Population Health: Behavioral and Social Science Insights
New Directions for Behavioral and Social Science Strategies to Improve Health
By Daryn H. David, Michael L. Spittel, and Robert M. Kaplan
This book offers an exciting collection of original chapters that highlight the varied contributions of the behavioral and social sciences to population health. The chapters also explore ways to increase the impact of these fields on innovations in health metrics and population health. In the following sections, we review some of the key points of this book and recommend some next steps for these continually evolving fields of research and practice.
Why the Behavioral and Social Sciences Matter
The vast majority of deaths in the United States and worldwide are due to non-communicable diseases (NCD) like cancer, cardiovascular disease (CVD), diabetes, and respiratory disease. The key determinants of these mortality rates are behavioral and social risk factors that include smoking, use of drugs and alcohol, poor diet, and lack of physical activity. According to the World Health Organization (WHO) World Health Assembly, eliminating these major risk factors, including unhealthy diet, tobacco use, and physical inactivity, could reduce the incidence of diabetes and CVD by 75 percent and the incidence of cancer by 40 percent. WHO estimates that these behavioral changes would reduce health inequalities by an estimated 50 percent.1
Further, a 2013 Institute of Medicine (IOM) report, U.S. Health in International Perspective: Shorter Lives, Poorer Health, showed that life expectancy for both men and women in the United States is below average in comparison with other high-income countries.2,3 We could, however, achieve substantial gains in life expectancy in the United States by reversing the current trends responsible for declining health, including overweight/obesity, sedentary lifestyle, tobacco use, and excessive alcohol consumption, as well as the accidental deaths resulting from firearms, poisoning, and other risky behaviors.
One of the key questions tackled by this volume is exactly how the behavioral and social science communities could bring a range of tools to bear on developing interventions that have the potential to improve health and well-being. Another question concerns the optimal point at which to intervene, ranging from the national, to community, to individual levels. A final point focuses on the necessity of utilizing the findings of behavioral and social science research when building sustainable efforts that aim to advance population well-being.
Behavioral and social scientists study these problems using a variety of outcomes, levels of analysis, and empirical approaches. In their chapter, Williams and Purdie-Vaughns cite several efforts to enhance health through larger-scale reductions in income inequality. Zimmerman and colleagues highlight the importance of community-level education for well-being, while Kazdin explores the need for novel, large-scale modes of treatment delivery to adequately and efficiently meet the mental and behavioral health needs of larger segments of the population. Baldwin notes that youth, families, schools, and communities must all be engaged to successfully reduce risk factors for non-communicable diseases among youth. Holtgrave and colleagues highlight the contributions of the behavioral and social science community at the national level toward controlling the spread of HIV and providing necessary supports to those affected by the virus. Teutsch and his co-authors describe the use of a community-based health impact assessment in Los Angeles, CA, to address obesity and overweight; they provide evidence that interventions—such as requiring restaurants to identify how many calories are associated with each menu item—results in wiser food choices. The effectiveness of statewide policy interventions to reduce injury are described by Sleet and Gielen, while Berkman explores the role that institutions, companies, and workplace policies can have on improving family health and well-being. Finally, Marteau and colleagues reveal how innovative population-level interventions that change the environment in which people live can affect the personal choices they make. In each of these chapters, the dynamic impact that the larger social, political, regulatory, treatment-delivery, and cultural milieus may have on individual decisionmaking, behaviors, and population health is brought to light.
The central importance of individual-level factors on behavior and well-being likewise should not be underestimated. The role of physical activity (Sallis and Carlson) and smoking-related choices (Abrams and colleagues) in maintaining, enhancing, or harming personal and population-level health are two examples. The interplay of biological and physiological factors with behavioral and social variables is likewise a key consideration when attempting to intervene to improve well-being. As the chapters by McEwen and Boyce suggest, the human body reacts to a range of pressures, and the social environment can have a major role in mitigating, attenuating, or accelerating what was once understood strictly as 'biological effects.' The traditional lines between behavioral and social science research and the human biological sciences are starting to blur. As Adler and Prather so aptly point out, future research and practice that aim to optimize population health will need to effectively draw on interdisciplinary perspectives and methods across the behavioral, social, and biological sciences to succeed.
