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New Horizons in Health: An Integrative Approach New Horizons in Health An Integrative Approach Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health Burton H. Singer and Carol D. Ryff, editors Board on Behavioral, Cognitive, and Sensory Sciences Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C.
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New Horizons in Health: An Integrative Approach NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The study was supported by Grant No. N01-OD-4-2139, #56, between the National Academy of Sciences and the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data National Research Council (U.S.). Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health. New horizons in health : an integrative approach / Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health, Board on Behavioral, Cognitive, and Sensory Sciences, Commission on Behavioral and Social Sciences and Education, National Research Council ; Burton H. Singer and Carol D. Ryff, editors. p. cm. Includes bibliographical references and index. ISBN 0-309-07296-4 (pbk.) 1. Health promotion—United States. 2. Medicine, Preventive—United States. 3. Health planning—United States. 4. Integrated delivery of health care—United States. I. Singer, Burton H. II. Ryff, Carol D. III. Title. RA394 .N365 2001 613'.0973—dc21 00-012474 Additional copies of this report are available from National Academy Press , 2101 Constitution Avenue, N.W. , Lockbox 285 , Washington, D.C. 20418 . Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area). This report is also available online athttp://www.nap.edu. Copyright 2001 by the National Academy of Sciences . All rights reserved. Suggested citation: National Research Council. 2001. New Horizons in Health: An Integrative Approach. Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health, Singer BH, Ryff CD, eds. (Washington, DC: National Academy Press). Printed in the United States of America
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New Horizons in Health: An Integrative Approach THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
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New Horizons in Health: An Integrative Approach COMMITTEE ON FUTURE DIRECTIONS FOR BEHAVIORAL AND SOCIAL SCIENCES RESEARCH AT THE NATIONAL INSTITUTES OF HEALTH Burton H. Singer (Chair), Woodrow Wilson School, Office of Population Research, Princeton University Lisa F. Berkman, Department of Health and Social Behavior, Harvard University Linda M. Burton, Center for Human Development and Family Research, Pennsylvania State University John T. Cacioppo, Department of Psychology, University of Chicago Margaret A. Chesney, Center for AIDS Prevention Studies, School of Medicine, University of California, San Francisco David Cutler, Department of Economics, Harvard University Baruch Fischhoff, Department of Social and Decision Sciences, Carnegie Mellon University Jerome Kagan, Department of Psychology, Harvard University Bruce S. McEwen, Laboratory of Neuroendocrinology, Rockefeller University Barbara J. McNeil, Department of Health Care Policy, Harvard Medical School Michael J. Meaney, Douglas Hospital Research Centre, McGill University, Montreal, Canada Carol D. Ryff, Department of Psychology, University of Wisconsin-Madison Robert J. Sampson, Department of Sociology, University of Chicago Shelley E. Taylor, Department of Psychology, University of California at Los Angeles David R. Williams, Survey Research Center, University of Michigan
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New Horizons in Health: An Integrative Approach BOARD ON BEHAVIORAL, COGNITIVE, AND SENSORY SCIENCES Anne Petersen (Chair), W.K. Kellogg Foundation Linda M. Burton, Center for Human Development and Family Research, Pennsylvania State University Stephen J. Ceci, Department of Human Development, Cornell University Eugene K. Emory, Department of Psychology, Emory University Rochel Gelman, Psychology and Cognitive Science, Rutgers University Anthony Jackson, Disney Learning Partnership, Burbank, California Peter Lennie, Center for Neural Science, New York University Marcia C. Linn, Graduate School of Education, University of California at Berkeley Elissa L. Newport, Department of Brain and Cognitive Sciences, University of Rochester Charles R. Plott, Division of Humanities and Social Sciences, California Institute of Technology Michael Rutter, Social, Genetic and Developmental Psychiatry Research Centre, Institute of Psychiatry, London Arnold Sameroff, Center for Human Growth and Development, University of Michigan Edward E. Smith, Department of Psychology, University of Michigan James W. Stigler, Department of Psychology, University of California at Los Angeles John A. Swets, BBN Technologies (Emeritus), Belmont, Massachusetts Esther Thelen, Department of Psychology, Indiana University Richard F. Thompson, Neuroscience Program, University of Southern California William A. Yost, Parmly Hearing Institute, Loyola University, Chicago
