1. On Purpose
A NEW DIRECTION FOR HEALTHRELATED BEHAVIOR CHANGE
Victor J. Strecher, PhD, MPH
Professor, University of Michigan School of Public Health
email: strecher@umich.edu
twitter: Vic Strecher@dungbeetlepress

3. High Tailored Testimonial
Tailoring Variables
Used In This Case:
+ Age
+ Gender
+ Ethnicity
+ Marital status
+ Smoking status of spouse
+ Child in home
+ Physically active
+ # of cigs smoked
+ Job status
+ Barrier
+ Social Support

4. MORE RELEVANT
MESSAGES
Information/advice
MORE
ELABORATION
AND MEMORY,
LESS WORK
Stories
Episodic
memories
Decisionmaking
MORE
BEHAVIOR
CHANGE

5. Re s e a rch
Real world
strecher@umich.edu

10. Change

11. 30%

12. ?

15. OPERATIONS RESEARCH
inform
s
®
Vol. 56, No. 6, November–December 2008, pp. 1335–1347
issn 0030-364X eissn 1526-5463 08 5606 1335
doi 10.1287/opre.1080.0588
© 2008 INFORMS
OR FORUM
Personal Decisions Are the Leading
Cause of Death
Ralph L. Keeney
The Fuqua School of Business, Duke University, Durham, North Carolina 27708,
keeney@duke.edu
This paper analyzes the relationships between personal decisions and premature deaths in the United States. The analysis
indicates that over one million of the 2.4 million deaths in 2000 can be attributed to personal decisions and could have been
avoided if readily available alternative choices were made. Separate analyses indicate 46% of deaths due to heart disease
and 66% of cancer deaths are attributable to personal decisions, about 55% of all deaths for ages 15–64 are attributable
to personal decisions, and over 94% of the deaths attributable to personal decisions result in the death of the individual
making the decisions. Relative to the current 45%, retrospective appraisal suggests that roughly 5% of deaths in 1900
and 20%–25% of deaths in 1950 could be attributed to personal decisions. These results suggest that more effort directed
toward improving personal choices regarding life risks may be an effective and economical way to save lives.
Subject classifications: risk; decision making; decision analysis: applications; health care; information systems:
management; statistics: data analysis.
Area of review: Special Issue on Operations Research in Health Care. OR Forum.
History: Received July 2006; revisions received March 2007, September 2007, February 2008; accepted April 2008.
Participate in the OR Forum discussion at http://orforum.blog.informs.org.

16. 1336
Operations Research 56(6), pp. 1335–1347, © 2008 INFORM
Figure 1.
Influences of personal decisions on causes of death.
Personal decisions concerning
Smoking
Actual causes of death
Medical causes of death
Smoking
Diseases of the heart
Malignant neoplasms (cancer)
Diet
Being overweight
Cerebrovascular diseases (stroke)
Chronic lower respiratory diseases
Exercise
Alcoholic diseases
Diabetes Mellitus (diabetes)
Influenza and pneumonia
Drinking alcohol
Accidents
Unintended injuries
Chronic liver disease and cirrhosis
Doing drugs
Unprotected sex
Hypertension and hypertensive
renal disease
Take your own life
Illicit drugs
Diseases of the circulatory system
AIDS
Condom use
Suicide
Intentional self-harm (suicide)
Assault (homicide)
Criminality
Note. An arrow means “influences.”
Homicide
Other

23. What do you know? Are you an expert on
boiling water? This water isn’t so hot. Now go away,
I’m getting kind of sleepy...

24. Why?

25. We’re defensive

26. We’re all defensive

27. Ego breaks open - then you
see who you really are!

28. Death is very likely the
single best invention of life.
It is life’s change agent.

31. “Do not act as if you
were going to live ten thousand
years. Death hangs over you. While you
live, while it is in your power, be good.”
Marcus Aurelius

32. Another way?

33. Good mother. Good spouse.
In control. Attractive.

34. Good mother. Good spouse.
In control. Attractive.

35. “These studies, in concert
with previous research,
suggest that values
affirmation reduces
defensiveness via selftranscendence...”

