BSSR Contributions to Public Health
Public Health Achievements of the Behavioral and Social Sciences:
Improving Health at Home and Abroad
Reducing Tobacco Use
The biggest public health success story of the 20th century may very well be the reduction in tobacco use and smoking- related diseases. Lung cancer is the leading cause of cancer death—accounting for about one-third of all cancer deaths.1
A well-known risk factor for lung cancer, smoking is also a risk factor for heart disease, chronic bronchitis, emphysema, and gastric ulcers.1 Behavioral and social sciences research has led to the development of interventions such as increased tobacco taxes and smoking bans in public places; in combination with pharmacological interventions, this has led to declines in smoking rates. The dramatic reductions in male smoking rates from 51.9 percent in 1965 to 23.5 percent in 2009, and from 33.9 percent in 1965 to 17.9 percent in 2009 in female smoking rates,2 have played a major role in decreasing death rates for cancer, heart disease, and chronic obstructive pulmonary disorder.3-5 Without these interventions, more than 45 million Americans might still be smoking,6 resulting in thousands of preventable deaths and millions of dollars in excess costs.
1 American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer Society; 2013. Retrieved online at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf
2 American Lung Association, Research and Program Services, Epidemiology and Statistics Unit. (2011). Trends in Tobacco Use. Retrieved online at: http://www.lung.org/finding-cures/our-research/trend-reports/Tobacco-TrendReport.pdf
3 Sedjo RL, Byers T, Barrera E Jr, Cohen C, Fontham ET, Newman LA, Runowicz CD, Thorson AG, Thun MJ, Ward E, Wender RC, Eyre HJ; ACS Cancer Incidence & Mortality Ends Committee. A midpoint assessment of the American Cancer Society challenge goal to decrease cancer incidence by 25% between 1992 and 2015. CA Cancer J Clin. 2007 Nov-Dec;57(6):326-40
4 Thun MJ, Jemal A. (2006). How much of the decrease in cancer death rates in the United States is attributable to reductions in tobacco smoking? Tobacco Control, 15(5):345-7.
5 Moolgavkar SH et al. Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975-2000. (2012). Journal of the National Cancer Institute. 104(7): 541-548.
6 Centers for Disease Control & Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 years – United States, 2005-2010. Morbidity & Mortality Weekly Report 2011; 60(33):1207-12 [accessed 2012 Jan 24]. Retrieved online at: www.cdc.gov/tobacco/data_statistics/fact_sheets.
Improving Mental Health and Reducing the Burden of Addiction
An estimated 26.2 percent of adults in the U.S., more than 57 million adults, suffer from a diagnosable mental disorder in a given year.7,8 Major depression is a leading cause of disability in the United States; however a range of neuropsychiatric disorders, including Alzheimer’s disease, schizophrenia, and bipolar disorder, continue to impact tens of millions of Americans each year.9,10 Biological, behavioral and social sciences research have made enormous strides in the past 30 years to understand the bio-behavioral mechanisms underlying mental disorders and to develop treatment options. Cost-effective therapies that combine behavioral and pharmacological regimens are now available for depression, anxiety disorders, and alcohol/drug abuse. Current advances help tens of millions of Americans with mental health conditions engage in healthier lifestyles; however those affected with mental health problems do not always receive treatment. In 2008, just over half (58.7 percent) of U.S. adults with a serious mental illness received treatment for a mental health problem.11 Additional research is needed to determine how to improve access to mental health services and treatments so they may lead healthy, productive lives.
7 KESSLER, RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005 Jun;62(6):617-27.
8 U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/
9 LOPEZ AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Measuring the Global Burden of Disease and Risk Factors, 1990-2001. In Global Burden ofDisease and Risk Factors. Eds. AD Lopez, CD Mathers, M Ezzati, DT Jamison, and CJL Murray. New York, NY: Oxford University Press and The World Bank; 2006. Available at http://files.dcp2.org/pdf/GBD/GBD.pdf.
10 National Institute of Mental Health. (2012). Statistics: Disorders within the Neuropsychiatric Category. Retrieved online at: http://www.nimh.nih.gov/statistics/2CDNC.shtml.
11 SAMHSA’s National Survey on Drug Use and Health (NSDUH) 2008. Accessed online at http://www.nimh.nih.gov/statistics/3USE_MT_ADULT.shtml.
