leads to a better chance of success and to a greater sense of self-efficacy--which

can motivate you to succeed even more.

Anticipate Barriers to Change Recognizing possi- ble stumbling blocks in advance will help you prepare fully for change. Various social determinants, aspects of the built environment, or lack of adequate health care can inhibit

change. In addition to negative determinants, a few gen- eral barriers to change include the following:

• Overambitious goals. Remember the advice to set

realistic goals? Even with the strongest motivation, overambitious goals can derail change. Habits are

best changed one small step at a time. • Self-defeating beliefs and attitudes.As

the health belief model explains, believ-

ing you're too young, fit, or lucky to worry about the consequences of your behavior can keep you from making a solid com- mitment to change. Likewise, thinking

you are helpless to change your habits can also undermine efforts. • Failing to accurately assess your cur- rent state of wellness. You might assume

that you will be able to walk 2 miles to campus each morning, for example, only

to discover that you're aching and winded after only a mile. Failing to make sure that the planned change is realistic for you can be a bar- rier that leaves you with weakened motivation

and commitment.

• Lack of support and guidance, If you want to cut down on your drinking, peers who drink heavily may be powerful barriers to that change. To suc- ceed, you need to recognize and limit interactions

with people in your life who might oppose your decision to change. • Emotions that sabotage your efforts and sap your will.

Sometimes the best laid plans go awry because you're hav-

ing a bad day or are fighting with someone. Emotional reactions to life's chal-

lenges aren't inherently

Step lhree: Prepare for Change You've contemplated change for long enough! Now it's time to set a realistic goal, anticipate barriers, reach out to others, and commit. Here's how.

bad. However, they can sabotage your efforts to change by distracting you and draining your reserves. Seek help for

more severe psychological problems, and recognize that you may need to focus on those issues before you can effect sig- nificant change in other aspects of your health.

Enlist Others as Change Agents The social cogni- tive model recognizes the importance of our social contacts in successful change. Most of us are highly influenced by the approval or disapproval (real or imagined) of close friends, family members, and other social and cultural groups. In addition, watching others successfully change their behavior can give you ideas and encouragement for your own change. This modeling, or learning from role models, is a key com- ponent of the social cognitive model of change. Observing a friend who is a good conversationalist, for example, can help you improve your communication skills.

Family Members From the time of your birth, your par- ents and other family members have given you strong cues about which actions are and are not socially acceptable. Your family also influenced your food choices, your religious be- liefs, your political beliefs, and many of your other values and

actions. Strong and positive family units provide care, trust, and protection; are dedicated to the healthful development of all family members; and work to reduce problems. When the loving family unit does not exist or when it does not pro-

vide for basic human needs, many young people have great difficulties.

yourself, as a public declaration of intent, as an organized plan that lays out start and end dates and daily actions, as a listing of barriers you may encounter, as a place to brain- storm strategies to overcome barriers, as a list of sources of

support, and as a reminder of the benefits of sticking with

the program. Writing a behav- modeling Learning specific behaviors ior change contract will help you by watching others perform them. clarifyyour goals and make acom- imagined rehearsal Practicing, mitment to change. Fill out the Be- through mental imagery, to become havior Change Contract at the be- better able to perform an event in ginning of this book to help you set actuality.

a goal, anticipate obstacles, and create strategies to overcome those obstacles. Figure 1.8 on page 22 shows an example of a completed contract.

Step Four: Take Action to Change It's time to put your plan into action! Behavior change strat- egies include visualization, countering, controlling the

situation, changing your self-talk, rewarding yourself, and journaling. The options don't stop here, but these are a good place to start.

Visualize New Behavior Mental practice can trans- form unhealthy behaviors into healthy ones. Athletes and others often use a technique known as imagined rehearsal to reach their goals. Careful mental and verbal rehearsal of

how you intend to act will help you anticipate problems and greatly improve the likelihood of success.

Friends Just as your family influences your actions during your childhood, your friends and significant others influence your behaviors

as you grow older. Most of us desire to fit the "norm" and avoid hassles in our daily interac-

tions with others. If you deviate from the expect-

ed actions, you may suffer ostracism, strange looks, and other negative social consequences. But if your friends offer encouragement, or even express interest in joining with you in the behav-

ior change, you are more likely to remain moti- vated. Thus, cultivating and maintaining close friends who share your personal values can greatly affect your behaviors.

