Promoting Health: Intervention Strategies from Social and Behavioral Research
At the dawn of the twenty-first century, Americans enjoyed better overall health than at any other time in the nation's history. Rapid advancements in medical technologies, breakthroughs in understanding some of the genetic underpinnings of health and ill health, improvements in the effectiveness and variety of pharmaceutical interventions, and other developments in biomedical research have helped to develop cures for many illnesses and to extend and improve the lives of those with chronic diseases. In support of these efforts, the vast majority of the nation's health research resources have been directed toward biomedical research endeavors. By itself, however, biomedical research cannot address the most significant challenges to improving the public 's health in the new century. Approximately half of all causes of mortality in the United States are linked to social and behavioral factors such as smoking, diet, alcohol use, sedentary life-style, and accidents (McGinnis and Foege, 1993). Yet less than 5% of the approximately $1 trillion spent annually on health care in the United States is devoted to reducing risks posed by these preventable conditions (Centers for Disease Control and Prevention, 1992; Health Care Financing Administration, 2000). Behavioral and social interventions therefore offer great promise to reduce disease morbidity and mortality, but as yet their potential to improve the public's health has been relatively poorly tapped.
Within this context, the Institute of Medicine (IOM) Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public's Health (hereafter referred to as “the committee”) was charged to help identify promising areas of social science and behavioral research that may address public health needs. Although this report is not intended as an encyclopedic review
of the growing literature on social and behavioral interventions that may improve health, it serves to assess whether this knowledge base has been useful, or could be useful, in the development of broader public health interventions.
To aid the committee, 12 papers were commissioned from some of the nation's leading experts to review these issues in detail (see paper contributions). The first of these papers provides a descriptive overview of the challenges posed in understanding the role of behavioral and social factors in health and the distribution of disease. The second paper considers how social and behavioral factors contribute to socioeconomic and racial/ethnic health disparities. Five papers then discuss what has been learned in behavioral and social research that is of value in improving health at different stages of life. Three papers examine specific “levers” for public health intervention: media and public health marketing; legislation and public policy; and efforts to enhance the social capital of communities. In addition, one paper was commissioned to provide a review of psychosocial and biobehavioral interventions in disease processes, an area of research that offers promise to uncover specific mechanisms linking social and behavioral forces to health. Of necessity, all of these papers deal with one or another particular aspect of the problem. For this reason, one paper was commissioned to consider all of these issues simultaneously in a multilevel, multidisciplinary approach. The case of tobacco control is used to illustrate this type of multifaceted intervention program.
When these papers were completed, the committee invited the authors to attend a symposium held at the Emory Conference Center in Atlanta, Georgia. In addition, 33 discussants were invited to comment on the papers. These discussants were specifically chosen not only because of their expertise in the subject matter, but also because they brought to the discussion a diversity of opinions and experience with intervention efforts. The committee's report reflects a careful consideration of information presented in these papers, as well as in the symposium discussion.
A Social Environmental Approach to Health and Health Interventions
The committee examined a wide range of social and behavioral research that was intended to promote the health and well-being of individuals, their families, and their communities, and found an emerging consensus that research and intervention efforts should be based on an ecological model. This model assumes that differences in levels of health and well-being are affected by a dynamic interaction among biology, behavior, and the environment, an interaction that unfolds over the life course of individuals, families, and communities (Satariano, in press). This model also assumes that age, gender, race, ethnicity, and socioeconomic differences shape the context in which individuals function, and therefore directly and indirectly influence health risks and resources. These demographic factors are critical determinants of health and well-being and
should receive careful consideration in the design, implementation, and interpretation of the results of interventions.
This ecological model is best operationalized by a social environmental approach to health and health interventions. This approach places emphasis on how the health of individuals is influenced not only by biological and genetic functioning and predisposition, but also by social and familial relationships, environmental contingencies, and broader social and economic trends. The model also suggests that intervention efforts should address not only “downstream” individual-level phenomena (e.g., physiologic pathways to disease, individual and lifestyle factors) and “mainstream” factors (e.g., population-based interventions), but also “upstream,” societal-level phenomena (e.g., public policies).
The latter two sets of health influences, however, have not received the same degree of scientific attention as individual-level phenomena, due in part to their inherent challenges. One challenge posed by population or societal-level research is that it is methodologically complex and requires different methods than individual-level research. As a result, some population-level research has been less conclusive because it is at an earlier stage of scientific development and sophistication. In addition, population-level interventions may raise social, political, and ethical questions regarding attempts to change social conditions, as changes may produce unintended effects. Further, individuals subject to change efforts rarely have an opportunity to offer consent to the intervention.
Evidence is emerging, however, that societal-level phenomena are critical determinants of health, and not just for those at the lower rungs of the socioeconomic hierarchy. Greater scientific attention must be given to the development of upstream interventions, for several reasons. First, many of the risks for disease and poor health functioning are shared by large numbers of people. Stress, insufficient financial and social supports, poor diet, environmental exposures, community factors and characteristics, and many other health risks may be addressed by one-to-one intervention efforts, but such efforts do little to address the broader social and economic forces that influence these risks. Further, one-to-one interventions do little to alter the distribution of disease and injury in populations because new people continue to be afflicted even as sick and injured people are cured. It therefore may be more cost-effective to prevent many diseases and injuries at the community and environmental levels than to address them at the individual level.
