A key group of publications includes scientific papers and chapters that report research to develop, test, refine, and replicate the social action theory of health behavior change and biologically adaptive strivings. Findings reported in these publications led to the discovery that agonistic striving may constitute a significant and persistent source of toxic environmentally induced stress.

Ewart, C.K. (1991). Social action theory for a public health psychology. American Psychologist, 46, 931-946. DOI: 10.1037//0003-066x.46.9.931

Ewart, C.K. (1994). Health promotion and disease prevention: A social action conception of compliance behavior. In N.A. Krasnegor, L. Epstein, S.B. Johnson, & S. Jaffe (Eds.), Developmental aspects of health compliance behavior (pp. 251-280). Erlbaum.

Ewart, C.K., & Fitzgerald, S.T. (1994). Changing behaviour and promoting well-being after heart attack: A social action theory approach. Irish Journal of Psychology, 15, 219-241. DOI: 10.1080/03033910.1994.10558005

Ewart, C.K. (2004). How integrative behavioral theory can improve health promotion and disease prevention. In: R. Frank, J. Wallander, & A. Baum (Eds.). Models and perspectives in health psychology. Washington, DC: American Psychological Association.

Ewart, C.K., (2009). Changing our unhealthy ways: Emerging perspectives from social action theory. In: R. DiClemente, R. Crosby, & M. Kegler (Eds.). Emerging theories in health promotion practice and research, 2nd. Edn. Jossey-Bass.

An important group of papers report research testing the hypothesis that agonstic striving activates stress systems to adversely shape health outomes across different age, race, and gender groups, social classes, cultural regions, and illnesses.

Ewart, C.K., & Jorgensen, R.S. (2004). Agonistic interpersonal striving: Social-cognitive mechanism of cardiovascular risk in youth? Health Psychology. 23, 75-85. DOI: 10.1037/0278-6133.23.1.75

Ewart, C.K., Elder, G.J., Smyth, J.M., Sliwinski, M., & Jorgensen, R.S. (2011). Do agonistic motives matter more than anger? Three studies of cardiovascular risk in youth. Health Psychology, 30, 510-534. DOI: 10.1037/a0023127

Ewart, C.K., Elder, G.J., & Smyth, J.M. (2012). How implicit motives and everyday self-regulatory abilities shape cardiovascular risk in youth. Annals of Behavioral Medicine, 43, 286-298. DOI: 10.1007/s12160-011-9336-3

Ewart, C.K., Elder, G.J. & Smyth, J.M. (2014). How neighborhood disorder increases blood pressure in youth: Agonistic striving and subordination. Journal of Behavioral Medicine, 37, 113-126. DOI: 10.1007/s10865-012-9467-4

Ewart, C.K., Elder, G.J., Laird, K.T., Shelby, G.D., Walker, L.S. (2014). Can agonistic striving lead to unexplained illness? Implicit goals, pain tolerance, and somatic symptoms in adolescents and adults. Health Psychology, 33, 977-985. DOI: 10.1037/a0033496

Maisto, S. M., Ewart, C. K., Witkiewitz, K., Connors, G. J., Elder, G., Krenek, M., & Ditmar, M. (2016). Predicting drinking lapses in alcohol use disorder: The toxic combination of agonistic striving and poor anger regulation. Journal of Social and Clinical Psychology, 35(3), 235-254. DOI:10.1521/jscp.2016.35.3.235

Ewart, C.K., Elder, G.J., Jorgensen, R.S., & Fitzgerald, S.T. (2017). The role of agonistic striving in the association between cortisol and high blood pressure. Psychosomatic Medicine. 79, 416-425. DOI: 10.1097/psy.0000000000000412

Maisto, S. A., Xie, F. C., Witkiewitz, K., Ewart, C. K., Connors, G. J., Zhu, H., Elder, G., Ditmar, M., & Chow, S. (2017). How chronic self-regulatory stress, poor anger regulation, and momentary affect undermine treatment for alcohol use disorder: Integrating social action theory with the dynamic model of relapse. Journal of Social and Clinical Psychology, 36, 238-263. DOI: 10.1521/jscp.2017.36.3.238

Ewart, C.K. (2024). Precarious Goals: A biopsychological model of adaptive strivings articulates how harsh social worlds erode physical health. Preprint available at the Open Science Framework, PsyArXiv: https://osf.io/preprints/psyarxiv/pjhku