Some behavioral and social interventions have the potential to increase life expectancy by years.4 Unfortunately, however, the potential for enhancing health outcomes through social and behavioral interventions may be underappreciated. A few back-of-the envelope calculations concerning cigarette smoking help to illustrate this point. About 18 percent of adults in the United States smoke cigarettes5 (also Abrams, et al.). Tobacco smoking contributes to an estimated 425,000 premature deaths per year. Each 1 percent reduction in cigarette use should result in about 21,500 premature deaths prevented. Even a modest 2 percent reduction in the smoking rate could have a large effect, perhaps rivaling that of completely eliminating breast cancer deaths. Further, meta-analysis suggests that minimal intervention in primary care would increase the marginal quit rate by about 0.94 percent.6 Given the severe health consequences associated with smoking, this small percentage would translate into an impressive savings of about 373,000 quality-adjusted life years (QALYs). Brief counseling combined with nicotine replacement could increase the marginal quit rate by 8.4 percent and produce about 3,333,000 QALYs. On a population basis, these effects are profound in relation to many widely accepted health care interventions that have been evaluated using similar methods (Russell).
Unfortunately, these smoking interventions are used rarely, and at best they are offered to only about a quarter of smokers. If utilized more widely, these simple interventions may save many more lives than those lost to infections from antibiotic-resistant organisms (e.g., methicillin-resistant Staphylococcus aureus [MRSA]), measles, and a variety of other health problems that occupy national attention. The cost-effectiveness of these simple interventions is also much more favorable than almost all other primary care services that have been analyzed.7
The above example of staggering lost opportunity stands in sharp contrast to the success of another set of behavioral and social science-based interventions. The Centers for Disease Control and Prevention (CDC) has listed motor vehicle injury prevention among the 10 greatest public health achievements in the United States from 1900 to 2000.8 This achievement was the result of multiple behavioral and cultural factors working in concert, including greater use of seat belts, better driver preparation, reduced frequency of driving while intoxicated, and improved road and automobile engineering. This example stands as a testament to the importance of integrating behavioral and social science considerations when working to improve population-level health.
Several chapters in this volume have explored the economic implications of investing in behavioral and social science interventions. Russell uses economic modeling methods to highlight which medical care alternatives may return the greatest health benefit for the investment made. She considers how many life years could be purchased for an investment of $1 million. In comparison to several medical, preventive, and environmental alternatives, smoking cessation consistently returns the most health benefits for the money invested. Further, Stewart and Cutler use economic analysis to demonstrate the importance of prioritizing behavioral and social interventions when addressing activities like smoking and dangerous driving. They found that changes in smoking between 1960 and 2010 improved quality-adjusted life expectancy in the United States by 1.42 years, and that cutting motor vehicle-related deaths resulted in another 0.43 year increase in life expectancy. Unfortunately, the costs saved by improvements in health behaviors such as smoking and reduced motor vehicle crashes were offset by increased costs associated with an uptick in obesity, poisonings, and firearm-related events. Finally, Frank and Glied discuss how health economics can yield improvements in mental health policy and practice. Taken together, these myriad chapters speak to the promise of behavioral interventions and point to areas for future research and investment.
The Path Forward
Perhaps it is best to conclude where we started. The mission of the National Institutes of Health (NIH) is "to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability." Through its programmatic development efforts and its efforts to build consensus across NIH Institutes and Centers, the NIH Office of Behavioral and Social Sciences Research (OBSSR) seeks to highlight and promote the crucial role that basic and applied research in the behavioral and social sciences plays in improving health and quality of life over the lifespan. Our other sponsor, the Agency for Healthcare Research and Quality (AHRQ), focuses on the translation of evidence-based research into the clinical practice of health care. AHRQ's mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable and to work with other U.S. Department of Health and Human Services (HHS) agencies and other public- and private-sector partners to make sure that this evidence is understood and used. Several chapters in this book focus on AHRQ's efforts relevant to the establishment of new lines of evidence and to the efficiency and equity of health care.
OBSSR and AHRQ achieve programmatic success by working with a broad range of scientific constituencies to define mission-specific goals. The current plan to advance behavioral and social science research along with health services research includes several different 'pillars' or targets, several of which are described below.
Advance Research Methods and Approaches
In order to harness the new understanding of health determinants, we must encourage continued development of the changing paradigms of behavioral and social science research methodologies, approaches, and practices.
Findings in the behavioral and social sciences are often minimized or dismissed outright because they are correlational and not causal. The chapter by Pickett and Wilkinson takes up the challenge of estimating causation from observational data. The authors make a case that the relationship between social determinants (specifically, socioeconomic status) and health outcomes is, indeed, causal. This finding, and the rigorous methodology that the authors used to come to it, can be crucially important for shaping health and income policies. Preston also provides a detailed account of how social science research has contributed to better understanding of the social forces that have improved health through (1) accurate measurement, (2) attention to research design, and (3) a disciplinary focus on populations. These contributions include an evaluation of the impact of changes in living standards, medical care, and public health on improvements in morbidity and mortality.
