Health: refers to the overall condition of a person’s body or mind to the presence or absence of

illness or injury
Wellness: expands this idea of health to include our ability to achieve optimal health and
vitality–to living life to its fullest.
●​ Health–or parts of it–can be determined or influenced by factors beyond your control,
such as your genes, age, and family history. For example, a man with a family history of
prostate cancer will have a higher-than-average risk for developing prostate cancer.
●​ Wellness is largely determined by the decisions you make about how you live. That
same man can reduce his risk of cancer by eating sensibly, exercising, and having
regular screening tests. Even if he develops the disease, he may still reduce its effects
and live a rich, meaningful life. This means not caring for himself physically, but also
maintaining a positive outlook, keeping up his relationships with others, challenging
himself intellectually, and nurturing other aspects of his life.
Wellness, therefore, involves making conscious decisions to control risk factors that contribute
to disease or injury. Age and family history are risk factors you cannot control. Behaviors such
as exercising, eating a healthy diet, and choosing not to smoke are well within your control.

The Dimensions of Wellness

Wellness encompasses nine dimensions, all which contribute to overall wellness.
-​ Physical
-​ Emotional
-​ Intellectual
-​ Interpersonal
-​ Cultural
-​ Spiritual
-​ Environmental
-​ Financial
-​ Occupational
The process of achieving wellness is continuing and dynamic, involving change and growth.
Each dimension affects the others.
Physical Wellness
Includes not just your body’s overall condition and the absence of disease, but also your fitness
level and your ability to care for yourself. The higher your fitness level, the higher your level of
physical wellness. Similarly, as you take better care of your own physical needs, you ensure
greater physical wellness. The decisions you make now–and the habits you develop over your
lifetime–will largely determine the length and quality of your life.

Emotional Wellness
Reflects your ability to understand and attend to your feelings. It involves listening to your
thoughts and feelings, monitoring your reactions, and identifying obstacles to emotional stability.

Self-acceptance: is your personal satisfaction with yourself, which might exclude society’s
expectations.
Self-esteem: Related to the way you think others perceive you
Self-confidence: Can be a part of both acceptance and esteem.

Achieving this type of wellness means finding solutions to emotional problems, with professional
help if necessary. Stress and anxiety are both emotional responses, although during the
pandemic, especially, it has sometimes been hard to draw a line between the two.
-​ Stress is typically caused by an external stressor
-​ Anxiety is defined by persistent, excessive worry that doesn’t go away

Interpersonal Wellness (Social)

-​ Satisfying and supportive relationships are important to physical and emotional
wellness
Learning good communications skills, developing the capacity for intimacy, and cultivating a
supportive network are all important to interpersonal (social) wellness. Because not everyone
has access to the same levels of social support, some people are more vulnerable to stress.
-​ In her book Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society,
public health researcher Arline Gerominus gives the example of African Americans and
low-income people accumulating more wear and tear in their bodies due to experiencing
more stress and less social support.
As more people from all subgroups felt isolated during and since the pandemic, digital wellness
has come into sharper focus. Using social media can both enhance our social networks and
encourage unhealthy relationships.

Cultural Wellness
Cultural wellness refers to the way you interact with others who are different from you in terms
of ethnicity, religion, gender, sexual orientation, age, and customs (practices). It involves
creating relationships with others and suspending judgement on others’ behavior until you have
lived with them or “walked in their shoes.” It also includes accepting, valuing, and even
celebrating the different cultural ways people interact in the world. The extent to which you value
your own and others’ cultural identities is one measure of cultural wellness.

Spiritual Wellness
To enjoy spiritual wellness is to possess a set of guiding beliefs, principles, or values that
give meaning and purpose to your life, especially in difficult times. The well person uses
spirituality to focus on positive aspects of life and to fend off negative feelings such as cynicism,
anger, or pessimism. Organized religions help many people develop spiritual health. Religion,
however, is not the only source or form of spiritual wellness. Many people find meaning and
purpose in their lives on their own–through nature, art, meditation, or good works–or with their
loved ones.

Environmental Wellness
Your environmental wellness is defined by the livability of your surroundings. Personal health
depends on the health of the planet–from the safety of the food supply to the degree of violence
in society. Access to nutritious food and physical safety in your own neighborhood can also have
profound effects on your environmental wellness. To improve your environmental wellness, you
can learn about and protect yourself against hazards in your surroundings and work to make
your world a cleaner, safer, and more beautiful place. As children grow up surrounded by
screens–at home, in school, and many other public spaces–screen addiction and digital
wellness become another important part of our environment to consider.

Financial Wellness
Financial wellness refers to your ability to live within your means and manage your money in a
way that gives you peace of mind. It includes balancing your income and expenses, staying out
of debt, saving for the future, and understanding your emotions related to money.

