PART THREE
Findings and Recommendations



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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences PART THREE Findings and Recommendations

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences This page in the original is blank.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences 8 Findings and Recommendations This report reflects the increasing attention being paid to the behavioral and psychosocial factors that enhance or compromise health. Many behaviors—tobacco use, excessive alcohol consumption and abuse of other substances, unhealthy diet, sedentary lifestyle, and nonadherence to medication regimens—are recognized as health-compromising. Evidence for the effects of social stressors, socioeconomic status, social support, and social capital on health outcomes is growing. First, this chapter explores the interactions of risk factors. Next, it presents the example of tobacco interventions to illustrate an effective multilevel approach and the difficulties in evaluating the interventions. Finally, it presents recommendations for research and practice regarding health and behavior. INTERACTIONS AMONG RISK FACTORS Recent decades have seen increasing attention given to the contribution of psychosocial factors, particularly behavior, to promoting or compromising health. The relationship between some behaviors and health status has been recognized since the 1974 Lalonde report. Healthy People (U.S. Department of Health, Education, and Welfare, 1979) and Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (IOM, 1982)

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences documented the importance of behavior to the burden of illness and disabilities in the United States. The association of tobacco use with heart disease, a variety of cancers, and poor pregnancy outcomes is perhaps the best known and most dramatic example of the interactions addressed in this report. However, the association of physical activity with fitness and health, dietary nutrients with health or illness, and excessive alcohol consumption with driving fatalities and poor pregnancy outcomes also are recognized widely. Recently, basic and applied research from a range of disciplines has demonstrated the importance of reciprocal interactions over time among health and biological, psychological, and social factors. Biological factors include genes, neurochemical and hormonal processes, and the functioning of physiological systems. Psychological factors include behavioral, personality, temperamental, cognitive, and emotional variables. Social factors include socioeconomic status, social inequalities, social networks and support, and work conditions. It is now evident that the relationships between health and many behaviors are much more complex than previously thought. Evidence attests that psychosocial factors influence health directly through biological mechanisms and indirectly through an array of behaviors. Example: Social Status and Health The role of social status in health and behavior is an example of interactions among biological, psychological, and social factors and health. Lower mortality, morbidity, and disability rates among socioeconomically advantaged people have been observed for hundreds of years, and studies have documented these effects using various indicators of socioeconomic status (SES) and multiple disease outcomes (Kaplan and Keil, 1993). Perhaps the most striking finding is the graded and continuous nature of the association between income and mortality, with differences persisting well into the middle-class range of incomes (Chapter 4). The fact that socioeconomic differences in health are not confined to segments of the population that are materially deprived in the conventional sense argues against an interpretation of socioeconomic differences as simply a function of absolute poverty. Moreover, because causes of death that seem not amenable to medical care show socioeconomic gradients similar to those of potentially treatable causes (Davey Smith et al., 1996; Mackenbach et al., 1989), differential access to health-care programs and services cannot entirely explain socioeconomic differences in health (Wilkinson, 1996).

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences People who are poor, have low levels of education, or are socially isolated are more likely to engage in risk-related behaviors and less likely to engage in health-promoting behaviors (Adler et al., 1994; Matthews et al., 1989). Behaviors (Chapter 3) occur in specific social contexts. Social environments influence behavior by shaping norms (e.g., the extent to which tobacco use is discouraged or encouraged); enforcing patterns of social control; providing or not providing opportunities to engage in particular behaviors (e.g., safe places to exercise, availability of nutritious foods); and reducing or producing stress, for which engaging in specific behaviors might be an effective coping strategy, at least in the short term (Berkman and Kawachi, 2000). The stresses associated with environmental and behavioral factors contribute to illness (Cohen and Herbert, 1996; Cohen et al., 1991; Hermann et al., 1995; Kiecolt-Glaser et al., 1996; McEwen, 1998). “Allostatic load” refers to the wear and tear that the body experiences as a result of the repeated activation of the stress response; it also includes contributions of food, alcohol, tobacco, exercise, and sleep through their ability to influence the production of stress hormones (McEwen, 1998; McEwen and Stellar, 1993). The “stress response” triggers and modulates physiological effects that can promote disease including modulation of the immune system (Chapter 2). BEHAVIOR CHANGE Producing Behavior Change Behavior can be changed and those changes can influence health. Interventions can successfully teach health-promoting behaviors or attenuate risky behaviors. Interventions aimed at management of chronic pain, smoking cessation, coping with cancer, and amelioration of eating disorders have been demonstrated empirically to be effective (Compas et al., 1998). Studies show that family or structured-group support, patient education, and behavior-based interventions can increase adherence to prescribed medication regimens (Anderson, 1996). Education aimed at increasing knowledge, control, and confidence (self-efficacy) among diabetics has produced benefits in both attitude and blood glucose management (Anderson et al., 1995). Many studies show that psychological interventions, especially those involving cognitive behavioral methods to enhance coping, are effective in facilitating adaptation to and coping with