Diabetes can lead to devastating complications such as heart disease, stroke, blindness, and premature death. Type 2 diabetes is growing at an epidemic rate, with
more than 25 million Americans currently affected and 79 million more with pre-diabetes.12 For many years, scientists believed that medication was the only tool to treat diabetes.
A landmark study, the Diabetes Prevention Program, demonstrated that lifestyle interventions– modest changes in dietary intake and regular physical activity to induce weight loss– can reduce the risk of developing type 2 diabetes in high-risk adults by 58 percent, compared to 31 percent reduction with medication alone.13 The lifestyle intervention was so successful that a group-based lifestyle intervention was offered to all of the study participants in the next phase of the program. The original effect was quite durable over the long term. The subjects engaged in the lifestyle intervention from the beginning continued to show reduced rates of development of diabetes, compared to those who started the original study in the medication or placebo groups.14 These findings led to “Small Steps, Big Rewards,” the first national diabetes prevention campaign.
12 Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
13 Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM; Diabetes Prevention Program Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403.
14 Lancet. 2009 Nov 14;374(9702):1677-86. doi: 10.1016/S0140-6736(09)61457-4. Epub 2009 Oct 29. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, Brown-Friday JO, Goldberg R, Venditti E, Nathan DM.
Slowing the HIV/AIDS Epidemic
Thanks to scientific advances in the biological, behavioral, and social sciences, HIV/AIDS in the U.S. is no longer considered the death sentence it was in the past. Whether the focus is to prevent transmission, to encourage testing and early treatment, or to increase adherence to medications, slowing the spread of HIV/AIDS requires understanding and changing attitudes, beliefs and human behavior at the individual, interpersonal, and community levels. Research in the behavioral and social sciences has extended our understanding of decision-making, drug abuse, and sexual behavior, and has resulted in innovative interventions to modify behaviors and slow the spread of HIV/AIDS.
Pharmacological treatment as prevention is also a promising new approach in the battle against HIV/AIDS. Several studies have demonstrated that combination antiretroviral therapy suppresses HIV viral loads in HIV positive individuals so that it is unlikely that they transmit HIV to their uninfected partners.15-18 Yet behavior continues to play a big role. Early HIV testing, and initiation of and adherence to treatment help ensure that persons during their most infectious period do not transmit HIV. As a result of this research, the number of people infected with HIV each year has dropped from a peak of 150,000 in the early 1980s to 49,273 in 2011,19 and mother-to-child transmission has fallen 94 percent from its peak in 1992.20-22
15 Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505.
16 Baeton J., Celum C. Antiretroviral pre-exposure prophylaxis for HIV-1 prevention among heterosexual African men and women: The Partners PrEP Study. 6th IAS Conference; July 17–20, 2011. Rome, Italy. Abstract MOAX0106. http://pag.ias2011.org/flash.aspx?pid=886 (accessed Nov 28, 2011).
17 Lalani, T. & Hicks, C. (2008). Does antiretroviral therapy prevent HIV transmission to sexual partners? Curr Infect Dis Rep, 10(2):140-145.
18 Donnell, D., Baeten, J.M., Kiarie, J., et al. (2010). Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: A prospective cohort analysis. Lancet, 375:2092-2098.
19 Centers for Disease Control and Prevention. (2011). HIV Surveillance Report: Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2011; Vol.23. Retrieved online at: http://www.cdc.gov/hiv/topics/surveillance/basic.htm#Main.
20 Centers for Disease Control and Prevention. HIV Prevention in the Third Decade: Activities of CDC’s Divisions of HIV/AIDS Prevention. October 2005. Available at https://stacks.cdc.gov/view/cdc/11375.
21 NIAID’s HIV/AIDS Research Program. July 2012. Available at: http://www.niaid.nih.gov/topics/hivaids/Pages/Default.aspx
22 Centers for Disease Control and Prevention. The Past Two Decades: How Far Have We Come? January 2006. Retrieved online at: http://www.cdc.gov/hiv/resources/reports/hiv3rddecade/chapter1.htm.
