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Health and Behavior The Interplay of Biological, Behavioral, and Societal Influences Committee on Health and Behavior: Research, Practice, and Policy Board on Neuroscience and Behavioral Health INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.
NATIONAL ACADEMY PRESS â¢ 2101 Constitution Avenue, N.W. â¢ Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Insti- tute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by Robert Wood Johnson Foundation, Contract No. 030324 and National Institutes of Health and Center for Disease Control, Contract No. N01-OD-4-2139, TO #38. The views presented in this report are those of the Insti- tute of Medicine Committee on Health and Behavior: Research, Practice and Policy and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Health and behavior : the interplay of biological, behavioral, and societal influences / Committee on Health and Behavior, Research, Practice, and Policy, Board on Neuroscience and Behavioral Health, Institute of Medicine. p. ; cm. Includes bibliographical references and index. ISBN 0-309-07030-9 (hardcover) 1. Medicine and psychology. 2. Social medicine. [DNLM: 1. Health Behavior. 2. Attitude to Health. 3. Preventive Health Services. 4. Socioeconomic Factors. W 85 H4338 2001] I. Institute of Medicine (U.S.). Committee on Health and Behavior: Research, Practice, and Policy. R726.5 .H43225 2001 613â².01â²9âdc21 2001003541 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAPâs home page at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
âKnowing is not enough; we must apply. Willing is not enough; we must do.â âGoethe INSTITUTE OF MEDICINE Shaping the Future for Health
National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meet- ing national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the respon- sibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academyâs purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the Na- tional Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
COMMITTEE ON HEALTH AND BEHAVIOR: RESEARCH, PRACTICE AND POLICY EDWARD N. BRANDT, (Chair), Regents Professor and Director, Center for Health Policy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma MACARAN A. BAIRD, (Vice Chair), Medical Director, Mayo Management Services, Inc.; Professor of Family Medicine Mayo Medical School, Rochester, Minnesota LISA F. BERKMAN, Director, Center for Society and Health; Florence Sprague Norman & Laura Smart Norman Professor and Chair, Department of Health and Social Behavior, Harvard School of Public Health, Boston, Massachusetts W. THOMAS BOYCE, Professor, Division of Health and Medical Sciences, School of Public Health, University of California at Berkeley, Berkeley, California MARGARET A. CHESNEY, Professor, UCSF School of Medicine; Co-Director, Center for AIDS Prevention Studies, University of California, San Francisco, California LAWRENCE O. GOSTIN, Director, Center for Law and Public Health; Professor of Public Health, the Johns Hopkins University; Professor of Law, Georgetown University, Washington, District of Columbia BARBARA A. ISRAEL, Professor, Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan ROBERT L. JOHNSON, Professor, Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey ROBERT M. KAPLAN, Professor and Chair, Department of Family and Preventive Medicine, University of California, San Diego School of Medicine, La Jolla, California BRUCE S. MCEWEN, Professor and Head, Laboratory of Neuro- endocrinology, Rockefeller University, New York, New York JOHN F. SHERIDAN, Professor, Departments of Medical Microbiology and Immunology, and Oral Biology, Ohio State University Health Sciences Center, Columbus, Ohio v
DAVID SPIEGEL, Professor of Psychiatry and Behavioral Sciences, Department of Psychiatry, Stanford University School of Medicine, Stanford, California Liaison to the IOM Board on Neuroscience and Behavioral Health BEATRIX A. HAMBURG, Visiting Scholar, Department of Psychiatry, Cornell University Medical College, New York, New York Liaison to the IOM Board on Health Promotion and Disease Prevention ELENA O. NIGHTINGALE, Scholar-in-Residence, National Academy of Sciences, Washington, District of Columbia Study Staff TERRY C. PELLMAR, Director, Board on Neuroscience and Behavioral Health (since May 1999) WENDY S. PACHTER, Study Director (until April 2000) ALLISON L. FRIEDMAN, Senior Project Assistant (until December 1999) AMELIA B. MATHIS, Project Assistant LINDA V. LEONARD, Administrative Assistant (until September 2000) LORA K. TAYLOR, Administrative Assistant (since October 2000) CARLOS GABRIEL, Financial Associate (until December 2000) JENNIFER CANGCO, Financial Associate (since January 2001) ROBERT COPPOCK, Consultant KATHLEEN R. STRATTON, Director, Board on Health Promotion Disease Prevention (until September 1999) ROBERT M. COOK-DEGAN, Director, National Cancer Policy Board (until June 2000) vi
