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Introduction

Recent decades have seen increasing attention to the contribution of psychosocial factors, particularly behavior, to enhancing or compromising health. Healthy People (U.S. Department of Health, Education, and Welfare, 1979) and Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (IOM, 1982; hereafter referred to as the 1982 report) identified and integrated a range of research and identified promising areas, or “scientific opportunities,” for future development. Cigarette smoking, excessive alcohol consumption, other substance abuse, unhealthy dietary habits, sedentary lifestyles, and nonadherence to effective medication regimens were among the health-compromising behaviors identified and targeted for modification or prevention with consequent benefit to the public health. The 1982 report recognized that “both access to health care and regard for its advice are behaviorally influenced” (IOM, 1982:25) and that “the burden of illnesses and disabilities in the United States and the world is closely related to social, psychological, and behavioral aspects of the way of life of the population” (IOM, 1982:49–50).

The 1982 report was influential in creating opportunities for research and was almost prescient in its statements about areas that have developed greatly since that time. For example, large-scale studies of social risk factors, such as social class or socioeconomic status, have contributed to our understanding of population health in many ways (Chapter 4). Fur-



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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences 1 Introduction Recent decades have seen increasing attention to the contribution of psychosocial factors, particularly behavior, to enhancing or compromising health. Healthy People (U.S. Department of Health, Education, and Welfare, 1979) and Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (IOM, 1982; hereafter referred to as the 1982 report) identified and integrated a range of research and identified promising areas, or “scientific opportunities,” for future development. Cigarette smoking, excessive alcohol consumption, other substance abuse, unhealthy dietary habits, sedentary lifestyles, and nonadherence to effective medication regimens were among the health-compromising behaviors identified and targeted for modification or prevention with consequent benefit to the public health. The 1982 report recognized that “both access to health care and regard for its advice are behaviorally influenced” (IOM, 1982:25) and that “the burden of illnesses and disabilities in the United States and the world is closely related to social, psychological, and behavioral aspects of the way of life of the population” (IOM, 1982:49–50). The 1982 report was influential in creating opportunities for research and was almost prescient in its statements about areas that have developed greatly since that time. For example, large-scale studies of social risk factors, such as social class or socioeconomic status, have contributed to our understanding of population health in many ways (Chapter 4). Fur-

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences ther research has supported most of what was presented in the 1982 report, but exciting progress has been made in the new areas, such as psychoneuroimmunology (Chapter 2). Times have changed since 1982, with consequent changes in perspective. It is now acknowledged, for example, that cardiovascular disease is an important killer of women as well as of men, necessitating research and improvements in practice. National concern about the public health consequences of tobacco use has led to a wide range of interventions and the evaluation of approaches. The emergence of new medical and public health problems, such as human immunodeficiency virus (HIV) and other infectious diseases, since the 1982 report has again demonstrated the importance of behavior to health and has led to the application of information about health and behavior to new problems as well as to the development of new knowledge itself. Finally, advances in methods and conceptual models since 1982 have enriched and challenged the biobehavioral sciences—the fields that have contributed knowledge and application in the areas of health and behavior addressed in this report. DEFINITION OF BEHAVIOR The 1982 Health and Behavior report adopted the term biobehavioral sciences to encompass the many disciplines that contribute to behavior and health. After considerable discussion, the Committee on Health and Behavior: Research, Practice and Policy also chose to use this term, as defined in 1982, because it reflects the rich, dynamic, and interactive nature of the fields contributing to knowledge of health and behavior and because it is still current: The term biobehavioral sciences is used…to refer to the panoply of basic, applied, and clinical sciences that contribute to an understanding of behavior. It naturally includes the behavioral sciences that conduct experimental analyses of animal and human conduct. It also includes such basic sciences as neurology, neurochemistry, endocrinology, and neuroanatomoy, as well as the fields of psychology, ethology, sociology, and anthropology. One merit of a broadly inclusive terminology is that it encompasses the many changes in specialties and subspecialties that currently characterize the area. As overlapping areas of interest emerge, they often are labeled with compound names, such as behavioral genetics, psychoneuroimmunology, immunohistochemistry, or behavioral medicine. All are part of the biobehavioral sciences. (IOM, 1982) Biopsychosocial is a related term used in this report to encompass con-