The model of biologically adaptive strivings was developed, tested, and refined initially in research conducted in large Baltimore high schools that served many Black and White students from across the city, including large numbers of students from neighborhoods with high levels of poverty, disorder, crime, and violence. The research program, known as Project Heart, developed reliable and ecologically valid methods to measure biologically adaptive strivings and emotion regulation capabilities in thousands of adolescents and young adults of diverse racial, ethnic, socioeconomic, and educational backgrounds. The research used methods that combined quantitative naturalistic observation (e.g., semi-structured interviews, electronic diaries, and ambulatory blood pressure monitoring) with controlled laboratory experiments that investigated physiologic and behavioral responses to social and nonsocial stressors. A combined experimental and naturalistic approach made it possible to examine stress-related behaviors and disease risk factors in their full complexity and to formulate and test an ecological theory of goal driven action, perception, emotion, and physiology that would be likely to generalize to other populations.

The Project Heart research produced reliable and ecologically valid behavioral-observational methods to measure adaptive strivings and emotion regulation processes by developing the Social Competence Interview (SCI) and the Anger Transcendence Challenge (ATC). The research also produced the City Stress Inventory (CSI), a reliable and valid method to measure social-environmental factors that impair self-regulation. The CSI has guided health research in different American cities and in countries that include India, Mexico, Lithuania, and Peru. Publications from this research include evidence indicating that chronic exposure to neighborhood disorder and violence increases hypertension risk by inducing agonistic striving. A second important group of publications report research that developed methods to detect and measure adaptive strivings that create an ecology of human stress.

Ewart, C.K. & Kolodner, K.B. (1991). Social competence interview for assessing physiological reactivity in adolescents. Psychosomatic Medicine, 53, 289-304. DOI: 10.1097/00006842-199105000-00003

Ewart, C.K., & Kolodner, K.B. (1993). Predicting ambulatory blood pressure during school: Effectiveness of social versus nonsocial reactivity tasks in black and white adolescents. Psychophysiology, 30, 30-38. DOI: 10.1111/J.1469-8986.1993.Tb03202.X

Ewart, C.K,. & Suchday, S. (2002). Discovering how urban poverty and violence affect health: Development and validation of a neighborhood stress index. Health Psychology, 21, 254-262. DOI: 10.1037/0278-6133.21.3.254

Ewart, C.K., Jorgensen, R.S., Suchday, S, Chen, E., & Matthews, K.A. (2002). Measuring stress resilience and coping in vulnerable youth: The Social Competence Interview. Psychological Assessment, 14, 339-352. DOI: 10.1037//1040-3590.14.3.339

Ewart, C.K., Jorgensen, R.S., Schroder, E., Suchday, S., & Sherwood, A. (2004). Vigilance to a persisting personal threat: Unmasking cardiovascular consequences in adolescents with the Social Competence Interview. Psychophysiology, 41, 799-804. DOI: 10.1111/J.1469-8986.2004.00199.X

Suchday, S., Kapur, S., Ewart, C.K., & Friedberg, J.P. (2006). Urban stress and health in developing countries: Development and validation of a neighborhood stress index for India. Behavioral Medicine, 32, 77-86. DOI: 10.3200/bmed.32.3.77-86

Maisto, S.M., Ewart, C.K., Connors, G.J., Funderburk, J.S., & Krenek, M. (2009). Use of the Social Competence Interview and the Anger Transcendence Challenge in individuals with alcohol use disorder. Journal of Behavioral Medicine, 32, 285-293. DOI: 10.1007/s10865-009-9201-z

My social-environmental studies have identified agonistic processes in close relationships that impair self-regulation and increase cardiovascular risk. Early studies with my Stanford colleagues produced the first experimental evidence indicating that agonistically driven communication patterns generate dangerous blood pressure rises in cardiac patients with hypertension. This work disclosed the importance of regulating agonistic exchanges and encouraged other health scientists to undertake research investigating interaction patterns in couples and families as sources of disease risk. An early publication reviewing evidence for genetic and nonshared familial environmental influences helped foster interest in understanding how genes and agonistic interpersonal processes might operate in combination to affect disease onset and severity. These publications afforded important evidence to support the social action theory hypothesis that agonistic striving can produce a harsh social ecologies that endanger cardiovascular health by fostering hypertension.