38. 92 College
Students
Social exclusion
Ego Threat
No Ego Threat
“you weren’t picked”
“you were picked”... but
“randomly chosen to
work alone

39. Selftranscendent
values
Selfenhancement
values
empathy
support needs
larger than self
growth
relationships
power
wealth
independence
attractiveness
prestige
Daily routine
(no values)
“Please taste-test
these cookies”
Selftranscendent
values
Selfenhancement
values
empathy
support needs
larger than self
growth
relationships
power
wealth
independence
attractiveness
prestige
Daily routine
(no values)

40. Ego threat by type of value affirmed on self-regulatory exertion
(measured by # of cookies eaten) F for interaction = 5.45, p<.01
# of cookies eaten
8.2
4.9
2.8
Selftranscendent
values
Selfenhancement
values
Daily routine
(no values)
Ego Threat
4.8
4.3
4.0
Selftranscendent
values
Selfenhancement
values
Daily routine
(no values)
No Ego Threat

41. Ego threat by type of value affirmed on self-regulatory exertion
(measured by # of cookies eaten) F for interaction = 5.45, p<.01
# of cookies eaten
8.2
4.9
2.8
Selftranscendent
values
Selfenhancement
values
Daily routine
(no values)
Ego Threat
4.8
4.3
4.0
Selftranscendent
values
Selfenhancement
values
Daily routine
(no values)
No Ego Threat

42. Ego threat by type of value affirmed on self-regulatory exertion
(measured by # of cookies eaten) F for interaction = 5.45, p<.01
# of cookies eaten
8.2
4.9
2.8
Selftranscendent
values
Selfenhancement
values
Daily routine
(no values)
Ego Threat
4.8
4.3
4.0
Selftranscendent
values
Selfenhancement
values
Daily routine
(no values)
No Ego Threat

43. ORIGINAL ARTICLE
Effect of a Purpose in Life on Risk of Incident
Alzheimer Disease and Mild Cognitive Impairment
in Community-Dwelling Older Persons
Patricia A. Boyle, PhD; Aron S. Buchman, MD; Lisa L. Barnes, PhD; David A. Bennett, MD
Context: Emerging data suggest that psychological and
Results: During up to 7 years of follow-up (mean, 4.0
experiential factors are associated with risk of Alzheimer disease (AD), but the association of purpose in life
with incident AD is unknown.
years), 155 of 951 persons (16.3%) developed AD. In a
proportional hazards model adjusted for age, sex, and education, greater purpose in life was associated with a substantially reduced risk of AD (hazard ratio, 0.48; 95% confidence interval, 0.33-0.69; PϽ.001). Thus, a person with
a high score on the purpose in life measure (score = 4.2,
90th percentile) was approximately 2.4 times more likely
to remain free of AD than was a person with a low score
(score=3.0, 10th percentile). This association did not vary
along demographic lines and persisted after the addition of terms for depressive symptoms, neuroticism, social network size, and number of chronic medical conditions. In subsequent models, purpose in life also was
associated with a reduced risk of MCI (hazard ratio, 0.71;
95% confidence interval, 0.53-0.95; P=.02) and a slower
rate of cognitive decline (mean [SE] global cognition estimate, 0.03 [0.01], P Ͻ .01).
Objective: To test the hypothesis that greater purpose
in life is associated with a reduced risk of AD.
Design: Prospective, longitudinal epidemiologic study
of aging.
Setting: Senior housing facilities and residences across
the greater Chicago metropolitan area.
Participants: More than 900 community-dwelling older
persons without dementia from the Rush Memory and
Aging Project.

44. J Behav Med
DOI 10.1007/s10865-012-9406-4
Purpose in life and reduced risk of myocardial infarction
among older U.S. adults with coronary heart disease:
a two-year follow-up
Eric S. Kim • Jennifer K. Sun • Nansook Park
Laura D. Kubzansky • Christopher Peterson
•
Received: June 6, 2011 / Accepted: February 7, 2012
Ó Springer Science+Business Media, LLC 2012
Abstract This study examined whether purpose in life
was associated with myocardial infarction among a sample
of older adults with coronary heart disease after adjusting
for relevant sociodemographic, behavioral, biological, and
psychological factors. Prospective data from the Health and
Retirement Study—a nationally representative panel study
of American adults over the age of 50—were used. Analyses were conducted on the subset of 1,546 individuals
who had coronary heart disease at baseline. Greater baseline purpose in life was associated with lower odds of
having a myocardial infarction during the 2-year follow-up
period. On a six-point purpose in life measure, each unit
Coronary heart disease is the leading cause of death among
both men and women in the United States—responsible for
one in every six deaths (Heron et al., 2009). It imposes
immense physical, psychological, social, and financial
burden on individuals, families, and society as a whole.
Ongoing research efforts have focused on identifying the
risk and protective factors that prevent coronary heart
disease and promote heart health.
Past research has mostly looked at the impact of negative
psychological states or traits (e.g. depression, anxiety, and
cynical hostility) on health outcomes such as myocardial
infarction (Kubzansky & Kawachi, 2000; Rozanski et al.,