Professionals You maywant to enlist support from professionals such as your health instructor, PE instructor, coach, health care provider, aca- demic adviser, or minister. As appropriate, con- sider the counseling services offered on campus, as well as community services such as smoking cessation programs, Alcoholics Anonymous sup- port groups, and your local YMCA.

Sign a Contract It's time to get it in writing! A formal behavior change contract serves many powerful purposes. It functions as a promise to

The people in your life can play a huge role--both positive and negative--in the health choices you make. The behaviors of those around you can predispose you to certain health habits, at the same time enabling and reinforcing them. Seeking out the support and encouragement of friends who have similar goals and interests will strengthen your commitment to develop and maintain positive health behaviors.

CHAPTER 1 [ ACCESSING YOUR HEALTH [ 21

Behavior Change Contract

My behavior change will be:

My long-term goal for Ihia behavior change is: Eÿ,7- {ÿ,ÿv ÿ3 s,-,ÿ ,ÿ ÿ ÿ o .ÿ,.ÿv..

so stupid," Now change this irrational self-talk into rational, positive statements about what is really going on: "I really didn't study enough for that exam. I'm certainly not stupid; I just need to prepare better for the next test:' Such self-talk

will help you recover quickly from disappointment and take

positive steps to correct the situation.

Challenge the Thoughts That Sabotage Change

These are three obstacles to change (Ihings that I am currently doing or situations that contribute to this behavior or make it harder to change):

1. Tÿ ÿ ÿoÿ, ÿ ÿ3 ÿ ÿ-P,,ÿ, \ ÿ ÿ <ÿ ÿt 2. \ ÿ.7- V,ÿTjV_. 'ÿe_ÿ,ÿq &ÿs, ÿ ve,ÿ..ÿ2 .,-ÿ'.ÿs oÿkÿ ÿ ÿ

The strategies I wiU use to overcome these obslacles are: 1. \ÿ1 ÿ ÿ ÿ, ÿo\ ÿ o v.ÿ,ÿ ÿ \ can ÿ- up ÿ ÿ!1%/ ÿ '.ÿ ÿ ,,,ÿ,ÿ'.ÿ. 2. \\1 ÿ-ÿi a p'ÿ,ÿ oÿ ÿ ÿ ÿ ÿ1ÿ/ ÿ.,-ÿv-ÿo ÿ-I- ÿe.7-'weÿ

When I make the Iong-lerm behavior change described above, my reward will be: sÿ !&7-7"Zÿ7-ÿ Gÿ, ÿ,.ÿ.aT-e/ ÿ,'ÿuÿÿ, target dale:Jÿe..4=ÿ I ÿ-

I intend to make the behavior change described above. I will use Ihe strategies and rewards to achieve the goals that will contribute Io a healthy behavior change.

I Signed:ÿ71,, ,ÿ.vÿ ÿ Witness:<ÿus,=ÿ ÿ,auÿ .ÿ

d © FIGURE / , 0 Example of a Completed Behavior Change Contract A blank version is included in the front of the book for you to fill out.

Learn to "Counter" Countering means substituting a

desired behavior for an undesirable one. If you want to stop eating junk food, for example, compile a list of substitute foods and places to get them and have this ready before your mouth starts to water at the smell of a burger and fries.

Control the Situation Sometimes, the right setting or the right group of people will positively influence your behav- iors. Any behavior has both antecedents and consequences. Antecedents are the events or aspects of the situation that come beforehand; these cue or stimulate a person to act in

certain ways. Antecedents can be physical events, thoughts, emotions, or the actions of other people. Consequences--the results of behavior--affect whether a person will repeat that

action. Consequences can also consist of physical events, thoughts, emotions, or the actions of other people. A diary

countering Substituting a desired behavior for an undesirable one. situational inducement Attempt to influence a behavior through situations and occasions that are structured to exert control over that behavior,

self-talk The customary manner of thinking and talking to yourself, which can affect your self-image,

noting your undesirable behav- iors and identifying the settings in which they occur can be useful in helping you determine the an- tecedents and consequences in-

volved. Once you have recognized the antecedents of a given behav-

ior, you can employ situational inducement to modify those that are working against you. By care-

fully considering which settings will help and which will hurt your effort to change, and by seeking the first and avoiding the second, you will improve your chances for change. Simi- larly, identifying substitute antecedents that can support a more positive result gives you a strategy for controlling the situation.