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences sideration of variables from the biological, psychological, and social domains. An important characteristic of biopsychosocial or biobehavioral research is that it “involves the study of the interactions of biological factors with behavioral or social variables and how they affect each other (i.e., the study of bidirectional, multilevel relationships)” (Anderson, 1999). DEFINITION AND MEASUREMENT OF HEALTH Health is sometimes negatively defined as the absence of disease and injury, sometimes as a normative judgment referring to the average state of most people, and sometimes as a positive concept of well-being. Disability and illness can be distinct from health or, together with health, represent different points on a continuum (Patrick and Erickson, 1993). The various definitions of health, each emphasizing different concepts, have been debated for centuries. Precise biomedical or biological definitions (absence of abnormal biological markers or physiological abnormalities) are useful because they offer opportunities for precise measurement, but they fail to capture all the attributes typically associated with health. On the other hand, the broad definition adopted by the World Health Organization in 1948 (“Health is a state of complete physical, mental, and social well-being and not merely the absence of infirmity”) is comprehensive but difficult to apply. Common epidemiologic measures, which emphasize morbidity and mortality, are incomplete. Morbidity data, for example, often omit information about mortality; mortality data typically do not include information about concurrent morbidity. Disease and disability affect multiple aspects of wellness. A comprehensive definition of health requires integration of broader concepts of morbidity and mortality (IOM, 1998). From a medical perspective, people are healthy if they are uninjured and free of disease, but a person with risk factors for disease might be considered unhealthy. As increasing numbers of people are screened or as technology improves, more disease is revealed (Black and Welch, 1997). New technologies might identify “diseases” that have little effect on life expectancy or quality of life. Pathology thus depends on the state of biomedical knowledge and technology. Despite the appeal of the medical model, however, it can provide evidence that is in conflict with other indicators of health. The health care system defines the need for health care based on the technology available for assessment and treatment. But,

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences when a patient feels distress, health care needs do not always correlate with health care system definitions (Evans and Stoddard, 1990). Although disease usually is regarded as a binary variable—it is either present or absent—most health problems fall on a continuum. Changing the thresholds associated with a disease can thus change the number of people who would be considered sick. For example, in the past, “overweight” was defined as a body mass index greater than 28. When that threshold recently was reset at 25 (NHLBI, 1998), most of the adult U.S. population became classified as overweight. Similarly, new methods for assessing subthreshold depression greatly increased the number of people characterized as having that condition (Judd et al., 1996). Although slightly more than 5% of patients in general medical practice qualify for a diagnosis of depression, as defined by the American Psychiatric Association in its DSM-IV (APA, 1994), more than 25% meet the criteria for “subsyndromal” depression (Wells, 1996). An alternative to the traditional biomedical model, the “outcomes model,” emphasizes patient outcomes rather than disease pathologies. The biomedical model is predicated on finding specific biological problems; the outcomes model considers consequences from the perspective of the patient. Successful treatments improve quality of life or extend length of life. This might differ significantly from what would be considered successful treatment using strictly biomedical measures. One review (Fowler et al., 1994), for example, found that although many surgical procedures have no effect on life expectancy, they can help relieve symptoms and improve functional status. Outcomes assessment is useful to determine whether symptoms are, in fact, relieved. A growing body of work demonstrates that measures of wellness are significant predictors of longevity for patients with chronic illnesses (Coates et al., 1997; Idler and Benyamini, 1997; Kaplan et al., 1994). Typically, simple self-report measures of overall health status perform at least as well as physiological indicators do. Contemporary definitions recognize that health is multidimensional. Spilker (1996) identified five major domains of life quality: physical status and functional ability, psychological status and well-being, social interactions, economic and vocational status and factors, and religious and spiritual status. Various health outcomes approaches assess different dimensions, and the dimensions themselves vary considerably in approach. An emerging consensus suggests that the concept of health must integrate mortality with multiple dimensions of life quality. Most attempts include physical and mental symptoms of behavioral and social functioning.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Symptoms could be as various as pain, cough, anxiety, or depressed mood. Physical functioning is typically measured by limited mobility or by confinement to bed or home. Social functioning is indicated by performance of usual social roles such as attendance at school, ability to work, or participation in recreational activities. The concept of health-related quality of life incorporates combinations of these attributes (Erickson et al., 1995; Patrick and Erickson, 1993). Time The concept of health implicitly includes a time dimension. Current wellness or illness must be considered together with prospects for the future. A person infected with HIV might seem healthy today, but might not be called healthy because he or she is at high risk for disease and premature death in the future. The failure to separate current health status from prognosis is a major conceptual obstacle to defining health. Both health and severity of illness should be assessed with respect to the two independent constructs of current function and prognosis (see NRC, 2000a). Time also is essential in considering development throughout life. Prenatal and early postnatal development are particularly important for life-long health and well-being. Not only do people of different ages have different health concerns, but the unique vulnerabilities and strengths of different periods of life have implications for health and behavior during each period as well as for those that follow. Research and practice in the field of health and behavior should be considered from the perspective of the entire lifespan (see NRC, 2000a; IOM, 2000). Positive Health The concept of positive health has evolved over the past 40 years, beginning with Current Concepts of Positive Mental Health (Jahoda, 1958). Recent definitions include at least four constructs: a healthy body; high-quality personal relationships; a sense of purpose in life; self-regarded mastery of life’s tasks; and resilience to stress, trauma, and change (Ryff and Singer, 1998). Each component is associated with positive health outcomes. Those who are physically fit and have healthy habits are less likely to develop disability or die prematurely from chronic disease (Rowe and Kahn, 1998). People with high-quality personal relationships and sup-

