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COMMENTARY |
Christine A. Bachrach is with the National Institute of Child Health and Human Development, Bethesda, Md. Ronald P. Abeles is with the National Institutes of Health, Bethesda, Md.
Correspondence: Requests for reprints should be sent to Christine A. Bachrach, PhD, National Institute of Child Health and Human Development, 6100 Executive Blvd, Room 8B07, MSC 7510, Bethesda, MD 20892-7510 (e-mail: cbachrach{at}nih.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE SOCIAL SCIENCES AND...SETTING AN AGENDA FOR...SIGNS OF PROGRESSReferences |
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Programs within the National Institutes of Health (NIH) have recently taken steps to enhance social science contributions to health research.
A June 2000 conference convened by the NIH Office of Behavioral and Social Sciences Research highlighted the role of the social sciences in health research and developed an agenda for advancing such research. The conference and agenda underscored the importance of research on basic social scientific concepts and constructs, basic social science research on the etiology of health and illness, and the application of basic social science constructs in health services, treatment, and prevention research.
Recent activities at NIH suggest a growing commitment to social science research and its integration into interdisciplinary multilevel studies of health.
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INTRODUCTION |
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During the 1960s and 1970s the National Heart, Lung, and Blood Institute developed a pioneering extramural program on health and behavior, and the National Institute on Child Health and Human Development and the National Institute on Aging (NIA) both established broad-ranging programs in support of basic and applied behavioral and social research. Other institutes, including the former constituent parts of the Alcoholism, Drug Abuse, and Mental Health Administration (ADAMHA), also played significant roles in fostering such research. For example, ADAMHA joined forces with NIH in 1979 to commission the landmark study by the Institute of Medicine (Health and Behavior: Frontiers of Research in the Biobehavioral Sciences) that subsequently gave direction to NIH’s expanding activities in the behavioral and social sciences, especially when ADAMHA rejoined NIH more than a decade ago.1
Historically, the behavioral sciences have been better represented than the social sciences at NIH. By the late 1990s, the behavioral sciences were generally recognized as having a firm place at NIH. However, many observers within and outside of NIH believed that the actual and potential contributions of the social sciences had not yet been fully recognized. Consequently, the NIH Office of Behavioral and Social Sciences Research (OBSSR) convened a committee, with representatives from most NIH institutes and centers and from 3 nongovernmental social science organizations, to consider the contributions of the social sciences to health research and the relevance of various social science concepts, theories, and methodologies as well as to identify examples of successes in and challenges to effectively integrating these elements in health research.
Out of these discussions developed a major conference on social science contributions to health research. David Takeuchi and Christine Bachrach chaired the conference, Towards Higher Levels of Analysis: Progress and Promise in Research on the Social and Cultural Dimensions of Health ("Levels of Analysis conference"), which was held in June 2000. Its purposes were to highlight the past and potential future contributions of the social sciences to health research and to generate a forward-looking research agenda. Eighteen months later, based on the conference, 15 NIH institutes and centers issued a joint program announcement on the social and cultural dimensions of health.2
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THE SOCIAL SCIENCES AND HEALTH RESEARCH |
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Basic Concepts
Social science concepts such as socioeconomic status and culture are used widely in health research, as are demographic concepts such as race, ethnicity, age, and gender. A central concern of the conference was to explore the contributions of the social sciences in "unpacking" these concepts, that is, in providing a deeper understanding of their meanings and the processes that shape their meanings. Research on these basic constructs and processes and a broader integration of such research into health studies are essential to guiding their appropriate use in health research and to counter the common tendency to use them superficially and mechanically.
For example, a long-standing tradition of research in the social sciences has examined the structures (e.g., educational systems, systems of production) and processes (e.g., discrimination, marital homogamy) that create and maintain differences in status, rewards, obligations, and constraints among members of a population. Socioeconomic status, a concept widely used in health research, is a measure of an individual’s position in such stratification systems. Scientists have extensively documented the relationship of socioeconomic status to health but are barely beginning to understand the processes generating the relationship.7 Pathways of influence are likely to be complex, and to reflect the multifaceted interactions between social structures and individual attributes and behaviors that produce and maintain stratification in a society.