Change Your Self-Talk The way you think to your- self, known as self-talk, can also play a role in modifying health-related behaviors. It can reflect your feelings of self- efficacy, discussed earlier in this chapter. When we don't feel self-efficacious, it's tempting to engage in negative self- talk, which can sabotage our best intentions. In the Skills

for Behavior Change box on the next page are some suggested strategies for changing self-talk.

Use Rational, Positive Statements 3he rational- emotive form of cognitive therapy, or self-directed behavior change, is based on the premise that there is a close connec-

tion between what people say to themselves and how they feel. According to psychologist Albert Ellis, most emotional problems and related behaviors stem from irrational state- ments that people make to themselves when events in their lives are different from what they would like them to beY

For example, suppose that after doing poorly on a test you say to yourself, "I can't believe I flunked that easy exam. I'm

J PART ONE I FINDING THE RIGHT BALANCE

In order to make my goal more attainable, I have devised these short-term goals: short-term goal ÿ7- ÿ 'ÿ,Aÿ, ÿ'ÿ ÿ7"ÿ W v,ÿ, target date %p.ÿ-,,.ÿ- I K- reward short-term goal Lÿ7"ÿ ÿ,ÿ o ÿ ÿ target date (ÿ'oÿ- \ ÿ- reward ÿ7'ÿ..ÿ-;ÿ short-term goal ÿ:,7- o ÿ s.aÿ K7'...ÿ.s pÿ "r-'ÿ \arget date ÿ I ÿ reward ,-ÿ.ÿ

Practice Blocking and Stopping By purposefully blocking or stopping negative thoughts, a person can con- centrate on taking positive steps toward behavior change. For

example, suppose you are preoccupied with your ex-partner, who has recently left you for someone else. By refusing to dwell on negative images and forcing yourself to focus else-

where, you can avoid wasting energy, time, and emotional resources and move on to positive change.

Reward Yourself Another way to promote positive behav- ior change is to reward yourself for it. 1his is called positive re- inforcement. Each of us is motivated by different reinforcers.

Most positive reinforcers can be classified under five

headings: consumable, activity, manipulative, possessional,

and social:

Consumable reinforcers are edible items, such as your

favorite fruit or snack mix. Activity reinforcers are opportunities to do something

enjoyable, such as going on a hike or taking a trip. Manipulative reinforcers are incentives such as getting a

lower rent in exchange for mowing the lawn or the promise

of a better grade for doing an extra-credit project. ® Possessional reinforcers are tangible rewards, such as a

new electronic gadget or sports car. Social reinforcers are signs of appreciation, approval, or

love, such as loving looks, affectionate hugs, and praise.

q-he

l

what do you think? What type of reinforcers would

most likely get you to change a behavior: money, praise, or recognition from someone? • Why would it motivate you? • Can you think of options to reinforce behavior changes?

difficulty with employing positive reinforcement often lies in determin- ing which incentive will be most effective. Your

" reinforcers may initially

come from others (extrin-

sic rewards), but as you see positive changes in yourself, you will begin to reward and rein-

force yourself (intrinsic rewards). Keep in mind that reinforcers should

immediately follow a behavior, but beware of overkill. If you

reward yourself with a movie every time you go jogging, this reinforcer will soon lose its power. It would be better to give yourself this reward after, say, a full week of adherence to

your jogging program.