The importance of utilizing robust methodologies has been further recognized by the OBSSR, which has been leading efforts in systems science for several years. Systems science methods can enable investigators to simultaneously examine the dynamic interrelationships of variables at multiple levels of analysis in complex systems (e.g., from cells to society), using modern computer modeling technologies. As one example, new methods based on systems science can help model the complexity of the multiple interacting factors that contribute to health disparities, adolescent sexual behavior, and poor health outcomes (Orr et al.). in addition to systems science initiatives, behavioral and social science research requires a shift in focus from the individual to an emphasis on the community level and, concurrently, to the use of appropriate population modeling tools. "Big Data" and machine learning represent other important and useful areas of emergence. On the level of practice, fostering and supporting an informed workforce of physicians who can be on top of the most recent advances in the biomedical sciences while also effectively serving both patients and the larger community is also warranted (Satterfield and Carney).
Promote Interdisciplinarity, Team Science, and Collaboration
As emphasized by Adler and Prather, there is also a critical need for an interdisciplinary research perspective that focuses on new ways to shift the boundaries and/or blur the lines between research disciplines. Such an approach should incorporate the methods of epidemiology and public health, sociology, psychology, environmental science, neurology, developmental biology, genetics, epigenetics, anthropology, political science, engineering, computer science, and other disciplines. One obstacle to this collaboration is the tendency to undervalue the behavioral and social sciences compared to biomedical science. Proactive communication among behavioral and social scientists and biologists is needed to spur collaboration. New scientific journals highlighting promising collaborations and professional societies recognizing the inter-connectedness between biology and behavior could play an important role, as could an expanded dialogue focused beyond the individual level to encompass communities and indeed whole populations.3
Not all investments in health are of equal value, but as many of the chapters in this volume have underscored, investments focused on health behaviors—including smoking, physical activity, and improved safety practices—represent a very good use of resources. Broadly speaking, behavioral and social science research should more fully embrace health economics to identify opportunity costs and return on investment for public health interventions that target behavior and social change. Health economic methods such as cost-effectiveness analysis (CEA), cost-benefit analysis (CBA) Russell, and health impact assessment (HIA) (Teutsch, et al.) can prove increasingly helpful. The potential impact of these and other approaches is highlighted by the use of health economics research to spur improvements in the behavioral health care system.
This book is the product of an important collaboration between NIH and AHRQ. There are other important potential collaborators in population-level research, including the CDC and the environmental health community. Within NIH, the National Cancer Institute (NCI) is providing tools to advance interdisciplinary efforts. As one example, the NCI Team Science Toolkit is an online resource that serves to integrate and disseminate information and resources for engaging in tobacco science, as well as facilitating, supporting, evaluating, or studying team science.a Likewise, translational research opportunities may become available through NIH T4 awards and through interaction with the National Center for Advancing Translational Sciences (NCATS) to identify opportunities for clinical translational science awards (CTSA).
Expand Visibility of Behavioral and Social Science Interventions
Behavioral and social scientists must increase their efforts to effectively communicate the importance of behavioral and social science interventions for public health. Researchers need to learn how much and what type of evidence is sufficient and of high enough quality to support public policy decisions; efforts are similarly required to better understand the methodologies and communication strategies that are needed to inform the public arena. The return on investment in behavioral and social science research and interventions, as noted in several of the chapters in this book, must be communicated to policymakers and the public alike. The value of behavioral and social sciences can be demonstrated by studies documenting how much additional heath benefit is added by interventions in areas such as diabetes prevention.9
Generally, investigators are not trained to make data accessible to nontechnical audiences, such as policymakers and the general public. Those interested in this undertaking may need to seek out opportunities to practice and hone these skills. Efforts are also needed to better communicate with regulatory agencies, such as the Food and Drug Administration (FDA). NCI is spearheading an effort in this area to develop an inter-agency initiative with FDA to inform regulatory decisions about tobacco products and their marketing. In keeping with AHRQ's efforts to ensure that the best scientific evidence is available for use in health care practice and that policymakers have access to high quality scientific evidence that can be used in their decisions about health care policy, the agency offers a variety of data resources for policymakers, including the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP).
Behavioral and social factors have profound effects on life expectancy and health-related quality of life. The magnitude of these effects has been under-recognized. The goal of extending the human life span and of improving health-related quality of life will require rigorous new research that establishes causal relationships, improves measurements, and systematically evaluates intervention strategies, as well as effective practices that emerge from this research.
