Population Health: Behavioral and Social Science Insights
Christine A. Bachrach
The United States spends more on health care than any other advanced economy but still lags behind other countries on most measures of population health. This is a familiar refrain to devotees of health statistics but a surprising and troubling revelation to many who take pride in the outstanding health care U.S. citizens enjoy. The truth is, as reports from the Institute of Medicine and the National Research Council document, current U.S. approaches to safeguarding the health of the American people are not working as they should.
It's not that policymakers have neglected the problem. The Patient Protection and Affordable Care Act (ACA) has been a promising step towards overhauling the country's health care system. If it remains in place, it should help to bring down health care costs and extend coverage to many vulnerable groups who previously could not afford needed care. However, the primary focus of the ACA on reforming the health care system points to a fundamental problem in our societal approach to health: we tend to equate health with health care. We pour millions of dollars into finding cures for disease, both through taxpayer investments in the National Institutes of Health and charitable contributions to the many nonprofit organizations that also fund the search for biomedical advances. Faced with problems such as smoking and obesity, we turn to physicians to advise patients about behavior change and think that will solve the problem, despite the limited time available for clinical visits and the proven inefficacy of information alone in producing lasting behavior change. Only a small proportion of our national health expenditures goes to prevention.
Beyond medical care, we link health to personal behavior. In the images of pharmaceutical advertising, healthy people are exercising, getting sleep, and planting gardens. Media and public health messages extoll healthy behaviors, urging people to gyms, farmers markets, and organic food stores. We lionize the superfit in our admiration of extreme sports, marathoners, and football players, even if such pursuits take an often negative toll on health. Overwhelmingly, our investments in encouraging healthy behavior are targeted toward the individual. Efforts to facilitate healthy behaviors at a structural level—for example, by limiting portion sizes for sugary soft drinks—are a hard sell in the context of cultural values that put personal responsibility and personal freedoms first.
What's missing from these medicalized and individual-focused approaches to health is the recognition that health is as much the product of the social and physical environments people occupy as it is of their biology and behavior. Although recognized centuries ago, this fact is now supported by a large body of scientific evidence that shows not only the alignment of health with supportive environments, but also causal mechanisms that translate poor environmental conditions into poor health outcomes. The successful reduction of tobacco use in the last decades of the 20th century provides a compelling example of how structural approaches, such as taxation and smoke-free public spaces, can combine with pharmaceutical and behavior-change interventions to produce lasting health improvements.
This approach is now gaining widespread support. Reports from the World Health Organization and the Institute of Medicine have urged action targeting the "upstream" determinants of health. The Robert Wood Johnson Foundation's Commission to Build a Healthier America pointed to specific steps that can be taken by local, State, and Federal governments, as well as by businesses, schools, health care providers, and local community groups. Institutions as diverse as the Federal Reserve Bank, the National Institutes of Health, and Best Buy have implemented initiatives and policies targeted at the community and workplace levels, while the movement for Health in All Policies by the National Association of County & City Health Officials draws attention to the potential consequences of all policies, not just health care system policies, for improving or diminishing health.
The promise of developing multi-level solutions to population health problems depends on continuing to build the scientific evidence that informs these efforts. Understanding and improving population health requires that scientists from widely differing disciplines combine their knowledge about the societal, behavioral, and biological causes of health and work towards an integrated science that can identify the many and complex mechanisms through which health and health disparities are produced. It requires an understanding of how individual-level processes translate to population-level processes, and vice versa. It also requires scientists to examine common health determinants across different diseases and conditions. In short, it requires the new integrative approach to the science of health that is coming to be known as population health science.
Population health science is advancing rapidly, thanks to investments by the U.S. Department of Health and Human Services through agencies such as the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH). NIH's Office of Behavioral and Social Sciences Research has devoted considerable effort to coordinating these activities. Advances in population health science are the product of leadership, creativity, and collaboration among scientists from a wide range of disciplines and professions. Because of their ability to address human behavior and social systems, the behavioral and social sciences have played a prominent role in advancing this field, but the most exciting advances are emerging out of science that transcends the biological, behavioral, and social sciences. The contents of this volume testify both to how far we have come in understanding the production of health from a multi- level perspective to the many opportunities that are available for increasing the rigor, reach, and impact of population health science.
Christine A. Bachrach, PhD
Research Professor, Department of Sociology and Maryland Population Research Center
University of Maryland, College Park
Co-Director, Health & Society Scholars Program Robert Wood Johnson Foundation
Page originally created August 2015