Culture is another concept commonly invoked in health research. Culture constitutes a powerful explanatory variable, but one that does not coincide very well with ethnic group labels, as is often assumed. The term has many interpretations. Perhaps in this context, it most commonly refers to meanings that are shared to varying extents with other people by virtue of membership in social groups. This concept of culture is complex and implies an ongoing, dynamic process.8 Culture affects health through numerous pathways, including influence on risk and protective behaviors, the nature of family and social relationships, and the meanings and expectations associated with group memberships based on gender, race, ethnicity, religion, social class, and other socially defined categories. For example, shared beliefs that disease symptoms are part of normal life and should be "toughed out" cause delays in accessing medical services and increase risk of harm in some minority populations.9 Culture may also be a mechanism through which other social processes, such as socioeconomic status, affect health.10–12
As noted earlier, several key sociodemographic constructs, including race, ethnicity, gender, and age, are widely used in studies of the etiology of health and disease and in research that describes and monitors the distribution of disease across social categories, geographic areas, and time. However, the meanings of such constructs depend on their cultural, geographical, and historical context, and their utility in health research depends on their being used in ways that are theoretically and historically grounded. Scientists face a significant challenge in incorporating sociodemographic constructs into their studies in ways that are sensitive to these complex issues.
Implicit in the preceding discussion of concepts and constructs is the idea that social and cultural phenomena are not merely qualities attaching to an individual but emergent properties of systems that operate at levels above the individual (but in which individuals are embedded and which they influence). These social and cultural systems have important consequences for health and are legitimate foci for health research. Such a perspective is fundamental to truly integrative, multilevel research strategies that consider the pathways to health operating at and between the social, cultural, individual, and biological levels.
Basic Research on Etiology
Within a multilevel model of the etiology of health and illness, the level of the social environment encompasses a diverse set of mechanisms operating among and within social structures existing at different levels. At the highest levels are structures and processes that involve and affect populations broadly: government, media, economic systems, social stratification, political processes and policymaking, and broadly held cultural values and practices. Some of these processes also operate in communities, neighborhoods, and institutions such as schools or professional organizations. At these levels, processes contributing to social cohesion, social support, social control, social and cultural conflict, and the development and enforcement of social and cultural norms also play a significant role. In families and small groups, interpersonal processes such as conflict and support, socialization, and sharing of resources play a dominant role. Characteristics of the individual and of biological mechanisms fill out the multilevel model.
The Levels of Analysis conference highlighted promising traditions of research on social environmental influences on health. One focus was on interpersonal processes that influence health. A broad set of research studies has documented that individuals engaged in supportive social networks are more likely to be healthy, to live longer, and to recover better from serious illnesses.13,14 Involvement in religious groups and marriage also appears to benefit health.14–17 Such social engagement is hypothesized to increase access to information as well as emotional and instrumental support. Emotional and instrumental social support affect health through mechanisms operating at the interpersonal level (e.g., a neighbor providing transportation to the doctor’s office) and the physiological level (e.g., impact on the immune system).18 Much of the research in this area has focused on the positive facets of social interaction. However, health is also negatively influenced by social interactions that promote stressful experiences (e.g., marital discord) or that explicitly and implicitly exploit, discriminate against, or unfairly treat groups of people.19
Other research traditions address how mechanisms that link social and cultural phenomena to health operate within, and emerge from, the attributes of social contexts.20 Social context, as defined here, refers to a variety of groups or institutions in which individuals may be embedded (e.g., families, peer groups, workplaces, and neighborhoods) and that may have an impact on individuals’ health by affecting resources, constraints, and social norms.21 Researchers have considered diverse contexts and characteristics of contexts in addressing "contextual" influences on health.