This book deals less with specific diseases and more with the broader topical groupings such as the demographic, biological, behavioral, and policy determinants that affect health outcomes. We hope these contributions will stimulate efforts that can maximize the impact of behavioral and social science research on health outcomes that are meaningful to patients, families, and communities. By bringing greater visibility to behavioral and social science research, we hope to inspire a new generation of creative research and application that ultimately will produce better health for populations, both here in the United States and around the world.
The opinions presented herein are those of the authors and do not necessarily represent the official position of the Agency for Healthcare Research and Quality, the National Institutes of Health, or the U.S. Department of Health and Human Services.
Daryn H. David, PhD, and Michael L. Spittel, PhD, Office of Behavioral and Social Sciences Research, Office of the Director, National Institutes of Health. Robert M. Kaplan, PhD, Agency for Healthcare Research and Quality; formerly the Office of Behavioral and Social Sciences Research, Office of the Director, National Institutes of Health.
Address correspondence to: Robert M. Kaplan, PhD, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Mailstop 06E37A, Rockville, MD 20857; email Robert.Kaplan@ahrq.hhs.gov.
- Preventing chronic diseases: a vital investment. WHO Global Report. Geneva: World Health Organization; 2005.
- Woolf SH, Aron L (eds). U.S. health in international perspective: shorter lives, poorer health. Panel on Understanding Cross-National Differences Among High-Income Countries. Washington, DC: National Academies Press; 2013.
- Woolf SH, Aron LY. The U.S. health disadvantage relative to other high-income countries: findings from a National Research Council/Institute of Medicine report. JAMA 2013;309(8):771-2.
- Kaplan RM. Behavior change and reducing health disparities. Prev Med 2014;68:5-10.
- Smoking & tobacco use. Current cigarette smoking among adults in the United States (Web site). Atlanta, GA: Centers for Disease Control and Prevention; 2015. Available at http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/. Accessed July 9, 2015.
- Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation interventions in medical practice. A meta-analysis of 39 controlled trials. JAMA 1988;259(19):2883-9.
- Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA 1997;278(21):1759-66.
- Achievements in Public Health, 1900-1999 Motor Vehicle Safety: A 20th Century Public Health Achievement. MMWR 1999;48(18):369-74.
- Dyson PA. Addressing noncommunicable disease at the population level: a focus on diabetes. Diabetes Manag 2014;4:153-63.
a. More information about NCI's Team Science Toolkit is available at https://www.teamsciencetoolkit.cancer.gov/public/Home.aspx.
We thank the following individuals for their contributions to this book as peer reviewers: Colin Baker, David Berrigan, Greg Bloss, Nancy Breen, Heather Cameron, Yen-Pin Chiang, Lee Eiden, Sheila Fleischhacker, Bob Freeman, Dionne Godette, Chris Hafner-Eaton, Martha Hare, Lynne Haverkos, Misty Heggeness, Carl Hill, Dionne Jones, Bill Lawrence, Amy Lossie, Patricia Mabry, Brett Miller, Carmen Moten, Peggy Murray, Susan Newcomer, Wendy Nilsen, Susan Persky, Barry Portnoy, Dan Raiten, Dianne Rausch, Dana Sampson, Michael Schoenbaum, Joel Sherrill, Bruce Simons-Morton, David Sommers, Erica Spotts, Shobha Srivasan, Steve Suomi, Derrick Tabor, Richard Troian, Deborah Young-Hyman, Sheryl Zwerski
The editors gratefully acknowledge the exceptional efforts of four people who made this book possible. Mary Grady served as managing editor for the project. In this role, she set a very high bar for precision and accuracy and kept a close eye on the production schedule. Sabrina Liao served as the graphic designer for the project. With a long history of working with the Office of Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health (NIH), Sabrina produced the cover, formatted the copy, and coordinated the aesthetic aspects of the book. Joel Boches managed the print and Web production process for the book. Finally, our colleague Stephane Philogene from OBSSR worked with us on all aspects of the project, including selection of the authors, coordination between NIH and the Agency for Healthcare Research and Quality (AHRQ), and oversight of the production. Stephane's contributions were essential in guiding both the content and production of the book. We feel lucky to have such talented and committed partners in this effort.
In addition to NIH and AHRQ, the following NIH Institutes, Centers, and Offices participated in the development and peer review of the chapters in this book.
Center for Scientific Review Office of the Director office of Disease Prevention
National Cancer Institute
National Human Genome Research Institute
National Heart, Lung, and Blood Institute
National Institute on Alcohol Abuse and Alcoholism
National Institute of Allergy and Infectious Diseases
Eunice Kennedy Shriver National Institute of Child Health and Human Development
National Institute on Drug Abuse
National Institute of Mental Health
National Institute on Minority Health and Health Disparities
National Institute of Neurological Disorders and Stroke
National Institute of Nursing Research
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