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New Horizons in Health: An Integrative Approach Contents PREFACE xi EXECUTIVE SUMMARY 1 1 INTRODUCTION 17 The Context: Behavioral and Social Sciences at the National Institutes of Health, 18 The Charge to the Committee, 19 The Integrative Approach to Health, 21 Key Influences on Pathways to Health, 22 2 PREDISEASE PATHWAYS 25 Cumulative Physiological Risk, 26 Characterizing Predisease Pathways, 28 Connecting Predisease Pathways to Cumulative Physiological Risk, 39 Recommendations, 40 3 POSITIVE HEALTH: RESILIENCE, RECOVERY, PRIMARY PREVENTION, AND HEALTH PROMOTION 45 Resilience and Resistance to Disease: Who Stays Well and Why?, 47 Recovery and Differential Survival Processes, 49 Advancing the Science of Primary Prevention, 51 New Directions in Positive Health Promotion, 54
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New Horizons in Health: An Integrative Approach Positive Health and the Council of Public Representatives, 56 Recommendations, 57 4 ENVIRONMENTALLY INDUCED GENE EXPRESSION 63 Genes Expression and Prenatal Development, 64 Personal Ties and Gene Expression in Midlife, 65 Animal Models and the Consequences of Mother-Child Interactions, 66 Intergenerational Transmission of Behavior, 67 Plasticity of Genetic Trajectories, 68 Whole-Genome Analyses, 69 Recommendations, 70 5 PERSONAL TIES 73 The Centrality of Personal Ties, 73 Personal Ties and Gene Expression, 77 Personal Ties and Brain Function and Structure, 78 Personal Ties and Neuroimmunological Activity, 79 Personal Ties and Infectious Disease, 81 Social Relational Routes to Health, 82 Recommendations, 84 6 COLLECTIVE PROPERTIES AND HEALTHY COMMUNITIES 91 Community Contexts and Multilevel Research, 92 Experimental Evidence, 93 Mechanisms, 94 Methodological Challenges and Research Priorities, 95 Interactions of Individual and Collective Properties, 97 Other Social Contexts, 97 Recommendations, 98 7 THE INFLUENCE OF INEQUALITY ON HEALTH OUTCOMES 100 Socioeconomic Status and Health, 100 Racial and Ethnic Inequality and Discrimination, 106 Recommendations, 111 8 POPULATION PERSPECTIVES: UNDERSTANDING HEALTH TRENDS AND EVALUATING THE HEALTH CARE SYSTEM 118 Time Trends and Spatial Variation in Population Health, 118 Accounting for Macro-Level Health Patterns, 130
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New Horizons in Health: An Integrative Approach Health and the Macroeconomy, 135 The Health Care System, 137 Future Directions in Population Surveys, 142 Recommendations, 143 9 INTERVENTIONS 148 Experience with Interventions, 150 Key Trends, 155 Future Research Needs and Directions, 157 Recommendations, 159 10 METHODOLOGY PRIORITIES 164 Characterizing Pathways, 165 Advancing the Understanding of Biological Mechanisms, 170 Methods of Data Analysis, 175 Design and Evaluation of Intervention Programs, 178 Recommendations, 179 11 RESEARCH INFRASTRUCTURE 184 High Priority Human and Animal Populations, 184 Clinical Research Centers, 186 Communities and Interventions, 187 Training, 188 Recommendations, 188 BIOGRAPHICAL SKETCHES 190 INDEX 197
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New Horizons in Health: An Integrative Approach Preface In 1999, Norman Anderson, director of the Office of Behavioral and Social Sciences Research (OBSSR) of the National Institutes of Health (NIH), asked the National Research Council (NRC) to form a committee that could develop a research plan to guide NIH in supporting areas of high priority in the behavioral and social sciences. Suggestions for committee membership came from numerous sources, including the NRC Board on Behavioral, Cognitive, and Sensory Sciences, OBSSR and the NIH institutes, and members of the Commission on Behavioral and Social Sciences and Education (CBASSE). This process, representing input from multiple sources, culminated in a committee whose membership consisted of 15 scientists (named at the beginning of this volume) with diverse backgrounds and perspectives in the biomedical and social behavioral fields as well as extensive experience reaching across the scientific disciplines. It is a notable strength of the committee that selection of its members was weighted on the side of those who have established track records in multidisciplinary research and are at the forefront of the biobehavioral interface in current science. It is therefore not surprising that a majority had previous exposure to multidisciplinary efforts such as the research networks of the John D. and Catherine T. MacArthur Foundation. These networks have played pivotal roles in nurturing integrative science over the last 15 years by bringing together teams of investigators from diverse fields to work together on targeted agendas. This background to the committee membership is relevant because bringing the behavioral and social sciences more strongly and visibly into the full panorama of health
