With few exceptions, the United States (U.S.) is not taking advantage of the potential for collective action that could generate transformative policies, ways of thinking about budgets and funding streams, or partnerships that hold promise for widespread and impactful improvement in health. Researchers have identified five conditions of collective impact: a common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support. These conditions, however, are not always sufficient for large-scale transformative change [1].

In 2014, the Robert Wood Johnson Foundation (RWJF) introduced a new framework to advance a Culture of Health [2, 3]. It draws attention to the interconnected nature of health and social issues and how U.S. systems, structures, and culture shape and reinforce policies and practices that impact health and well-being. Culture of Health connotes a strong focus on the need to make health a shared value to advance and accelerate improvements in health outcomes [4]. A key driver of making health a shared value is health mindset.

Health mindset is a group of beliefs or assumptions that individuals hold about the causes of health and well-being [5, 6]. Several important factors contribute to health mindset, including an understanding of factors that generate health, such as social determinants of health; perceptions of the relative roles of personal and environmental health influences; and thoughts about equity [4]. Individual mindsets can contribute to a larger community narrative about health and ultimately influence the health priorities of a community. The mindset of individuals, particularly if that mindset is prevalent within a community, can also affect the success and sustainability of potential solutions to current and emerging health crises in the U.S. such as the COVID-19 pandemic, disparities in health, and gun violence. This is evidenced by strong reactions for and against policies to curb the COVID-19 pandemic, extend Medicaid coverage to ensure more Americans have health insurance, and require waiting periods for the purchase of guns. An assessment of whether the proposed solution aligns with one’s mindset, for example, can shape whether people embrace the solution, resist, or ignore it [9, 10]. Research shows that people are motivated to perceive the strength and credibility of solutions and messages in accordance with their predisposing beliefs and values [11, 12]. Gaining a better understanding of the relationships between mindset and the resulting expectations for who is responsible for health can help stakeholders actively working to address health challenges shape potential solutions and implementation strategies.

We examine the personal characteristics and lived experiences that shape two common health-related mindsets in the United States: (1) poor health is driven by poor choices and (2) poor health is driven by factors outside of one’s control. While the two exist and interact to produce health, this forced dichotomy is helpful for understanding these prevailing mindsets and the factors that contribute to them. Next, we explore how health mindset shapes expectations of who can and should be responsible for addressing health challenges, using obesity as an example of a health outcome well-known to be influenced by both personal choices (diet and exercise) and environmental context and conditions outside of one’s control (availability and affordability of healthy foods, safe neighborhoods).

Economic individualism characterizes success as stemming from hard work and self-reliance. This core value of personal responsibility, when extended to conceptualizations of health, lends itself to the parallel conclusion that individuals, rather than government, should be responsible for ensuring the health of individuals [11]. This mindset incorporates a view that changing the choices that individuals make about health behaviors, engagement with the health system, and how they spend their time, among other health-related choices, will result in improved health and well-being.

This mindset is supported by a formidable amount of evidence linking individual behaviors to health outcomes and the effectiveness of behavioral interventions to prevent disease, improve disease management, increase quality of life, and reduce health care costs [13, 14]. Such findings have resulted in powerful summary statements citing behavior as “central to the development, prevention, treatment, and management of the preventable manifestations of diseases and health conditions.” [13]. Underlying notions of individualism and personal responsibility, central to political thought in the U.S., also support this mindset [11, 15,16,17]. These also play roles in current health policy debates related to COVID-19, abortion, and gun control.

This mindset captures core constructs of social determinants and health equity and acknowledges that while individual choices related to one’s health do impact health and well-being, not everyone is afforded the same choices; as a result, factors outside of one’s control ultimately drive poor health. Literature on health equity [18,19,20,21] posits that the “choices” that people make around their health are not available for many marginalized or disadvantaged populations due to policy, structural, or system level barriers that may have existed for generations [18].

Various models point to the importance of factors outside of one’s control, including Dahlgreen and Whitehead’s societal model [22]. It calls attention to the importance of social and community networks, living and working conditions, and general socio-economic, cultural, and environmental conditions as important for health, in addition to individual and lifestyle factors. Related to this mindset, although not the focus of this paper, are other factors that individuals believe influence health. These include fatalistic beliefs that health is “beyond one’s control and instead dependent on change, luck, fate or God.” [23].

Attitudes about obesity intertwine with attitudes about personal responsibility and choices. Although the recognition of the role of environmental factors (food availability, neighborhood opportunities for exercise) is growing, many people continue to believe that obesity is the result of poor choices [16] and lack of self-discipline [24]. Some evidence suggests that this mindset—poor health is driven by poor choices—influences support for obesity policy. Associating obesity with individual choice, for example, is negatively associated with support for government policies to fight obesity [25]. Brownell and colleagues [26] argue that personal responsibility beliefs about obesity constitute “a leading basis for inadequate government efforts,” given that public health interventions may be perceived as forcing people to behave in certain ways, and thus threaten individuals’ autonomy. We saw this play out in the pandemic response, in protests against masking and vaccine mandates.