Occupational Wellness
Occupational wellness refers to the level of happiness and fulfillment you gain through your
work. High salaries and prestigious titles can be gratifying, but they alone do not bring about
occupational wellness. Your occupational wellness depends on liking your work, feeling
connected with others in the workplace, and feeling as though you’re learning something and
making a contribution. Another important aspect is recognition from managers and colleagues.

In the 19th and early 20th centuries, Americans considered themselves lucky just to survive to
adulthood. A boy born in 1850, for example, could expect to live only about 38 years, and a girl,
40 years. Many people died from common infectious diseases (such as pneumonia,
tuberculosis, or diarrhea) and poor environmental conditions (such as water pollution and
poor sanitation).
By 2000, however, life expectancy nearly doubled. This increase in life span is due largely to the
development of vaccines and antibiotics to fight infections, and to public health measures to
improve living conditions. The health of our society at large also relies on social movements:
Social activists help bring scientific breakthroughs to the general public—for example, promoting
pasteurization of milk, wider access to safe drinking water, and use of vaccines and masks
during infectious disease outbreaks.

Public health and life expectancy of Americans from birth. Public health achievements during the 20th and 21st centuries are credited with adding more
than 25 years to life expectancy for Americans, greatly improving quality of life, and dramatically reducing deaths from infectious diseases. Recent
public health improvements include greater roadway safety, a steep decline in childhood lead poisoning, and an expansion of health insurance
coverage. The decline in life expectancy in 2021 was greatest for American Indian and Alaska Native populations, followed by white and Black people.
Covid-19 helped drive the decline, as well as fatal drug overdoses. These unintentional deaths were the leading factor behind the life expectancy
decline among Hispanic people.

While life expectancy has consistently increased in the United States each decade since 1850,
the rate of improvement has slowed and, in some recent years, actually declined—even before
factoring in the Covid-19 pandemic. Covid-19 was the leading contributor to the decline between
2019 and 2021, when life expectancy fell to 76.1 years of age, its lowest level since 1996.
Medical advances may also be reaching their limits in treating heart disease and in preventing
other early deaths related to obesity. Moreover, people are developing obesity at earlier ages,
exposing them to the adverse effects of excess body fat over a longer period of time. Obesity
and poor eating habits contribute to all the major chronic diseases. Heart disease and cancer,
now the top two leading causes of death for Americans, are chronic diseases. In 2021, Covid-19
was followed by increases in drug overdose deaths, heart disease, chronic liver disease and
cirrhosis, and suicide.

Despite spending more money per person on health care, U.S. life expectancy is lower than that
in nearly all other high-income countries. U.S. health care often focuses more on treatment of
disease than on prevention. A cross-cultural comparison with Japan could be enlightening:
people living there live 5 or 6 years longer than people in the United States. Is it because
Japanese elders are highly revered and live with their children and grandchildren, staying social
and physically active, reaping more health care benefits than Americans? Or is longer life due to
a cultural emphasis on smaller portions, and fewer sweets and red meat?
Research has shown that lifestyle choices count. In an analysis of data for over 125,000 people,
healthy lifestyle choices—never smoking, maintaining a healthy weight, getting regular physical
activity, eating a healthy diet, and keeping alcohol consumption moderate—were found to
significantly raise life expectancy. The greater the number of healthy choices adopted, the
bigger the increase
Table 1.1 helps illustrate why, highlighting strong links between lifestyle factors and the leading
causes of death among Americans, including Covid-19. For young adults, healthy choices
related to safety behaviors are also critical, as injuries are the leading cause of death among
those aged 15–24 years (Table 1.2).

Lifestyle factors impact both quantity and quality of life. The major difference between life span
(how long we live) and health span (how long we stay healthy) is freedom from chronic or
disabling disease. Healthy lifestyle choices help delay, prevent, or reduce the impact of chronic
diseases.
Most Americans contend with some level of physical and cognitive impairment during the last
15% of their lives. Another important factor in overall quality of life is level of happiness. An
analysis of responses to the Health and Retirement Study from 11,964 older adults found that
happiness and cognitive impairment are not closely linked; we can expect to live happy years,
even if they overlap with cognitive impairment. While healthy lifestyle habits are often viewed as
individual choices, they are impacted by environmental and social context. Figure 1.4 illustrates
how widely one lifestyle behavior—exercise—varies among people in different income and
education groups and in different parts of the country.

Figure 1.4 Differences in rates of exercise associated with social and environmental factors. The overall proportion of U.S. adults who meet the federal
recommendations for aerobic and muscle-strengthening exercise is 24%, but that value masks significant variations, especially in education, income,
and geography. Exercise rates are 2.2 times higher among college graduates than among those with less than a high school education, 1.8 times
higher among adults with a high annual household income ($75,000 or more) than for those with a low income (less than $25,000), and 1.9 times
higher in the state with the highest rate compared to the state with the lowest rate.

