Chapter 18

BEHAVIORAL RISK AND

PROTECTIVE FACTORS:
EVIDENCE, MODELS, AND
INTERVENTIONS
Dawn K. Wilson, Allison M. Sweeney, and Nicole Zarrett

Risk for developing a noncommunicable chronic & Wang, 2013; Paxton et al., 2007). In a study
disease is strongly linked to behavioral lifestyle involving 96,000 adults age 45 years or older,
factors, including engaging in regular physical grouping analyses highlighted that for males but
activity, eating a healthy diet, maintaining a normal not females, living in poor neighborhoods was
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body mass index, never smoking, and limiting associated with greater psychological distress and
alcohol consumption (Ford et al., 2012; Y. Li et al., lower quality of life (Griffin et al., 2014). These sex
2018). Engaging in four or more of these health differences were further demonstrated in a study
behaviors is associated with a reduced risk of 66% of more than 4,000 adults age 65 or older, which
for all-cause mortality (Loef & Walach, 2012). found that women were more likely to show
Health-related behaviors also have important clustering of positive healthy behaviors such
implications for individuals’ social well-being as physical activity and lower consumption of
and cognitive functioning across the lifespan. alcohol than men (Lee et al., 2012). Conversely,
Drawing from the World Health Organization’s for men positive behaviors mostly centered
definition of health as a complete state of physical, around smoking status such that nonsmokers
social, and mental well-being (WHO, 2019), were more likely to engage in physical activity
this chapter reviews health-promoting and health- and consume less alcohol. Taken together, these
compromising behaviors and provides the evidence studies demonstrate that health behaviors pair
base for the importance of developing effective, with mental and social well-being (as well as
theory-based interventions for increasing protec- environmental and social conditions). Thus,
tive health behaviors and reducing behavioral embracing theories and developing interventions
risk factors at a population level. that intentionally target physical, psychological,
Many health-related behaviors cluster and and social outcomes related to well-being may be
are driven by similar underlying psychological a cost-effective approach for impacting population
attributes. Such intertwining of physical, psycho- health.
logical, and social factors has been demonstrated Although traditionally the field of health
across the lifespan (Wilson, 2015). National psychology has focused on chronic diseases,
studies have demonstrated that for youth, both the coronavirus (COVID-19) pandemic has
risk-taking behaviors and mental health factors demonstrated an increased need to consider
couple with unhealthy lifestyle habits such as infectious diseases as relevant to our conceptual
poor diet and a lack of physical activity (Iannotti framework of risk behaviors. National studies have

https://doi.org/10.1037/0000394-018
APA Handbook of Health Psychology: Vol. 1. Foundations and Context of Health Psychology, N. Schneiderman (Editor-in-Chief)
Copyright © 2025 by the American Psychological Association. All rights reserved.

389
APA Handbook of Health Psychology, Volume 1: Foundations and Context of Health Psychology,
edited by N. Schneiderman, T. W. Smith, N. B. Anderson, M. H. Antoni, F. J. Penedo, T. A.
Revenson, and A. F. Abraído-Lanza
Copyright © 2025 American Psychological Association. All rights reserved.
 Wilson, Sweeney, and Zarrett

