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Behavioral and Social Science We know that the greatest improvements in the nation 's health wiR result from a better understanding of social and behavioralfactors that affect health. S. Leonard Syme, Chair, IOM Committee on Promoting Health: Intervention Strategies from Social and Behavioral Research Approximately half of all deaths in the United States, as well as the majority of diseases and disabilities, are linked to behav- ioral and social factors. Some of these factors such as smoking, poor diet, excess alcohol use, and sedentary lifestyles re- late directly to the choices and actions of individuals. Other factors, such as pov- Approximately half of all cleaths in erty and exposure to environments that the United States, as well as the discourage healthy behavior, involve majority of diseases and disabili- society at large. All of these factors are ties, are linked to behavioral anc! amenable to change, but research tells us social factors. that achieving change at the individual or environmental level is difficult. Yet, less than 5 percent of the ap- proximately $] tnIlion spent annually on health care nationwide is de- voted to reducing risks posed by behavioral and social factors. Greater investments are needed to address the fundamental behavioral and so- cial causes of disease, disability, and mortality. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (1982) brought national attention to the important role of 49

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Informing the Future: Critical Issues in Health behavior in health. The report reviewed research on the role of be- havior in the prevention and treatment of a variety of diseases, de- scnbed psychosocial arid behavioral risk factors and prevention ef- forts, discussed the relationship of mental health care with primary care, arid recommended directions for research on health and behav- ior. The report was one of the first to recognize the contributions of the behavioral sciences to medical practice and to promote multidis- ciplinary research on known behavioral risk factors for disease. The charge to society is to blend Prowess since 1982 has been dis- the skepticism of a scientist, the appointingly slow. Today, such re- passion of an advocate, the search comprises a small but growing pragmatism of a policymaker, the segment of the National Institutes of creativity of a practitioner, and the Health's portfolio, while also receiving devotion of a parent and to use support from the Centers for Disease existing knowledge to ensure both Control and Prevention and several a decent quality of life for all our foundations. However, major baITiers children end a productive future remain In the design, funding, and for the nation. conduct of research to develop reliable interventions to change individual and From Neurons lo Neighborhoods: The Science of Early Chilc/hoo~ population-level patterns in such areas Deve/opment(2000) as ~et, smoking, and exercise. Even when effective interventions are known, communicating them to diverse populations presents a major challenge. Healthy People 2010, the national health agenda developed by the Of lice of the Surgeon General, with input from the TOM, offers a roadmap for achieving major improvements in the nation's health and for reducing health disparities among diverse populations. Suc- cessful navigation of this roadmap depends on continued progress in Me behavioral and social sciences, as well as on incorporation of the resulting knowledge into education, clinical practice, arid population- leve! health interventions. The TOM continues to play an important role in assessing needs in the behavioral and social sciences and in the translation of research findings into practice. 50

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Behavioral and Social Science ADVANCING THE FIELD A key to helping people enjoy longer, healthier lives is to understand how to promote behavioral change arid to create healthier environments. Promoting Health: Intervention Strategies Mom Social and Behavioral Research (2000) summarizes what has been learned in behavioral and so- cial research that is of value in improving health at differ- ent stages of life. The report acknowledges that health, disease, arid well-being are complex states that develop and change over the entire life course. In addition, behav- ioral and social influences on health are complex, and no single intervention, or set of interventions, is likely to ad- dress all of these factors. Thus, health experts must use multiple approaches (e.g., education, laws, social support systems, and programs designed to help people change their dest~c- tive behaviors), and they must address multiple levels of influence simultaneously (e.g., individuals, families, communities, states, and the nation as a whole). For example, efforts to reduce the number of people who smoke should take into account not only the physiological and psychological effects of nicotine addiction, but also such larger issues as the ~nflu- ence of friends amp colleagues who smoke, the availability of tobacco products, amp the number of public places where smoking is allowed.. The . . . children shouIcl be a major report also notes Mat children should focus of [behavioral] intervention be a major focus of intervention ef- efforts, since many of the risk forts, since many of the risk factors factors observed in adults, such as observed in adults, such as being beina overweight and shunning overweight and shunning physical ac- tivitv can he detecte(land chanced as' ^.ce ce.. ' - 'nut'Or con PROMOS HEALTH INT_mNnON STRATEGIES FROM SOCUU AND 11F14AVU,Q&[ I - - _ _ _ physical activity, can be detected and changed in childhood. , ~ ~ - in childhood. And, in designing ~nter- vention programs for people of all ages, public health practitioners arid researchers should seek community involvement and work closely with the individuals who are targeted for participation. 51