National Health

National Health Wellness is a personal concern, but the U.S. government has financial and
humanitarian interests in it, too. A healthy population is the nation’s source of vitality, creativity,
and wealth. Poor health drains the nation’s resources and raises health care costs for all.

Health Insurance Options

The Affordable Care Act (ACA), also called “Obamacare,” was signed into law in 2010. It has
remained in effect since that time, although certain provisions have been altered.
FINDING A PLAN

Under the ACA, health insurance marketplaces, also called health exchanges, facilitate the
purchase of health insurance at the state level. The health exchanges provide a selection of
government-regulated health care plans that students and others may choose from. Those who
are below income requirements are eligible for federal help with the premiums. Many employers
and universities also offer health insurance to their employees and students. Small businesses
and members of certain associations may also be able to purchase insurance through
membership in a professional group.

BENEFITS TO COLLEGE STUDENTS

The ACA permits young adults to stay on their parents’ health insurance plans until age
26—even if they are married or have access to coverage through an employer. Students not on
their parents’ plans who do not want to purchase insurance through their schools can do so
through a health insurance marketplace. Young, healthy people may be tempted to buy a
“catastrophic” health plan. Such plans tend to have low premiums but require you to pay all
medical costs up to a certain amount, usually several thousand dollars. This can be risky if you
select a plan that does not cover the ACA’s 10 essential benefits: outpatient care, emergency
services, hospitalization, maternity care, mental health and substance use treatment,
prescription drugs, rehabilitative services and devices, lab services, preventive services and
chronic disease management, and pediatric care. It’s recommended that everyone select a plan
that covers all of these important types of care. Students whose income is below a certain level
may qualify for Medicaid. Check with your state. Individuals with nonimmigrant status, which
includes worker visas and student visas, qualify for insurance coverage through the exchanges.
You can browse plans and apply for coverage at ([Link]).

The Healthy People Initiative

The national Healthy People initiative aims to prevent disease and improve Americans’ quality
of life. Healthy People reports, published each decade since 1980, set national health goals
based on 10-year agendas. Healthy People 2030 proposes the eventual achievement of the
following broad national health objectives:
-​ Eliminate preventable disease, disability, injury, and premature death.
-​ Achieve health equity, eliminate disparities, and improve health literacy.
-​ Create social, economic, and physical environments that promote good health for all.
-​ Promote healthy development and healthy behaviors across every stage of life.
-​ Engage leadership and the public to design effective health policies.
Behaviors That Contribute to Wellness

A lifestyle based on good choices and healthy behaviors maximizes quality of life. It helps
people avoid disease, remain strong and fit, and maintain their physical and mental health as
long as they live.

Be Physically Active

The human body is designed to be active. It readily adapts to nearly any level of activity and
exertion. Physical fitness is a set of physical attributes that allows the body to respond or adapt
to the demands and stress of physical effort. The more we ask of our bodies, the stronger and
more fit they become. When our bodies are not kept active, they deteriorate: Bones lose density,
joints stiffen, muscles become weak, and cellular energy systems degenerate. To be truly well,
human beings must be active.
Unfortunately, a sedentary lifestyle is common among Americans. According to the U.S.
Department of Health and Human Services, only 28% of men, 20% of women, and 16.5% of
adolescents meet the federal physical activity guidelines for aerobic physical activity (150
minutes or more per week of moderate aerobic exercise or 75 minutes per week of vigorous
aerobic exercise) and muscle-strengthening activity. The older the adults, the less likely they are
to meet the guidelines.
The benefits of physical activity are both physical and mental, immediate and long term. In the
short term, being physically fit makes it easier to do everyday tasks, such as lifting; it provides
reserve strength for emergencies; and it helps people look and feel good. In the long term,
being physically fit confers protection against chronic diseases and lowers the risk of dying
prematurely. (See the box “Does Being Physically Active Make a Difference in How Long You
Live?”) Physically active people are less likely to develop or die from heart disease, respiratory
disease, high blood pressure, cancer, osteoporosis, and type 2 diabetes (the most common
form of diabetes). As they get older, they may be able to avoid weight gain, muscle and bone
loss, fatigue, and other problems associated with aging.

The concept of physical literacy focuses on exercise and physical activities as a long-term
pursuit that requires learning. We do not intrinsically understand how beneficial it is for us to
stay vigilant about our physical activity, and so it is important, according to the International
Physical Literacy Association, to gain “the motivation, confidence, physical competence,
knowledge, and, understanding to value and take responsibility for engagement in physical
activities for life.

Choosing a Healthy Diet

In addition to being sedentary, many Americans have a diet that is too high in calories,
unhealthy fats, and added sugars, as well as too low in fiber, complex carbohydrates, fruits, and
vegetables. Like physical inactivity, this diet is linked to a number of chronic diseases. A healthy
diet provides necessary nutrients and sufficient energy while limiting dietary substances linked
to diseases.