demonstrated that the COVID-19 pandemic has plays a central role in healthy development and
had a wide-reaching impact on people’s physical, aging, including enhancing cognitive functioning
social, and mental well-being (Vindegaard & in childhood, promoting neural growth, and
Benros, 2020). The behavioral and psychosocial reducing risk for age-related cognitive decline
aspects of the pandemic are pertinent for scientists and neurodegenerative diseases in older adults
in the field of health psychology, including improv- (Bherer et al., 2013; Donnelly et al., 2016; Fabel
ing adherence to health-promoting behaviors & Kempermann, 2008). Physical activity has
(e.g., maintaining physical activity, social distancing, also been implicated as an important treatment
wearing masks), and mitigating negative mental component for preventing and reducing depression
health outcomes (e.g., loneliness, depression). and anxiety symptoms (Rebar et al., 2015).
Freedland et al. (2020) argued that the United Complementing these findings is emerging
States is vulnerable to a wide assortment of evidence that fruit and vegetable consumption
emerging pathogens, and that COVID-19 will is associated with greater subjective well-being,
not be the last epidemic or pandemic that calls enhanced health-related quality of life, and reduced
for behavioral expertise. Thus, the field of health psychological distress (Baden et al., 2020; Gła˛bska
psychology will need to support a new generation et al., 2020; Ocean et al., 2019). Furthermore,
of scientists, practitioners, and educators with longitudinal evidence suggests that subjective
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special expertise in the behavioral and psycho­ well-being increases in a dose–response relation-
social aspects of infectious diseases. ship with the number of portions and daily
This chapter provides an overview of the frequency by which fruit and vegetables are
evidence base for the importance of improving consumed (Ocean et al., 2019). Taken together,
health-related behaviors and examples of existing these studies demonstrate that increasing physical
models for behavioral lifestyle interventions. activity and fruit and vegetable intake have
Through these examples, we argue that although important implications for promoting both
research to date has focused on behavioral physical and mental well-being.
approaches, more dynamic theoretical frameworks Another health-promoting behavior with
are needed that integrate ecological systems with wide-reaching protective benefits is sleep. Short
behavioral changes theories to better understand sleep duration (defined as less than five to six
the social context that impacts physical, mental, hours per night) is associated with a variety of
and social well-being. We also contextualize these chronic diseases and conditions, including obesity,
issues within the emerging challenges of the diabetes, hypertension, stroke, cardiovascular
COVID-19 pandemic to better inform future disease, and some cancers (Cappuccio & Miller,
interventions for chronic and infectious diseases. 2017; Luyster et al., 2012). Lack of sleep is also
associated with increased risk for accidents
(e.g., motor and work-related) and impaired
SIGNIFICANCE OF HEALTH-PROMOTING
cognitive and motor function that is comparable
BEHAVIORS
with the negative effects of high alcohol con-
National evidence is accumulating that engaging sumption (Durmer & Dinges, 2005; Williamson
in health-promoting behaviors is critical to et al., 2000). Insufficient sleep is linked as well
longevity and quality of life. Research shows that to poorer self-regulation and enhanced stress
engaging in regular physical activity and meeting (Hisler et al., 2019; Massar & Chee, 2019), which
recommendations for fruit and vegetable consump- may undermine adherence to other health-
tion are important protective factors for reducing promoting behaviors, such as physical activity,
risk for mortality, cardiovascular disease, and diet, and chronic disease self-management
some cancers (Bhupathiraju et al., 2013; Ekelund (Tambalis et al., 2018; Tracy et al., 2020). Fur-
et al., 2019; Sattelmair et al., 2011). In addition thermore, sleep is closely linked to emotions in a
to reducing the risk for disease, physical activity bidirectional manner, such that lack of sleep

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 Behavioral Risk and Protective Factors

is associated with an increase in negative affect, death from cardiovascular disease by at least 20%,
depressive symptoms, and emotional distress (e.g., resulting on average in 1.6 to 5.0 fewer years of
stress, anxiety) which can also lead to difficulty life (Borrell & Samuel, 2014). Further exacer-
with sleeping (Kahn et al., 2013). Whereas many bating these physical health risks, weight-based
studies have focused on the negative impacts stigma and bias have increased in recent years
of insufficient sleep and emotion, evidence also across a variety of domains, including health
indicates that positive affect and well-being are care and work settings (Spahlholz et al., 2016).
associated with fewer sleep problems, which Weight-based bias increases the likelihood of
may act as a buffer against the negative effects of overt unfair treatment, including poor quality of
psychosocial risk factors, such as financial strain care in medical settings (Phelan et al., 2015), as
(Steptoe et al., 2008). A growing evidence base well as the internalization of negative stereotypes,
of research has demonstrated that sufficient sleep which is associated with negative mental health
is a key protective factor for promoting optimal outcomes, including depression, anxiety, and
physical, cognitive, and emotional functioning. poor health-related quality of life (Pearl & Puhl,
The COVID-19 pandemic has introduced 2018). Obesity in adulthood is strongly linked to
additional barriers and challenges for engaging rates in childhood and adolescence, with some
in health-promoting behaviors. Physical activity studies estimating 80% of obese adolescents
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levels have decreased since the COVID-19 remain obese in adulthood (Simmonds et al.,
pandemic (Bates et al., 2020; Dunton, Do, et al., 2016). Such findings highlight the critical need
2020), with greater declines among low-income for intervening early to address bias and stigma
and ethnic minority groups (Dunton, Wang, to reduce risk for long-term physical and mental
et al., 2020). The COVID-19 pandemic has also health problems.
introduced numerous challenges for maintaining Another major risk factor is smoking, which,
a healthy diet, including limited access to fresh despite a decrease in prevalence in recent decades,
fruits and vegetables, food insecurity, more remains the leading cause of preventable death in
frequent snacking, and elevated distress levels the United States (HHS, 2014). Smoking affects
(Akseer et al., 2020; Naja & Hamadeh, 2020). nearly every organ in the body, leading to an
Furthermore, the rise in anxiety and distress increased risk for a variety of cancers, cardio-
during the COVID-19 pandemic may also be vascular disease, respiratory disease, reproductive
contributing to sleep problems, especially during health issues, and Type 2 diabetes (Burns, 2003;
confinement and lockdowns (Altena et al., 2020; Gandini et al., 2008; HHS, 2014). Adding to these
Pinto et al., 2020). The behavioral and psycho- risks, smoking is associated with more rapid
logical challenges of the COVID-19 pandemic cognitive decline (e.g., executive functioning)
call for increased efforts to understand effective across middle and older adulthood (Sabia et al.,
strategies for overcoming barriers in high-risk 2012; Weuve et al., 2012). Smoking tends to
conditions, such as lockdowns. cluster with other risk factors, including excessive
alcohol use (Meader et al., 2016), which further
exacerbates risks for cardiovascular disease and
SIGNIFICANCE OF HEALTH-COMPROMISING
cancer (Ronksley et al., 2011; WHO, 2022).
BEHAVIORS
Alcohol consumption is another risk behavior
Obesity, defined as a body mass index (BMI) that has been the focus of national health
≥ 30 kg/m2, is a major risk factor for a range promotion efforts. Excessive drinking, including
of chronic diseases including Type 2 diabetes, binge drinking and heavy drinking, increases
cardiovascular disease, osteoarthritis, chronic short-term health risks, including injuries and
back pain, and some cancers (Guh et al., 2009; risky sexual behaviors (Cooper, 2002; Hingson
Renehan et al., 2008). Relative to those with a et al., 2009; Townshend et al., 2014). Excessive
normal weight, obesity increases risk for premature drinking is also associated with long-term cognitive