Resources I will use to help me change this behavior include: a friend/partner/relative: .ÿ, ÿoÿo7-ÿ: \ÿ1 ÿn,-ÿ,ÿn% ÿ ÿ!1ÿ'ÿ, s.ÿ:ÿ '.ÿ7"ÿ oÿ ÿW '-"ÿ -ÿ'

,ÿ ÿpÿ.ÿ a school-based resourco,'7ÿ_'&f.,.0 ÿ,ÿ1!: \ÿ1 ÿ.ÿ,ÿ .,ÿ,.ÿ.-ro pÿ,ÿ.:%. ÿTlÿ, ÿ ÿ ÿ7"ÿ

a communtty-based resoume,'7ÿ_ \),-,,-ÿ.y,: \'ÿ\ 2.-ÿ. ÿ7" ÿ ÿ..ÿ.ÿ7-o ÿ;;-,ÿ ÿ ÿ'ÿ a book or reputable website: ÿ ÿ ,ÿ,-ÿ7- ÿo7-o6ÿ. ÿ ÿ,ÿ,.ÿ,ÿ.,:ÿoÿ: I'ÿ1 ÿ -ÿ sÿa'ÿ 7"ÿ ,,'ÿe- ÿ ÿ \ ÿ:ÿ ÿ-ÿ ÿJÿTÿ. ÿ'ÿ.

Are any of the following thought patterns and beliefs holding you back? Try these strategies to combat self

sabotage:

) "1 don't have enough time!" Chart your hourly activities for I day. What are your highest priorities and what can you eliminate? Plan to make time for a healthy change next week. ) "I'm too stressed!" Assess your major stressors right now. List those you can control and those you can change or avoid. Then identify two things you enjoy that can help you reduce stress now. ]) "I'm worried about what others may think." Ask your- self how much others influence your decisions about drinking, sex, eating habits, and the like. What is most important to you? What actions can you take to act in line with these values? I "1 don't think I can do it." Just because you haven't done something before doesn't mean you can't do it now. To develop some confidence, take baby steps and break tasks into small segments of time. I "1 can't break this habit!" Habits are difficult to break, but not impossible. What trigge;'s your behavior? List ways you can avoid these triggers. Ask for support from friends and family.

Journal Writing personal experiences, interpretations and results in a journal, notebook, or online in a blog is an impor- tant skill for behavior change. You can log your daily activi-

ties, monitor your progress, record how you feel about it, and

dote ideas for improvement.

Let's Get Started! After you acquire the skills to support successful behav-

ior change, you're ready to apply those skills to your target behavior. Create a behavior change contract incorporating the goals and skills we've discussed, and place it where you will see it every day and where you can refer to it as you work through the chapters in this text. Consider it a visual reminder that change doesn't "just happen:' Reviewing your

contract helps you to stay alert to potential problems, to be

aware of your alternatives, to maintain a firm sense of your positive reinforcement Presenting values, and to stick to your goals something positive following a behav-

ior ttTat is being reinforced under pressure.

CHAPTER 1 [ ACCESSING YOUR HEALTH { 23

MyHealthLab°

Summary Models of behavior change include the health belief model, the social cognitive model, and the transtheo-

retical (stages of change) model. A person can increase the chance of successfully changing a health-

related behavior by viewing change as a process containing several steps and components.

When contemplating a behavior change, it is helpful to examine current habits, learn about a target behavior, and assess motivation and readiness to change. When

preparing to change, it is helpful to set realistic and incremental goals

that employ shaping, anticipate barriers to change, enlist the help and support of others, and sign a behavior change contract. When

taking action to change, it is helpful to visualize new behavior, practice countering, control the situation, change self-talk, reward oneself,

and keep a log, blog, or journal.

goal, list the small steps and specific ac- tions that you will take.

Within the next 2 weeks, you can: C) Start a journal and begin chart- ing your progress toward your behavior

change goal.

(ÿ Tell a friend or family member about your behavior change goal, and ask them to support you along the way.

(ÿ Reward yourself for reaching your short-term goals, and reevaluate your plan if you find they are too ambitious.

By the end of the semester, you can: C) Review your journal entries and consider how successful you have been in following your plan. What helped you be successful? What made change more difficult? What will you do differently next week?

C) Revise your plan as needed: Are the goals attainable? Are the rewards satisfy- ing? Do you have enough support and

motivation?

24 l PART ONE I FINDING THE RIGHT BALANCE

Today, you can: O Evaluate your behavior and identify patterns and specific things you are doing.

C) Select one pattern of behavior that you want to change.