Some researchers have examined the characteristics of neighborhoods and communities, including socioeconomic properties (e.g., concentrated poverty), cultural properties (e.g., shared values and norms), residential stability, and racial/ethnic composition. Others have focused on processes such as social cohesion and social control, which refer to the extent to which groups are knit together and able to enforce behavioral norms, or collective efficacy, a term introduced by the Project on Human Development in Chicago Neighborhoods to refer to neighborhood residents’ collective sense of trust and cohesion combined with their willingness to intervene to achieve shared goals.22
A similar concept, used in relation not only to neighborhoods but to other social groupings, is social capital.23 This term refers to resources that are inherent in social relationships and that facilitate the achievement of some end. Social capital may contribute to health both at the group level, through political action and the enforcement of shared norms, and at the individual level, through increasing access to resources.24 The structure, characteristics, and dynamics of social networks within a group or collectivity are a fundamental feature underlying these concepts and the mechanisms through which they influence health.
Beyond the social attributes of groups and neighborhoods, many aspects of the broader society also need to be considered in explanatory models of health and illness. Political processes affect the distribution of public resources, such as decisions to locate highways and redevelop urban areas as well as kinds and extent of health and income support for indigent populations. Economic conditions and the structure of the economy affect the availability and characteristics of jobs and employees’ ability to negotiate benefits, along with the price and availability of housing and other necessities. The content of messages offered in the media is influenced less by the local community than by broader social, economic, and cultural processes in national and international marketplaces. These broader influences have far-reaching effects on health, but this same breadth of influence makes it difficult to study them using conventional empirical approaches.
Research on Improving Health
The Levels of Analysis conference also highlighted the importance of basic social science knowledge for improving health. The social sciences can contribute to preventing and treating illness by pinpointing the environmental settings, social relationships, interpersonal processes, and cultural factors that lead people to engage in healthy and unhealthy behaviors, seek health services before disease symptoms worsen, and participate with medical professionals in treating illness.25–27 Moreover, social science approaches emphasize social structural and organizational factors that influence the kinds of care available, access to that care, and quality of care. Insights from this research can guide the design of health care delivery practices and interventions that acknowledge and adapt to social, cultural, and economic barriers; harness social mechanisms to increase their effectiveness; or even attempt to manipulate social and cultural determinants of health directly.
Drawing upon social and behavioral science research on communication, diffusion, and behavior change, mass media campaigns have a long history in health promotion and disease prevention.25 For example, the Back to Sleep Campaign strove to reduce mortality from sudden infant death syndrome by changing the common and culturally preferred practice of placing infants in a prone sleep position. Over a period of 4 years, in response to a campaign that involved the use of a variety of professional and media channels, the prevalence of use of the prone sleep position fell from 70% to 24%, and the rate of sudden infant death syndrome declined by 38%.28
Another common approach is the community-level intervention that attempts to modify multiple influences on health within a community. This approach seeks to magnify intervention outcomes by producing mutually reinforcing effects across domains of the social and cultural environment. For example, a project seeking to reduce alcoholinvolved injuries and deaths in 3 experimental communities developed 5 mutually reinforcing components: community organization, intervention in bars and restaurants, intervention in retail outlets to reduce sales to minors, increased drunk-driving enforcement, and use of zoning and municipal controls to reduce availability of alcohol. The intervention communities achieved greater reductions than comparison communities in high-risk alcohol consumption and in alcohol-related injuries resulting from motor vehicle crashes and assault.29 An extensive literature exists on community-level health interventions, but significant challenges to definitive evaluation designs limit what we know about their effectiveness.25
In recent years, a variety of prevention programs have taken their inspiration from basic research on social processes. For example, an HIV prevention researcher drew on the resources inherent in naturally occurring friendship groups by enrolling entire groups into an HIV prevention intervention.30 Another successful HIV prevention program recruited opinion leaders in gay bars to promote HIV risk reduction behaviors. As a result of the intervention, risky sexual practices decreased and condom use increased among the patrons of the bars in the intervention city.31
Home-visiting programs have recently emerged as a strategy for delivering services to individuals and families. This strategy recognizes social, economic, and other barriers to seeking services and draws at least in part on concepts of social support. Home-visiting programs have been shown to reduce mortality among the elderly,32 to contribute in many cases to healthy pregnancies and child development,33,34 and to improve asthma management among inner-city children.35