Maintain a Healthy Body Weight

The effect of obesity can be measured by cases of coronary artery disease. Except for smoking,
no other modifiable risk factor contributes to a shorter life span than obesity. Overweight and
obesity are associated with a number of disabling and potentially fatal conditions and diseases,
including heart disease, cancer, and type 2 diabetes. Healthy body weight is an important part of
wellness—but short-term dieting is not part of fitness or wellness. Maintaining a healthy body
weight requires a lifelong commitment to regular exercise, a healthy diet, and effective stress
management.

Manage Stress Effectively

Many people cope with stress by eating, drinking, or smoking too much. Others don’t deal with it
at all. In the short term, inappropriate stress management can lead to fatigue, sleep
disturbances, and other symptoms. Over longer periods of time, poor stress management can
lead to less efficient functioning of the immune system and increased susceptibility to disease.
Learning to incorporate effective stress-management techniques into daily life is an important
part of a fit and well lifestyle.

Avoid Tobacco and Drug Use and Limit Alcohol Consumption

Tobacco use is associated with 9 of the top 10 causes of death in the United States; personal
tobacco use and secondhand smoke kill nearly 500,000 Americans each year, more than any
other behavioral or environmental factor. In 2020, 12.5% of adult Americans described
themselves as current smokers. Lung cancer is the most common cause of cancer death among
both males and females and one of the leading causes of death overall. On average, the direct
health care costs associated with smoking exceed $240 billion per year. If the cost of lost
productivity from sickness, disability, and premature death is included, the total exceeds $600
billion.
Excessive alcohol consumption is linked to 8 of the top 10 causes of death and results in about
140,000 deaths a year in the United States. The social, economic, and medical costs of alcohol
abuse are estimated at more than $250 billion per year. Alcohol or drug intoxication is an
especially notable factor in the death and disability of young people, particularly through
unintentional injuries (such as drownings and car crashes caused by drunken driving) and
violence.

Protect Yourself from Disease and Injury

The most effective way of dealing with disease and injury is to prevent them. Many lifestyle
strategies discussed here help protect you against chronic illnesses. In addition, you can take
specific steps to avoid infectious diseases, particularly those that are sexually transmitted.

Take Other Steps toward Wellness

Other important behaviors contribute to wellness, including these:
●​ Developing meaningful relationships—for example, learning to communicate and dealing
with anger
●​ Planning for successful aging—for example, anticipating physical challenges and
maintaining hobbies
 ●​ Learning about the health care system—for example, knowing what treatment options
are available to you
●​ Acting responsibly toward the environment—for example, helping to reduce pollution and
encouraging sustainable practices

Wellness Factors That Seem Outside Our Control

Heredity, the environment, and adequate health care are other important influences on health
and wellness. These factors can interact in ways that raise or lower the quality of a person’s life
and the risk of developing particular diseases. For example, a sedentary lifestyle combined with
a genetic predisposition for diabetes can greatly increase a person’s risk of developing the
disease. If such people also lack adequate health care, they are much more likely to suffer
dangerous complications from diabetes.
But in many cases, behavior can tip the balance toward health even if heredity or environment is
a negative factor. Breast cancer, for example, can run in families, but it is also associated with
being overweight and a sedentary lifestyle. A woman with a family history of breast cancer is
less likely to die from the disease if she controls her weight, exercises, and has regular
mammograms to help detect the disease in its early, most treatable stage.

College Students and Wellness

Each year, thousands of students lose productive academic time to activities causing stress and
other physical and emotional health problems—some of which can continue for a lifetime.
According to the Fall 2022 American College Health Association National College Health
Assessment III, the following were commonly reported factors affecting academic performance.
●​ Procrastination (45% of students affected)
●​ Stress (39%)
●​ Anxiety (32%)
●​ Depression (23%)
●​ Finances (15%)
●​ Sleep difficulties (22%)
●​ Headaches/migraines (11%)
●​ Health of someone close (10%)
Each of these factors is related to one or more dimensions of wellness, and most can be
influenced by choices students make daily. For example, learning about our circadian
rhythms—our internal body clocks that regulate times of day and night to sleep, eat, and
exercise—can help us maximize health benefits that come from these activities. Listening to our
internal clocks helps us prepare our sleep environment and get to bed on time and optimize the
exercise goals we set: Depending on if we want to control blood sugar, lose weight, or gain
strength, we might undertake low-intensity or high-intensity exercise at certain times of the day.

What about wellness choices in other areas? The American College Health Association survey
found the following:
 ●​ Only 41% of sexually active students reported that they used a condom mostly or always
during vaginal intercourse in the past 30 days.
●​ About 9% of students had seven or more drinks the last time they drank in a social
setting.
●​ About 4% of students misused one or more prescription stimulants, sedatives, or opioids
within the past three months.
●​ About 8% of students smoked cigarettes, and 15% used e-cigarettes, at least once
during the past three months.

