[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE ROLE OF SOCIAL AND BEHAVIORAL
SCIENCES IN PUBLIC HEALTH
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON RESEARCH AND
SCIENCE EDUCATION
COMMITTEE ON SCIENCE AND TECHNOLOGY
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 18, 2008
__________
Serial No. 110-123
__________
Printed for the use of the Committee on Science and Technology
Available via the World Wide Web: http://www.science.house.gov
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______
COMMITTEE ON SCIENCE AND TECHNOLOGY
HON. BART GORDON, Tennessee, Chairman
JERRY F. COSTELLO, Illinois RALPH M. HALL, Texas
EDDIE BERNICE JOHNSON, Texas F. JAMES SENSENBRENNER JR.,
LYNN C. WOOLSEY, California Wisconsin
MARK UDALL, Colorado LAMAR S. SMITH, Texas
DAVID WU, Oregon DANA ROHRABACHER, California
BRIAN BAIRD, Washington ROSCOE G. BARTLETT, Maryland
BRAD MILLER, North Carolina VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois FRANK D. LUCAS, Oklahoma
NICK LAMPSON, Texas JUDY BIGGERT, Illinois
GABRIELLE GIFFORDS, Arizona W. TODD AKIN, Missouri
JERRY MCNERNEY, California TOM FEENEY, Florida
LAURA RICHARDSON, California RANDY NEUGEBAUER, Texas
DONNA F. EDWARDS, Maryland BOB INGLIS, South Carolina
STEVEN R. ROTHMAN, New Jersey DAVID G. REICHERT, Washington
JIM MATHESON, Utah MICHAEL T. MCCAUL, Texas
MIKE ROSS, Arkansas MARIO DIAZ-BALART, Florida
BEN CHANDLER, Kentucky PHIL GINGREY, Georgia
RUSS CARNAHAN, Missouri BRIAN P. BILBRAY, California
CHARLIE MELANCON, Louisiana ADRIAN SMITH, Nebraska
BARON P. HILL, Indiana PAUL C. BROUN, Georgia
HARRY E. MITCHELL, Arizona VACANCY
CHARLES A. WILSON, Ohio
ANDRE CARSON, Indiana
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Subcommittee on Research and Science Education
HON. BRIAN BAIRD, Washington, Chairman
EDDIE BERNICE JOHNSON, Texas VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois ROSCOE G. BARTLETT, Maryland
JERRY MCNERNEY, California RANDY NEUGEBAUER, Texas
RUSS CARNAHAN, Missouri DAVID G. REICHERT, Washington
BARON P. HILL, Indiana BRIAN P. BILBRAY, California
ANDRE CARSON, Indiana RALPH M. HALL, Texas
BART GORDON, Tennessee
JIM WILSON Subcommittee Staff Director
DAHLIA SOKOLOV Democratic Professional Staff Member
MELE WILLIAMS Republican Professional Staff Member
BESS CAUGHRAN Research Assistant
C O N T E N T S
September 18, 2008
Page
Witness List..................................................... 2
Hearing Charter.................................................. 3
Opening Statements
Statement by Representative Brian Baird, Chairman, Subcommittee
on Research and Science Education, Committee on Science and
Technology, U.S. House of Representatives...................... 6
Written Statement............................................ 7
Statement by Representative Vernon J. Ehlers, Ranking Minority
Member, Subcommittee on Research and Science Education,
Committee on Science and Technology, U.S. House of
Representatives................................................ 7
Written Statement............................................ 8
Witnesses:
Dr. Lisa Feldman Barrett, Professor of Psychology; Director of
the Interdisciplinary Affective Science Laboratory, Boston
College; Appointments at Harvard Medical School and
Massachusetts General Hospital
Oral Statement............................................... 9
Written Statement............................................ 11
Biography.................................................... 13
Dr. John B. Jemmott III, Kenneth B. Clark Professor of
Communication; Professor of Communication in Psychiatry;
Director, Center for Health Behavior and Communication
Research, University of Pennsylvania, School of Medicine and
Annenberg School for Communication
Oral Statement............................................... 13
Written Statement............................................ 15
Biography.................................................... 29
Dr. Donald S. Kenkel, Professor of Policy Analysis and
Management, College of Human Ecology, Cornell University
Oral Statement............................................... 30
Written Statement............................................ 32
Biography.................................................... 35
Dr. Harold G. Koenig, Professor of Psychiatry and Behavioral
Sciences; Associate Professor of Medicine; Director of the
Center for Theology, Spirituality, and Health, Duke University
Oral Statement............................................... 36
Written Statement............................................ 38
Biography.................................................... 51
Discussion....................................................... 51
Appendix: Additional Material for the Record
Statement of David B. Abrams, Executive Director, The Steven A.
