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Book Forum: Mind, Body, and Behavior   |    
Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences
JOHN J. SCHWAB, M.D.
Am J Psychiatry 2003;160:603-a-605. doi:10.1176/appi.ajp.160.3.603-a
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By the Committee on Health and Behavior: Research, Practice, and Policy, Board on Neuroscience and Behavioral Health, Institute of Medicine. Washington, DC, National Academy Press, 2001, 377 pp., $49.95.

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This comprehensive volume updates the 1982 Institute of Medicine’s landmark study, "Health and Biobehavioral Frontiers of Biobehavioral Research," which stimulated research and education during the past two decades and contributed to recognition of the role of behavior in HIV and AIDS. The current book presents new findings on the areas covered in 1982 and also discusses evaluations and applications of the newer research findings and the cost-effectiveness of research and intervention programs.

The committee that authored the report was composed of authorities in internal, family, adolescent, and pediatric medicine along with authorities in health policy, epidemiology, social epidemiology, family therapy, clinical and social psychology, law and ethics, health education, neuroendocrinology, immunology, and psychiatry. Its charge was to 1) update scientific findings about the links between biological, psychosocial, and behavioral factors and health, 2) identify factors involved in health and disease for which research on them and on effective behavioral and psychosocial interventions is complete, 3) identify and review applications of newer behavioral and psychosocial interventions, 4) examine the implementation of behavioral and psychosocial interventions, 5) review evidence of cost-effectiveness of programs, and 6) make recommendations for further research, its applications and financing, and psychosocial interventions.

The committee handled that formidable charge by reviewing about 1,700 research reports on health and behavior published since 1982 (there are 99 pages of citations). Committee members focused on developments in those fields and also included psychosocial factors, conceptualized as the individual’s interpretations of social relationships, events, or status, inasmuch as they reflect psychological and social variables that, when internalized, affect biological processes.

The overwhelming mass of data, descriptive material, and comments is masterfully organized. The volume begins with a helpful 18-page executive summary, followed by a 19-page introduction containing many of the definitions that will be used. Part 1, Biological, Behavioral, and Social Factors Affecting Health, consists of three chapters: "Biobehavioral Factors and Health and Disease," "Behavioral Risk Factors," and "Social Risk Factors." Part 2, Health-Related Interventions, also contains three chapters: "Individuals and Families: Models and Interventions," "Organizations, Communities, and Society," and "Evaluating and Disseminating Intervention Research." Part 3, Findings and Recommendations, provides a short, superb summary in 19 pages.

The committee presents their ecological definition of health as "a state of complete physical, mental, and social well-being and not the absence of infirmity." They insist that a comprehensive definition of health requires both an integration of broader concepts of morbidity and mortality than we now consider and also an "outcomes model" focused on patients’ outcomes rather than disease pathology. Furthermore, they point out that health is multidimensional and present a concept of positive health that has four constructs: a healthy body, high-quality personal relationships, a sense of purpose in life, and self-regarded mastery of life tasks, along with resilience to stress, trauma, and change.

Behavior is not simply a matter of individual choice but is shaped by the multiple influences of families, social networks, communities, and such organizations as workplaces and schools. Thus, there are multiple targets for change and strategies for interventions at different levels. The committee expresses hope that their report will stimulate researchers, practitioners, program developers, and policy makers to consider multiple levels for assessments.

The organization of Health and Behavior deserves special attention. Part 1 describes the status of knowledge about biological, behavioral, and social factors that affect health and their interactions. Part 2 addresses research interventions in health-related behaviors at the individual, family, community, and society levels. The committee points out that the associations between socioeconomic status and health and the influences of social networks, employment status, and personal beliefs have not received sufficient attention. Part 3 presents the committee’s principal findings and recommendations.

The concepts of allostasis and of the allostatic load are introduced in chapter 1 after a brief discussion of stress and homeostasis. Allostasis is defined as the "maintenance of overall stability (homeostasis) through the constant adjustment and balancing of various common components in the process of adapting to challenges"—in a sense, the capacity to adapt. The allostatic load, the wear and tear the body experiences as a result of repeated allostatic responses, affects all bodily systems, especially the hormonal, immunologic, and central nervous systems. The allostatic load is more than chronic stress; it reflects failure to cope efficiently with daily challenges related to such influential life-style factors as diet, physical activity, and alcohol. Adrenal steroids and catecholamines are the main mediators of both the protective and the damaging effects of allostatic responses, and the brain, as the interpreter, regulator, and also target of the allostatic load, is subject to long-term wear and tear.

In chapter 3, "Behavioral Risk Factors," cigarette smoking is indicted as the major cause of preventable morbidity and mortality in the United States, accounting for 400,000 deaths each year. Obesity, now the second leading factor contributing to mortality, influences gall bladder disease, sleep apnea, respiratory diseases, and musculoskeletal problems. Avoiding weight gain as an adult needs to be a high priority because the treatment of obesity has notoriously poor long-term success.