Reaching Wellness Through Lifestyle Management

Moving in the direction of wellness means cultivating healthy behaviors and working to
overcome unhealthy ones. This approach to lifestyle management is called behavior change. As
you may already know from experience, changing an unhealthy habit, or a condition such as
depression, can be harder than it sounds. When you embark on a behavior change plan, it may
seem like too much work at first. But as you make progress, you will gain confidence in your
ability to take charge of your life. You will also experience the benefits of wellness—more
energy, greater vitality, deeper feelings of appreciation and curiosity, and a higher quality of life.

Getting Serious about Your Health

Before you can start changing a wellness-related behavior, you have to know that the behavior
is problematic and that you can change it. To make good decisions, you need information about
relevant topics and issues, including what resources are available to help you change.

Choose a Target Behavior

After you’ve chosen a target behavior, you need to learn its risks and benefits for you–both now
and in the future. Ask these questions:
●​ How is your target behavior affecting your level of wellness today?
●​ Which diseases or conditions does this behavior place you at risk for?
●​ What effect would changing your behavior have on your health?

Building Motivation to Change

Knowledge is necessary for behavior change, but it isn’t usually enough to make people act.
Millions of people have sedentary lifestyles, for example, even though they know it’s bad for
their health. To succeed at behavior change, you need to be motivated and to know that even
though an active lifestyle may seem difficult, we are all capable of great change.

Examine the Pros and Cons of Change

Health behaviors have short-term and long-term benefits and costs. Consider the benefits and
costs of an inactive lifestyle:
●​ Short term. Such a lifestyle allows you more time to watch TV and hang out with friends,
but it leaves you less fit and less able to participate in recreational activities.
●​ Long term. This lifestyle increases the risk of heart disease, cancer, stroke, and
premature death.
To successfully change your behavior, you must believe that the benefits of change outweigh
the costs. Carefully examine the pros and cons of continuing your current behavior and of
changing to a healthier one. Focus on the effects that are most meaningful to you, including
those tied to your personal identity and values. For example, engaging in regular physical
activity and getting adequate sleep can support an image of yourself as an active person who is
a good role model for others. Eliminating dependencies like tobacco or alcohol use is a way to
be more independent and exercise greater control of your life, not to mention save money. To
complete your analysis, ask friends and family members about the effects of your behavior on
them. For example, a younger sister may tell you that your vaping habit influenced her decision
to take up vaping.
Although some people are motivated by long-term goals, such as avoiding a disease that may
hit them in 30 years, most are more likely to be moved to action by short-term goals. Feeling
better, doing better in school, improving at a sport, reducing stress, and increasing self-esteem
are common, more immediate benefits of health behavior change. Many wellness behaviors are
associated with immediate improvements in quality of life. For example, within hours of quitting
smoking, blood oxygen levels normalize; within two days, the sense of taste and smell return to
normal; and within two weeks, lung functions improve. Similarly, a single bout of moderate to
vigorous physical activity can reduce anxiety, lower blood pressure, and improve sleep.
Over time, these changes add up to a substantially higher quality of life. Surveys have found
that both nonsmokers and physically active people feel healthy and full of energy more days
each month, and report fewer days of sadness and troubled sleep than do smokers and
sedentary people.

Boost Self-Efficacy
When you start thinking about changing a health behavior, a big factor in your eventual success
is whether you have confidence in yourself and in your ability to change. Self-efficacy refers to
your belief in your ability to successfully take action and perform a specific task. Strategies for
boosting self-efficacy include developing an internal locus of control, using visualization and
self-talk, and getting encouragement from supportive people.

Locus of Control
Who do you believe is controlling your life? Is it your parents, friends, or school? Is it
“fate”? Or is it you? Locus of control refers to the figurative “place” a person designates
as the source of responsibility for the events in their life. People who believe they are in
control of their own lives are said to have an internal locus of control. Those who believe
that factors beyond their control determine the course of their lives are said to have an
external locus of control.
For lifestyle management, an internal locus of control is an advantage because it
reinforces motivation and commitment. An external locus of control can sabotage efforts
to change behavior. For example, if you believe that you are destined to die of breast
cancer because your mother died from the disease, you may view screening
mammograms as a waste of time. In contrast, if you believe that you can take action to
reduce your risk of breast cancer in spite of hereditary factors, you will be motivated to
follow guidelines for early detection of the disease.
If you find yourself attributing too much influence to outside forces, gather more
information about your wellness-related behaviors. List all the ways that making lifestyle
changes will improve your health. If you believe you’ll succeed, and if you recognize that
you are in charge of your life, you’re on your way to wellness.