Schroeder Institute for Tobacco Research and Policy Studies,
American Legacy Foundation.................................... 72
THE ROLE OF SOCIAL AND BEHAVIORAL SCIENCES IN PUBLIC HEALTH
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THURSDAY, SEPTEMBER 18, 2008
House of Representatives,
Subcommittee on Research and Science Education,
Committee on Science and Technology,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:02 a.m., in
Room 2318 of the Rayburn House Office Building, Hon. Brian
Baird [Chairman of the Subcommittee] presiding.
hearing charter
SUBCOMMITTEE ON RESEARCH AND SCIENCE EDUCATION
COMMITTEE ON SCIENCE AND TECHNOLOGY
U.S. HOUSE OF REPRESENTATIVES
The Role of Social and Behavioral
Sciences in Public Health
thursday, september 18, 2008
10:00 a.m.-12:00 p.m.
2318 rayburn house office building
1. Purpose
The purpose of the hearing is examine the role of the social,
behavioral and economic sciences in improving our nation's health and
well being and reducing the economic burden of health care.
2. Witnesses:
Dr. Lisa Feldman Barrett is a Professor of Psychology
and Director of the Interdisciplinary Affective Science
Laboratory at Boston College, with appointments at Harvard
Medical School and Massachusetts General Hospital.
Dr. John B. Jemmott III is the Kenneth B. Clark
Professor of Communication at Annenberg School of
Communication, and a Professor of Communication in Psychiatry
and Director of the Center for Health Behavior and
Communication Research in the Department of Psychiatry, School
of Medicine at the University of Pennsylvania.
Dr. Donald S. Kenkel is a Professor of Policy
Analysis and Management in the College of Human Ecology at
Cornell University.
Dr. Harold Koenig is a Professor of Psychiatry and
Behavioral Sciences, Associate Professor of Medicine, and
Director of the Center for Theology, Spirituality and Health at
Duke University.
3. Overarching Questions:
How can the behavioral, social and economic sciences
contribute to the design and evaluation of more effective
public health policies? What lessons can be learned from the
decades-old national campaign to reduce smoking? To what extent
are public health policies in general being shaped by what has
been learned from the social, behavioral and economic sciences?
What new and continuing areas of basic research in
the social, behavioral and economic sciences could
significantly improve our ability to design effective policies?
What new technologies and methodologies are enabling advances
in the research? Are there promising research opportunities
that are not being adequately addressed?
What is the nature of interactions and collaborations
between behavioral and social scientists, biomedical scientists
and health (including mental health) practitioners? How might
these disparate research and practitioner communities be better
integrated to improve human health and well being? Is the
Federal Government playing an effective role in fostering such
collaboration?
4. Federal Spending on Social, Behavioral and Economic Sciences
Basic and applied research in the social, behavioral and economic
sciences is funded out of a number of federal agencies, led by the
National Institutes of Health (NIH) and the National Science Foundation
(NSF). According to research funding statistics compiled by NSF,\1\ a
total of $1.215 billion was obligated to basic and applied research in
all social sciences for fiscal year 2006 (FY06), including economics.
Psychology was counted separately, and was funded at a total of $1.91
billion in FY06, of which $1.76 billion was funded by Health and Human
Services (primarily NIH). Federal support for academic research in
particular was $711 million for social sciences and $629 million for
psychology. There is also a significant amount of foundation support
for public health related research.
---------------------------------------------------------------------------
\1\ Data are based on self-reporting by agencies. In many cases,
especially where there is interdisciplinary work, it is hard to tally
exact dollars spent on one field or another, so these values are at
best an estimate.
