In Spain, the population over 65 years of age is expected to increase by 10% in the next 50 years (1); and the total dependency ratio to grow from the current 54.2 to 72.2%. The aging of the population is associated with an increase in the number of people with chronic diseases (osteoarticular, cardiovascular, respiratory, mental, neurodegenerative, and cancer) and the resulting higher multimorbidity (two or more concurrent conditions) (2). This poses a great challenge to the health systems because the demand for health and social services escalates (3).

Chronic diseases are the leading cause of overall mortality and premature mortality in the world (they are related to 42% of the deaths occurring before 70 years of age). These conditions have an enormous impact on people’s daily life and their families, and represent a heavy burden on society (4). Among chronic diseases, the high prevalence of mental disorders is worth mentioning (5). Major depression, specifically, holds second place worldwide in terms of disability and disease burden (6). Mortality rates in people with mental health problems are up to double those in people without them. But importantly, most chronic diseases and their complications could be prevented through health promotion and primary prevention strategies; approximately 80% of cardiovascular diseases and 30% of all cancers could be averted (4).

Health promotion and prevention interventions play an essential role when considering the wellbeing of the population from a comprehensive perspective. According to the World Health Organization (WHO), health is a state of physical, mental, and social well-being that includes the ability to function, and not only the absence of disease or infirmity (7). From the perspective of health promotion, the Ottawa Charter defines health as a resource that allows people to lead individual, social, and economically productive lives (8). The general practitioner Jordi Gol stated that ‘health is an autonomous, supportive, and happy way of living’ (9). Furthermore, changes in society have also implied evolution in the role of the population concerning their care and decision making about their health.

In such a framework, health promotion is the process of equipping people with the necessary means to improve their health and exercise greater control over it (10, 11). According to the World Health Promotion Conference in Shanghai (2016), three areas within health promotion need priority: (1) good governance for health, (2) the promotion of healthy cities and communities, and (3) the reinforcement of health knowledge. These areas substantially coincide with the aims of the Strategy for Health Promotion and Prevention from the Spanish National Health System (SNS): to build healthy public policies, to create environments that support health and well-being, to support the empowerment of the individual through the development of personal skills, to reinforce community action, and to reorient the health services (12).

The health and well-being of both individuals and communities depends on the combination of many factors like where we live, our environment, genetics, income and education level, and family and social relationships. Notably, the access to and use of health care services have a limited impact; 80% of determinants of health are outside the influence of the health system (13).

These factors or determinants of health have been analyzed using various models. The Dahlgren-Whitehead model is one of the most widely used (14); it presents the main determinants of health as a range of concentric hierarchical layers where each layer determines the successive layers towards the center. Individuals are located in the center, with their non-modifiable characteristics such as age, sex, and genetic load. Around them, there are various layers of influences over health, such as lifestyles, social and community networks, living and working conditions, and socioeconomic, cultural and environmental conditions. Those factors that enhance the capacity of individuals to maintain health and well-being are defined as “Health Assets” according to the theory of salutogenesis (15). According to Marmot, control over one’s life and opportunities for full social participation are crucial aspects for health, well-being, and longevity (16).

Despite the endorsement of certain elements to improve the future well-being of the population (participation in the decision-making processes, the way people experience and cope with the diseases; and the ability to self-manage their own health and care), little is known about the role of personal determinants and individual aptitudes on the capacity to adopt health-promoting behaviors and respond appropriately to adverse situations. Several classic health-related behavior models and theories and the more recent integrative frameworks try to explain human behavior, the most widely used being the Theoretical Domains Framework (TDF) (17). This framework includes 12 domains derived from 33 theories and covers the main factors that influence behavior, namely knowledge, skills, social/professional role and identity, beliefs about capacities and consequences, memory, attention and decision processes, and social influences. Nevertheless, population-based studies on the predictive validity of the behavioral frameworks applied to health and well-being are lacking.

The importance of the development of personal aptitudes is stated in the Ottawa Charter (8) as one of the bases for establishing health public policies. The efforts to attain such a development should be directed towards providing information and health education and improving the abilities essential for life. This, in turn, would increase the options available for the population so they could exercise higher control over their health and the environment that influences it (8). The evaluation of personality traits includes a whole set of psychological and behavioral characteristics and the internal organization, which make different persons act differently when facing a similar circumstance (18). Certain personality traits are related to harmful behaviors, physical and mental health problems, lower longevity, and more mortality from all causes (19–23).

Some personal aptitudes stand out among those with higher potential impact on health improvement, quality of life, or reduced use of health services: personality traits, locus of control (LOC), self-efficacy, resilience, activation, and health literacy.