A long tradition of health care research relies heavily on social science concepts and approaches drawn, for example, from organizational sociology, health economics, and social anthropology to explore how the organization and structure of health care affect a wide range of process and health outcomes (e.g., morbidity, mortality, satisfaction with care, quality of life) among individuals and populations. The structural and organizational features studied include staff characteristics (e.g., years of experience, educational background), size of the organization, staffing mix and ratio, type of ownership (e.g., private vs public, for-profit vs nonprofit), standardization of care (e.g., clinical protocols, practice guidelines), specialization, volume of services, and centralization (e.g., locus of decisionmaking).36 For example, greater conformity and uniformity in the behavior of physicians is found in larger group practices (e.g., they are more likely to adhere to care protocols).37 Other studies indicate that communication, coordination, and control mechanisms in nursing homes are associated with degree of inappropriate drug prescribing and overall quality of care.36
Finally, research on the health effects of policy is also an important aspect of applied health research in the social sciences. Research suggests that income transfer programs such as Aid to Families with Dependent Children positively affect health outcomes such as infant birthweight.38,39 A substantial body of research demonstrates positive outcomes of programs designed to alleviate the effects of poverty on health. For example, Medicaid has been linked to decreased infant mortality,40 while nutritional supplementation through the Special Supplemental Nutrition Program for Women, Infants, and Children has been shown to improve birthweight41 and developmental and growth outcomes.42 Evidence from the Moving to Opportunity Study, an experimental investigation in which families eligible for housing assistance were offered the opportunity to move to more affluent neighborhoods, suggests that the study program (vs a housing voucher alternative) reduced injuries, asthma attacks, and crime victimization rates among children.43
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SETTING AN AGENDA FOR SOCIAL SCIENCE RESEARCH |
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summarizes the key recommendations produced by the group. Most of the recommendations speak to the expansion and further development of health-related social sciences research at NIH.
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A fifth and equally important goal calls for the integration of social science research into interdisciplinary multilevel studies of health. Integration of social science research with the biological and behavioral sciences is an essential component of this task. A growing chorus of voices is endorsing this goal, perhaps best exemplified by the recent National Research Council report New Horizons in Health,20 but also by other recent National Research Council/Institute of Medicine reports (Table 2). Such integration is a 2-way street. Social and biomedical scientists need to become more conversant with each other’s concepts and methods. Proactive efforts will be needed to foster a multidisciplinary, multilevel health science. We will need to foster communication among scientists who have been isolated too long within disciplinary walls; learn to work together across barriers of language, culture, and scientific prejudice; and put in place institutional structures that will ensure our long-run success.
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SIGNS OF PROGRESS |
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Similarly, the National Institute on Drug Abuse published a request for applications for community multisite prevention trials45 to (1) accelerate research on the processes and mechanisms that contribute to the adoption, adaptation, and implementation of science-based prevention models and (2) examine prevention delivery factors such as structural features, management practices, and financial strategies that foster the sustainability of such models in community settings. During the past 2 years, OBSSR and the NIH institutes and centers have convened various workshops and organized trans-NIH committees as the first step toward developing funding initiatives addressing such topics as the effects of community-level factors, education, economic disparities, and racial discrimination on health; the role of social epidemiology in studying drug abuse; and interactions among genetic, behavioral, and social factors in health.
In addition, plans for major data collection efforts reflect the growing recognition of the social environment as a contributor to health over the life course. For example, current planning for the National Children’s Study, a large cohort investigation of environmental effects on children’s health and development (information on the study is available at http://www.nationalchildrensstudy.gov), provides an outstanding opportunity for pursuing an integrated health science. Over the next few years, we expect to see the publication of multiple funding announcements designed to stimulate the submission of grant applications and contract proposals that integrate social science concepts and methods more fully into health research.
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Acknowledgments |
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Footnotes |
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Accepted for publication May 11, 2003.
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References |
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