social and behavioral determinants of health than has been given in the past to achieve greater gains in women’s health.

The committee initially planned to discuss health determinants in relation to each separate condition under consideration. However, the pervasive impact of social and behavioral determinants became apparent in that the same risk factors (such as smoking, eating habits, lack of physical activity, sexual risk behavior, and alcohol use) played a role in most of the conditions under consideration; therefore, the committee reviewed them in a separate chapter and provided evidence of their associations with a variety of conditions. For example, there is substantial evidence of links between smoking, alone and in conjunction with oral contraceptive use, and breast cancer, lung cancer, and cardiovascular disease (Burkman et al., 2004). There is growing evidence, from large cohort studies of women, on the role of eating habits and physical activity in the health of women.

As highlighted in the ecologic model presented in Chapter 2, smoking, eating habits, physical activity, and other behaviors are shaped by cultural and social contexts, including factors associated with social disadvantage. The marked differences in condition prevalence and mortality in women who experience social disadvantage are associated with race and ethnicity, lack of education, low income, and other factors such as differential exposure to stressors and violence, which are more common in more disadvantaged communities. Such exposures are related to outcomes as varied as injury and trauma, depression, arthritis, asthma, heart disease, human immunodeficiency virus (HIV) infection, and other sexually transmitted infections (Campbell et al., 2002; Coker et al., 2000; Ozer and Weinstein, 2004; Tjaden and Thoennes, 1998). Although the impact of social and community factors has been documented, little research on how to modify these factors to improve women’s health has been conducted. Even less research has been conducted on the effects of those social and community factors in specific groups of women.

Greater support for research on social and behavioral determinants is needed, particularly research on how to modify them to improve health. Social and behavioral factors are important determinants of health for men as well as women, but the underlying factors probably differ by sex, and interventions tailored to women may be more effective than general treatments. For example, some studies show that women have a more difficult time with smoking cessation than men (Gritz et al., 1996) and face unique barriers to cessation (Schnoll et al., 2007). Smoking-cessation treatments designed to address barriers specific to women may be more effective, but they require empirical validation. Many intervention programs show promise, but most have not been well tested, and the health effects of smoking, such as cardiovascular disease and lung cancer, are still the leading killers of women. Similarly, interventions to improve eating habits, increase physical activity, decrease sexual risk behavior, and decrease substance abuse have not been as successful as they need to be to improve women’s health.

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