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The main support for basic research in the (non-medical) social and
behavioral sciences comes from the Social, Behavioral and Economics
Directorate (SBE) at NSF. Overall, NSF accounts for approximately 60
percent of federal support for basic research in anthropology, social
psychology and the social sciences at U.S. colleges and universities.
In some fields, including archaeology, political science, linguistics,
and non-medical aspects of anthropology, psychology, and sociology, NSF
is the predominant or exclusive source of federal basic research
support. The SBE budget for FY08 is approximately $220 million, making
it the second smallest research directorate at NSF. Fifteen percent of
SBE's budget is used not for basic research but to fund the collection
and analysis of data on science and engineering research, education and
workforce trends (including the data presented here), resulting in the
biannual ``S&E Indicators.''
NIH funds both very basic research, such as that of Dr. Barrett,
and research-based interventions such as those designed by Dr. Jemmott.
NIH also supports most health economics research, such as that carried
out by Dr. Kenkel. NIH's Office of Behavioral and Social Sciences
Research (OBSSR), created by Congress in 1993, serves as a coordinating
and policy development office for research across NIH's many
institutes, rather than funding research directly. OBSSR also serves as
NIH's focal point for coordination of social and behavioral research
agendas with other agencies, including NSF. Staff at both NSF and NIH
report having a close and productive working relationship. Occasionally
the agencies issue joint solicitations, such as a current solicitation
in computational neuroscience.
5. Public Health Applications of Social and Behavioral Sciences
NSF does not explicitly fund health research, but it does fund
basic research on human behavior as it relates to biological and social
phenomena. For example, NSF funds medical anthropologists who study the
distribution of genes in a particular region as it relates to the
prevalence of a certain disease, and cognitive neuroscientists who
study aspects of brain function relevant to autism. NIH funds social
and behavioral research with direct public health applications, such as
reducing tobacco use, improving mental health, preventing obesity and
slowing the HIV/AIDS epidemic.
One of the biggest public health stories of the 20th century is the
reduction in tobacco use and smoking-related diseases. Behavioral and
social science research helped shape policies to stop kids from taking
up smoking, and interventions to help those already addicted to quit.
According to the Centers for Disease Control and Prevention, the
portion of Americans who smoke dropped from 42.4 percent in 1965 to
20.8 percent in 2007. However, cigarette smoking remains the leading
preventable cause of death in the United States, accounting for
approximately one of every five deaths (438,000 people) each year.\2\
The economic costs associated with smoking-related illnesses are
estimated to be $165 billion in health care and disability.
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\2\ http://www.cdc.gov/tobacco/data-statistics/
fact-sheets/adult-data/
adult-cig-smoking.htm
---------------------------------------------------------------------------
As biomedical and clinical researchers continue to develop
understanding of disease mechanisms and develop effective
pharmaceutical therapies, social and behavioral scientists continue to
elucidate the role of social and behavioral factors in health and
illness. The research community, however, has moved beyond genes or
environment arguments about physical and mental health to studying how
genes and environment interact in complex ways to produce behavioral
and health outcomes. As such, there is an increasing need for these
disparate research and practitioner communities to break down
disciplinary and cultural barriers to advance public health and well
being.
6. Questions for Witnesses
Two of the witnesses in this hearing carry out the basic behavioral
and economics research. One of the witnesses uses theories based on
research to design interventions to stem the spread of HIV/AIDS among
urban youth. A fourth witness studies the relationship between
spirituality and health. All of the witnesses were asked to testify
about the nature of their own research and its significance to public
health policy. They were also asked about the increasing role of
collaborations between behavioral scientists, biomedical scientists and
public health practitioners to advance public health, and the role of
the Federal Government in fostering such collaborations.
Chairman Baird. Good morning. Thank you all being here for
another of this committee's series of hearings on the role of
social sciences and helping to meet some of the grand
challenges facing our country today. This is the third in a
series. We have previously had an operable hearing on social
sciences as they impact energy policy and practices, then we
had one on defense issues and its applications there.