Reducing Sudden Infant Death Syndrome (SIDS)
Formerly known as “crib death”, SIDS is one of the leading causes of infant death, claiming the lives of more than 2,000 infants each year in the United States.23,24 One of the leading risk factors for SIDS is entirely behavioral – stomach sleeping.
Behavioral and social sciences research led to the 1994 “Back to Sleep” campaign to promote infant back sleeping to prevent SIDS. As a result of the Back to Sleep Campaign, back sleeping increased from 13 percent in 1992 to 76 percent in 2006,25 and overall SIDS rates declined by more than 50 percent since recommendations for back-sleeping were instituted in the early 1990s.26,27 The new-and-improved “Safe to Sleep” campaign builds on the success of “Back to Sleep” by describing ways that parents and caregivers can reduce the risk of other sleep-related causes of infant death, such as suffocation.28
23 Mathews TJ, MacDorman MF. Infant mortality statistics from the 2004 period linked birth/infant death data set. Natl Vital Stat Rep. 2007 May 2;55(14):1-32.
24 Heron, M., Hoyert, D.L., Murphy, S.L., Xu, J., Kochanek, K.D., Tejada-Vera, B., (2009). Deaths: Final data for 2006. National Vital Statistics Reports, 57(14). Hyattsville, MD: National Center for Health Statistics:1-135.
25 National Infant Sleep Position Study. The usual position in which mothers place their babies to sleep: data from the national NISP telephone survey for years 1992 – 2006. Accessed May 2, 2008 at http://dccwww.bumc.bu.edu/ChimeNisp/Tables_in_PDF/NISP%201992-2006%20The%20usual%20sleep%20position.pdf.
26 Centers for Disease Control and Prevention, Division of Reproductive Health. (2013). Sudden Unexpected Infant Death (SUID). Retrieved online at: http://www.cdc.gov/SIDS/
27 Centers for Disease Control and Prevention. (1996). Sudden Infant Death Syndrome—United States, 1983-1994. MMWR, 45(40): 859-863.
28 Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep Public Education Campaign. Accessed October 26, 2012 at http://www.nichd.nih.gov/sids/
Promise of the Behavioral and Social Sciences
There is strong evidence that more than half of all deaths in the U.S. can be attributed to behavioral factors such as smoking, poor diet, and physical inactivity which may lead to heart disease, type 2 diabetes, lung disease, and some cancers.29,30,31
Even with the dramatic contributions of scientific research to date, much more needs to be done to understand the role of behavioral and social factors in disease and to use that knowledge to improve the nation’s health.
29 McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993 Nov 10;270(18):2207-12.
30 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004 Mar 10;291(10):1238-45.
31 Oxford Health Alliance. (2012). 3Four50: Connect Collaborate Create. Accessed November 1, 2012 at: www.3four50.com.
Transforming Health Care
Achieving the triple aims of better care, better health, and lower costs requires continued breakthroughs from behavioral and social sciences research. One focus of study is health care delivery. It is widely recognized that we spend nearly $750 billion each year on health services that have little benefit.32 In addition, there is remarkable variation in use and cost of health care across demographically comparable regions. For example, the costs of end of life care in Los Angeles are up to 80 percent higher than in San Diego, despite essentially no differences in patient outcomes or satisfaction with care.33 What happens to people is largely a function of provider choice, which often occurs with insufficient patient involvement. New behavioral research may inform polices on provider incentives, organization of health plans, and patient activation in shared medical decision-making. Evidence suggests that patients make good choices when they have the right information. One systematic review found that shared-decision making techniques improved patient knowledge and the patient experience, which included satisfaction, communication, quality of life, and self-efficacy.34 Newer approaches expose patients to the very best outcome evidence and allow them to be more active participants in the decision making process.
32 Yong, P.L., Olsen, L., Roundtable on Evidence-Based Medicine, & Institute of Medicine. (2010). The healthcare imperative: Lowering costs and improving outcomes: Workshop series summary. National Academy of Sciences. Retrieved from: http://www.nap.edu/catalog.php?record_id=12750
33 Kaplan, R.M. (2011) Variation between end-of-life health care costs in Los Angeles and San Diego: Why are they so different? Journal of Palliative Medicine, 14(2):215-220.
34 Coulter, A. & Ellins, J. (2007). Effectiveness of strategies for informing, educating, and involving patients. BMJ, 335:24-27.