Chapter 4, "Social Risk Factors," presents many new data and emphasizes some from the past as well. For example, not only is the socioeconomic status of the individual and the family inversely associated with illness and mortality, but recent studies of census tract incomes indicate that the socioeconomic status of the community makes an independent contribution to mortality. Also, there is a graded, continuous association between income and mortality that persists well into the middle-class range of incomes. Furthermore, strong correlations are being found between measures of income equality and standardized mortality rates. Even modestly lower relative income is associated with higher rates of infant mortality and deaths from coronary heart disease. Among social risk factors are the reverse causation seen when poor health leads to a lowering of socioeconomic status rather than just lower socioeconomic status leading to poor health.

Research is showing the benefits of social support in managing stress, coping, and improving family relationships. Powerful epidemiologic evidence supports views that social ties, especially intimate ones, along with emotional support, are associated with improved prognosis and survival for patients with cardiovascular disease. For example, significant evidence indicates that marital discord affects general health and immunity adversely. Not all social connections, however, are beneficial. Conflicted, hostile, and/or abusive family environments affect health negatively. Individuals in positive relationships are less likely to show a high allostatic load than the lonely and isolated. The committee also presents data on the adverse effects of racial disparities, discrimination, and lack of social cohesion.

Among other influential social factors are those pertaining to religious belief and practices; participating in religious activities and/or holding religious beliefs are associated with improved health status. In chapter 4, the discussion of social risk factors, including the short 2-page section on social cohesion and social capital, is especially valuable.

Part 2 is devoted to health-related interventions. In accord with their social systems/ecologic perspective, the committee finds that the family provides the social context that has the most immediate effects on disease management and the greatest implications for intervention.

In part 3, the committee concludes with a summary of the following seven major findings and recommendations:

1. Health and disease are determined mainly by interactions over time among biological, psychological, behavioral, and social factors. Recommendation number l, therefore, is that cooperation and collaborations among multiple disciplines are necessary in order to influence health and behavior favorably. Funding agencies need to direct resources toward interdisciplinary research efforts and prevention studies that integrate biological, psychological, behavioral, and social variables. Collaborations across disciplines need further encouragement.

2. A fundamental finding is that psychosocial factors influence health both directly through biological mechanisms and indirectly through behaviors. Recommendation number 2, therefore, is that research efforts need to bring to the surface the mechanisms by which social and psychological factors influence health, and intervention studies are needed to evaluate the effectiveness of modifying factors that promote health and prevent disease. Such studies need to cover a broad research span, from clinical trials to feasibility and randomized double-blind studies to community-based participatory research.

3. Behavior can be changed; behavioral interventions can successfully teach new behaviors and diminish risky ones. However, maintaining behavior change over time is the challenge. Improved health outcomes often require prolonged interventions and lengthy follow-up protocols. Recommendation number 3, therefore, is that funding for health-related behavioral and psychosocial interventions needs to support long-duration efforts.

4. Individual behavior, family interactions, community and workplace relationships, resources, and public policy all can influence behavioral change and contribute to health. Only interventions at those multiple levels will sustain behavioral change. Recommendation number 4, therefore, is that concurrent interventions at multiple levels and assessments of coordinated efforts across those levels are necessary.

5. Initiating and maintaining behavior change is difficult. It is easier to generalize a newly learned behavior than to change existing behaviors. Recommendation number 5, therefore, is that resources should be allocated to promote long-term health-enhancing behaviors and primary prevention programs that then become public health and health care priorities.

6. The goals of public health and health care are to increase life expectancy and improve health-related quality of life, not just to modify risk factors. Recommendation number 6, therefore, is that intervention research must include all appropriate biological and psychosocial measures to determine whether the strategies being used are producing the desired health effects.

7. Changing unhealthy behavior is not just a matter of willpower because behavior has biological underpinnings and is influenced by its social and psychological contexts. Much can be learned, for example, by studying the effects of higher cigarette taxes, controlled advertising of unhealthful products, communities’ increasing or decreasing facilities for healthful recreation, and social and other policy decisions. Recommendation number 7, therefore, is that policy makers and program planners need to consider how to modify social and societal conditions to enable healthy behaviors and enhance social relationships. Also, longitudinal research design, quasi-experimental methods, and community-based participatory research, along with the development of new research methods, can advance knowledge about health and behavior.

Health and Behavior is an important book, an outstanding compilation of the available information on this vital topic. The committee members who authored it extracted the essential data and findings from many references and wove them into a well-organized, coherent, readable volume. They should be both thanked and commended for their successful efforts. Obviously, reading all of it is a somewhat daunting, laborious task, but the importance of the content and quality of the writing make the task interesting.

Inasmuch as this book will be used most often as a reference, it needs to be available in all medical and other scientific libraries for researchers in health and behavior and related fields. Also, many clinicians will find that it has utility in validating their frequently necessary recommendations and admonitions to patients about unhealthful behaviors, for example, about diet and exercise in order to control the burgeoning epidemic of obesity and its consequences. In summary, Health and Behavior presents a mass of information that, in whole or in part, will be useful to many clinicians, researchers, other scientists, and policy makers involved with the many challenges to improve health in our society.

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