Preface I n 1982, the Institute of Medicine published a landmark study titled Health and Behavior: Frontiers of Biobehavioral Research. That study drew on the findings of six invitational conferences to provide a per- spective on the frontiers of the biobehavioral sciences, their relevance to public healthâparticularly to decreasing the burden of illnessâand their implications for science policy. The report stimulated research and train- ing in the biobehavioral sciences, and although the report is now 18 years old, much of it is still current. The Board on Neuroscience and Behavioral Health and the Board on Health Promotion and Disease Prevention of the Institute of Medicine were interested in updating the 1982 report because of the broad range of research and intervention activity it stimulated, and the growing recogni- tion of the importance of behavior to health during the years since the original report. The Robert Wood Johnson Foundation, the Office of Be- havioral and Social Science Research of the National Institutes of Health, and other Department of Health and Human Services sponsors, including the National Institute of Mental Health and the Centers for Disease Con- trol, provided funding for a new study that would differ in several ways from the original report. First, the new study was not to be merely an update of the areas covered in the original report or diseases in which the contribution of behavior is recognized (such as HIV and AIDS), but in- stead was to identify factors involved in health and disease for which re- vii
viii PREFACE search is incomplete. Second, this study was to go beyond biobehavioral research to consider applications and cost-effectiveness. The Institute of Medicine convened the Committee on Health and Behavior: Research, Practice and Policy in September 1998. The Com- mittee comprised 12 members with experience in basic, clinical, and pub- lic health research; practice in settings ranging from public health to pri- vate practice and managed care; and experience with federal, local, and private policy. Committee members had specific expertise in internal, fam- ily, adolescent, and pediatric medicine; health policy; epidemiology and social epidemiology; family therapy; clinical and social psychology; law and ethics; health education; neuroendocrinology; and immunology and psychiatry. The Committee refined its statement of task at the first meeting. The Committee decided that the health and behavior field had become much too large to study comprehensively in the time allotted. The Committee therefore agreed to focus primarily on new and promising developments in the field since 1982, based on the best available research, or, occasion- ally, on the Committeeâs assessment of where the field is heading. Com- mittee members agreed that health and behavior should be broadly de- fined to include both behavioral and psychosocial factors as in the 1982 report, rather than limiting consideration to âhealth behaviorsâ such as eating, smoking and other substance use and abuse, and physical activity. This decision also reflected the sense of the Committee that since 1982 the social sciences have made new and exciting contributions to under- standing health and behavior and that these have implications for inter- ventions and policy. Psychosocial factors are the individual interpreta- tions or understandings of social relationships, events, or status that reflect a combination of psychological and social variables and are internalized and affect biological factors. The Committee also decided at the first meeting to consider âapplica- tionsâ of behavioral and psychosocial interventions rather than âpractice.â The significance of this change was to enable the Committee to think beyond traditional medical or other clinical practice to include program- matic and public health interventions. The resulting charge to the Committee was to (1) update scientific findings about the links between biological, psychosocial and behavioral factors, and health; (2) identify factors involved in health and disease but for which research on these factors and effective behavioral and psychoso- cial interventions is incomplete; (3) identify and review effective applica-
PREFACE ix tions of behavioral and psychosocial interventions in a variety of settings; (4) examine implementation of behavioral and psychosocial interven- tions, including guidelines and changes in provider behaviors; (5) review evidence of cost-effectiveness; and (6) make recommendations concern- ing further research, applications, and financing. The Committee prepared papers on a variety of topics and deliberated in a series of five meetings, several of which were open to the public. Several experts in health and behavior were invited to address the Com- mittee at meetings, and several more were invited to a workshop on health, communications, and behavior (see agenda in Appendix A). Ad- ditional information was obtained through six commissioned papers; a contribution by the Working Group on Family-Based Interventions in Chronic Disease; active participation in meetings by consultants in public health, health psychology and law; and comments on draft papers by a number of additional expert consultants prior to formal review (see Ap- pendix B). The Committee noted great enthusiasm in the health and behavior field, and many busy experts were willing to give generously of their time and effort for little or no compensation. The Committee is grateful to all who provided assistance; those who served as consultants are acknowledged by name in Appendix B.