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New Horizons in Health: An Integrative Approach research at the NIH is dependent on building bridges across the scientific disciplines. The committee met four times between May 1999 and February 2000. After reviewing the charge from OBSSR and NRC procedures for preparing such a report, the committee planned a workshop to solicit information and advice from representatives of each of the NIH institutes and the NIH director's Council of Public Representatives (COPR) regarding topics the committee needed to consider in its deliberations. Second, the workshop was to be a forum for an exchange of views between members of the committee and representatives of the institutes concerning useful ways to respond to the committee's charge. At the workshop, the committee listened to presentations by representatives of nearly all institutes of NIH. They spoke about ongoing programs in the behavioral and social sciences and provided their views of promising future directions. These presentations were lucid, informative, and especially helpful to the committee regarding the scope of extant social behavioral work as well as for identifying future venues for biobehavioral integration. After the workshop, the committee worked for several months to shape and develop its report. In addition to the workshop presentations, valuable input to the committee was also provided by Melanie Dreher, dean of the School of Nursing at the University of Iowa, who was the liaison with the COPR. Authorized by Congress, the COPR is charged with consulting, advising, and making recommendations to the NIH on issues of development of programmatic priorities. The COPR also has the task of enhancing public participation in NIH activities, increasing public understanding of NIH and its programs, and bringing important matters of public interest forward for discussion in public settings. COPR input to the committee played an important role in shaping the research priorities put forward in this report. Benefiting the health of the public is central to the proposed integrative approach, and an entire chapter of this report is focused on positive health promotion, a key theme from the COPR. This report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Nancy E. Adler, Department of Psychiatry and Pediatrics, Center for Health and Community, University of California, San Francisco;
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New Horizons in Health: An Integrative Approach Bernard J. Carroll, Pacific Behavioral Research Foundation, Carmel, California; David S. Cordray, Institute for Public Policy Studies, Vanderbilt University; Karen Emmons, Dana Farber Cancer Institute, Boston, Massachusetts; Victor R. Fuchs, Department of Economics, Stanford University (emeritus); Beatrix Hamburg, Department of Psychiatry, Cornell University Medical College; E.A. Hammel, Department of Demography, University of California, Berkeley; James House, Institute of Social Research, University of Michigan; Stephen Manuck, Department of Psychology, University of Pittsburgh; Elissa L. Newport, Department of Brain and Cognitive Sciences, University of Rochester; and Robert Sapolsky, Department of Biological Sciences, Stanford University. Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Neil Smelser, Center for Advanced Study in the Behavioral Sciences, Stanford, California, and David R. Challoner, Institute for Science and Health Policy, University of Florida. Appointed by the Commission on Behavioral and Social Sciences and Education and the NRC's Report Review Committee, respectively, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. We would especially like to thank Barbara Boyle Torrey, executive director of the Commission on Behavioral and Social Sciences and Education, for sustained support, encouragement, and guidance throughout the preparation of this report. Help from NRC staff has also been valuable. We would like to thank representatives of the NIH institutes, who made presentations to the committee about their programs in social and behavioral science research. Finally, we would like to again thank Melanie Dreher of COPR for identifying health issues and concerns from the general public that need to be factored into future priorities about research and practice. Burton H. Singer, Chair and Coeditor Carol D. Ryff, Coeditor Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health
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