Integrating Multiple Health Behaviors in Single Interventions

The Problem of Multiple Co-existing Health Risks among Youth 

The Centers for Disease Control and Prevention recently reported (CDC, 2014) that millions of American youth experience a wide range of risk behaviors known to harm their physical and mental health.  Research indicates that the majority of youth in the US experience two or more co-occurring health risk behaviors, and over a third have three or more risk habits (Fox, et al., 2010).   

Unfortunately, there is little information available describing how to address multiple, diverse health behaviors in prevention and health programs for youth.  In this article we discuss how health behaviors are associated, practice implications for health behavior associations, and how to connect substance use risk behaviors with health promoting behaviors in single interventions that link prevention with wellness. 

How Are Health Behaviors Associated? 

We can group health behaviors into two types.  Risk behaviors such as substance use habits, and health promoting behaviors like physical activity and healthy eating.  The associations between these two types of health behaviors pose both bad news and good news which youth should understand to be able to make informed health decisions.   

The bad news is that participation in one or more risk behaviors is associated with increases in other risk behaviors.  For example, youth who drink alcohol are also more likely to engage in additional risk behaviors such as cigarette smoking, marijuana consumption, violence, suicide, and unprotected sex.    

In addition, risk behaviors are linked with decreases in the initiation and maintenance of health promoting habits.  For example, underage youth who drink alcohol are also less likely to participate in regular physically activity, eat healthy, and have good control of their stress.   

The good news is that participation in one or more health promoting habits is associated with increases in other healthy behaviors.  For example, youth participating in regular physical activity are also more likely to practice other healthy habits such as eating healthy, getting adequate sleep, and controlling their stress.   

In addition, health enhancing habits are linked with decreases in risk behavior initiation and continuation.  For example, young people who get regular exercise are also less likely to experiment with and engage in frequent substance use, violence, and suicide.   

Practice Implications of Health Behavior Associations 

The connections between health risk and health promoting behaviors may or may not be causative.  However, they are associated in either a positive or negative direction, providing hints as to how they should be addressed in programs to protect and enhance the physical and mental health of youth.  

The key implications of health behavior associations for prevention and health specialists are threefold.  First, we need to continue to do all we can to effectively prevent and reduce health risk behaviors among youth.  Not just because they cause harm in and of themselves, but also because they can compound pain and suffering among youth by increasing the probability of engaging in other risk behaviors while decreasing healthy behaviors.    

Second, to help prevent the onset and continuation of risk behaviors, we should be focusing on increasing healthy behaviors along with working to prevent risk behaviors.  Healthy behaviors are positively associated with engaging in other healthy habits, but equally important is that they are also linked with retarding the initiation and reducing continuation of risk habits.   

Third, to achieve broad-based health behavior improvements, we should be addressing the connections between health risk and health enhancing behaviors in our prevention and health programs for young people.  But how can individual health risk habits and health promoting habits be integrated in a manner that would influence multiple behavior change among youth?   

Three Steps for Integrating Specific Health Risk and Health Promoting Behaviors in Single Interventions 

Since health risk and health promoting habits are interrelated, youth should be taught how individual health behaviors are connected to improve their decision-making skills and motivation to achieve multiple health behavior improvements.  One proven approach to integrating specific health risk and health promoting behaviors in single interventions is by applying the Behavior-Image Model (BIM).   

Below are three steps for connecting specific health habits using BIM. 

Step #1: Generate a list of the positive effects or benefits that can result from youth engaged in each of the targeted health promoting behaviors, including positive behaviors and images. 

You can create this list on your own, or ask your youth to come up with ideas.  The goal is to generate as many positive outcomes as possible that can result from youth who participate in each of the health promoting habits.  This should include healthy behaviors and positive or appealing images. 

For example, if you are interested in increasing physical activity among your youth population, brainstorm a list of all of the good outcomes that can happen when young people exercise regularly.  This could include feeling and looking fit, weight loss and control, preventing heart disease, getting more and better sleep, and helping avoid smoking cigarettes.  

Another way to create a list of benefits that emphasize positive image outcomes is for you or your youth to list characteristics or social images of young people who engage in regular physical activity.  For example, being active, athletic, popular, and successful.   

Step #2: Pairing each risk behavior you wish to address with each of the health promoting habits already identified, create a parallel list of all of the negative effects or costs which can result if you participated in each risk behavior. 

This list differs from the first list by focusing on future self-images and not social images.  This means we want a list of how the risk behaviors might have a negative effect on us in the future, and not youth in general.  This approach prevents communicating negative aspects of youth populations which can harm health message reception.   

You or your youth can again brainstorm a list, but this time it is to identify as many negative outcomes as possible which can result from our engagement in each health risk behavior on each of the health promoting habits and related positive outcomes.  In other words, how each risk behavior interferes with achieving each of the healthy behaviors as well as each of their positive outcomes, and in some cases results in opposite negative effects.   

For example, if you are interested in preventing and reducing marijuana consumption among your youth and you’ve already generated benefits for participating in regular exercise, make a list of all of the bad things marijuana smoking can have on your trying to get daily exercise.  This includes direct effects on the healthy habit such as not having time to engage in regular exercise because of time spent using marijuana, less interest in physical activity because you have new friends that want you to smoke marijuana instead of exercise regularly, or harming your motivated to participate in exercise or sports due to the amotivational effects or weight gain because of marijuana use.   

Marijuana consumption can also negatively influence each of the positive outcomes resulting from regular exercise.  For example, smoking pot on a regular basis could result in your becoming less physically active, harming your athletic abilities, hurting your popularity especially with your original friends, and negatively impacting your school grades and work performance.   

Step #3: Communicate first the positive and then the negative effects associated with each paired health promoting and health risk behavior to youth. 

If you’ve asked youth to generate their own ideas for benefits of participating in individual health promoting behaviors and costs for engaging in selected health risk behaviors, you can just list them as they are being generated and then add any effects that may have been missed.   

If not, you can present positive and negative effects of specific health behaviors to your youth.  First indicate the benefits of each healthy habit and then present how one or more risk habits can interfere with and harm their efforts to obtain each healthy behavior and their resulting positive self-images.    


Most American youth experience multiple, co-existing health risks.  Health risk and health promoting behaviors are associated with each other and therefore should be integrated within single interventions to improve the whole health of young people.     

Youth need to be taught about how health risk and health promoting behaviors are interrelated.  Most importantly, they should be given an opportunity to think about the positive behavior and image outcomes that result from participating in specific health promoting behaviors, and how individual risk behaviors interfere with these desired future behaviors and images.

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