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences portive social networks tend to be more resistant to disease and to recover more quickly than those with poorer social relationships. Several epidemiologic studies show that supportive social relationships reduce the risk of death from cardiovascular disease (Berkman, 1995). The magnitude of the effect of social isolation on the risk of cardiovascular disease is comparable to that of elevated serum cholesterol or mild hypertension (Atkins et al., 1991). Positive psychological states are associated with better coping with severe stress attendant to acquired immune deficiency syndrome (AIDS), cancer, or arthritis (Folkman, 1997). Frankl (1992) demonstrated that a sense of purpose in life was associated with a greater likelihood of surviving Nazi concentration camps and of psychological recovery from that experience. Although the concept of positive health is clearly important, it presents several challenges (NRC, 2000a). First, it is not clear whether positive health is incorporated into other definitions of health—particularly those that include both current function and prognosis. Most of the evidence supporting positive health per se is associated with better outcomes for those with healthy bodies, high-quality personal relationships, a sense of purpose, and high self-regard. Like people who refrain from smoking cigarettes or who have low serum cholesterol, those with positive psychological attributes could stay healthy longer than other people do or adapt better to health challenges. Second, assessing positive health is difficult. Across cultures, socioeconomic status, and ethnic groups, people rate restrictions in activities associated with health conditions as less desirable than not having such restrictions (Patrick et al., 1985). The requirement to use a wheelchair is consistently rated as less desirable than is being able to walk freely (Kaplan, 1994). Such consensus is not evident, however, for attributes associated with good health. For example, there is much greater variability in ratings for the desirability of having a spouse, of participating in community activities, or of other aspects of social affiliation (Kaplan, 1985). There is considerable agreement regarding desirable aspects of physical functioning but there is little agreement regarding social components. There is also a difficulty with the “algebra” of positive health. Current approaches regard optimal health as the condition of having no limitations on activity and being free of symptoms. This frames health in negative terms. Rather, the concept of positive health suggests that optimal health should be characterized by having a sense of purpose in life, of