Visualization and Self-talk

One of the best ways to boost your confidence and self-efficacy is to visualize yourself
successfully engaging in a new, healthier behavior. Imagine yourself going for a run
three days a week or no longer smoking cigarettes. Also visualize yourself enjoying all
the short-term and long-term benefits that your lifestyle change will bring. Create a new
self-image: What will you and your life be like when you become a regular exerciser or a
nonsmoker?
You can also use self-talk, the internal dialogue you carry on with yourself, to increase
your confidence in your ability to change. Counter any self-defeating patterns of thought
with more positive or realistic thoughts: “I am a strong, capable person, and I can
maintain my commitment to change.” See Chapter 10 for more on self-talk.

Role Models and Other Supportive Individuals

Social support can make a big difference in your level of motivation and your chances of
success. Perhaps you know people who have reached the goal you are striving for; they could
be role models or mentors, providing information and support for your efforts. Gain strength from
their experiences, and tell yourself, “If they can do it, so can I.” In addition, find a friend who
wants to make the same changes you do and who can take a helpful role in your behavior
change program. For example, an exercise partner can provide companionship and
encouragement when you might be tempted to skip your workout.

Identify and Overcome Barriers to Change

Don’t let past failures at behavior change discourage you; they can be a great source of
information you can use to boost your chances of future success. Make a list of the problems
and challenges you faced in previous behavior change attempts. To this list, add the short-term
costs of behavior change that you identified in your analysis of the pros and cons of change.
After you’ve listed these key barriers to change, develop a practical plan for overcoming each
one. For example, if you always smoke when you’re with certain friends, decide in advance how
you will turn down the next cigarette you are offered.

Enhancing Your Readiness to Change

The transtheoretical, or “stages-of-change,” model is an effective approach to lifestyle
self-management. According to this model, you move through distinct stages as you work to
change your target behavior. It is important to determine what stage you are in now so that you
can choose appropriate strategies for progressing through the cycle of change. This approach
can help you enhance your readiness and intention to change.

Precontemplation
People at this stage do not think they have a problem and do not intend to change their
behavior. They may be unaware of the risks associated with their behavior or may deny them.
They may have tried unsuccessfully to change in the past and may now think the situation is
hopeless. They may also blame other people or external factors for their problems. People in
the precontemplation stage believe that the reasons not to change outweigh the costs and
reasons to change.

Contemplation
People at this stage know they have a problem and intend to take action within 6 months. They
acknowledge the benefits of behavior change but worry about the costs of changing or specific
barriers that appear too difficult to overcome. To be successful, people must believe that the
benefits of change outweigh the costs. People in the contemplation stage wonder about
possible courses of action but don’t know how to proceed.

Preparation
People at this stage plan to take action within a month or may already have begun to make
small changes in their behavior. They may be engaging in their new, healthier behavior but not
yet regularly or consistently. They may have created a plan for change but may be worried
about failing.

Action
During the action stage, people outwardly modify their behavior and their environment. Although
people in this stage are at risk for reverting to old, unhealthy patterns of behavior, they may also
be reaping the rewards of a positive behavior change. The action stage requires the greatest
commitment of time and energy.

Maintenance
People at this stage have maintained their new, healthier lifestyle for at least six months. Lapses
may have occurred, but people in maintenance have been successful in quickly reestablishing
the desired behavior. The maintenance stage can last for months or years.

Dealing with Relapse

People seldom progress through the stages of change in a straightforward, linear way. Rather,
they tend to move to a new stage and then slip back to a previous stage before resuming their
forward progress. Research suggests that most people make several attempts before they
successfully change a behavior; 4 out of 5 people experience some degree of back-sliding. For
this reason, the stages of change are best conceptualized as a spiral in which people cycle back
through previous stages but are further along in the process each time they renew their
commitment.
A final stage can be called Termination. People at this stage have exited the cycle of change
and are no longer tempted to lapse back into their old behavior. They have a new self-image
and total self-efficacy with regard to their target behavior. Because this stage is rarely achieved,
it is not included in the main model of change.

If you experience a lapse—a single slip—or a relapse—a return to old habits—don’t give up.
Relapse can be demoralizing, but it is not the same as failure. Failure means stopping before
you reach your goal and never changing your target behavior. During the early stages of the
change process, it’s a good idea to plan for relapse so that you can avoid guilt and self-blame
and get back on track quickly. Follow these steps:
●​ Forgive yourself. A single setback isn’t the end of the world.
●​ Give yourself credit for the progress you have already made. You can use that success
as motivation to continue.
●​ Move on. You can learn from a relapse and use that knowledge to deal with potential
setbacks in the future.