Ewart, C.K., Burnett, K.F., & Taylor, C.B. (1983). Communication behaviors that affect blood pressure: An A-B-A-B analysis of marital interaction. Behavior Modification, 7 (3), 331-344. DOI: 10.1177/01454455830073003

Ewart, C.K., Taylor, C.B., Kraemer, H.C., & Agras, W.S. (1991). High blood pressure and marital discord: Not being nasty matters more than being nice. Health Psychology, 10, 155-163. DOI: 10.1037/0278-6133.10.3.155

Ewart, C.K. (1991). Familial transmission of essential hypertension: Genes, environments, and chronic anger. Annals of Behavioral Medicine, 13, 40-47. DOI: 10.1093/abm/13.1.40

Ewart, C.K. (1993). Editorial Comment: Marital interaction: The context for psychosomatic research. Psychosomatic Medicine, 55, 410-412. DOI: 10.1097/00006842-199309000-00002

Ewart, C.K., (1994). Nonshared environments and heart disease risk: Concepts and data for a model of coronary-prone behavior. In E.M. Hetherington, D. Reiss, & R. Plomin (Eds.), Separate social worlds of siblings: Impact of the nonshared environment on development (pp. 175-203). Erlbaum.

Chen, E., Matthews, K.A., Salomon, K., & Ewart, C.K. (2002). Cardiovascular reactivity during social and non-social stressors: Do children’s personal goals and expressive skills matter? Health Psychology, 21, 16-24. DOI: 10.1037/0278-6133.21.1.16

Attempts to explain data linking psychological factors to illness have faced the challenge of identifying the social-cognitive mechanisms that could cause organic harm by impairing behavioral self-regulation and activating stress systems. Scientific progress has been hampered by a reliance on global personality constructs that are vaguely defined, and by the practice of measuring psychological traits as behavioral trends or averages as opposed to measuring the causal social and neurocognitive processes that generate the trait. My research has addressed this problem by investigating the social problem-solving processes that let people select and pursue self-regulatory goals when trying to change their behavior or manage stressors. This work has included studies that examine: (a) social problem-solving processes that facilitate and sustain health behavior change; (b) mechanisms of sociotropic cognition and emotion that shape problem-solving and cardiovascular responding during interpersonal transactions; and (c) perceptions of self-efficacy that facilitate goal-driven health behavior changes. The studies of problem-solving and social cognition developed practical behavioral interventions for use in large multi-center trials of dietary change, asthma management, and HIV prevention in urban youth. The work also pioneered the application of self-efficacy theory to the challenge of health behavior change and produced the first self-efficacy scales to measure perceived ability to change exercise and diet behaviors—assessments that subsequently formed a central component of the Stanford Five City Study of community-based heart disease prevention.

Social Problem-Solving Facilitates Health Behavior Change

Ewart, C.K. (1990). A social problem-solving approach to life style change in coronary heart disease. In Schumaker, Schron, & Ockene (Eds.). Handbook of health behavior change (pp. 153-190). Spinger.

Hanna, K.J., Ewart, C.K., & Kwiterovich, P.O. (1990). Child problem-solving competence, behavioral adjustment, and adherence to lipid-lowering diet. Patient Education and Counseling, 16, 119-131. DOI: 10.1016/0738-3991(90)90086-z

Wade, S.L., Holden, G., Lynn, H., Mitchell, H., & Ewart, C. (2000). Cognitive-behavioral predictors of asthma morbidity in inner-city children. Developmental and Behavioral Pediatrics, 21, 340-346. DOI: 10.1097/00004703-200010000-00004

Social Problem-Solving Shapes Stress Exposure and Responding

Ewart, C.K. (1978). Self-observation in natural environments: Reactive effects of behavior desirability and performance standards. Cognitive Therapy and Research, 2, 39-56. DOI: 10.1007/BF01172511

Ewart, C.K., & Thoresen, C.E. (1978). The Rational-Emotive manifesto. In J. Whitely (Ed.), Rational-emotive therapy, Brooks-Cole.

Ewart, C.K., & Kolodner, K.B. (1992). Diminished pulse pressure response to psychological stress: Early precursor of essential hypertension? Psychosomatic Medicine, 54, 436-446. DOI: 10.1097/00006842-199207000-00006

Roter, D., & Ewart, C.K. (1992). Emotional inhibition in essential hypertension: Obstacle to communication during medical visits? Health Psychology, 11, 163-169. DOI: 10.1037/0278-6133.11.3.163

Ewart, C.K., & Kolodner, K.B. (1994). Negative affect, gender, and expressive style predict ambulatory blood pressure in adolescents. Journal of Personality and Social Psychology, 66, 596-605. DOI: 10.1037//0022-3514.66.3.596

Ewart, C.K. (1995). Social-cognitive origins of chronic stress in adolescents: Recent findings from school-based studies of urban youth. Journal of Health Education, 26, 132-138. DOI: 10.1080/10556699.1995.10603084