Today we look at one of the other great challenges facing
our country, and that is health care. Our nation faces a triple
challenge of access, cost, and outcome. We have 45 to 47
million Americans with no health insurance. We spend more per
capita than any other country on Earth on health care and yet
our outcomes are not what they ought to be, and a great number
of illnesses are fairly preventable, and a vast amount of our
spending nationwide is related to behaviorally-influenced
illnesses, either the behavior directly caused the illness or
they can exacerbate the impact or behavioral factors can impede
the treatment process. And this includes everything on the
causal part, it includes everything from smoking to some degree
of obesity.
On the treatment side behavioral interventions have been
immensely helpful in helping us address things like adherence
to chemotherapy regimes or in the case of, for example,
tuberculosis, drug adherence, medication adherence. These are
absolutely critical.
And so we believe as a former social scientist myself, that
if we want to solve some of these health care problems, the
social scientists have an absolutely essential role to play in
that, and we have witnesses today who will share a diverse
perspective on that.
In a moment I am going to acknowledge my dear friend and
colleague, Dr. Vern Ehlers, for opening remarks. We also have
Dr. Roscoe Bartlett with us here today, and Eddie Bernice
Johnson is here as well.
Before we do, though, I want to acknowledge a Member of the
Science Committee staff. Jim Wilson is retiring at the end of
this year. I think this will be our last hearing before this
committee, so hence, perhaps, Jim's last hearing. He is
probably wiping away tears as I speak. Jim has been on the
professional staff of the Committee since 1987. He invented the
Internet, the Blackberry, and a host of other modern devices.
Jim received his BS, MS, and Ph.D. degrees in aerospace
engineering from West Virginia University, completed the Senior
Manager's in Government Program at Harvard's Kennedy School of
Government. He previously managed research programs in fluid
dynamics at the Air Force Office of Scientific Research in
Washington, DC, and served as an officer in the U.S. Air Force
at the Flight Dynamics Laboratory at Wright Patterson Air Force
Base in Ohio. Then he decided to do something with his life and
came to work for us here at the staff.
He has done an outstanding job. He is a good friend and has
been a great public servant, and I just want to express my
personal appreciation, and Jim, we have a small token of that.
This is a flag which we took to Antarctica, and this has
actually been to the South Pole and around the South Pole, so
it has been in every time zone. That is an easy trip. You just
walk around. But, Jim, please accept this with our gratitude
for many years of service.
[The prepared statement of Chairman Baird follows:]
Prepared Statement of Chairman Brian Baird
Good morning and welcome to this Research and Science Education
Subcommittee hearing on the role that social, behavioral and economic
sciences play in improving our nation's health and well being and
reducing the economic burden of health care. This happens to be the
very last scheduled hearing before the Science and Technology Committee
this year. It seems fitting, as we are in the midst of a heated
campaign season in which skyrocketing health care costs are a hot
topic, that we highlight an aspect of health care that gets too little
attention from the research and medical communities and government
alike: prevention.
We have a health care system that discourages doctors from spending
time on preventative care. I don't think this committee is going to
solve that problem. But we will look today at the choices that
individuals make, and what researchers know about how and why we make
those choices and how public policy might be shaped to help influence
those choices to the benefit of both ourselves and society.
Each of us decides whether to smoke, to exercise, to cook at home
or stop at the nearest fast food joint. Most if not all of us in this
room are pretty lucky. We are blessed with a good education, good
health insurance and a well-paying job. We have all of the tools and
resources we need to make the healthy choice every time, but we still
engage in unhealthy behaviors. Access to information and resources is
not the sum of what influences our decisions.
Take smoking. After decades of an aggressive public anti-smoking
campaign, the overall rate of smoking in the U.S. decreased by one-half
to 21 percent. I imagine there are few teenagers in the U.S. who
haven't had it drilled into them that smoking can kill. Yet, according
to the CDC, each day approximately 4,000 kids between the ages of 12
and 17 years initiate cigarette smoking. Social, behavioral and
economics research did and continues to shape effective anti-smoking
policies and to provide insight into why some efforts have fallen
short. This is first and foremost about the health and well being of
individual Americans. But it is also about the cost to our society.
Smoking alone can be blamed for approximately $165 billion per year in
health care and disability costs.