The Role of Stress and Emotions on Health
The physiology of emotions has powerful effects on health and disease. One active area of research is stress and cancer. While psychological stress does not appear to cause cancer, long-term stress may affect the progression of the disease. Behavioral stress management interventions have been shown to influence immune function in cancer patients, raising the possibility that these therapies might be useful in battling the disease.35 Similarly, drugs that block the actions of certain stress hormones have shown promise in reducing cancer progression in animal models and may have similar outcomes on certain cancers in humans.36,37 Other research focuses on how stress and emotion influence the body’s response to viruses and injury. One study showed that positive feelings of happiness, liveliness and calm were associated with a lower risk of developing an infection and fewer illness symptoms than expected in response to exposure to the cold virus.38 Another found that married couples’ blister wounds healed more slowly following marital discord than after supportive interactions.39 Additional research that integrates the biological, behavioral and social sciences is needed to understand how psychosocial factors influence physiological function and to use that knowledge to develop new interventions to improve health.
35 Lutgendorf SK, Sood AK, Antoni MH. Host factors and cancer progression: biobehavioral signaling pathways and interventions. Journal of Clinical Oncology 2010;28(26):4094-4099.
36 Melhem-Bertrandt A, Chavez-Macgregor M, Lei X, et al. Beta-blocker use is associated with improved relapse-free survival in patients with triple-negative breast cancer. Journal of Clinical Oncology 2011;29(19):2645-2652.
37 Yang, Eric, V; Sood, Anil, K; Chen, Min; Li, Yang; Eubank, Tim, D; Marsh, Clay, B; Jewell, Scott; Flavahan, Nicholas, A; Morrison, Carl; Yeh, Peir-En; Lemeshow, Stanley; Glaser, Ronald. 2006. Norepinephrine up-regulates the expression of vascular endothelial growth factor, matrix metalloproteinase (MMP)-2, and MMP-9 in nasopharyngeal carcinoma tumor cells. Cancer research. Vol. 66, no. 21: 10357-64.
38 Cohen, S., Alper, C.M., Doyle, W.J., Treanor, J.J., Turner, R.B. (2006). Positive emotional style predicts resistance to illness after experimental exposure to Rhinovirus or Influenza A virus. Psychosomatic Medicine, 68:809-815.
39 Kiecolt-Glaser, J.K., Loving, T.J., Stowell, J.R., Malarkey, W.B., Lemeshow, S., Dickinson, S.L., Glaser, R. (2005). Hostile marital interactions, proinflammatory cytokine production and wound healing. Arch Gen Psychiatry, 62: 1377-1384
The “nature versus nurture” debate has evolved into a much richer exploration of how genetic and environmental factors interact in complex ways to explain traits and health outcomes. The explosion of genetics research has increased the number of tools available to behavioral and social scientists and has expanded the types of questions that can be addressed. For example, studies in rodents have demonstrated how different parenting styles cause specific changes in gene expression in the brain of their offspring that in turn, dictate how those offspring respond to stress and how to behave when they become parents.40 From this type of work, we are beginning to understand how gene-environment interactions are responsible for the intergenerational transmission of parenting behaviors and stress reactivity.40 Gene-environment interplay is not limited to rodents. Studies in humans have shown that genes in our immune systems are expressed differently depending on the social context; such gene-environment interplay may explain the effects of loneliness and other psychosocial factors on health and well-being.41 New efforts to measure the “exposome”, or the totality of an individual’s exposures over the life course — including exposures to the chemical, physical, social and behavioral environments — are critical to our understanding of how genes and environments interact over a lifetime to influence health and disease.
This knowledge has the potential to inform prevention and intervention efforts, and to help us design our environments to optimize health.
40 Champagne FA, 2010, Early Adversity and Developmental Outcomes : Interaction Between Genetics, Epigenetics, and Social Experiences Across the Life Span, Perspectives on Psychological Science 5: 564-574.