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences high-quality personal relationships, and high self-regard. The way in which “positive” and “negative” components interact to produce a given health status has not been described. THE INTERSECTION OF HEALTH AND BEHAVIOR In 1974, the Lalonde report presented a framework of the health field that went beyond providing medical care and identified human biology, environment, lifestyle, and health care organization as major elements. That report initially led to a focus on lifestyle, or individual behavior, as both the locus of responsibility and the target of clinical and community interventions. Later, Evans and Stoddart (1990), attempting to encompass the dimensions that individuals, care providers, and policymakers believe to be important, provided an even broader framework for determinants of health (Figure 1-1). One goal was to bridge the gap between the increasingly sophisticated knowledge of the relationships among multiple categories of conditions that influence health, and health policy that fo- FIGURE 1-1 A model of the determinants of health. Source: Reprinted from R.G.Evans and G.L.Stoddart, 1990, Producing Health, Consuming Health Care, Social Science and Medicine 31:1347–1363, with permission from Elsevier Science Ltd, Kidlington, UK.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences cused primarily on providing health care. The model shows that factors that include social and physical environment and genetic endowment also influence individual biological and behavioral determinants of health. This crucial point—that behavior is not simply individual choice but is shaped by multiple forces operating at different levels of organization—is developed further in this report. Individuals influence and are influenced by their families, social networks, the organizations in which they participate (workplaces, schools, religious organizations), the communities of which they are part, and the society in which they live. Interventions to improve health or to influence behavior can occur at any one of those levels or at more than one. This ecologic framework suggests that, because all of the levels are in dynamic interaction (continually changing as a result of reciprocal influences), planned change is likely to be most effective if a comprehensive intervention targets all levels and if the likely consequences (for the other levels) of intervening at one level are recognized (Gottlieb and McLeroy, 1994; Stokols, 1992, 1996). Clearly, no one organization or intervention can address all components of this model. The framework therefore implies the need to bring together a range of individuals and organizations with a variety of skills and interests in efforts to promote or improve health. Table 1-1 outlines multiple targets of change and strategies for intervention at each level (from individual to population). The targets and strategies are not comprehensive. The table provides an overview of how the ecologic approach can be used to examine change at various levels. Interventions that target cigarette smoking provide some of the best examples, because interventions have occurred at most of these levels and rates of cigarette smoking have declined among adults in the United States. Without carefully planned research, however, it is impossible to know which intervention, or what combination of interventions, was necessary and sufficient to achieve that result. It is important to give people information through clinical or public health messages, but disapproval of smoking by family and friends, constraints on smoking in workplaces and other locations, lawsuits, congressional hearings, taxes, and advertising policies all confound efforts to attribute the result to a single intervention or level of intervention. This report is not the first to propose an ecologic (see McLeroy et al., 1988) or contextual approach (see Ewart, 1991) to health and behavior. However, the committee has amassed evidence from many disciplines that

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences points to the same conclusion: health and behavior are influenced by factors at multiple levels, including biological, psychological, and social Interventions that involve only the person—for example, using self-control or willpower—are unlikely to change long-term behavior unless other factors, such as family relationships, work situation, or social norms, happen to be aligned to support a change. The committee hopes that this report will stimulate researchers, practitioners, program developers, and public and private policymakers to consider the multiple levels for assessments and interventions in health and behavior. UNDERLYING ASSUMPTIONS The committee agreed on the following assumptions: Biological, behavioral, and social factors such as genetic endowment, cognitive and emotional interpretations of experience, physical environment, social relationships, and socioeconomic status interact through multiple feedback mechanisms to influence individual health over time. Those interactions are often bidirectional, so cause-and-effect models, used alone, are likely to misrepresent relationships among them. Because health is not defined solely in biological terms but also is a function of psychological and social variables, many events or interventions traditionally considered irrelevant actually are quite important for the health status of individuals and populations. STATEMENT OF TASK An Institute of Medicine Committee on Health and Behavior: Research, Practice, and Policy was convened in 1998 to update the 1982 Health and Behavior report. Funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the Centers for Disease Control, the committee was charged with the following tasks: (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 psychosocial interventions is incomplete; (3) identify and review effective applications of behavioral and psychosocial interventions in a variety of settings; (4) examine implementation of behavioral and psychosocial interventions, including guidelines and changes in provider behaviors;

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences TABLE 1-1 Ecological Approach to Health and Behavior Research and Practicea Ecological Level Change Process Target of Change at Each Level Strategies and Skills at Each Level Individual Physiological HPA (hypothalamic-pituitary-adrenal) axis Physical activity   CNS (limbic and other systems) Pharmacologic therapies   Immune system Meditation   Metabolism Biofeedback   Cardiovascular system Hypnosis   Cognitive therapies   Psychological Developmental processes Tests and measurements   Knowledge Role modeling   Attitudes Education   Beliefs Mass media   Values Social marketing   Skills Skills development   Behavior Resistance to peer pressure   Self-concept, self-efficacy, self-esteem Patient counseling and education Family, social networks Psychosocial Social networks Extending social networks   Social support Changing group norms   Families Strengthening families   Workgroups Social support groups   Peers Increasing social support   Neighbors