Of course our health is not governed entirely by our behavior. Even
those of us with the healthiest habits can be struck by a physical or
mental illness that requires treatment. How do we respond to such
challenges? Do we have the tools, and do our doctors have the tools to
help us combat depression for example, whether it comes on out of the
blue or in response to a major illness or trauma? They say a healthy
body makes a healthy mind. The inverse is equally true. Yet it is only
in the last decade or two that researchers are seriously exploring the
mind-body connection. Another important and recent advance is that
increasingly, clinicians, biologists and behavioral scientists are
joining forces to answer the question: how do genes and environment
interact, rather than making it an either/or proposition.
The panel before us is engaged in some exciting work, ranging from
very basic research on emotions to design of theory-based interventions
to stop the spread of HIV/AIDS. I thank all of the witnesses for being
here this morning and I look forward to your testimony.
Chairman Baird. Vern, I recognize my dear friend, Dr.
Ehlers.
Mr. Ehlers. Thank you for yielding. I would just like to
add my accolades. I have worked with Jim for a number of years.
He has always been imminently fair, very thorough, and very
capable. And we are certainly going to miss him. The only
puzzle I have had constantly after all my great intelligent
conversations with him is how he ended up being a Democrat. But
that may be a partisan point of view. But, Jim, we really
appreciate your work, and we are all going to miss you. Thank
you.
Chairman Baird. When you look at Jim's resume, those of us
who are Members of Congress may not be rocket scientists, but
some of our staff are. And that is very nice.
Thank you for your remarks, Dr. Ehlers.
With that I am pleased to recognize Dr. Ehlers for an
opening statement.
Mr. Ehlers. Thank you, Mr. Chairman. Today's hearing will
delve into the public health implications of social science
research and its application. Preventing disease and premature
death is the underlying goal of the marriage between public
health and the social sciences, and the impacts of this
research are substantial.
And I must confess, Mr. Chairman, I recognize we have had
all these hearings because you are a social scientist, but you
have done us a service because all the different hearings we
have had this year have certainly opened my eyes to the power
and usefulness and the social sciences in many different areas.
So I thank you for holding all these hearings.
The Social Behavior and Economics Directorate at the
National Science Foundation provides support for the
fundamental research that underpins many of today's public
health interventions. In addition to studying the science of
the brain NSF works to integrate the microscopic with the
macroscopic actions of our day-to-day lives.
In many ways the social sciences face similar challenges as
the physical sciences do in bringing an innovative idea from
the laboratory to the marketplace. Humans are such dynamic
characters, particularly when it comes through their own
health, that the scientists before us must juggle many
different variables. Conducting gold-standard research projects
with human subjects certainly poses unique challenges.
Understanding the root causes of human behavior and emotion
will assist lawmakers in crafting effective public health
policy.
I appreciate the work of the Chairman and staff on this
series of hearings which have educated Members and the public
about how social science research is impacting human behavior,
energy, national security, and today perhaps the most important
topic, how it affects our health. I look forward to hearing
from our witnesses today about the research in these areas, and
I thank you all for your attention.
[The prepared statement of Mr. Ehlers follows:]
Prepared Statement of Representative Vernon J. Ehlers
Today's hearing will delve into the public health implications of
social science research and its application. Preventing disease and
premature death is the underlying goal of the marriage between public
health and the social sciences, and the impacts of this research are
substantial.
The Social, Behavioral and Economics directorate at the National
Science Foundation (NSF) provides support for the fundamental research
that underpins many of today's public health interventions. In addition
to studying the science of the brain, NSF works to integrate the
microscopic with the macroscopic actions of our day-to-day lives. In
many ways, the social sciences face similar challenges as the physical
sciences do in bringing an innovative idea from the laboratory to the
marketplace. Humans are such dynamic characters, particularly when it
comes to their own health, that the scientists before us must juggle
many different variables. Conducting ``gold standard'' research
projects with human subjects certainly poses unique challenges.
Understanding the root causes of human behavior and emotion will assist
lawmakers in crafting effective public health policy.
I appreciate the work of the Chairman and his staff on this series
of hearings in the 110th Congress, which have educated Members and the
public about how social science research is impacting human behavior as
it relates to energy, national security, and, today, our health.
I look forward to hearing from our witnesses today about their
research in the social sciences. Thank you for your attendance.