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 Wilson, Sweeney, and Zarrett

and mental health outcomes, including cognitive neighborhoods, health care systems) remains
impairment, learning and memory problems, a central focus of efforts to improve health and
and increased risk for depression and anxiety well-being at a population level. The use of
(Sullivan et al., 2005; Thomas & Rockwood, 2001; theory in behavioral interventions is essential for
WHO, 2018). Quitting smoking and reducing identifying potentially important intervention
alcohol consumption (i.e., sobriety or no heavy content and behavioral strategies while evaluating
drinking) can also result in significant decreases the mechanisms that underlie health behavior
in risk for cardiovascular disease and some change (Glanz & Bishop, 2010; Sheeran et al.,
cancers, as well as improvements in mental health 2017). Many previous theory-based interventions
outcomes (Taylor et al., 2014; Witkiewitz et al., have focused on improving self-regulation,
2018). Taken together, these findings demonstrate cognitions, and behaviors. This approach often
the need for effective behavioral interventions involves targeting the behavioral skills needed
to reduce health-compromising risk factors to to improve coping and enhance motivation for
improve physical and mental well-being. health behavior change. For example, evidence
The COVID-19 pandemic has further is robust that goal setting and self-monitoring
exacerbated numerous behavioral risk factors. are effective behavioral change techniques for
For example, alcohol use increased during the promoting changes in diet and physical activity
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pandemic (Pollard et al., 2020), current drinkers (Michie et al., 2009).

demonstrating worse stress-related coping skills Behavioral interventions have been shown
than nondrinkers (Chodkiewicz et al., 2020). to be effective for improving health behaviors
Other studies have documented that COVID-19 such as physical activity, diet, and weight-related
has been associated with worsening of a variety outcomes in large-scale national studies. A land-
of health-compromising behaviors, including mark study, known as the Diabetes Prevention
obesity and smoking status (Kwok et al., 2020; Program (DPP Research Group, 2002, 2009),
Patanavanich & Glantz, 2020; Popkin et al., involved 27 centers in a randomized controlled
2020). In addition, numerous studies have also trial that compared the effectiveness of a lifestyle
revealed significant mental health consequences intervention relative to pharmacological therapy
from the pandemic, including an increase in and a placebo control group for preventing the
chronic stressors, such as caregiver responsibilities, onset of Type 2 diabetes among high-risk indi­
job strain, and social isolation (Patrick et al., 2020), viduals. Participants in the lifestyle intervention
and a decrease in psychological well-being across condition set weight loss and physical activity
COVID-19 patients, health care workers, and the goals. They worked weekly with a case manager
general public (Vindegaard & Benros, 2020). on sessions that included a weigh-in, reviewing
of self-monitoring records and continuous
identification of barriers to weight loss as well
BEHAVIORAL LIFESTYLE INTERVENTIONS
as developing weekly action plans. Across a
Despite the importance of engaging in health- 3-year follow-up period, diabetes incidence
promoting behaviors and minimizing health- was lowered among the lifestyle intervention
compromising behaviors, adherence to maintaining group, showing reductions in relative risks of
a healthy lifestyle remains low nationally, especially 58% relative to 31% in the control group (DPP
among underserved communities (low income, Research Group, 2002). In a long-term follow-up
racial–ethnic minorities; Benjamin et al., 2018; study, 10 years post intervention, the cumulative
Kanny et al., 2020; Lee-Kwan et al., 2017). Given incidence of diabetes remained lowest among
evidence that adherence to these essential health individuals assigned to the lifestyle intervention
behaviors is low, the development of effective group (DPP Research Group, 2009). Over this
behavioral interventions that account for multiple period, all three groups in the DPP trial showed
systems (e.g., individuals, interpersonal factors, significant reductions in systolic blood pressure,