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences rheumatoid arthritis (Keefe and Caldwell, 1997; Lorig and Holman, 1993; NIH Technology Assessment Panel, 1996; Parker, 1995). Studies of support groups, provision of education and information, expression of emotions, and hypnosis suggest the utility of these approaches in the treatment of a range of conditions, including irritable bowel syndrome (Whorwell et al., 1984, 1987), peptic ulcer disease (Klein and Spiegel, 1989), coronary heart disease (Linden et al., 1996), and cancer (improving quality of life and psychological adjustment of cancer patients, possibly affecting health status and survival; see reviews by Andersen, 1992; Compas et al., 1998; Fawzy et al., 1995; Helegeson and Cohen, 1996; Meyer and Mark, 1995). Interventions for insulin-dependent diabetes patients that involved family members meeting together with patients showed an effect on metabolic control (Delamater et al., 1990; Ryden et al., 1994; Satin et al., 1989), but interventions with patients and family members separately did not (McNabb et al., 1994; Thomas-Dobersen et al., 1993). Further research is needed to replicate the results of those studies, determine their efficacy, and identify the conditions under which specific types of psychosocial interventions are most effective. Maintaining Behavior Change Maintaining induced behavior change over time and across a variety of settings remains a problem, however, for behaviors as diverse as smoking (Ockene et al., 2000), physical activity (Marcus et al., 2000), diet and weight loss (Jeffery et al., 2000), and adherence to medication regimens. Although interventions can effectively lead to weight loss or smoking cessation, for example, substantial proportions of those who are successful will regain the lost weight or resume smoking. Most studies, though demonstrating the ability to alter behavior, either do not test, or when tested do not demonstrate, sustained behavior change. These factors present major challenges for the research and application of behavioral interventions and point to the need for long-term studies. Individual behavior has biological underpinnings and consequences and is influenced by the social and psychological contexts in which it occurs. Therefore, changing behavior is generally not simply a matter of personal choice. Instead, interventions are likely to be most effective when they address the individual and the psychological and social contexts in which the behavior occurs. This suggests the utility of intervening at the

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences multiple levels that influence behavior individual (physiological, psychological), family, social networks, organizations, community, and society (state or national population). For example, a person might lose weight as the result of an intervention, but in the months and years after that intervention, the effects of family and friends, eating and offering favorite fatty foods, advertisements for high-calorie treats, exposure to situations in which more nutritious food is not readily available, stress at work combined with little time to seek out nutritious foods, and confusing labeling or messages emphasizing low-fat but not sugar and caloric content are likely to result in weight gain. Interventions that involve family and community members and others with whom an individual has social relationships; community, organizational, and workplace changes; and public policy interventions have all been demonstrated to affect behavior. However, additional research is needed on the functioning and effectiveness of interventions at the levels of family, community, organizations, and public policy, as well as on combinations of them to determine which might be most effective and under what circumstances. Interventions that focus solely on individual attributes, such as self-control or willpower, to change behavior leave many relevant factors to chance and thus are unlikely to be successful over the long term unless other factors (e.g., family and social relationships, work policies, social norms, and individual stress reactivity) happen to be aligned in a way that is conducive to the desired change. AN INTERVENTION CASE STUDY: TOBACCO Tobacco use is the leading cause of preventable death in the United States (McGinnis and Foege, 1993), and tobacco control provides a good illustration of the translation of research to application. This example was selected because there is substantial evidence that tobacco use causes ill health (Chapter 3), public health interventions and clinical effectiveness have been evaluated, and cost-effectiveness studies are available. Clinical Interventions In 1994, the Agency for Health Care Policy and Research (AHCPR) launched a comprehensive effort to translate research findings on the most effective smoking-cessation strategies into clinical guidelines for health care providers, administrators, and smoking-cessation specialists. AHCPR