Chairman Baird. Thank you, Dr. Ehlers. If there are other
Members who wish to submit additional opening statements, your
statements will be added to the record at this point, and at
this time I would like to introduce our distinguished
witnesses.
Dr. Lisa Feldman Barrett is a Professor of Psychology and
Director of the Interdisciplinary Affective Science Laboratory
at Boston College with Appointments at Harvard Medical School
and Massachusetts General Hospital. Dr. John B. Jemmott, III,
is Kenneth B. Clark Professor of Communication at the Annenberg
School of Communication and a Professor of Communication in
Psychiatry and Director of the Center for Health Behavior and
Communication Research, and the Department of Psychiatry at the
School of Medicine at the University of Pennsylvania.
Dr. Donald S. Kenkel is Professor of Policy Analysis and
Management in the College of Human Ecology at Cornell
University, and Dr. Harold G. Koenig is a Professor of
Psychiatry and Behavioral Sciences and Associate Professor of
Medicine and Director of the Center for Theology, Spirituality,
and Health at Duke University.
As our witnesses know, we spoke briefly before, their
spoken testimony is limited to five minutes each for your
initial comments, and after that Members of the Committee will
have five minutes each to ask questions. We are grateful for
your years of research and contribution and that you would take
the time from certainly busy schedules to join us today.
With that we will, we have been joined, I should mention by
Dr. Lipinski and thank you. And we will start with Dr. Barrett,
please.
STATEMENT OF DR. LISA FELDMAN BARRETT, PROFESSOR OF PSYCHOLOGY;
DIRECTOR OF THE INTERDISCIPLINARY AFFECTIVE SCIENCE LABORATORY,
BOSTON COLLEGE; APPOINTMENTS AT HARVARD MEDICAL SCHOOL AND
MASSACHUSETTS GENERAL HOSPITAL
Dr. Barrett. Congressman Baird, you and your colleagues
deserve our deepest thanks for encouraging NIH to support basic
research in the social and behavioral sciences. My colleagues
and I are very grateful for your efforts, and I very much
appreciate the opportunity to speak with you today.
Seven years ago when the Twin Towers collapsed, people had
many reactions. I would like to read two to you. One person
said, ``My first reaction was terrible sadness but then came
anger, because I couldn't do anything with the sadness.'' A
second person said, ``I felt a bunch of things I couldn't put
my finger on, maybe anger, confusion, fear. I just felt bad.''
These examples demonstrate a phenomenon that I discovered
almost 20 years ago. Some people feel the heat of anger, they
feel the despair of sadness, they feel the dread of fear. Other
people use the same words, but they feel, for lack of a better
word, bad. Same words, different feelings.
Over a 10-year period my lab found that people like the
first speaker who have emotional expertise are more flexible in
regulating their emotions. They are more centered, they are
less buffeted by the slings and arrows of life than the second
speaker.
These basic research findings have now been translated into
emotional literacy programs for children, teachers, and school
administrators. By the end of next year 250 schools in the New
York System alone will participate, and the results are already
clear. Children who can identify, understand, and label their
emotions effectively have fewer clinical symptoms, they are at
lower risks for violent behavior, and for drug and alcohol
abuse. They have better social skills, they have stronger
leadership skills, and perhaps most surprisingly, they have
higher scores, grades, in math, science, reading, and so on,
meaning that emotional literacy must be a central piece of
educational reforms like No Child Left Behind.
These are welcome outcomes, especially given the recent
UNICEF report showing that U.S. children have the second lowest
well-being scores across 21 developed nations.
Now, emotional literacy isn't just about happiness.
Emotionally-intelligent children turn into the skilled and
productive workforce of tomorrow, which translates into an
increase in the gross domestic product. And emotional literacy
has the potential to play a role in addressing some of the
Nation's most pressing problems. For example, anecdotal
evidence shows that regardless of people's plans, they often
decide to retire on the spur of the moment after, let us say, a
particularly bad day at the office.
So instead of retiring at age 67, when they should, or at
age 65, when they planned to, they retire on average at age 63.
By teaching people emotional literacy when they are adults, we
may be able to prevent that bad day at the office from causing
them to retire early, allowing people more financial security
and saving the government substantially in Social Security and
health care benefits.