The locus of control (LOC) is defined as the extent to which individuals hold agency regarding the events that occur in their life. It can be internal—when the individuals believe that events in their lives are due to their own actions, attitudes, or behaviors; or external—when people believe it is the result of luck, chance, destiny, or the decisions of others (24). The presence of an internal LOC has been associated with a better perception of general health, a lower perceived burden of the diseases (25, 26), and a positive attitude towards health promotion and primary prevention activities (27). Regarding the workplace, the presence of an internal LOC is associated with higher job satisfaction and well-being, better job performance, and lower levels of stress (28). An external LOC has been associated with a worse health status (29), more use of the emergency services and hospital admissions (30), a higher risk of developing cardiovascular diseases (25) and other chronic diseases (31), and a worse physical and psychological health status (32).

Self-efficacy refers to the feeling of confidence in one’s abilities to adequately manage certain stressors in life (33). High self-efficacy was related to better mental function (34); better memory levels, speed of thought, and intelligence (35, 36); and a higher probability of acquiring healthy lifestyles (37). Low self-efficacy has been associated with anxious personality disorder (38).

Resilience is a dynamic process of positive adaptation to stress and adversity regarded as a protective factor against mental problems (39). A high degree of resilience has been considered a protective factor against mental diseases (40). Some authors have even suggested that it is a form of “mental immunity” (41). Resilience is also related to better cognitive function in older adults, specifically, greater verbal fluency and speed of perception (42).

Activation is defined as the capacity and ability to manage one’s personal condition, collaborate with the health provider to maintain one’s own health and wellbeing, access adequate and high-quality care, and prevent health deterioration (43). The Patient Activation Measure (PAM) allows evaluation of the self-knowledge, motivation, and aptitude to manage one’s own health (43). Activation is a tool that allows individuals to reach and maintain healthy lifestyles, and optimize their quality of life (44). Higher activation levels are associated with people with better self-healing capacity, better health status, and lower use of health services (45, 46).

Health literacy refers to the health knowledge of the population, their motivation and individual abilities to understand and make decisions related to the promotion and maintenance of their health (47). Adequate health literacy levels have been associated with healthy lifestyle behaviors, such as eating five servings of fruit and vegetables per day or being a non-smoker-regardless of age, educational level, sex, ethnicity, or income (48, 49). Low health literacy can hinder health self-care and be related to a higher incidence of chronic diseases (50). From a health and social perspective, the improvement of health literacy is an unavoidablechallenge.

To date, we have not identified longitudinal studies that delve into the analysis of all these personal aptitudes and their impact on health in our population. And yet, consideration of the interrelation of personal aptitudes and determinants of health is essential. Even more, there is solid evidence to support the association of socioeconomic, cultural, and environmental determinants with lifestyles, certain risk factors, and diseases (51). In the framework of the WHO 25 × 25 strategy, a recent meta-analysis of 48 cohorts that included 1.7 million people compared persons with low versus high socioeconomic status. Overall mortality rates were higher in the first group (hazard ratio, 95% confidence interval of 1.42, 1.38–1.45 in men, and 1.34, 1.28–1.39 in women), who also had those lifestyles that caused higher premature mortality (52). Other recent findings have shown that social and emotional support can protect health and well-being. However, further research should explain the reasons for this association, and understand its context and mechanisms (53). One of the most highlighted social determinants is the social capital, which refers to the resources available to individuals and groups through social networks (54, 55). Greater social capital has been associated with a better subjective perception of health and well-being (56, 57). Several observational studies indicated that higher social capital is a protective factor against mental and physical health, and mortality (58–60). Another conditioning factor is the working environment (13). Work stress has been associated with worse health status (61), increased risk of depressive disorders (62, 63), sleep disturbances (64), coronary heart disease (65), musculoskeletal pathology (66), alterations of lipid metabolism, and increased metabolic syndrome markers (67).

We believe that the analysis of the causal relationship between personal aptitudes and the adoption of healthy lifestyles, improvements in self-management of chronic conditions, quality of life, incidence and control of risk factors, incidence of chronic diseases and mortality is of special interest, and the creation of a cohort from Primary Health Care (PHC) is a most appropriate framework.

This project will contribute to provide essential knowledge for enabling and promoting the design of individualized interventions adapted to personal abilities and the evaluation of their role as prognostic factors. The interventions would also aim at improving the aptitudes that can be modified, such as health literacy, and the impact of these modifications may be assessed. Identification of the key determinants of multimorbidity is essential for the development of effective strategies for the healthcare and well-being of the person (2).

Accordingly, we propose to conduct an extensive investigation, with a holistic approach, on the determinants of health. Special focus will be given to the influence and effects of factors that determine individual behavior; a gender perspective and other aspects of social inequality will be included in the design and analysis. The description of these individual determinants involved in behaviors and their relation to social determinants, lifestyles, risk factors, chronic diseases and mortality are of paramount interest to our evolving societies and health systems.