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences convened a panel of researchers to summarize the findings of 300 studies into a series of guidelines for clinical practice (USDHHS, 1996; AHCPR, 1996). Primary, secondary, and tertiary prevention strategies were proposed on the basis of meta-analyses of relevant studies: A combination of psychosocial counseling and nicotine replacement therapy appeared to be the most effective strategy. A dose/response relationship demonstrated that longer counseling sessions (more than 10 minutes) were more effective than were shorter ones (less than 3 minutes) and that more sessions (more than 8) produced better results than did fewer (under 4), but that even fewer or shorter sessions still had a more substantial influence on smoking behavior than did no sessions at all. All health-care providers could provide effective counseling that resulted in measurable smoking cessation, but cessation specialists were more effective than were generalists, and multiple providers were more effective than were single providers. Since that review, new treatments have become available, including nicotine inhalers and nasal spray and bupropion hydrochloride (Hughes et al., 1999). Moreover, the nicotine patch and gum have been made available over the counter. A review of studies of these treatments led to the recommendation that physicians intervene by discussing smoking and potential treatment with every patient who smokes (Hughes et al., 1999). Assessing patients for a combination of behavioral and pharmacotherapeutic approaches also was advised. The trend in smoking-cessation research has been away from brief interventions studied sequentially to multicomponent interventions that integrate several approaches (Schwartz, 1992). Those programs target smoking at the social, physiological, and psychological levels. They have been found to be more effective in promoting sustained smoking cessation than are single-component approaches (Shiftman, 1993). Recent evidence also suggests that smoking-cessation efforts are more successful when they are tailored to the target population. Specifically, an intervention tailored to specific needs, barriers, and smoking patterns of African Americans resulted in a higher cessation rate at 1 year than did a standard intervention (Orleans et al., 1998). Opportunities to increase the influence of smoking-cessation strategies are becoming available through managed-care programs in which more aggressive efforts can be undertaken to reach target populations. For

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences example, interactive telephone contact combined with tailored self-help materials (computer-generated recommendations based on questionnaire response patterns; Velicer et al., 1999) and smoking-cessation programs tailored to be responsive to the weight control concerns of women (Suchanek et al., 1999) were provided to substantial portions of the eligible populations and yielded impressive results. Although long-term abstinence rates were low (for instance, around 5–10%), participation of 50–85% produced success rates well beyond what would be expected from a typical reactive program. It should be noted that when success rates were matched to readiness stage (Prochaska, 1997), abstinence significantly improved for those in the preparation stage (to 20–30%) (Velicer et al., 1999), although this stage accounted for only 20% of the sample. Cost-Effectiveness A study by Cromwell et al. (1997) evaluated the cost-effectiveness of 15 smoking-cessation interventions endorsed by AHCPR (1996). The entry in Table 7–4 for smoking cessation comes from that study and shows the result for the guidelines as a whole and for each intervention. The authors presented results in terms of cost per quitter, per life-year saved, and per QALY. They also presented sensitivity analyses that included the time that smokers spent in the programs as a cost. (The committee endorses the inclusion of time, a scarce resource, in costs. Recognizing that analysts do not have much experience with this variable, sensitivity analyses might be the way to start.) The results of the study by Cromwell et al, (1997) show that smoking-cessation programs are a cost-effective way to improve health. More intensive interventions, which involve more counseling or use of nicotine replacement, are more cost-effective (their higher costs are more than offset by greater effectiveness). The total first-year cost of implementing the guidelines was estimated at $6.7 billion (1997 dollars). The return for that investment would be smoking cessation by 1.7 million people at a cost (in 1997 dollars) of about $4,000 per person. In terms of health outcome, the cost would be $2,800 per life-year, or just over $2,000 per QALY. Evaluating Clinical Interventions Chambless and Hollon (1998) have proposed a four-component model for the evaluation of health behavior change strategies: efficacy, effectiveness, generalizability, and cost-effectiveness. In a recent review of