Developing Skills for Change: Creating a Personalized Plan

Once you are committed to making a behavior change, it’s time to develop the necessary skills
to make that change successful. This includes setting goals, anticipating problems, finding
rewards, and taking the following steps:
1. Monitor your behavior and gather data. Keep a record of your target behavior and the
circumstances surrounding it. Record this information for at least a week or two. Keep your
notes in a health journal or on your smartphone. Record each occurrence of your behavior,
noting the following:
●​ What the activity was
●​ When and where it happened
●​ What you were doing
●​ How you felt at that time

If your goal is to be more active, monitoring your behavior will help you see patterns. For
example, noticing that sedentary behavior frequently occurs when you get home after classes
might suggest that the ideal time to begin exercise is directly after classes and before going
home.
If your goal is to be more active, monitoring your behavior will help you see patterns. For
example, noticing that sedentary behavior frequently occurs when you get home after classes
might suggest that the ideal time to begin exercise is directly after classes and before going
home.
2. Analyze the data and identify patterns. After you have collected data on the behavior, analyze
the data to identify patterns. Note the connections between your feelings and such external
cues as time of day, location, situation, and actions of others around you. When are you most
likely to overeat? To skip a meal? What events trigger your appetite? For example, as in Figure
1.7, perhaps you drink a soda every time you go to the campus food court or when you’re with
certain friends.
3. Be “SMART” about setting goals. If your goals are too challenging, you may have trouble
making steady progress and may be more likely to give up altogether. If, for example, you are in
poor physical condition, it will not make sense to set a goal of being ready to run a marathon
within two months. If you set goals you can live with, it will be easier to stick with your behavior
change plan and be successful.
Following the SMART criteria, your behavior change goals should be:
 ●​ Specific. Avoid vague goals like “eat more fruits and vegetables.” Instead, state your
objectives in specific terms, such as “eat two cups of fruit and three cups of vegetables
every day.” In the health journal of Figure 1.7, you might start imagining afternoon snack
and dinner choices involving a large salad or multiple vegetables to meet your goal of
three cups of vegetables that day.
●​ Measurable. Your progress will be easier to track if your goals are quantifiable, so give
your goal a number. You might measure your goal in terms of time (such as “walk briskly
for 20 minutes a day”), distance (“run 2 miles, 3 days per week”), or some other amount
(“drink eight glasses of water every day”).
●​ Attainable. Set goals that are within your physical limits. For example, if you are a poor
swimmer, you might not be able to meet a short-term fitness goal by swimming laps.
Walking or biking might be better options.
●​ Realistic. Manage your expectations when you set goals. For example, long-time
smokers may not be able to quit cold turkey. A more realistic approach might be to use
nicotine replacement patches or gum for several weeks while getting help from a support
group.
●​ Time frame–specific. Give yourself a reasonable amount of time to reach your goal, state
the time frame in your behavior change plan, and set your agenda to meet the goal
within the given time frame.

Using these criteria, sedentary people who want to improve their health and build fitness might
set a goal of being able to run 3 miles in 30 minutes, to be achieved within a time frame of six
months. To work toward that goal, they might set a number of smaller, intermediate goals that
are easier to achieve. For example, the list of goals might look like this:

You may not be able to meet these goals, but you never know until you try. As you work toward
meeting your long-term goal, you may find it necessary to adjust your short-term goals. For
example, you may find that you can start running sooner than you thought, or you may be able
to run farther than you originally estimated. In such cases, you may want to make your goals
more challenging. To stay motivated, however, some people may make them easier.
For some goals and situations, it may make more sense to focus on something other than your
outcome goal. If your goal involves a long-term lifestyle change, such as reaching a healthy
weight, focus on developing healthy habits rather than targeting a specific weight loss. Your goal
in this case might be exercising 30 minutes every day, reducing portion sizes, or eliminating
late-night snacks.
4. Devise a plan of action. Develop a strategy that will support your efforts to change. Your plan
of action should include the following steps:
●​ Get what you need. Identify resources that can help you. For example, you can join a
community walking club or sign up for a smoking cessation program. You may also need
to buy some new running shoes or nicotine replacement patches. Get the items you
need right away; waiting can delay your progress.
●​ Modify your environment. If you have cues in your environment that trigger your target
behavior, try to control them. For example, if you normally have alcohol at home, getting
rid of it can help prevent you from indulging. If you usually study with a group of friends
in an environment that allows smoking, move to a nonsmoking area. If you always buy a
snack at a certain vending machine, change your route to avoid it.
●​ Control related habits. You may have habits that contribute to your target behavior;
modifying these habits can help change the behavior. For example, if you usually plop
down on the sofa while watching TV, try putting an exercise bike or yoga mat in front of
the TV so that you can burn calories while watching.
●​ Reward yourself. Giving yourself instant, real rewards for good behavior will reinforce
your efforts. Decide in advance what each reward will be and how you will earn it. For
example, you might treat yourself to a movie after a week of avoiding snacks. Make a list
of items or events to use as rewards. They should be special to you and preferably
unrelated to food, tobacco, or alcohol.
●​ Involve the people around you. Ask family and friends to help you with your plan. To help
them respond appropriately to your needs, create a specific list of dos and don’ts. For
example, ask them to support you when you set aside time to exercise or when you
avoid second helpings at dinner.
●​ Plan for challenges. Think about situations and people that might derail your program
and develop ways to cope with them. For example, if you think it will be hard to stick to
your usual exercise program during exams, schedule short bouts of physical activity
(such as a brisk walk) as stress-reducing study breaks.