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Informing the Future: Critical Issues in Health Health and Behavior: The Interplay of Cells, Self; and Society (2001) reviews the evidence linking biological, psychological, and social risk factors to medical disease. For example, the relationships between cardiovascular disease and the neuroendocnne system, stress, individual behavior, social networks, and socioeconomic status are explored. The report also describes the variety of interventions that have been used at the levels of the individual, the family or social network, the organization, the commurlity, and society, and it evalu- ates the limitations and potential of these approaches. The recom- mendations for future directions in research could help federal agen- cies arid foundations make decision about priorities for funding. 52 Behavioral and social science research provides a frame of reference to better understand drug and sub- stance abuse. Dispelling the Myths about Ad~dtictiorl (1997) describes the psychosocial factors, as well as the biological factors, that influence an individual's potential for drug use and addiction. Beliefs and attitudes, many of which are learned from role models at home, in the com- munity, or in the media, have a strong influence on drug use. The report notes that cognitive and behavioral re- search on the psychosocial factors related to drug initia- tion and use Carl lead to the development of new and ef- fective prevention interventions. WORKING ACROSS DISCIPLINES Providing answers to the comniex health questions facing today's so- . . . , . ~ ciety requires an integrated approach that melds multiple disciplines. A recently released report, Bridging Disciplines in the Brain, Behav- ioral, and Clinical Sciences (2000), examines the needs, obstacles, and strategies for interdisciplinary research and training in these fields. Its findings may be broadly applicable in other fields of scien- tific research and training as well. The report concludes that while interdisciplinary training programs are growing in number, barriers persist. For example, disciplinary jargon and cultural differences among scientists inhibit easy interactions. Some believe that interdis-

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Behavioral and Social Science 20% 1992 1993 1994 1995 1996 1997 1998 1999 Year 153 Interdisciplinary O Single Discipline O Unclassified Annual distribution of Requests for Applications (RFAs) at the National Institutes of Health. RFAs are posted to encourage research in fields of special interest. The importance of interdisciplinary research at NIH is clear, as an average Of 23% Of all RFAs issued in 1992-1999 by NIH institutes addressed interdisciplinary research. SOURCE: Bridging Dis- ciplines in the Brain, Behavioral, and Clinical Sciences, 2000; page 48. ciplinary research reduces the likelihood of receiving funding or achieving "first authorship" of publications, recognition that tradi- tionally has been essential in gaining tenure. The duration and cost of interdisciplinary education also can be discouraging. Among the proposed remedies, government funding agencies caI1 implement peer-review procedures that reward scientists working across disciplines, fiend shared core facilities, and require universities to endorse interdisciplinary efforts. For their put, universities can take preemptive steps to ensure that ap- pointment, promotion, and tenure poli- Interdisciplinary research shouIcl cies do not impede interdisciplinary re- supplement, not clisplace, single- search and teaching; develop ways discipline efforts. . . allocate appropriate credit for interdis- ciplinary efforts; and to support the types of shared facilities that are needed when bndg~ng disciplines. Interdisciplinary research should supplement, not displace, single discipline efforts, but interdiscipli- nary training opportunities should be available at all stages of a sci- entist's career. 53

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Informing the Future: Critical Issues in Health 80 - 70 60 40 30 10 o Under 1-~ar old Under 6-years old 6- to 17-years old 1 975 1 999 Trends in the proportion of mothers in the labor force, by age of child, 197~1999. NOTE: since 1975 data for mothers with children under 1 year of age are not available, the data for this column are from the June 1977 Current Population Survey. SOURCE: From Neurons to Neighborhoods: The Science of Early Childhood Devel Opment, 2000; page 270. TRANSLATING KNOWLEDGE INTO PRACTICE As a nation, we are not taking full advantage of what is known about early childhood development, between bird and age 5. Such inatten- tion could not come at a worse time. Despite the unprecedented na- tional prospenty, financial hardship is not uncommon. ~ fact, preschoolers today are more likely to be Tom poor f~nilies than they were 25 years ago. Marty parents work long hours out of economic necessity, aIld open outside the typical 9-to-5 time Dame, an in- creased workload that has left many parents straining to balance making a living with family time. Record numbers of women win young children work outside the home, re- suldng In Increased reliance on childcare for infarcts and toddlers. Despite the unprecedented national prosperity, financial harcI- ship is not uncommon. In fact, preschoolers today are more likely to be from poor families than they were 25 years ago. 54