45. Contents lists available at SciVerse ScienceDirect
Primary Care Diabetes
journal homepage: http://www.elsevier.com/locate/pcd
Original research
Association of HbA1c with emotion regulation, intolerance of
uncertainty, and purpose in life in type 2 diabetes mellitus
Norman H. Rasmussen a,c,∗ , Steven A. Smith b,e , Julie A. Maxson c , Matthew E. Bernard c ,
Stephen S. Cha d , David C. Agerter c , Nilay D. Shah e
a
Department of Psychiatry and Psychology, Division of Integrated Behavioral Healthcare, Mayo Clinic, Rochester, MN, USA
b Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
c Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
d Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
e Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
a r t i c l e
i n f o
a b s t r a c t
Article history:
Background: The extant literature lacks breadth on psychological variables associated with
Received 19 December 2012
health outcome for type 2 diabetes mellitus (T2DM). This investigation extends the scope of
Received in revised form
psychological information by reporting on previously unpublished factors.
28 March 2013
Objective: To investigate if intolerance of uncertainty, emotion regulation, or purpose in life
Accepted 16 April 2013
differentiate T2DM adults with sustained high HbA1c (HH) vs. sustained acceptable HbA1c
Available online xxx
(AH).

46. Contents lists available at SciVerse ScienceDirect
Journal of Psychosomatic Research
Purpose in life and reduced incidence of stroke in older adults: 'The Health and
Retirement Study'
Eric S. Kim ⁎, Jennifer K. Sun, Nansook Park, Christopher Peterson
Department of Psychology, University of Michigan, Ann Arbor, USA
a r t i c l e
i n f o
Article history:
Received 13 July 2012
Received in revised form 19 January 2013
Accepted 22 January 2013
Keywords:
Stroke
Purpose in life
Meaning in life
Healthy aging
Positive psychology
a b s t r a c t
Objective: To determine whether purpose in life is associated with reduced stroke incidence among older
adults after adjusting for relevant sociodemographic, behavioral, biological, and psychosocial factors.
Methods: We used prospective data from the Health and Retirement Study, a nationally representative panel
study of American adults over the age of 50. 6739 adults who were stroke-free at baseline were examined. A
multiple imputation technique was used to account for missing data. Purpose in life was measured using a
validated adaptation of Ryff and Keyes' Scales of Psychological Well-Being. After controlling for a comprehensive list of covariates, we assessed the odds of stroke incidence over a four-year period. We used psychological and covariate data collected in 2006, along with occurrences of stroke reported in 2008, 2010, and during
exit interviews. Covariates included sociodemographic factors (age, gender, race/ethnicity, marital status,
education level, total wealth, functional status), health behaviors (smoking, exercise, alcohol use), biological
factors (hypertension, diabetes, systolic blood pressure, diastolic blood pressure, BMI, heart disease), negative psychological factors (depression, anxiety, cynical hostility, negative affect), and positive psychological
factors (optimism, positive affect, and social participation).
Results: Greater baseline purpose in life was associated with a reduced likelihood of stroke during the four-year
follow-up. In a model that adjusted for age, gender, race/ethnicity, marital status, education level, total wealth,
and functional status, each standard deviation increase in purpose was associated with a multivariate-adjusted
odds ratio of 0.78 for stroke (95% CI, 0.67–0.91, p=.002). Purpose remained significantly associated with a reduced likelihood of stroke after adjusting for several additional covariates including: health behaviors, biological
factors, and psychological factors.
Conclusion: Among older American adults, greater purpose in life is linked with a lower risk of stroke.
© 2013 Elsevier Inc. All rights reserved.

47. 009). Meaning in life and mortality. Journal of Gerontology: Social Sciences, 64B(4), 517–527, doi:10.1093/geronb/gbp047. Advance Access publication on June 10, 2009.
Meaning in Life and Mortality
Neal Krause
Department of Health Behavior and Health Education, School of Public Health and the Institute of Gerontology,
University of Michigan, Ann Arbor.
Objectives. The purpose of this exploratory study was to see if meaning in life is associated with mortality in old age.
Methods. Interviews were conducted with a nationwide sample of older adults (N = 1,361). Data were collected on
meaning in life, mortality, and select control measures.
Results. Three main findings emerged from this study. First, the data suggest that older people with a strong sense of
meaning in life are less likely to die over the study follow-up period than those who do not have a strong sense of meaning.
Second, the findings indicate that the effect of meaning on mortality can be attributed to the potentially important indirect
effect that operates through health. Third, further analysis revealed that one dimension of meaning—having a strong sense
of purpose in life—has a stronger relationship with mortality than other facets of meaning. The main study findings were
observed after the effects of attendance at religious services and emotional support were controlled statistically.
Discussion. If the results from this study can be replicated, then interventions should be designed to help older people
find a greater sense of purpose in life.
Key Words: Meaning in life—Mortality.