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Organization Organizational Norms Organizational development   Incentives Incentive programs   Organizational culture Coalition development   Management styles Participatory action research   Organizational structure Team development   Communication networks   Community Cultural and social Economic opportunities Community development   Community resources Community coalitions   Neighborhood organizations Empowerment   Community competencies Conflict strategies   Social and health services Media advocacy   Organizational relationships Public advocacy   Governmental structures Consciousness raising   Formal leadership Social action   Informal leadership Community-based participatory research Population (societal) Public policy Legislation Media advocacy   Regulations Policy analysis   Tax policy Political change   Lobbying   Political organizing a Adapted from Health Promotion in the Workplace, 2nd ed., by M.P.O’Donnell and J.S.Harris. Copyright 1993. Reprinted with permission of Delmar, a division of Thomson Learning.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences (5) review evidence of cost-effectiveness; and (6) make recommendations concerning further research, applications, and financing. The committee interpreted their charge with a focus on research rather than policy issues. The report is an overview and summary of available research aimed at a diverse audience. Even with this focus, the committee encountered limitations as to what it was able to address. After examining the evidence, it became clear that there are inadequate data to evaluate fully the cost-effectiveness of behavioral and psychosocial interventions in comparison with other ways of promoting health. Cost-effectiveness analysis attempts to determine ways of promoting good health— procedures, tests, medications, educational programs, regulations, taxes or subsidies, and combinations and variations of these—provide the most effective use of resources. Currently, there are few studies assessing which behavioral and psychosocial interventions contribute the most to good health that are set in this larger context and based on information that demonstrates that they are in the public interest. Comparing behavioral and psychosocial interventions with other ways of promoting health on the basis of cost-effectiveness requires additional research. This topic is only briefly reviewed in Chapter 7. The committee began this endeavor expecting to discover and share what works and what does not regarding health and behavior. After diligently exploring the literature, the complexity of the issue became evident. The committee noted the vast array of interventions at various levels, with varying endpoints on different populations, with different methodologies. Each committee member brought to the table their own perspective about what would be most effective, but the data were inadequate to convince any of the experts of a best approach to shaping and maintaining behavior change. While conventional wisdom tells us that we need to do more exercise, eat less, avoid tobacco, wear seatbelts, and be careful with firearms, deciding what specific interventions produce these sustained changes presents a dilemma. A critical obstacle to answering definitively the question of what works best is the difficulty of generalizing the findings of current studies. Many factors contribute to this problem: outcome measures among the studies differ, populations studied differ, and methodologies differ. For example, an intervention may be exceptionally effective on a highly motivated population but fail for the general public. Measurement of a behavioral outcome such as self-reported tobacco use is difficult to compare with an outcome measure such as change in sales of tobacco. Another

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences obstacle is that there are no rigorous evaluations of interventions. Evaluations may assess short-term changes, but long-term effectiveness must enter the equation because maintaining behavior change has been shown to be difficult. Only with additional research and evaluation of interventions will the best approaches be found. This report illustrates the current level of understanding and demonstrates the limits of the currently available research. The example of tobacco in Chapter 8 aims to illustrate the complications inherent in the field. BOUNDARIES OF THE STUDY The field of health and behavior is very large. It includes, at minimum, the intersection of biological, social, and behavioral sciences with public health and medicine. The Committee, therefore, had to make hard choices about what to include and exclude from this report. The areas represented in this report are those in which Committee members either had expertise or found to be important enough to seek expert input with the resources available. While behaviors associated with the greatest burden of illness, such as tobacco use, seemed important to consider, the Committee also found it important to focus on health, not just morbidity and mortality. Stress and adaptation, psychosocial aspects of coping with illness, and resilience were deemed important by the Committee. The Committee chose to examine developments in biological, social, and behavioral determinants of health as well as the implications of these factors for intervention and research at the levels of individuals, families, communities, and populations. Issues in translation from research to application, including cost-effectiveness, were also considered. A number of areas were excluded for a variety of reasons. Injury and substance abuse have been the subjects of recent IOM reports (IOM 1996, 1997a, 1999), so the Committee chose not to devote resources to these. Genetics, health, and behavior were the subject of a concurrent IOM study, and developments in genetics are occurring very quickly. The Committee therefore decided not to go into depth in that area, in which recent, excellent material is available (see Collins, 1999, for an overview of medical and societal implications of the human genome project; Carson and Rothstein, 1999, for various perspectives on behavioral genetics). Child and spousal abuse are difficult and controversial topics, and the Committee was not sufficiently constituted to consider these areas from the range of perspectives necessary to be thorough. While the report does