(ÿ Fill out the Behavior Change Contract at the front of your book. Be sure to in- clude your long- and short-term goals for change, the rewards you'll give yourself for reaching these goals, the potential ob- stacles along the way, and the strategies for overcoming these obstacles. For each

Choosing good health has imme- diate benefits, such as reducing the risk of injury and illnesses and improving academic perfor-

mance; long-term rewards, such as disease prevention, longevity, and improved quality of life; and societal and global benefits, such as reducing the global disease burden.

For the U.S. population as a whole, the leading causes of death are

heart disease, cancer, and chronic lower respiratory diseases. In the 15- to 24-year-old age group, the leading causes are unintentional

injuries, homicide, and suicide.

he average life expectancy at birth in the United States is 78.3 years. This has increased greatly over the

past century; however, unhealthy behaviors related to chronic disease

may prevent further increases in total life expectancy and cause a

reduction in healthy life expectancy.

The definition of health has changed over time. 3Jae medical

model focused on treating disease, whereas the current ecological or public health model focuses on fac- tors contributing to health, disease

prevention, and health promotion.

Health can be seen as existing on a

continuum and encompassing the dynamic process of fulfilling one's

potential in the physical, social, emotional, spiritual, intellectual, and environmental dimensions of

life. Wellness means achieving the highest level of health possible in each of the health dimensions.

Health is influenced by factors called determinants. The Surgeon General's health promotion plan, Healthy People, classifies determi- nants as individual behavior, biology

and genetics, social factors, policy- making, and health services. Dis- parities in health among different groups contribute to increased risks.

Once you've gone online and used the ÿI]ÿsVOiÿiSÿiÿ activity to gauge your total health status, you may see various dimensions where you could improve your health.

Pop Quiz 1. What statistic is used to describe

the number of deaths from heart

disease this year?

a. Morbidity b. Mortality c. Incidence '

d. Prevalence

2. Your ability to perform everyday tasks, such as walking up the stairs or tyingyour shoes, is an example of

a. improved quality of life. b. healthylife expectancy. c. health promotion. d. activities of daily living.

3. Janice describes herself as confi-

derit and trusting, and she displays both high self-esteem and high self-efficacy. The dimension of health this relates to is the a. social dimension.

b. emotional dimension.

c. spiritual dimension. d. intellectual dimension.

5,

6.

7.

Healthy People 2020 is a(n) a. blueprint for health actions

designed to improve health in the United States.

b. projection for life expectancy rates in the United States in the

year 2020. c. international plan for achieving

health priorities for the environ-

ment in the year 2020. d. set of specific goals that states

must achieve in order to receive

federal funding for health care.

Because Craig's parents smoked, he is 90 percent more likely to start

smoking than someone whose parents didn't. This is an example

of what factor influencing behavior

change? a. Circumstantial factor

b. Enabling factor c. Reinforcing factor d. Predisposing factor

Suppose you want to lose 20 pounds. To reach your goal, you take small steps. You start by join-

ing a support group and counting calories. After 2 weeks, you begin an exercise program and gradually build up to your desired fitness level. What behavior change strat-

egy are you using? a. Shaping b. Visualization

c. Modeling d. Reinforcement

After Kirk and Tammy pay their bills, they reward themselves by watching TV together. The type of positive reinforcement that moti-

vates them to pay their bills is a(n) a. activity reinforcer. b. consumable reinforcer.

c. manipulative reinforcer.

d. possessional reinforcer.

CHAPTER 1 I ACCESSING YOUR HEALTH I 25

8. Jake is exhibiting self-efficacy when he a. believes that he can andwill be

able to bench-press 125 pounds

in his specified time frame. b. is doubtful that his bad shoul-

der will heal enough to bench-

press the weight he is hoping for.

c. claims he is not good enough to do any physical exercise that will ever allow him to bench-

press 125 pounds. d. does not possess personal con-

trol over this situation.

9, ]he setting events for a behavior

that cue or stimulate a person to act in certain ways are called

a. antecedents.

b. frequency of events. c. consequences.

d. cues to action.

10. What strategy for change is advised for an individual in the preparation stage of change? a. Seeking out recommended

readings b. Finding creative ways to main-

tain positive behaviors

c. Setting realistic goals d. Publicly stating the desire for

change

4.

5.