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences smoking-cessation interventions using the Chambless and Hollon model, Compas et al. (1998) identified the most efficacious and effective smoking-cessation programs as multicomponent (typically, cognitive/behavioral therapy combined with nicotine patch or gum or such other pharmacologic agents as buproprion [Hurt et al., 1997], nicotine inhalers, social support, and environmental restructuring) and group-based, consisting of 8–12 sessions (Hall et al., 1994; Hill et al., 1993; Stevens and Hollis, 1989), achieving 1-year abstinence rates of 32–34%. Maintenance sessions that included relapse prevention skill training were particularly effective, raising 1-year abstinence rates to 41%. Other studies (e.g., Cinciripini et al., 1995, 1994) have achieved similar 1-year abstinence rates (44%) with the addition of scheduled smoking-reduction strategies. These rates compare favorably with those of earlier studies (e.g., Hunt et al., 1971) in which 20–25% abstinence after 1 year was the norm. Community-Based Interventions Chapters 5 and 6 review a number of community, workplace, and school-based interventions targeting the reduction of tobacco use. In the workplace, several programs were successful in reducing smoking among employees through implementation of restrictive tobacco control policies. School-based programs tried to provide educational messages about the health risks of tobacco use and to develop social skills that would allow youths to resist the pressures to smoke. These programs met with varied success, and changes were difficult to sustain. The study of Altman et al. (1999) illustrates a broad-based community participation approach to reducing tobacco availability and use among adolescents and youths. In that study, four rural communities in Monterey, California, were randomly assigned to treatment or comparison groups. Middle school and high school students in the communities completed questionnaires that evaluated their knowledge, attitudes, and behaviors concerning tobacco use. In the intervention communities, a series of actions were implemented over a 3-year period: widespread community education, training of merchants who sold tobacco, and voluntary policy change. Within the treatment communities, the proportion of stores that sold tobacco to minors dropped from 75% at the baseline assessment to zero at the final evaluation period. There also were reductions in tobacco sales in the comparison communities, but they were much less dramatic (from 64% down to 39%). Although tobacco availability was reduced in

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences the intervention communities, young people still reported that they were able to obtain tobacco from other sources. The strongest effect of the intervention was for younger students (seventh graders). The intervention had only small effects for ninth and eleventh graders. A recent school-based smoking prevention program (Peterson et al., 2000) calls into question the effectiveness of the social-influences approach to smoking prevention. The Hutchinson Smoking Prevention Project (HSPP), conducted 1984–1999, randomly assigned 40 school districts to experimental or control groups. Students were followed from grade 3 until 2 years after high school. An enhanced social-influence approach to the intervention was used, containing the 15 “essential elements” for school-based tobacco prevention developed by an NCI Advisory Panel (explained in Flay, 1985; Glynn, 1989). Included in the interventions were the following activities. Every year, from grade 3 to grade 10, the students received multiple lessons from trained teachers regarding the strategies for identifying and resisting the influences to smoke, motivating the students not to smoke, and promoting self-confidence in the ability to refuse to smoke. This was supplemented by a biannual newsletter and the availability of materials to help stop smoking. No significant differences between the control and experimental groups were evident at grade 12 or 2 years after high school, suggesting that the intervention had little, if any, impact. The highly controlled, and well-designed nature of the study, including the high follow-up rates, high compliance with the intervention, the maintenance of the randomization by the school districts, well-matched control and treatment groups, and appropriate statistical analysis, strongly suggest that the failure to achieve change was a result of a failed intervention and not poor methodology. This conclusion implies that future interventions need to take a different approach, critically rethinking the interactions of biological, behavioral, and psychosocial risk factors at social and cultural contexts. Government Level Anti-Tobacco Interventions The government has adopted multiple strategies to reduce smoking, particularly among children and adolescents. Those interventions are directed toward individual-level behavioral changes using education (e.g., anti-tobacco campaigns), deterrence (e.g., bans on retail sales to minors), and disincentives (e.g., tobacco taxes). They also are directed toward manufacturers (various litigation strategies), information sources (e.g.,