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Behavioral and Social Science From Neurons to Neighborhoods: The Science of Early Child- hood Development (2000) takes a comprehensive look at the interac- tions among a child's genetic inheritance, early environment, and per- sonal experiences, and provides science-based advice about the interventions that can make a difference in a child's cognitive, physi- cal, and emotional development. The report notes, for example, that a child's early relationships are cntical, and that a child who lacks at least one loving and consistent care- giver, whether a parent or attentive . . . the nation's policies and child-care provider, may suffer from practices regarding childcare and severe and long-lasting developmental early childhood education are problems. Yet, the nation's policies often based on little or no evidence and practices regarding childcare and that they actually promote chil- early childhood education are often dren's well-being. . based on little or no evidence that they actually promote children's well-being. The report calls for a Presi- dential task force to review all public investments in child care and early childhood education, with the goal of making the most of scien- tific knowledge. The task force would be charged with developing a lO-year plan focused on ways to foster sustained relationships be- tween preschoolers and qualified careg~vers; that addresses the spe- cial needs of children with developmental disabilities or chronic health conditions; and that ensures all child-care settings are safe, stimulating, and responsive to families' concerns. The report also recommends that the major funding sources for child care and early education should support improvements in qualifications, pay, and benefits of child-care professionals. Encouraging the adoption of healthy behaviors and avoidance of n sky ones, requires usefill intonation on specific health issues and clear incentives to change. ~ culturally and demographically diverse populations, many factors magnify this challenge. For example, cul- tural differences in the perception of health and disease, differences in health literacy, and differences in social norms, as well as social arid system barriers interfere with adoption of recommended behavior charges. ~ this regard, diversity is not limited to race, ethnicity, gen- der, or age. Socioeconomic status, education, religious affiliation, sex- ual preference' health status, and geographic location often exert en

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Informing the Future: Critical Issues in Health greater influence over the processes of health communication and be- havior change than do the more easily identified charactenstics. The upcoming report Speaking of Health: Assessing Health Communica- tior' Strategies for Diverse Populations (2001) will review recent ad- vances in research on health communication and health behavior change, offer specific examples of public health interventions, and evaluate the characteristics of individuals, social networks, and com- munities that influence the effectiveness of public health campaigns. Promising strategies will be identified for public health interventions to achieve a sustained change in the behaviors in diverse populations. 56

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Selected Recommendations for Public Health Policy. ~ . HIV Prevention: The nation urgently needs a comprehensive, effective, and efficient strategy for prevention of HIV. The organizing principle should be to avert as many new HIV infections as possible within the resources available for Hi\/ prevention. It will be necessary to improve the way the epidemic is monitored, change how prevention resources are allocated and how activities are prioritized and conducted, foster interactions between the public and private sectors to promote new prevention tools and technolo- gies, and reduce or eliminate social barriers to HIV prevention. (No Time to Lose: Getting More from HIV Prevention) Food Safety: Develop a comprehensive food safety plan that includes a unified, science-based food safety mission; integrates federal, state, and lo- cal food safety activities; allocates funding in accordance with science-based assessments of risk and benefit; and provides adequate support for research and surveillance. Congress should establish a unified and central framework for managing federal food safety programs, one that is headed by a single official with the responsibility and control of resources for all federal food safety activities. (Ensuring Safe Food: From Production to Consumption) Tobacco Policy: Congress should enact a comprehensive regulatory statute delegating to an appropriate agency the necessary authority to regulate tobacco products, for the dual purpose of discouraging consump- tion and reducing the morbidity and mortality associated with use of to- bacco products. The agency should be authorized to regulate the design and constituents of tobacco products, with the purpose of setting and gradually reducing ceilings on their nicotine content. (Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths) Sexually Transmitted Diseases: Sexually transmitted diseases (STDs) are at epidemic levels in the United States, with tremendous health and economic consequences. Congress and the administration should collabo- rate to develop and support a national system for STD prevention. Major components of this system will closely parallel an effective strategy for HIV prevention and thus have multiple payoffs. (The Hidden Epidemic: Con- fronting Sexually Transmuted DiseasesJ . Tuberculosis: The opportunity exists to virtually eliminate tuberculosis in the United States over the next decade through relatively modest invest- ments in prevention efforts. The opportunity should not be lost. IOM rec- ommends a series of actions from fully funding the TO Strategic Plan to in- creased professional training, and from mandated completion of therapy to vaccine development. (Ending Neglect: The Elimination of Tuberculosis in the United States ~