States today? Why do you think these differences exist? What policies do you think would most effectively address or eliminate

health disparities? What is the health belief model? How may this model be working when a young woman decides to smoke her first cigarette? Her last

cigarette? Using the transtheoretical model,

discuss What you might do (in stages) to help a friend stop smok- ing. Why is it important that a person be ready to change before

trying to change?

1. How are the words health and

wellness similar? What, if any, are important distinctions between these terms? What is health pro-

motion? Disease prevention? 2. How healthy is the U.S. popula-

tion today? Are we doing better or worse in terms of health status

than we have done previously? What factors influence today's dis-

parities in health? 3. What are some of the heakh dis-

parities existing in the United

Think about It!

5.

Accessing ili: on the Internet

The following websites explore further topics and issues related to personal health. For links to the websites below, visit the Companion Website for Access

to Health, 13th Edition, at www.pearsonhighered.com/donatelle. 1. CDC Wonder. ]his is a clearing-

house for comprehensive informa- tion from the Centers for Disease

Control and Prevention (CDC), including special reports, guide- lines, and access to national health

data. http://wonder.cdc.gov 2. MayoClinic.com. This reputable

resource for specific information

about health topics, diseases, and treatment options is provided by the staff of the Mayo Clinic. It is easy to navigate and is consumer friendly.

www.mayoclinic.com

3. National Center for Health Statistics. his is an outstanding place to start

for information about health status in the United States. It contains

links to key reports; national survey information; and information on

mortality by age, race, gender, geo- graphic location, and other impor- tant data. www.cdc.gov/nchs

4. National Health Information Cen- ter. This is an excellent resource for consumer information about

health, www.health.gov/nhic

26 I PART ONE ] FINDING THE RIGHT BALANCE

Answers to these questions can be found

on page A-1.

Worm Health Organization. ]his resource for global health informa- tion provides information on the current state of health around the world, such as illness and disease statistics, trends, and illness out- break alerts, www.who.int/en

References 1. The World Factbook--Country Compari-

sons: Life Expectancy at Birth--2012 Esti- mates;' CIA, June 1, 2012. https://www .cia.gov/library/publications/the-wofld- factbook/rankorder/2102rank.html.

2. Centers for Disease Control and Preven-

tion, "Achievements in Public Health, 1900-1999: Control of Infectious Dis- eases" Morbidity and Mortality Weekly Report48, no. 29 (1999): 621-29, www .cdc.gov/mmwr/preview/mmwrhtml/ mm4829al.htln.

3. S.]. Olshanskyet al., 'ÿPotenfialDecline in Life Expectancy in the United States in the 21st Century;' NewEnglandJournal of Medicine 352, no. 11 (2005): 1138-45.

4. G. Danaeiet al., "The Promise of Preven-

fion: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States" PLoS Medicine 7, no. 3 (2010): e1000248, www.plosmedicine.org/article/ info%3Adoi%2F10.137 l%2Fj ournal .pmed.1000248.

5. U.S. Department of Health and Human Services, Healthy People 2020, www .healthypeople.gov/2020/about/QoL .WBabout.aspx.

6. E.A. Finkelstein et al., 'gmnual Medical

Spending Attributable .to Obesity: Payer- and Service-Specific Estimates;' Health Affairs 28, no. 5 (2009): w822-31.

7. M. Bittman, "Soda: A SinWe Sip Instead of Smoke?" New York Times, February 12, 2010, www.nytimes.com/2010/02/14/ weekinreview/14bittman.html.

8. World Health Organization (WHO), "Constitution of the World Health Organ- ization" Chronicles of the World Health Organization (Geneva: WHO, 1947), www.who.int/governance/eb/ constitution/en/index.html.

9. R. Dubos, So Human an Animal: How We

Are Shaped by Surroundings and Events (NewYork: Scribner, 1968), 15.

10. U.S. Department of Health and Human Services, Healthy People 2020 (Wash- ington, DC: U.S. Government Printing Office, 2011), www.healthypeople .gov/2020/about/D OHAbout.aspx.