392
 Behavioral Risk and Protective Factors

diastolic blood pressure, and LDL (low-density 2014; Kaplan, 2019). Social determinants of
lipoprotein) cholesterol; however, the lifestyle health are the broader environmental conditions
group demonstrated the lowest use of lipid in which people live, work, and age that affect
and blood pressure medication (DPP Research health, longevity, and quality of life, such as
Group, 2013). economic stability, access to quality education
In addition to preventing the onset of chronic and health care, and experiences of racism,
illness, behavioral lifestyle changes may also discrimination, or violence (WHO, 2022). Social
improve health outcomes among patients with determinants fundamentally affect the opportuni-
chronic illness. The Look AHEAD trial (Look ties people have for practicing healthy behaviors,
AHEAD Research Group 2006) was the first which in turn lead to widespread health disparities
randomized controlled trial to provide direct by income, sex, race, and ethnicity (Braveman
evidence for the longitudinal health benefits et al., 2011; Braveman & Gottlieb, 2014; Kaplan,
of lifestyle changes such as weight loss among 2019). For example, people living in communities
patients with chronic illness. The lifestyle inter- with high rates of crime, low neighborhood
vention drew on similar methods used in the walkability, and limited access to grocery stores
DPP trial but was adapted for individuals already are less likely to engage in health-promoting
diagnosed with Type 2 diabetes. The results showed behaviors such as physical activity and eating
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that the lifestyle intervention group was effective fruits and vegetables. For this reason, consensus is
in weight loss, the largest change in body weight growing that behavioral interventions are needed
being observed in the first year, such that the that directly address broader social-environmental
intervention group had an average of 8.6% weight and community-level factors in order to have
loss relative to the control group, which had only down-stream positive impacts on individuals’
0.7% weight loss (Look AHEAD Research Group, health-promoting and health-compromising
2007). By the end of the fifth year, patients in behaviors.
the intervention group had gradually regained
about half of their lost weight but remained at
NEED FOR INTERVENTIONS THAT ADDRESS
that weight for the rest of the trial (Look AHEAD
SOCIAL-ENVIRONMENTAL FACTORS
Research Group, 2013, 2014). The results also
demonstrated that successful weight loss of the Health psychology is rooted in a biopsychosocial
intervention group may have been attributable approach, which emphasizes the importance
to in part to self-monitoring skills acquired of an ecological relationship between individuals
during the individual and group sessions (West and their (perceived and actual) environments
et al., 2016). However, although the intervention (Adler, 2009). This framework has provided a
was successful at helping patients achieve and foundation for targeting health behavior change
maintain weight loss, no difference in cardio­ by addressing multiple systems of influence.
vascular deaths was found between the interven- Social cognitive theory, for example, proposes
tion and control groups, which was the primary that the self-regulation of health behaviors is
outcome of this trial (Look AHEAD Research shaped in part by broader social and structural
Group, 2013). impediments to change, including impediments
Although behavioral lifestyle approaches to rooted in the inequitable delivery of health services
interventions have been somewhat effective, (Bandura, 1986, 2004). Self-determination theory
such interventions have focused primarily on emphasizes the importance of the social envi­
intervening at the individual level. Increasingly, ronment for promoting an individual’s long-term
however, researchers are recognizing the impor- motivation for health behavior change, including
tance of evaluating multiple systems of influence the need for autonomy, competency, and related-
(Sallis et al., 2015) and social determinants of health ness across a variety of social contexts, including
(Braveman et al., 2011; Braveman & Gottlieb, interactions with health care providers, family,

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 Wilson, Sweeney, and Zarrett