Highly prevalent serious conditions should be one of the targets of research efforts. This is the case of chronic diseases, the leading cause of death in our population, and a major cause of disease burden, number of life-years lost, and resource consumption in our society. Chronic diseases and their consequences will be aggravated by an ongoing demographic trend that is predicted to linger on: the progressive ageing of the population (95, 96).

Health promotion and the strategies for disease prevention are particularly effective in the context of chronic diseases, because many of their associated risk factors could certainly be modified and prevented. This project aims to contribute to a framework on which efficient and safe interventions on health promotion and prevention could be developed, and the number of persons suffering these diseases in the future could be reduced. We need to promote and encourage the autonomy of people to carry out their activities, a constant care and improvement of their physical and psychological abilities, a delayed onset of early dependence, and the maintenance of their social environment. This would lead to a reduction in the burden of disease on society, a huge improvement in people’s quality of life, and also a reduction of the enormous cost on overloaded health systems.

The evidence generated in this study will add new knowledge to previous attempts at establishing comprehensive theoretical frameworks that explain people’s health behaviors, such as TDF (17) or the capability, opportunity, and motivation (COM-B) model (97, 98). The Primary Care context is the ideal environment to start this research due to the almost total similarity with the characteristics of the reference population. Moreover, it is where many of the indicators that we intend to analyze are developed and undertaken. Additional to the identification of the subjects, collection of all the baseline information and initial cross-sectional analysis, the longitudinal follow-up will explore the influence of these factors as predictors of lifestyles and the impact on multimorbidity, as reported in several systematic reviews (99, 100).

The conduct of this project will lay the basis for pioneering new methods in clinical practice, particularly for tailoring interventions according to the individual characteristics of each person, aiming to improve their acceptance and efficiency. Indeed, the project is directed towards extending personalized medicine, caring for and treating the person as a whole, and not only the disease. At the same time, it offers an opportunity to optimize the resources and sets a sustainable strategy that can be transferred into clinical practice through recommendations.

Health promotion is a priority within the public health policy of developed and developing countries. Current knowledge describes the association of genetic, socioeconomic, cultural, and environmental determinants with lifestyles, risk factors, and diseases. However, little is known about the real effect of personal determinants on individual behaviors; these aptitudes may be connected with our personal capacity to adopt healthy lifestyles and respond suitably in the face of adverse situations. This project will fulfill the need for cohort studies on behavioral changes, maintenance of healthy behaviors, reduction of harmful habits, improvement in the self-management of chronic conditions, and increase in the quality of life related to health determinants. The collaborators in charge of this study present a holistic approach to examine health determinants with a special focus on individual behaviors. Description of these individual factors, their relation with social factors, lifestyles, and chronic diseases will be highly interesting and useful to the society and the national health system. This knowledge will allow the evaluation of their role as prognostic factors and the interaction with the rest of determinants to tailor interventions, and the design of interventions directly aimed at improving these individual capacities.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (reference number 19/150-P); Comité de Ética de la Investigación con medicamentos del Área de Salud de Salamanca (reference number PI 2020 02424); Andalusian Ministry of Health, Spain (reference number: 1260-M1-21); Comité de Ética de la Investigación de medicamentos de Euskadi (CEIm-E; reference number: PI2020185); Hospital Virgen de la Luz Clinical Reasearch Ethics Comiitte, Cuenca, Spain (Reference number 2019/PI2119). Research Central Commission of the Primary Care Assistance Management, Madrid, Spain. (Reference Number 07/21); Comité de Ética de la Investigación de la Comunidad Autónoma de Aragón (reference number: PI20/302); Galician Ministry of health, Spain: high impact study authorization (Reference number: 2021/047). The patients/participants provided their written informed consent to participate in this study.