48. 009). Meaning in life and mortality. Journal of Gerontology: Social Sciences, 64B(4), 517–527, doi:10.1093/geronb/gbp047. Advance Access publication on June 10, 2009.
Meaning in Life and Mortality
Neal Krause
Department of Health Behavior and Health Education, School of Public Health and the Institute of Gerontology,
University of Michigan, Ann Arbor.
Objectives. The purpose of this exploratory study was to see if meaning in life is associated with mortality in old age.
Methods. Interviews were conducted with a nationwide sample of older adults (N = 1,361). Data were collected on
meaning in life, mortality, and select control measures.
Results. Three main findings emerged from this study. First, the data suggest that older people with a strong sense of
meaning in life are less likely to die over the study follow-up period than those who do not have a strong sense of meaning.
Second, the findings indicate that the effect of meaning on mortality can be attributed to the potentially important indirect
effect that operates through health. Third, further analysis revealed that one dimension of meaning—having a strong sense
of purpose in life—has a stronger relationship with mortality than other facets of meaning. The main study findings were
observed after the effects of attendance at religious services and emotional support were controlled statistically.
Discussion. If the results from this study can be replicated, then interventions should be designed to help older people
find a greater sense of purpose in life.
Key Words: Meaning in life—Mortality.

49. Intensive meditation training, immune cell
telomerase activity, and psychological mediators
Tonya L. Jacobs a,*, Elissa S. Epel b, Jue Lin c, Elizabeth H. Blackburn c,
Owen M. Wolkowitz b, David A. Bridwell d, Anthony P. Zanesco a,
Stephen R. Aichele e, Baljinder K. Sahdra a, Katherine A. MacLean f,
Brandon G. King a, Phillip R. Shaver e, Erika L. Rosenberg a, Emilio Ferrer e,
B. Alan Wallace g, Clifford D. Saron a,h
a
UC Davis Center for Mind and Brain, Davis, CA, USA
b
UC San Francisco Department of Psychiatry, San Francisco, CA, USA
c
UC San Francisco Department of Biochemistry and Biophysics, San Francisco, CA, USA
d
UC Irvine Department of Cognitive Science, Irvine, CA, USA
e
UC Davis Department of Psychology, Davis, CA, USA
f
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
g
Santa Barbara Institute for Consciousness Studies, Santa Barbara, CA, USA
h
UC Davis Medical Center M.I.N.D. Institute, Sacramento, CA, USA
PURPOS E
Received 22 January 2010; received in revised form 28 August 2010; accepted 17 September 2010
KEYWORDS
Meditation;
Neuroticism;
Perceived control;
Purpose in life;
Stress;
TELOMERE
Summary
Background: Telomerase activity is a predictor of long-term cellular viability, which decreases
with chronic psychological distress (Epel et al., 2004). Buddhist traditions claim that meditation
decreases psychological distress and promotes well-being (e.g., Dalai Lama and Cutler, 2009).
Therefore, we investigated the effects of a 3-month meditation retreat on telomerase activity
and two major contributors to the experience of stress: Perceived Control (associated with

50. Journal of Substance Abuse Treatment 40 (2011) 183 – 188
Regular article
Purpose in life predicts treatment outcome among adult cocaine abusers
in treatment
Rosemarie A. Martin, (Ph.D.) a,⁎, Selene MacKinnon, (Psy.D.) a ,
Jennifer Johnson, (Ph.D.) b , Damaris J. Rohsenow, (Ph.D.) a,c
a
b
Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA
Department of Psychiatry and Human Behavior, Brown University, Providence, RI 02912, USA
c
Providence VA Medical Center, 830 Chalkstone Ave., Providence, RI 02908, USA
Received 15 June 2010; received in revised form 14 September 2010; accepted 6 October 2010
Abstract
A sense of purpose in life has been positively associated with mental health and well-being and has been negatively associated with
alcohol use in correlational and longitudinal studies but has not been studied as a predictor of cocaine treatment outcome. This study
examined pretreatment purpose in life as a predictor of response to a 30-day residential substance use treatment program among 154
participants with cocaine dependence. Purpose in life was unrelated to cocaine or alcohol use during the 6 months pretreatment. After
controlling for age, baseline use, and depressive symptoms, purpose in life significantly (p b .01) predicted relapse to any use of cocaine and
to alcohol and the number of days cocaine or alcohol was used in the 6 months after treatment. Findings suggest that increasing purpose in
life may be an important aspect of treatment among cocaine-dependent patients. © 2011 Elsevier Inc. All rights reserved.
Keywords: Cocaine; Purpose in life