%

11. Centers for Disease Control and Pre-

vention, Chronic Disease and Health Promotion, Chronic Disease Overview, December 17, 2009, www.cdc.gov/

chronicdisease/overview/index.htm#2. 12. G. Danaei et al., "The Preventable Causes

of Death in the United States: Compara- tive RiskAssessment of Dietary, Lifestyle, and Metabolic Risk Factors," PLoS Medi- cine 6, no. 4 (2009): e1000058, www .plosmedicine.org/article/ info:doi/10.1371/journal.pmed.1000058; Centers for Disease Control and Preven-

tion, Chronic Disease Overview, 2009. 13. K-T. Khaw et al., "Combined Impact of

Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospec- tive Population Study." PLoS Medicine 5, no. 1 (2008): el2, doi:10.1371/journal .pmed.0050012.

14. U.S. Department ofHealth andHuman Services, Healthy People 2020, 2011.

15. American College Health Association, American College Health Association- National College Health Assessment II: Reference Group Executive Summary Fall 2010 (Linthicum, MD: American College Health Association, 2011), www.acha.org.

16. H. Gagnon, S. Tessier, and J. Cote, et al.,

"Psychosocial Factors and Beliefs Related to Intentions to Not Binge DrinkAmong Young Adults:' Alcohol and Alcohol- ism, 2012. May, 02. Doi 10.1093/alcalc/ ags049; 1. Macy, S. Middlestadt, L. Kolbe, et al., 'ÿpplying the Theory of Planned Behavior to Explore the Relationship

Between Smoke-Free Air Laws and Quit- ting Intention;' Health Education and Behavior, 2012.39(1):27-34.

17. W. C. Willett and A. Underwood,

"Crimes of the Heart," Newsweek,

February 5, 2010, www.newsweek.com

/id/233006. 18. U.S. Department of Health and Human

Services, Healthy People 2010, 2011. 19. W. C. Willett and A. Underwood, "Crimes

of the Heart;' 2010. 20. K. Sebelius, Affordable Care Act in

Action: Fewer Uninsured Young Adults in America (2011, September 13). U.S. Department of Health and Human Services. www.healthcare.gov/

blog/2011/09/fewer_uninsured091311 .html.

21. National Institutes of Health, National Institutes of Health (NIH) Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities: Volume 1, Fiscal Years 2002-2006 (Bethesda, MD: National Institutes of Health, May 12, 2006), http: //ncmhd .nih.gov/our_programs /strategic/pubs/VolumeI_031003EDrev .pdf.

22. I. Rosenstock, "Historical Origins of the Health Belief Model:' Health Education Monographs 2, no. 4 (1974): 328-35.

23. J. O. Prochaska and C. C. DiClemente,

"Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change;' Journal of Consulting and Clini- calPsychology 51 (1983): 390-95.

CHAPTER 1

24. W. C. Willett andA. Underwood, "Crimes

of the Heart;' 2010. 25. M. Hesse, "The Readiness Ruler as a

Measure of Readiness to Change Poly- drug Use in Drug Abusers," Journal of Harm Reduction 3, no. 3 (2006): 1477-81; M. Cismaru, "Using Protection Motiva-

tion Theory to Increase the Persuasive- ness of Public Service Communications" The Saskatchewan Institute of Public Policy, Public Policy Series paper no. 40 (February 2006); E. A. Fallon, S. Wilcox, and M. Laken, "Health Care Provider Advice for African American Adults Not Meeting Health Behavior Recommenda- tions;' Preventing Chronic Disease 3, no. 2 (2006): A45; M. R. Chacko et al., "New Sexual Partners and Readiness to Seek Screening for Chlamydia and Gonor- rhea: Predictors among Minority Young Women;' Sexually Transmitted Infections 82 (2006): 75-79.

26. H. Gagnon, S. Tessier, and ]. Cote, et al.,

"Psychosocial Factors and Beliefs Related to Intentions to Not Binge Drink Among Young Adults;' Alcohol and Alcoholism, 2012. May, 02. Doi 10.1093/alcalc/ ags049; J. Macy, S. Middlestadt, L. Kolbe, et al., '7ÿpplying thd Theory of Planned Behavior to Explore the Relationship Between Smoke-Free Air Laws and Quit- ting Intention:' Health Education and Behavior, 2012.39(1):27-34.

27. A. Ellis and M. Benard, ClinicalApplica- tion of RationaI Emotive Therapy (New York: Plenum, 1985).

I ACCESSING YOUR HEALTH I 27'