and friends (Ng et al., 2012; Ryan & Deci, 2000). or permissive households (low control, low
Complementing these frameworks, ecological monitoring). These reviews provide support
theory (Bronfenbrenner, 1992; Sallis et al., that parenting strategies that create positive
2015) proposes that multilevel interventions and nurturing environments are associated with
should be most effective for promoting health improvements in health outcomes in youth.
behavior change, including intervening to address A meta-analysis by Ng et al. (2012)
individual-level characteristics (e.g., behavioral demonstrated that SDT-based strategies were
skills, coping strategies), social-environmental effective in improving a broad range of both
factors (e.g., primary social groups and cultural physical and mental health outcomes including
influences), and broader community and envi­ physical activity, weight loss, diet, depression,
ronmental factors (e.g., policy, neighborhood and quality of life. Providing individuals with
access, social intuitions, health care systems). the choices and opportunities to engage in self-
Expanding on the work of Biglan et al. initiated behavior change has been shown to
(2012), we argue that to effectively increase increase autonomous motivation (Ferrer-Caja &
health-promoting behaviors and decrease health- Weiss, 2000; Wilson et al., 2011). These studies
compromising behaviors it is important to under- indicate that positive autonomy supportive
stand the mechanisms that may reinforce social interactions with members of the broader social
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nurturance and the promotion of positive social environment may play a critical role in facilitating
environments across contexts (Wilson et al., 2017). sustained health behavior change. By targeting
Growing evidence suggests that interventions distinct communication, motivation, and behav-
that integrate family systems, motivational, and ioral factors at the individual, family, and social-
behavioral theories are likely to have greater environmental levels, integration of these theories
success in producing positive health behavior offers an ecological perspective of the different
changes (Kitzman-Ulrich et al., 2010; Wilson systems and mechanisms that promote health
et al., 2015, 2017). We argue for an ecological behavior change.
model, however, that integrates elements from An example of this integrated theoretical
family systems theory (Broderick, 1993), self- approach has been demonstrated in the Families
determination theory (SDT; Ryan & Deci, 2000), Improving Together (FIT) for weight loss trial
and social cognitive theory (SCT; Bandura, (Wilson et al., 2015, 2022). The FIT group-
1986, 2004) to better understand how individual- randomized trial evaluated the efficacy of a
level behavioral skills, family-level support and motivational plus positive parenting (M+FWL)
communication, and autonomous motivation intervention versus a comprehensive health
support the broader social environment in education program on reducing body mass index
facilitating health and well-being. and improving physical activity and diet in
In a review by our research group (Kitzman- African American adolescents with overweight
Ulrich et al., 2010), we found that family-based or obesity. Phase 1 of the trial tested the efficacy
interventions that targeted authoritative parenting of an eight-week face-to-face group-based
styles (moderate control, high nurturance, shared M+FWL intervention program. In phase 2 of
decision making) and positive parenting strategies the trial, participants were rerandomized to
(e.g., monitoring) had the greatest success in either an 8-week tailored online intervention
both preventing and treating obesity in youth. or a control online program resulting in a
In another review (Sleddens et al., 2011), children 2 (M+FWL vs. comprehensive health education
in more authoritative households (e.g., nurturing, group) × 2 (intervention vs. control online
autonomy supportive, moderate control) had program) factorial design. The curriculum for
healthier diets, greater physical activity, and the FIT trial integrated SCT, SDT, and family
lower weight-related outcomes than those in systems theory with cultural tailoring strategies
authoritarian (high control, rigid, inflexible) to target weight-related outcomes in African

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 Behavioral Risk and Protective Factors

American youth and their caregivers (Wilson et al., variance contributing to death, the remainder
2015). Essential elements included autonomy, being attributable to environmental exposure
parent social support, communication skills, (5%), social circumstances (15%), and genetic
parental monitoring, goal setting, self-monitoring, predispositions (30%). Most chronic diseases
and behavioral skills. can be linked to a limited number of modifiable
Similar to an intent to treat analysis, a complier health behaviors, including tobacco smoking,
average causal effect model (which provides a alcohol consumption, physical activity, and diet
more accurate treatment estimate in the presence of (Suhrcke et al., 2006). In one example, of a
noncompliance), showed no significant treatment population impact of lifestyle interventions
effects on BMI for either adolescents or parents. in primary care settings, Resnicow et al. (2015)
However, adolescents who were compliers provided motivational interviewing and behavioral
(defined through attendance in the group-based skills training to pediatricians and registered
program) showed a 10-min per day increase in dieticians. Pediatric offices were randomized to
physical activity, whereas noncomplying adolescents either provide parents with overweight youth
showed almost a seven-minute decrease in daily with usual care or with motivational interviewing
physical activity (Wilson et al., 2022). Parents sessions targeted at just the pediatrician or at
showed a similar pattern, with a nearly eight- both the pediatrician and the dietician. At a
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minute increase in physical activity for compliers 2-year follow-up, youth in the integrated care
and a decrease in daily physical activity for treatment that included both the pediatrician
noncompliers. These findings provide some and the dietician demonstrated the lowest body
support for the importance of integrating essential mass index; this was significantly better than the
elements from multiple theories. Given that this usual care group. Thus, as this example shows,
study was limited in focusing only on physical the field of health psychology has the potential
health-related outcomes (BMI, physical activity, to play a fundamental role in reducing health
diet), future research is needed that evaluates care utilization and costs by improving lifestyle
the cascading effects of these comprehensive habits that have been related to the prevention of
theoretical interventions on mental and social chronic disease (for examples across the lifespan,
well-being (Wilson, 2015). A recent qualitative see Wilson & Sweeney, 2018).
follow-up study, for example, showed a ripple Although interventions that included behavioral
effect of the FIT intervention on improving skills training have been effectively delivered
positive communication and social support among by health psychologists, those delivered by
adolescents and their parents (Sweeney et al., physicians have been shown to produce relatively
2019). Other recent trials also support this small effects. A meta-analysis of 17 randomized
approach to integrated theories that address trials that offered brief advice from physicians
individual, family, and social-environmental demonstrated small effects (Stead et al., 2013).
factors (St. George et al., 2013; Sweeney et al., Similarly, in another meta-analysis of physician-
2022; Zarrett et al., 2021). offered interventions for weight loss (Mitchell
Integrating these theoretical approaches to et al., 2016), the effect sizes were of small
promote healthy lifestyle change is important in magnitude (d = 0.26). In conclusion, although
a variety of contexts, including the health care physician-delivered interventions have shown
system. Improving the quality of health care and only small effects on improving health behavior
population health has become a national priority outcomes, further research is needed to compare
(Stoto, 2013). When examining factors that the integration of behavioral interventions in
contribute to premature death, investigators have health care settings.
estimated that access to health care explains In summary, we argue for the importance of
10% of variance in outcomes (Schroeder, 2007). improving adherence to a healthy lifestyle by
Behavioral patterns, however, explain 40% of the including targeting family, motivational, behavioral,