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences At the individual level, findings suggest that counseling and pharmacological therapies are effective (AHCPR, 1996; Tobacco Use and Dependence Clinical Practice Guideline Panel, 2000). The U.S. Public Health Service issued a Clinical Practice Guideline (Tobacco Use and Dependence Clinical Practice Guideline Panel, 2000) based upon the recommendations of an expert panel. They reviewed nearly 6,000 peer-reviewed articles and recommended that all tobacco users should be offered treatment since effective treatments exist: institutionalizing consistent identification, documentation, and treatment of all tobacco users; brief treatment is effective; greater intensity of counseling is more effective; three types of counseling and five pharmacotherapies were found to be effective. This approach was evaluated for tobacco cessation, but in modified form might also be effective for prevention. Many community-based interventions have shown variable success. Many of them have been directed toward youth in the belief that they would have the greatest impact for the future. One exemplary study of school-based smoking prevention, the Hutchinson Smoking Prevention Project (HSPP) (Peterson et al., 2000) sponsored by the National Cancer Institute, is described above. This 15-year study, in 40 school districts of Washington state that were randomly assigned to intervention or control groups, involved 8,388 third graders who were followed to 2 years after high school with 94% follow-up. The authors concluded “there is no evidence from this trial that a school-based social-influences approach is effective in the long-term deterrence of smoking among youth.” Similarly, an assessment of policy interventions in a school setting was found to have limited impact. Based on the observation that organizational smoking policy may be a potentially effective way to influence smoking behavior in worksites (Borland et al., 1990), Bowen et al. (1995) surveyed 239 schools as to their smoking policies. They identified three types of policies: a ban on smoking on school grounds; smoking allowed on school grounds; and smoking allowed in designated areas in the building. Their conclusion was: “current smoking policies may have limited ability to reduce student smoking.” A scholarly review of government level approaches to tobacco use prevention and cessation by the Advocacy Institute (2000) found that although single approaches via clean air laws, price increases, counter-advertising, enforcement of existing laws restricting youth access and others may be effective with some people. However, a combination of these approaches has the greatest possibility of success.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences In summary, there is limited evidence that any single step is effective in reducing tobacco use. Although a number of studies have been published, many if not most suffer from design flaws that fail adequately to consider co-factors existing in the community. The conclusion of the committee is that a multi-pronged approach including (but not limited to) education, physician intervention, price increases, restricted access to tobacco, clean air laws, and counter-advertising must be used. In current tobacco users, counseling and pharmacotherapies have the greatest potential APPLICATION OF RESEARCH RESULTS Much research is needed to complete the picture of how individual genetic endowments and physiological processes interact with individual personalities, development, other psychological characteristics and processes, and social status and relationships to affect health status. Simply put, how does the environment “get under the skin” (Taylor et al., 1997), and what can be done to optimize health (Ryff and Singer, 1998)? Such research will require the collaboration and cooperation of multiple disciplines. New research methods are likely to be required as multiple influences are considered simultaneously and as causes and effects are considered dynamically and systemically, rather than linearly. To develop programs that are effective in modifying health behaviors, expanded efforts in all five phases (NHLBI, 1983) of intervention research are needed. These five phases include hypothesis generation, development of intervention methods, controlled intervention trials, studies in defined populations, and demonstration research (Chapter 7). Systematic clinical trials are needed to evaluate the value of behavioral and psychosocial interventions; in particular, more studies are needed that document the effects of these interventions on health, quality of life, and longevity. Studies suggest that interventions at multiple levels are more effective than interventions at single levels, but well-designed evaluations are necessary. Innovative methods and naturalistic experiments also will be necessary to evaluate community, organizational, and public policy interventions, and particularly multilevel interventions. Those methods will be critically important if knowledge from behavioral and psychosocial research is to be translated into applications in more natural settings.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences FINDINGS AND RECOMMENDATIONS Finding 1: Health and disease are determined by dynamic interactions among biological, psychological, behavioral, and social factors. These interactions occur over time and throughout development. Cooperation and interaction of multiple disciplines are necessary for understanding and influencing health and behavior. Recommendation 1: Funding agencies should direct resources toward interdisciplinary efforts for research and intervention studies that integrate biological, psychological, behavioral, and social variables. The investigations that will be most productive will reflect an understanding of the complexity and interconnections of disciplines. Collaborations across disciplines need to be encouraged and expanded. Finding 2: A fundamental finding of the report is the importance of the interaction of psychosocial and biological processes in health and disease. Psychosocial factors influence health directly through biological mechanisms and indirectly through an array of behaviors. Social and psychological factors include socioeconomic status, social inequalities, social networks and support, work conditions, depression, anger, and hostility. Recommendation 2: Research efforts to elucidate the mechanisms by which social and psychological factors influence health should be encouraged. Intervention studies are needed to evaluate the effectiveness of modifying these factors to improve health and prevent disease. Such intervention studies should span the breadth of all phases of clinical trials, from feasibility studies to randomized double-blind studies. Community-based participatory research should also be conducted. Research should include all levels of intervention, from individual to family, community, and society. Finding 3: Behavior can be changed: behavioral interventions can successfully teach new behaviors and attenuate risky behaviors. Maintaining behavior change over time, however, is a greater challenge. Short-term changes in behavior are encouraging, but improved health outcomes will often require prolonged interventions and lengthy follow-up protocols. Recommendation 3: Funding for health-related behavioral and psychosocial interventions should support realistically long-duration efforts. Finding 4: Individual behavior, family interactions, community and workplace relationships and resources, and public policy all contribute to health

