Recommendation 21: Greater attention should be paid to funding research on social determinants of health and on behavioral and social science intervention research addressing generic social determinants of disease.
Behavioral and social science research has provided many new advancements in the effort to improve population health, and offers promise for the development of new interventions with even greater utility and efficiency in the years to come. As summarized below, the committee finds that social and behavioral interventions can improve health outcomes across a range of developmental stages and levels of analysis (e.g., individual, interpersonal, and community levels). Further, coordination of intervention efforts across these levels may efficiently and effectively promote healthy individuals and environments.
The committee found compelling evidence that expectant mothers can deliver healthier children as we improve our understanding of the social, economic, and intrapersonal conditions that influence the mother's health status over her life course, not just in the period prior to conception and birth. The physical, cognitive, and emotional health of infants can be improved with comprehensive, high-quality services that address basic needs of children and families. These same interventions assist children to enter school ready to learn. Similarly, adolescents can enjoy healthier life-styles as researchers and public health officials pay greater attention to the social and environmental contexts in which youth operate. These interventions pay great dividends for later health, as poor health habits can be avoided and developmental risks averted.
The evidence also suggests that adolescents and adults can benefit from co-ordinated health promotion efforts that address the many sources of health influences (e.g., family, school, work settings). Opportunities for behavioral and social interventions to improve health do not end during adulthood, however; compelling data indicate that older adults can age more successfully as policies and institutions attend to their social, cognitive, and psychological needs, as well as their physical health needs.
While further research is needed, evidence is developing that elucidates the pathways through which behavioral and social interventions may mediate physiological processes and disease states. This evidence indicates that behavioral and social interventions can directly impact physiological functioning, and do not merely correlate with positive health outcomes due to improvements in health behavior or knowledge. Further refinements of this research will aid in the development of more efficient and effective interventions.
As interventions are developed, special consideration must be given to gender as well as to the needs of individuals of different socioeconomic, racial, and ethnic backgrounds. These attributes powerfully shape the contexts in which individuals gain access to health-promoting resources (e.g., education, income, social supports), the barriers that restrict more healthful life-styles (e.g., demands
of gender roles), and the ways in which individuals in these groups interpret and respond to interventions. Because socioeconomic status exerts direct effects on health, intervention efforts must attend to the broader social, economic, cultural, and political processes that determine and maintain these disparities.
Efforts to improve the health of communities can benefit from specific levers for public health intervention, such as enhancing social capital and enacting public policies that promote healthful environments. While further research is needed to better understand means of manipulating these levers, it is clear that these interventions are most effective when members of target communities participate in their planning, design, and implementation. Communities that are fully engaged as partners in this process are more likely to develop public health messages that are relevant, are more likely to fully “buy in” and commit to community change, and are more likely to sustain community change efforts after research and/or demonstration programs end.
All such interventions are likely to be more successful when applied in co-ordinated fashion across multiple levels of influence (i.e., at the individual level; within families and social support networks; within schools, work sites, churches, and other community settings; and at broader public policy levels). While more research is needed to ascertain how coordination is best achieved and the cost-effectiveness of each component of a multilevel intervention strategy, the evidence from the tobacco control effort suggests that such a multilevel strategy can reap benefits for broad segments of the public. This success can extend both to those individuals at greatest risk for poor health by virtue of their unhealthful behaviors or disadvantaged social, political, or economic status, as well as those at relatively low risk. Such efforts require, however, that funders, public health officials, and community leaders are patient and persist with intervention efforts over a longer period than the 3 to 5 years typically allotted for most demonstration or research efforts.
To best accomplish these goals, researchers must learn to work across traditional disciplinary boundaries, and adopt new methodologies to evaluate intervention efforts. A range of social, behavioral, and life scientists must collaborate to fully engage a biopsychosocial model of human health and development. Further, these researchers must be open to adopting less traditional evaluation approaches, such as qualitative methodologies, and combining these approaches with quantitative methodologies.
In summary, the committee concludes that serious effort to apply behavioral and social science research to improve health requires that we transcend perspectives that have, to this point, resulted in public health problems being defined in relatively narrow terms. Efforts to design and implement multipronged interventions will require the cooperation of public health officials, funding agencies, researchers, and community members. Evaluation efforts must transcend traditional models of randomized control trials and incorporate both quantitative and qualitative methodologies. Models of intervention must consider individual behavior in a broader social context, with greater attention to the social construction of gender, race, and ethnicity, and to ways in which social