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 Wilson, Sweeney, and Zarrett

and ecological systems including health care The first principle of this life course framework
systems. The field of health psychology is is to view health as a process that develops over
grounded in theoretical approaches that emphasize the lifespan and involves the acquisition and
the role of multiple systems of influence and is optimization of health capacities through the
well poised to play a central role in developing early years, maintenance of these capacities during
effective behavioral interventions with a midlife, and management, adjustment, and
population-level impact. adapting to decline in these capacities in the
late years of adulthood. Within this framework,
health pathways are conceived as driven by
EMPIRICAL SUPPORT FOR PROTECTIVE
cumulative risk or protective processes with
FACTORS OVER THE LIFESPAN
the development of earlier health promotion or
Health behaviors can be best understood through compromising behaviors influencing one’s capacity
an integration of relational and dynamic systems for later health and well-being. Figure 18.1
life course perspectives of human development presents our proposed conceptual model for
(Bronfenbrenner, 2005; Halfon et al., 2014). addressing health capacity across the lifespan.
These models health as a complex, developing, The development of capacity begins prior to
and emergent process across the lifespan that conception with a woman’s reproductive health
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involves dynamic interactions between individu- (e.g., nutrition, neural-hormonal environment)

als and their environments over time to promote and continues with maternal prenatal health and
and optimize health outcomes (Bronfenbrenner, resources to support fetal and postnatal develop-
2005; Schwartz, 1982). Several key principles of an ment (Larqué et al., 2019). Early developmental
integrated relational systems life course perspective experience that either support or hinder the
on health development inform approaches for development of personal capacity (i.e., physical,
improving health trajectories. social, cognitive assets or tools) continue to

CULTURAL
Exo- and macrosystemic factors, social and
institutional supports, policies

ENVIRONMENT
Physical, social, emotional, and cognitive
resources and constraints within family,
school, work, and other microsystems

BEHAVIOR
Regulatory processes, dietary intake, physical
activity, risk and preventive behavior

COGNITIVE, SOCIAL, AFFECTIVE

Health-based self-concepts, self-efficacy,
identity, value, enjoyment, motivation

BIOLOGY
Inner biological/physiological genetic activity,
neural activity, disease, disability

Prenatal Late adulthood

INDIVIDUAL DEVELOPMENT

FIGURE 18.1.   A developmental systems approach: Bidirectional (transactional) influences on health capacity.
Data from Gottlieb (1992), Bronfenbrenner (2005), and Lerner (2004).

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 Behavioral Risk and Protective Factors