Reviewers T he report was reviewed by individuals chosen for their diverse per- spectives and technical expertise in accordance with procedures approved by the National Research Councilâs Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and respon- siveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the delib- erative process. The committee wishes to thank the following individuals for their participation in the report review process: Bobbie Berkowitz, University of Washington Joel Dimsdale, University of California, San Diego Lewis Kuller, University of Pittsburgh Michael Marmot, University College, London Medical School James Prochaska, University of Rhode Island Sally Shumaker, Wake Forest University Medical School Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the con- clusions or recommendations nor did they see the final draft of the report xi
xii REVIEWERS before its release. The review of this report was overseen by Paul Cleary, Harvard Medical School and Maureen Henderson, University of Wash- ington. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institu- tional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Contents EXECUTIVE SUMMARY 1 Definition of Behavior, 3 Definition of Health, 3 Risk Factors, 3 Health-Related Interventions, 8 An Intervention Case Study: Tobacco, 15 Findings and Recommendations, 16 1 INTRODUCTION 19 Definition of Behavior, 20 Definition and Measurement of Health, 21 The Intersection of Health and Behavior, 25 Underlying Assumptions, 27 Statement of Task, 27 Boundaries of the Study, 31 Organization of the Report, 33 References, 34 xiii
xiv CONTENTS PART ONE: BIOLOGICAL, BEHAVIORAL, AND SOCIAL FACTORS AFFECTING HEALTH 37 2 BIOBEHAVIORAL FACTORS IN HEALTH AND DISEASE 39 Stress, Health, and Disease, 40 The Brain as Interpreter, Regulator, and Target, 47 Immune System Function in Health and Disease, 51 Additional Factors Influence Long-Term Effects of Stress, 57 Cardiovascular Health and Disease, 61 Developmental Trajectories, 68 References, 70 3 BEHAVIORAL RISK FACTORS 87 Tobacco Use, 87 Obesity: Physical Activity and Diet, 92 Alcohol Consumption, 102 Sexual Practices, 107 Disease Screening Practices, 113 References, 121 4 SOCIAL RISK FACTORS 138 Socioeconomic Status, 139 Social Networks and Social Support, 145 Occupational Factors, 151 Social Inequalities, 157 Religious Belief, 165 References, 166 PART TWO: HEALTH-RELATED INTERVENTIONS 179 5 INDIVIDUALS AND FAMILIES: MODELS AND INTERVENTIONS 183 Models of Behavior Change, 183 Interventions Targeted at Individuals, 191 Families and Health, 209 Interventions Targeted at Family Interactions, 211 References, 221
CONTENTS xv 6 ORGANIZATIONS, COMMUNITIES, AND SOCIETY: MODELS AND INTERVENTIONS 241 Organizations and Health, 241 Interventions Targeted at Organizations, 243 Communities and Health, 250 Community-Level Interventions, 254 Society and Health, 258 Society-Level Interventions, 260 References, 264 7 EVALUATING AND DISSEMINATING INTERVENTION RESEARCH 274 Evaluating Interventions, 275 Cost-Effectiveness Evaluation, 291 Dissemination, 294 References, 309 PART THREE: FINDINGS AND RECOMMENDATIONS 329 8 FINDINGS AND RECOMMENDATIONS 331 Interactions Among Risk Factors, 331 Behavior Change, 333 An Intervention Case Study: Tobacco, 335 Application of Research Results, 347 Findings and Recommendations, 348 References, 350 APPENDIXES A WORKSHOP ON HEALTH, COMMUNICATIONS, AND BEHAVIOR 357 B CONSULTANTS 359 INDEX 363
Health and Behavior