Second, a social environmental approach is useful because many population groups have a characteristic pattern of disease and injury over time, even though individuals come and go from these groups. This suggests that there may be something about the group or the broader social and environmental conditions in which they live that either promotes or discourages injury and disease among individuals in these groups. This patterned consistency of disease rates among various social and cultural groups emphasizes the importance of social and other environmental factors in disease etiology. The identification of these factors is important in order to develop intervention programs to prevent or control disease.
Third, there is impressive evidence from previous work in infectious diseases and injury control that an environmental approach can be successful. There is strong evidence (McKeown, 1976; McKinlay and McKinlay, 1977; Fogel, 1994) that the dramatic decline since 1900 in overall mortality in both Britain and the United States cannot be explained by the introduction and use of medical interventions. Indeed, many medical measures against disease (both chemotherapeutic and prophylactic) were introduced several decades after a marked decline in mortality from these diseases already had taken place. In fact, it has been argued that most of the decline in mortality during the second half of the nineteenth century was primarily due to improvements in hygiene and to rising standards of living, especially improved nutrition. Likewise, the marked reduction in motor vehicle crash deaths and injuries that has been achieved over the past 50 years is due largely to improvements in the design of crashworthy automobiles, the construction of safer roadways, and to recent changes in social norms regarding alcohol use and seat-belt use (Institute of Medicine, 1998; Centers for Disease Control and Prevention, 1999).
A fourth reason for an environmental approach to disease prevention and health promotion is that while some behavioral interventions have succeeded in improving health behaviors, many narrow, individually focused models of behavior change have proven insufficient in helping people to change high-risk behavior. The importance of this problem is illustrated by interventions such as the Multiple Risk Factor Intervention Trial. In this study, 6,000 men who were in the top 10%–15% risk group in the nation because of their high rates of cigarette smoking, hypertension, and hypercholesterol levels were enrolled in a 6-year intervention program. They knew ahead of time of their risk status, the behavioral changes they would be required to make, the difficulties they faced, and the time they would need to invest to improve their health. The intervention was well-funded, well-staffed, and used the best behavior change techniques available at the time. The results were disappointing: 62% of these men continued to smoke after 6 years of effort, 50% still had hypertension, and very few men had changed their eating patterns (Multiple Risk Factor Intervention Trial Research Group, 1981, 1982).
To prevent disease, we increasingly ask people to do things that they have not done previously, to stop doing things they have been doing for years, and to do more of some things and less of other things. Although there certainly are examples of successful programs to change behavior, it is clear that behavior change is a difficult and complex challenge. It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change. If successful programs are to be developed to prevent disease and improve health, attention must be given not only to the behavior of individuals, but also to the environmental context within which people live.
For all of these reasons, the committee decided to focus attention not only on individual behavior, but also on the social forces that shape and support such behavior. In addition, the committee decided not to organize its work around
clinical disease categories such as coronary heart disease, arthritis, or cancer, because most behavioral and social factors transcend particular diseases, and instead influence susceptibility to disease in general. Thus, for example, people in lower social class positions have higher morbidity and mortality rates for diseases involving many body systems, including the digestive, genitourinary, respiratory, circulatory, nervous, blood, and endocrine systems. They also experience higher rates of most malignancies, infectious and parasitic diseases, unintentional injuries, poisoning and violence, perinatal mortality, diabetes, and musculoskeletal impairments. A similarly broad range of diseases has been observed in relation to smoking, poor diet, stress, physical inactivity, inadequate social support, and other psychological and social factors. Not only do people in these high-risk groups have higher rates of diseases, they also are at higher risk for multiple, comorbid conditions (Syme and Balfour, 1998). An exclusive focus on the presence or absence of single disease categories does not provide the best characterization of the health of individuals, and certainly not the best characterization of the health of communities.
Summary of Findings and Recommendations
The recommendations developed by the committee are based on papers presented by the commissioned authors, the views of discussants who reviewed these papers, and the committee's deliberations. These recommendations are organized below in terms of promising intervention strategies, important research gaps, the needed partnerships between researchers and community members, and funding priorities.
The committee's review of the prepared papers and study of the discussants' opinions reinforced the view that assessing the promise of social and behavioral research for improving the public's health is a complex task. There are several reasons for this. First, of course, is the recognition that health, disease, and well-being are complex states that develop and change over the entire life course. No single intervention, or set of interventions, is likely to address the wide range of factors that influence health, disability, and longevity. It is also apparent from the committee's work that the most effective interventions have involved research evidence that transcends the boundaries of a single scientific discipline. Because health is a complex issue and because interventions need to be similarly complex, the science underpinning this work must integrate the work of many disciplines and professions. These include medicine, nursing, psychology, sociology, anthropology, engineering, economics, political science, biology, history, law, and demography, among others.
A review of successful and unsuccessful interventions also reveals that communities must be involved as partners in the design, implementation, and evaluation of interventions. The best intervention results have been achieved when people who benefit from interventions work closely with researchers and public health practitioners. This phenomenon emphasizes the fact that those in the health community have “messages, ” while individuals in target communities