5. Make a personal contract. A serious personal contract—one that commits you to your
word—can result in a higher chance of follow-through than a casual, offhand promise. Your
contract can help prevent procrastination by specifying important dates and can also serve as a
reminder of your personal commitment to change. Your contract should include a statement of
your goal and your commitment to reaching it. The contract should also include details, such as
the following:
●​ The date you will start
●​ The steps you will take to measure your progress
●​ The strategies you will use to promote change
●​ The date you expect to reach your final goal
Have someone—preferably someone who will be actively helping you with your program—sign
your contract as a witness.

Putting Your Plan into Action

The starting date has arrived, and you are ready to put your plan into action. This stage
requires commitment, the resolve to stick with the plan no matter what temptations you
encounter. Remember all the reasons you have to make the change—and remember that you
are the boss. Use all your strategies to make your plan work. Make sure your environment is
change-friendly, and get as much support and encouragement from others as possible. Keep
track of your progress in your health journal, and give yourself regular rewards. Most important,
congratulate yourself; notice how much better you look or feel, and feel good about how far
you’ve come and how you’ve gained control of your behavior.

Staying with It

As you continue with your program, don’t be surprised when you run up against obstacles;
they’re inevitable. In fact, it’s a good idea to expect problems and give yourself time to step back
and see how you’re doing. Feel free to make some changes before going on. If your program is
grinding to a halt, identify what is blocking your progress. It may come from one of the sources
described in the following sections.

Social Influences

Take a hard look at the reactions of the people you’re counting on, and see if they’re really
supporting you. If they come up short, connect with others who will be more supportive. A
related trap is trying to get your friends or family members to change their behaviors. The
decision to make a major behavior change is something people come to only after intensive
self-examination. You may be able to influence someone by tactfully providing facts or support,
but that’s all. Focus on yourself. When you succeed, you may become a role model for others.

Levels of Motivation and Commitment

You won’t make real progress until an inner drive prompts you to the stage of change at which
you are ready to make a personal commitment to the goal. If commitment is your problem, you
may need to wait until the behavior you’re dealing with makes you unhappier or unhealthier;
then your desire to change it will be stronger. Or you may find that changing your goal will
inspire you to keep going.

Choice of Techniques and Level of Effort

If your plan is not working as well as you thought it would, make changes where you’re having
the most trouble. If you’ve lagged on your running schedule, for example, maybe it’s because
you don’t like running. An aerobics class might suit you better. Alternatively, you may not be
trying hard enough. Plan to push toward your goal. If it were easy, you wouldn’t need a plan.

Stress Barrier

If you hit a wall in your program, look at the sources of stress in your life. If the stress is
temporary, such as catching a cold or having a term paper due, you may want to wait until it
passes before strengthening your efforts. If the stress is ongoing, find healthy ways to manage
it. You may even want to make stress management your highest priority for behavior change.
Procrastinating, Rationalizing, and Blaming

Be alert to games you might be playing with yourself, so you can stop them. Such games
include the following:
●​ Procrastinating. If you tell yourself, “It’s Friday already; I might as well wait until Monday
to start,” you’re procrastinating. Break your plan into smaller steps that you can
accomplish one day at a time.
●​ Rationalizing. If you tell yourself, “I wanted to go swimming today but wouldn’t have had
time to wash my hair afterward,” you’re making excuses. Blaming. If you tell yourself, “I
couldn’t exercise because Dave was hogging the elliptical trainer,” you’re blaming others
for your own failure to follow through.
●​ Blaming is a way of taking focus off the real problem and denying responsibility for your
own actions.

Being Fit and Well for Life

Your first attempts at making behavior changes may never go beyond the contemplation or
preparation stage. But as you experience some success, you’ll start to have more positive
feelings about yourself. You may discover new physical activities and sports you enjoy, and you
may encounter new situations and meet new people. Perhaps you’ll surprise yourself by
accomplishing things you didn’t think were possible—breaking a long-standing nicotine habit,
competing in a race, climbing a mountain, or developing a leaner body. Most of all, you’ll
discover the feeling of empowerment that comes from taking charge of your health. Being
healthy takes effort, but the paybacks in energy and vitality are priceless.
Once you’ve started, don’t stop. Assume that health improvement is forever. Take on the easier
problems first, and then use what you learn to tackle more difficult problems later. When you feel
challenged, remind yourself that you are creating a lifestyle that minimizes your health risks and
maximizes your enjoyment of life. You can take charge of your health in a dramatic and
meaningful way. Fit & Well will show you how.