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The Future of the Public’s Health in the 21st Century
of what makes people healthy, research on the multiple determinants of health has begun to enrich the understanding of the numbers and complexities of factors that determine the health of the population (see Chapter 2 for a more comprehensive discussion of the determinants of health).
Increased understanding of the determinants of health has demonstrated the importance of social and behavioral factors to health. McGinnis and Foege (1993) reported that about half of all causes of mortality in the United States are linked to social and behavioral factors and accidents. Several studies have shown the relationship between unintentional injuries and certain risk factors: for example, accessibility to firearms, use of alcohol and tobacco, and use of seat belts (Turnock, 2001). Other research has shown the influence of psychological risk factors on disease; for example, the management of diabetes is influenced by coping skills and family stresses; other research demonstrates that acute stress may trigger myocardial ischemia (IOM, 2001).
Another important area for increased research is public health systems research. Bialek (2000) makes the point that there is little scientific evidence about what constitutes effective public health departments. He defines public health systems research as “a field of inquiry using quantitative or qualitative methodology to examine the impact of the organization, financing, staffing, and management of systems on the access to, delivery, cost, outcomes, and quality of population-based services.” Turnock (2001) states that improving public health practice requires research that explicates the links and relationships of key processes, programs, and services or outputs. The limited amount of public health systems research conducted to date has produced some important findings, such as the findings that the effectiveness of local health departments does not appear to be influenced by jurisdiction size and full-time leadership appears to positively influence effectiveness (Bialek, 2000). The committee believes that public health systems research is an important area for increased attention.
Despite the many achievements of research, much remains to be accomplished. The vast majority of the nation’s health research resources have been directed toward biomedical research endeavors that cannot, by themselves, address the most significant challenges to improving the public’s health (IOM, 2000). Past and current research funding priorities focus especially on risk factor identification through either large- or small-scale epidemiological studies. Comparatively few resources have been devoted to supporting prevention research, community-based research, or the translation of research findings into practice. For example, in the area of obesity, a great deal of research is needed about causes and about appropriate and effective interventions. Despite a significant reduction since 1990 in the amount of dietary fat consumed by the population, the rate of obesity has increased significantly. Clearly, achieving a reduction in obesity is not as