cumulate through childhood and adolescence moment-to-moment pattern of exchange

and determines the degree to which individuals between the individual and their surroundings.
are able to effectively interact with their biological, The ecological model outlined by Bronfenbrenner
physical, and social environments to optimize (2005) provides a framework for understanding
their health potentials. Similarly, early disruptions health and health behaviors as shaped by the
in capacity development can set in motion a interaction of intrapersonal factors with key
cascade of developmental processes that result environmental subsystems, including micro­
in an individuals’ reduced capacity to optimize systemic factors (e.g., families, schools, churches,
their health potentials. For example, exposure to neighborhoods, and other institutions), meso-
adverse experiences during infancy can lead to systemic factors (interactions between family,
compromised emotional and behavioral regulatory schools, and other institutions), exosystemic
abilities during childhood and adolescence, which factors (broader community resources, events,
in turn can set an individual on a pathway of poor policies), and macrosystemic effects (all systems,
physical and mental health through the impact that micro-, meso-, and exo-, as they are related to
dysregulation has on eating behaviors, vulnerability a culture or subculture). A multilevel devel­
to substance use, addiction, and financial instability opmental system approach emphasizes the
(Repetti et al., 2002). Under optimal developmental need to address change both in the individual
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conditions, this early part of the lifespan through and the contexts in which individuals develop
young adulthood can be utilized to invest in future with the goal of promoting positive development.
health potentials and build health reserves to help This principle has highlighted the need and
offset the impact of declines experienced in later effectiveness of “horizontal” or “whole community”
life (Li & Freund, 2005). approaches to health care, where medical services
During adulthood and midlife through late are only one part of an integrated system of
adulthood, the focus increasingly shifts from supports across an individual’s daily settings.
growth to the maintenance of capacities as For example, rather than addressing obesity
individuals fend off accumulating risks and solely within a physician’s office, a collaborative
weathering associated with age. As individuals network of both traditional medical services and
begin to experience physical and cognitive declines nontraditional services and settings—including
during late adulthood, the primary focus is to families, workplaces, parks and recreational
identify strategies to adjust for loss and to optimize services or settings, daycares, schools, local gyms,
functioning. Although access to cultural and grocery stores—is needed to optimize effective
social-environmental supports are important prevention and intervention approaches (Halfon
across the lifespan, during the formidable pre- et al., 2007). The development of this more
gestational through childhood period and again comprehensive community-based intervention
during declines at the later end of the lifespan, approach, or what Halfon et al. (2007, 2014) call
individuals are most dependent (and affected by) health-promoting networks, has been shown to
on the access they have to external environmental be highly effective for supporting the prevention
resources to establish and maintain optimal health or reduction of other health-compromising
functioning (Halfon et al., 2014; Li & Freund, behaviors. For example, the Oregon Reducing
2005). In the context of health as a process Youth Access to Alcohol intervention (Flewelling
across the life course, this finding highlights et al., 2013) was initiated as a collaborative effort
the importance of taking a future-orientated involving researchers, local community actors,
approach to health care and toward identifying and the Addictions and Mental Health Division
risk and protective factors and their cumulative of Oregon’s Department of Health and Human
impact on individuals’ health trajectories. Services. The five specific programs included
Another principle of the life course framework community mobilization to educate, train.
is that healthy development results from the and coordinate community partners; a reward

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and reminder program for alcohol merchants and nurturing the physical, cognitive and social-
that included education and training to prevent emotional foundation for lifelong health and
underage sales; media advocacy that included well-being. During this period, individuals have
newspaper articles and community or school the greatest dependency on parents and other
newsletters to reach families, teachers, and other caregivers and thus risks and promotive factors
youth advocates; enforcement of activities; and embedded within the family system are likely to
coordination and community outreach. Significant have the greatest influence on health (Repetti et al.,
reductions in 30-day drinking and underage binge 2002). For example, research has demonstrated
drinking were found in com­munities with the that an authoritative (autonomy supportive)
highest levels of implemen­tation. This study parenting style that supports attachment, warmth,
provides a clear example of an ecological systems and the development of self-regulation skills,
approach to reducing alcohol use in youth. as well as positive parental feeding styles and
Another principle of the life course framework practices (e.g., parent perceived responsibility
is that the individual is perceived as an active agent for child’s diet, parental monitoring of dietary
in the developmental process. That is, individuals intake; introduction of fruits and vegetables) and
actively construct their lives through the choices physical activity practices (e.g., role modeling,
and actions they take within the range of resources direct provision of activity-related experiences,
Copyright American Psychological Association. Not for further distribution.

and constraints of their biological and contex- values and efficacy beliefs about physical activity)
tual affordances within historical time. Aligned with are highly influential on children’s physical
theory (e.g., SCT, expectancy-value model, SDT) activity and dietary intake (Emmett et al., 2015;
and empirical research on motivation and behavior, Pugliese & Tinsley, 2007). At the other extreme,
key characteristics of the individual including exposure to adverse experiences—such as violence
health-based self-concepts and identities, self- or maltreatment, or even the prevalent, day-to-day
efficacy and expectancies for future achievement impoverished interactions between parent and
of one’s health-based goals, as well as one’s interest child due to parent depression, economic hard-
or value of health promotive or compromising ship, or stress during these formidable years—
behaviors have been identified as primary predic- is associated with lifelong health risk behaviors
tors of individuals’ engagement and long-term (i.e., alcohol, tobacco use, risky sexual behavior,
motivation in health behaviors (Bandura, 1986; and teen pregnancy) and associated health
Eccles & Wigfield, 2002; Ryan & Deci, 2000) and problems including obesity, heart disease, Type 2
are common mechanisms targeted in behavioral diabetes, sexually transmitted diseases, premature
interventions (e.g., Bandura, 2004). These studies mortality, accelerated aging and memory loss,
cover a vast range of health-promoting behaviors, poor mental health, and attempted suicide
including nutritional and dietary modifications (Amemiya et al., 2019; Hughes et al., 2017;
through fostering family and youth self-efficacy Repetti et al., 2002).
for healthy eating (Bestle et al., 2020; Wilson, Adolescence and early adulthood are considered
2015, 2022), building efficacy for engaging in the healthiest time in the lifespan, with morbidity
physical activity (Olander et al., 2013), the efficacy and mortality driven almost exclusively by
of key change agents (e.g., teachers, afterschool preventable risks. Given that health behaviors
program staff) to model physical activity within initiated during adolescence often extend into
youth settings (Zarrett et al., 2021), refusal and adulthood, development of negative behaviors
quitting or abstinence efficacy for substance use during the adolescent period can have dire
and sexual risk behaviors (Cordova et al., 2020), consequences on lifelong health outcomes,
and promotion of mental health and well-being educational and occupational attainment, housing,
(Toledano-González et al., 2019). and overall quality of life. By early adolescence,
Infancy through middle to late childhood have youth have begun to formulate their own health
been identified as critical years for developing attitudes, beliefs, goals, and intentions with