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences and influence behavior change. Existing research suggests that interventions at multiple levels (individual, family, community, society) are most likely to sustain behavioral change. Recommendation 4: Concurrent interventions at multiple levels (individual, family, community, and society) should be encouraged to promote healthy behaviors. Assessments of coordinated efforts across levels are needed. Such efforts should address the psychosocial factors associated with health status (e.g., access to healthy foods or safe places to exercise) as well as individual behavior. Finding 5: Initiating and maintaining a behavior change is difficult. Evidence indicates that it is easier to generalize a newly learned behavior than to change existing behavior. The old adage “an ounce of prevention is worth a pound of cure” is valid in the context of behavior and health as well. Recommendation 5: Resources should be allocated to the promotion of health-enhancing behavior and primary prevention of disease. This should be a priority for public health and health care systems. Finding 6: The goals of public health and health care are to increase life expectancy and improve health-related quality of life. Many behavioral intervention trials document the capacity of interventions to modify risk factors, but relatively few measured mortality and morbidity. However, ramifications of interventions are not always apparent until they are fully evaluated, and unexpected consequences can result. Recommendation 6: Intervention research must include appropriate measures (including biological measures) to determine whether the strategy has the desired health effects. Finding 7: Changing unhealthy behavior is not simply a matter of “willpower.” Individual behavior has biological underpinnings and consequences and is influenced by the social and psychological contexts in which it occurs. While biological interventions and exhortations to individuals to change their behaviors are easier to administer, changes in social factors, policies, and norms are necessary for improvement and maintenance of population health. Much can be learned as states change cigarette taxes, create controls on public advertising for various products, and increase or decrease opportunities for exercise during the school day or as communities implement or eliminate walking and bicycle paths.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences Such social and policy decisions are rich opportunities for learning about behavior change and health. Recommendation 7: Program planners and policy makers need to sider modifying social and societal conditions to enable healthy behavior and social relationships. Interventions must be evaluated to enable continuous improvement of programs and policies. Research in these domains should be rigorous and scientific, but method should not dominate substance. Longitudinal research designs, natural experiments, quasiexperimental methods, community-based participatory research, and development of new research methods are necessary to advance knowledge in these areas. REFERENCES Abt (1997). Independent Evaluation of the Massachusetts Tobacco Control Program. Cambridge, MA: Abt Associates. Adler, N., Boyce, T., Chesney, M., Cohen, S., Folkman, S., Kahn, R., and Syme, L. (1994). Socioeconomic status and health: The challenge of the gradient. American Psychologist, 49, 15–24. Advocacy Institute (2000) Making The Case: State Tobacco Control Policy Briefing Papers, 1707 L St., NW, Suite 400, Washington, DC 20036. AHCPR (Agency for Health Care Policy and Research) (1996). Smoking Cessation Clinical Practice Guideline. Journal of the American Medical Association, 275 (16), 1270–1280 Albright, C.L., Altman, D.F., Slater, M.D., and Maccoby, N. (1988). Cigarette advertisements in magazines: Evidence for a differential focus on women’s and youth magazines. Health Education Quarterly, 15, 225–233. Altman, D.G., Wheelis, A.Y., McFarlane, M., Lee, H., and Fortmann, S.P. (1999). The relationship between tobacco access and use among adolescents: A four community study. Social Science and Medicine, 48, 759–775. Andersen, B.L. (1992). Psychosocial interventions for cancer patients to enhance quality of life . Journal of Consulting and Clinical Psychology, 60, 552–568. Anderson, B.J. (1996). Involving family members in diabetes treatment. In B.J.Anderson and R.R.Rubin (Eds.) Practical Psychology for Diabetes Clinicians (pp. 43–50). Alexandria, VA: American Diabetes Association. Anderson, R.M., Funnell, M.M., Butler, P.M., Arnold, M.S., Fitzgerald, J.T., and Feste, C.C. (1995). Patient empowerment. Results of a randomized controlled trial. Diabetes Care, 18, 943–949. Bal, D.G., Kizer, K.W., Felten, P.G., Mozar, H.N., and Niemeyer, D. (1990). Reducing tobacco consumption in California. Development of a statewide anti-tobacco use campaign. Journal of the American Medical Association, 264, 1570–1574. Berkman, L. and Kawachi, I. (Eds.) (2000). Social Epidemiology. New York: Oxford University Press.

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