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences discuss various aspects of obesity, the Committee found that the biology of metabolism and weight regulation—along with clinical and public health perspectives and interventions in this area—are developing, complex, and controversial, and therefore deserve much more attention than the Committee was able to pay here. The Committee recommends that resources be devoted to a comprehensive study of biological, social and psychology cal factors in obesity and weight regulation and to the effects of medical, public health, and advertising messages about weight. The role of advertising and social marketing is an important consideration in health and behavior and is the topic of a forthcoming IOM report (2001). That report focuses on communication of health messages to diverse populations. The role of diversity in health and disease is a critical concern that is also very relevant to the behavioral and societal influences. Recently, an IOM study was initiated to assess racial and ethnic differences in health care and to provide recommendations regarding interventions to eliminate these disparities (Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, IOM). The Committee believes that lifespan and lifecourse development (Elder, 1996) are very important to the understanding of health and behavior. The Committee drafted materials and discussed differences in health and behavior across the lifespan, as well as the implications of early experience for later health at many of its meetings. The Committee coneluded that it did not have the full range of necessary expertise or the resources to comprehensively address the complex intersection of lifespan and lifecourse development and health and behavior, though it is mentioned in various places in the report. At the first Committee meeting, David Hamburg, the chair of the 1982 study, told the Committee that lifespan development was the one area he most wished could have been addressed in the 1982 report. This Committee feels similarly about this report. Recent reports from the National Academies (IOM, 2000; NRC, 2000a,b,c) provide some discussion of health-related behavioral and social research at various points throughout life. The Committee agreed that development across the lifespan is an important determinant of health that deserves further attention. Because the field of health and behavior is so extensive, the committee was unable to provide an exhaustive review for all covered topics. This is true, for example, in the description of interventions for behavior change at the various levels. Instead, the report presents a sampling of the

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences many approaches that have been used. These provide the reader with a feel for the state of the science rather than an all-inclusive account of what has been done. For other topics such as the health behaviors described in Chapter 3, the committee relied heavily on existing comprehensive reviews, especially publications from United States government agencies, to provide an overview of the area and supplemented this with data from recent peer-reviewed articles. Other sections of the report carefully reviewed the current literature from peer-reviewed journals to provide a summary of topics that are not available elsewhere. The resulting report should not be considered to be a comprehensive analysis of all efforts in health and behavior but rather an overview that tries to convey a sense of the excitement and growth in this multidisciplinary field. ORGANIZATION OF THE REPORT The charge to the committee preparing this report included updating scientific findings about the links between biological, psychosocial, and behavioral factors and health since the 1982 report (IOM, 1982) and addressing the links between determinants of health and interventions based on them in a variety of settings. Part One describes the status of knowledge regarding biological, behavioral, and social factors that affect health. To emphasize the importance of reciprocal interactions among those factors in the determination of the health status of individuals and populations, without implying that “everything is related to everything else,” the report groups biobehavioral linkages with physiological evidence in Chapter 2, behavioral risk factors in Chapter 3, and social risk factors in Chapter 4. Part Two addresses research and practice regarding interventions in health-related behavior. Chapter 5 discusses the interventions at the level of individual behavior and families. Chapter 6 reviews interventions at the levels of organization, community, and society. Chapter 7 addresses the evaluation of interventions and the dissemination of research findings and practical experience. Part Three (Chapter 8) presents the principal findings and the committee’s recommendations. It includes a description of experience with interventions aimed at reducing cigarette smoking because these interventions have been pursued at all of the levels addressed in this report.

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