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respect to health behaviors based on their child- to access to and availability of healthy foods, and
hood experiences; these rudimentary conceptions safe spaces and opportunities for physical activity,
are further shaped by adolescent influences, which health challenges related to access, type, and
then predict health behaviors through the lifespan. quality of work, time constraints associated with
Although the home context continues to play a balancing work and caregiving of children and
role in providing opportunities that either support older parents (Ding et al., 2020; Robert Wood
or inhibit particular health behaviors, the major Johnson Foundation, 2008). Unemployment
biological, cognitive, and social changes during is associated with financial hardship, limited
the transitional period of adolescence increase access to health insurance, and other barriers to
the influence of other social and cultural systems health promotion (e.g., inability to afford healthy
on youth health behaviors, as youth orientation housing, nutritious food, medical care) and
toward interactions and relationships, with peers the engagement in health promotion behaviors
becoming more prominent during adolescence (Robert Wood Johnson Foundation, 2008).
(Brown & Larson, 2009; Steinberg, 2005). Aligned In addition, unemployment is associated with
with these developmental changes, as research higher risk of suffering from stress-related
has consistently demonstrated, is the powerful illnesses such as high blood pressure, stroke,
influence that adolescents’ peers have on their heart attack, heart disease, and arthritis, as well
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health promotive (Springer et al., 2006) and risky as stress-induced poor mental health including
behaviors (Defoe et al., 2019); relatedly, peer depression, anxiety, and physical pain (Friedland
networks have been shown to diminish or amplify & Price, 2003). Longitudinal research has
prevention programs (Shin et al., 2014). Likewise, suggested that unemployment also increases
peer-led interventions to prevent tobacco, alcohol, the risk of unhealthy coping behaviors such as
or drug use (MacArthur et al., 2016) as well as alcohol, smoking, and drug use (Korpi, 2001).
interventions that promote healthy behaviors The dire ramifications of unemployment are
through fostering peer connectedness (Zarrett currently a key public health concerns as
et al., 2021) show particularly high promise unemployment and disparities of the working
in leveraging these developmental needs for poor have only been exacerbated by the COVID-19
health promotion. As adolescents increasingly pandemic (Karpman et al., 2020). Studies show
look toward their social worlds, school and that workers who experience any of these work
neighborhood policies as well as societal-cultural stressors are at higher risk for preventable injuries,
norms and cues also grow more salient for heart disease, and digestive disorders (Robert
informing young people’s adoption of health Wood Johnson Foundation, 2008). Additionally,
promotive or compromising behaviors. Adoles- workplace injustices disproportionately expe-
cents increasingly become active agents in their rienced by African Americans, Hispanics, and
own construction of health attitudes, beliefs, immigrants—such as discrimination, harassment,
goals, and intentions. Youth participatory abuse, and bullying—have also been shown to
approaches centered on empowering adoles- be related to poor mental and physical health
cents to engage with school and community (Okechukwu et al., 2014). Interventions for adults
partners to inform school and community must consider systemic issues concerning access
policies to support their health behaviors have and quality of employment, financial stability,
been identified as a particularly effective strategy and child or elderly care. Recent implementation
for helping foster adolescents’ self-efficacy of career-friendly workplace programs that support
and empowerment for behavioral change, and flexible working hours, telecommuting, support
improved health behaviors (Abraczinskas & services, paid or unpaid leave, financial assistance,
Zarrett, 2020). and culture change have been shown to be
The adulthood years are also characterized by highly effective for improving health outcomes
unique health challenges and supports. In addition (Ding et al., 2020).

399
 Wilson, Sweeney, and Zarrett

The successful aging perspective is multi- Through these examples, we argue that more
dimensional and highlights the importance of dynamic theoretical frameworks are needed that
social determinants of health with a focus on integrate ecological systems with behavioral
the avoidance of disease and disability as well changes theories to better understand the social
as the maintenance of physical and cognitive context that impacts physical, mental, and social
functioning and sustained engagement in social well-being. Future research should focus on the
and productive activities (Rowe & Kahn, 1997). development and maintenance of health capacity
With the physical and cognitive declines associated occurs through a process of systemic interactions
with older adulthood, reliance on social and within and between the individual and the
institutional supports increases (Li & Freund, environment, over time.
2005). Lack of adequate societal allocation of
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