Andalucía . Universidad Loyola Andalucía: Emma Motrico, Irene Gómez-Gómez. Instituto de Investigación Biomédica de Málaga: Patricia Moreno-Peral, Sonia Conejo-Cerón, Juan Ángel Bellón. Aragón . Fundación Instituto de Investigación Sanitaria Aragón: Rosa Magallon-Botaya, Fátima Méndez-López, Alejandra Aguilar-Latorre, Maria Beltrán-Ruiz, Bárbara Oliván-Blázquez, Marta Dominguez-García, Maria Isabel Rabanaque Hernandez, Eva María Andrés Esteban. Castilla-La Mancha . Centro de estudios sociosanitarios: Blanca Notario Pacheco, Montserrat Solera Martínez, Lidia Lucas-de la Cruz, Miriam Garrido Miguel, María Martínez Andrés, María Eugenia Visier Alfonso, Irene Marcilla Toribio. Castilla y León . Unidad de Investigación de Atención Primaria de Salamanca. José A Maderuelo-Fernández, Leticia Sierra-Martínez, Olaya Tamayo-Morales, Miriam Daniela García-Cubillas, Ana B Castro-Rivero, María D Martín-Santos, Carmen Castaño-Sánchez, Luis García-Ortiz. Catalunya . Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina: Bonaventura Bolíbar, Ruth Martí-Lluch, Rafel Ramos, Marc Casajuana-Closas, Anna Berenguera, Constanza Jacques-Aviñó, Yudy Young-Silva, Lia Alves-Cabratosa, Lluís Zacarías-Pons, Anna Ponjoan, Eva Espigulé-Ribas, Francesc Ribas-Aulinas, Jordi Blanch, Èric Tornabell-Noguera, Anna Moleras-Serra. Parc Sanitari Sant Joan de Déu: Enric Vicens-Pons, Montserrat Gil-Girbau, Mari Carmen Olmos Palenzuela, María del Carmen Gallardo González, Mª Teresa Peñarrubia-María, Paula Arroyo-Uriarte. Comunidad de Madrid . Centro de Salud Infanta Mercedes, Servicio Madrileño de Salud. Francisco Camarelles Guillem. Euskadi . Instituto para la Investigación Sanitaria Biocruces Bizkaia. Jose María Aiarzaguena, Álvaro Sánchez Pérez, Sandra Garcia-Martinez, Usue Elizondo Alzola, Mónica Miranda de la Maza, Ainhoa Abrisketa Ullibarri, Mikel Rueda-Etxebarria. Galicia . Instituto de de investigación Galicia Sur: Mª José Fernández Domínguez, Sabela Couso Viana, Roberto Fernández Alvarez, Ana Claveria Fontan, Ana Isabel Castaño Carou, Clara González Formoso, María Victoria Martín Miguel, Clara Guede Fernández, Macarena Chacón Docampo. Illes Balears . Gerencia de atención primaria de Mallorca, Instituto de investigación sanitaria de las Islas Baleares: Joan Llobera Cànaves, Caterina Vicens, Maria J. Serrano-Ripoll, Laura Gallardo-Alfaro, Oana Bulilete, Christian Jean-Mairet Soler, David Medina-Bombardó, T Coll Benejam.

RR and RM-L conceived the quantitative part of the study. RM-L and LA-C led the drafting of this manuscript. RM-L, JL, JM-F, RM-B, ÁS-P, MD, EM, EV-P, and BN-P obtained ethical approval from each institution. RM-L, RR, BB, JL, JM-F, RM-B, ÁS-P, MD, EM, EV-P, and BN-P advised and contributed to the study design. RM-L contributed to design the training program on the questionnaires and measurements. RR, RM-L, and JM-F developed the statistical analysis plan. RM-L, RR, and EV-P designed the economic components of the study and developed the economic analysis. All authors have revised the draft substantively, given approval of the submitted version (and any substantially modified version involving their contribution to the study), and agreed to be accountable for their own contributions and to ensure that all aspects of the study, including those in which they were not personally involved, are appropriately addressed.

This study has been funded by Instituto de Salud Carlos III (ISCIII) with competitive grants for the period 2019–2022 through the Fondo de Investigación para la Salud (FIS), which is co-funded by European Regional Development Fund/European Social Fund “A way to make Europe”/“Investing in your future.” Project Grants codes are: P19/01285; P19/00997; P19/01140; P19/00147; P19/01076; P19/00434; P19/01459; P19/01314; P19/01264 and P19/00115. The coordinator group received a pre doctoral training contract in health research (PFIS-FI20/00270) from the 2020 caLL of the Strategic Action in Health 2017–2020. Investigation groups were also funded through the Research Network in Preventive Activities and Health Promotion in Primary Care (redIAPP), RD16/0007/0001; RD16/0007/0002; RD16/0007/0003; RD16/0007/0004; RD16/0007/0005; RD16/0007/0006; RD16/0007/0008; RD16/0007/0009; RD16/0007/0010 and RD16/0007/0012; and through the research grants on the call for the creation of Health Outcomes-Oriented Cooperative Research Networks (RICORS) co-funded with European Union-NextGenerationEU funds, allowing the creation of the Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) with the following references: RD21/0016/0001; RD21/0016/0003; RD21/0016/0005; RD21/0016/0009; RD21/0016/0010; RD21/0016/0012; RD21/0016/0018; RD21/0016/0022; RD21/0016/0025 and RD21/0016/0029. Additional grants: Gerencia Regional de Salud de Castilla y León (GRS 2306/B/21 and GRS 2356/B/21); Andalusian Ministry of Education and Science (PY20 RE 025). The funders had no role in the study design, writing of the report, or in the decision to submit the protocol for publication. All authors confirm that they worked independently from funders.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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