Ewart, C.K., Jorgensen, R.S., & Kolodner, K.B. (1998). Sociotropic cognition moderates blood pressure response to interpersonal stress in high-risk adolescent girls. International Journal of Psychophysiology, 28, 131-142. DOI: 10.1016/S0167-8760(97)00091-3

Fitzgerald, S.T., Haythornthwaite, J.A., Suchday, S., & Ewart, C.K. (2003). Anger in young Black and White workers: Effects of job control, dissatisfaction, and support. Journal of Behavioral Medicine, 26, 283-296. DOI: 10.1023/A:1024228026022

Fitzgerald, S.T., Brown, K.M., Sonnega, J.R., & Ewart, C.K. (2005). Early antecedents of adult work stress: Social emotional competence and anger in adolescence. Journal of Behavioral Medicine, 28, 223-230. DOI: 10.1007/S10865-005-4658-X

Sauro, M.D., Jorgensen, R.S., Ewart, C.K., Schum, J.L., & Gelling, P. (2005). Sociotropic cognition moderates stress-induced cardiovascular responsiveness in women through effects on total peripheral resistance, but not cardiac output. International Journal of Psychophysiology, 56, 55-64. DOI: 10.1016/j.ijpsycho.2004.09.008

Self-Efficacy Perceptions Mediate Health Behavior Changes

Ewart, C.K., Taylor, C.B., Reese, L.B., & DeBusk, R.F. (1983). The effects of early post myocardial infarction exercise testing on self-perception and subsequent physical activity. American Journal of Cardiology, 51, 1076-1080. DOI: 10.1016/0002-9149(83)90348-x

Taylor, C.B., Bandura, A., Ewart, C.K., Miller, N.H., & DeBusk, R.F. (1985). Exercise testing to enhance wives’ confidence in their husband’s capability soon after clinically uncomplicated myocardial infarction. American Journal of Cardiology, 55, 635-38. DOI:10.1016/0002-9149(85)90127-4

Ewart, C.K., Stewart, K.J., Gillilan, R.E., & Kelemen, M.H. (1986). Self-efficacy mediates strength gains during circuit weight training in men with coronary artery disease. Medicine and Science in Sports and Exercise, 18, 531-540. DOI: 10.1249/00005768-198610000-00007

Ewart, C.K. (1992). Self-efficacy and recovery from acute myocardial infarction. In R. Schwarzer (Ed.), Thought control of action (pp. 287-304). Springer.

Ewart, C.K. (1995). Self-efficacy and recovery from heart attack: Implications for a social cognitive analysis of exercise and emotion. In: Self-efficacy, adaptation, and adjustment: Theory, research, and application. J. E. Maddux (Ed.). Plenum.

It is crucial to determine if social-ecological and self-regulatory mechanisms of illness (a) can be modified by behavioral interventions, and (b) if the interventions can lower risk. My research publications include some of the earliest contributions to these questions. Early papers helped build scientific interest in developing biopsychological approaches to health promotion and disease prevention. This work involved conducting experiments to evaluate behavioral risk-reduction interventions targeting social and self-regulatory mechanisms. It produced the first experimental evidence that altering communication patterns during marital arguments could lower blood pressure responses to interpersonal stress in patients with hypertension, as well as the first randomized clinical trial (RCT) of self-calming (relaxation, diaphragmatic breathing, meditation) to lower blood pressure in low-income urban youth whose high-normal blood pressure increased their risk for cardiovascular disease. This research showed that a self-calming intervention delivered daily in school reduced resting blood pressure levels in Black and White adolescents who lived in high-stress Baltimore neighborhoods. Another RCT demonstrated that school-based exercise can lower blood pressure in adolescent girls who are at increased risk for hypertension. These findings have encouraged research on interventions to lower disease risk by modifying the social ecologies of self-regulation, targeting high-risk youth in school settings.

Ewart, C.K., Taylor, C.B., Kraemer, H.C., & Agras, W.S. (1984). Reducing blood pressure reactivity during interpersonal conflict: Effects of marital communication training. Behavior Therapy, 15, 473-484. DOI: 10.1016/S0005-7894(84)80050-7

Ewart, C.K., Harris, W. L., Iwata, M., Bullock, R., Coates, T.J., Simons, B. (1987). Feasibility and effectiveness of school-based relaxation to lower blood pressure. Health Psychology, 6, 399-416. DOI: 10.1037//0278-6133.6.5.399

Ewart, C.K., Young, D., & Hagberg, J.M. (1998). Effects of school-based aerobic exercise on blood pressure in adolescent girls at risk for hypertension. American Journal of Public Health, 88, 949-951. DOI: 10.2105/ajph.88.6.949