41 Cole, S. W., Hawkley, L. C., Arevalo, J. M. G., & Cacioppo, J .T. (2011). Transcript origin analysis identifies antigen presenting cells as primary targets of socially regulated leukocyte gene expression. Proceedings of the National Academy of Sciences, 108, 3080-3085. doi: 10.1073/pnas.1014218108. www.pnas.org/cgi/doi/10.1073/pnas.1014218108
Understanding Behavior in Real Time and Space
Researchers and clinicians have long relied on patients’ recall of past behavior to understand their symptoms, concerns, and treatment needs. Individuals are asked to describe, for example, how intense their pain is during the day, what they ate in the previous 24 hours, how strong their cravings are to smoke, and on how many days they experienced pain or anxiety in the last month.
This information is then used to guide treatment or to shape research questions. The challenge is that recall is often inaccurate, as it only includes what the individual is able and willing to recall. It also fails to measure or take into account the complex interplay of psychological and biological processes that shape behavior and, ultimately, health. Mobile Health (mHealth) involves using mobile phones and sensors to allow individuals to provide multiple reports about their experiences in real-time, real-world settings, as they go about their everyday lives. In addition to an individual’s self-report of his/her mood, behaviors or interactions, mHealth technologies simultaneously allow for objective measurement of environmental and social factors (using cameras, sensors, microphones, and global positioning systems), as well as biological states, through the use of on-body and implanted sensors. Such mHealth approaches have created exciting opportunities to capture a rich, dynamic picture of people’s experiences – essentially, the ability to move out of the laboratory or doctor’s office and into real life. For example, providing mobile self-management skills feedback to people with type 2 diabetes was more effective in reducing hemoglobin A1c levels (a key indicator of diabetes management) than traditional diabetes care.42 mHealth tools have also been used to support adherence to medication regimens in settings around the world,43 as well to promote sustained increases in fruit and vegetable intake and reductions in sedentary behavior.44 In addition to interventions, mHealth tools are being developed for realtime tracking of personal air quality,45 physiological signs of stress,46 illicit drug use,47 and emotion.48 Thus, mHealth techniques are now being used to study the full range of human behavior and hold enormous potential to inform breakthroughs in behavioral and biomedical treatments and thereby improve health.
42 Quinn, CC, Shardell, MD, Terrin, ML, Ballew, SH, Gruber-Baldini, AL. ClusterRandomized Trial of a Mobile Phone Personalized Behavioral Intervention for
Blood Glucose Control. Diabetes Care. 2011 September, 34(9):1934-1942.
43 Lester, RT, Ritvo, P, Mills, EJ, Kariri, A, Karanja, S, Chung, MH, Jack, W, Habyarimanaa, J, Sadatsafavi, M, Najafzdeh, M, Marra, CA, Estambale, B, Ngiugi, E, ball, TB, Thabane, L, Gelmon, LJ, Kimani, J, Ackers, M and plummer, FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. The Lancet. 2010 November, 376(9755): 1838-1845.
44 Spring B, Schneider K, McFadden H, et al. Multiple Behavior Changes in Diet and Activity: A Randomized Controlled Trial Using Mobile Technology. Archives of Internal Medicine. 2012;172(10):789-796.
45 Indira Negi, Francis Tsow, Kshitiz Tanwar, Lihua Wang, Rodrigo A. Iglesias, Chen Cheng, Anant Rai, Erica Forzani, N.J. Tao, “Novel Monitor Paradigm for Real-Time Exposure Assessment”, Journal of Exposure Science and Environmental Epidemiology. 2011, 21: 419-426.
46 E. Ertin, N. Stohs, S. Kumar, A. Raij, M. al’Absi, T.Kwon, S. Mitra, Siddharth Shah, and J. W. Jeong, “AutoSense: Unobtrusively Wearable Sensor Suite for Inferencing of Onset, Causality, and Consequences of Stress in the Field,” In Proceedings of ACM SenSys, Seattle, WA. 2011.
47 Boyer, EW, Fletcher, R, Fay, RJ, Smelson, D, Ziedonis, D, & Picard, RW. Preliminary Efforts Directed Toward the Detection of Craving of Illicit Substances: The iHeal Project. Journal of Medical Toxicology. 2012, 8(1): 5-9.
48 Hernandez, J.*, Hoque, M. E.*, Drevo, W., Picard, R.W., “Mood Meter: Counting Smiles in the Wild”, Proceedings of International Conference on Ubiquitous Computing (Ubicomp), Pittsburgh, PA, September 5-8, 2012.