From a purely scientific standpoint the discovery that not
everybody feels anger or sadness or fear has ignited a literal
paradigm shift in the study of emotion. We now know that
emotions are not simple reflexes that are flipped on like a
light switch in certain parts of the brain, which is why there
is no single pill that cures depression, and there is no single
gene that controls happiness.
The exact nature of emotion is now the topic of heated
debate and furious research, and the history of science teaches
us that key scientific discoveries are made during such times.
At the frontiers of science nothing speeds scientific progress
like the clash of competing viewpoints. This may not be
comfortable, and it is certainly not cheap, but it is
absolutely necessary.
Science is like a food chain, with basic research at the
base, feeding translational research, which feeds applied
research, and so on. Without this healthy base the entire
ecosystem becomes weak and can't survive. Basic research in the
social and behavioral sciences, you know, surprisingly, it may
sound surprising to say this, is really being starved in
America, and without the basic research today there will be no
critical health solutions for tomorrow.
It takes time for basic science to feed solutions, often
decades. Scientific discovery is like slowly peeling an onion,
while exploring one question, other, more nuanced questions,
are revealed beneath. This means that you can't run science
like you run on a business model where you set a tangible goal
and try to meet it on a strict timeline of five years.
Because the neuroscientist who discovered that canary
brains grow new cells after birth wasn't trying to solve the
puzzle of human mental illness. Social scientists who studied
the evils of conformity after World War II weren't trying to
keep people from using drugs and alcohol, and my own research
on emotion wasn't originally targeted at helping children read
better or helping retirees decide, you know, when is the
financially right time to decide.
Regardless of the goals that motivated my basic research or
any basic research in the first place, it is simply a fact that
this research is necessary to achieve the critical, and often
surprising, results that help people live healthier and more
productive lives.
[The prepared statement of Dr. Feldman Barrett follows:]
Prepared Statement of Lisa Feldman Barrett
Abstract
People differ markedly in their emotional expertise. Many people,
but not all, feel the heat of anger, the despair of sadness, the dread
of fear. Some instead experience amorphous feelings that are either
pleasant or unpleasant. This basic research finding has been translated
into emotional literacy training programs with proven health, economic,
and educational benefits. It also illustrates how basic research in the
social and behavioral sciences allows people to live healthier and more
productive lives.
Thank you for the opportunity to speak with you today. I run an
interdisciplinary lab where we study the very basic nature of emotion,
from both the standpoint of the psychologist (who measures behavior)
and the neuroscientist (who measures the brain). Today, I'll wear my
psychologist's hat and tell you the story of a single scientific
discovery that is already improving the lives of Americans. It is also
a promising lead to solving some of the country's most pressing public
health issues, and illustrates the value of basic research in making a
healthier and more productive nation.
Seven years ago, when the twin towers collapsed, people had many
reactions. Here are just two. One person said ``The first reaction was
terrible sadness and tears . . .. But the second reaction is anger,
because you can't do anything with the sadness.'' Another said ``I felt
a bunch of things I couldn't put my finger on. Maybe anger, confusion,
fear. I just felt bad on September 11th. Really bad.'' These examples
demonstrate a phenomenon about emotion that I discovered fifteen years
ago.
When I was in graduate school, I noticed something curious in my
psychotherapy patients. Some people used emotion words to refer to very
precise and distinct experiences--they felt the heat of anger, the
despair of sadness, the dread of fear. Others used the words ``anger,''
``sadness,'' and ``fear'' interchangeably, as if they did not
experience these states as different from one another. They felt, for
lack of a better word, ``bad.'' Outside the therapy room, I saw the
same thing in friends and family and students. This observation was the
basis for a decade-long research project (supported by both NSF and
NIH) where my lab tracked the emotional experience of over 700 people
during the course of everyday life using a then-novel scientific
procedure called computerized experience-sampling (www.experience-
sampling.org). Using novel software and statistical procedures, we made
an important discovery: people differ in their emotional expertise.
Some people, as in the first example, are emotion experts and
experience a wide variety of nuanced emotions, in much the same way
that a wine expert can distinguish the type of wine as well as its
vineyard and vintage. Other people, like the second example, experience
emotion as an amorphous feeling that is either pleasant or unpleasant,
just like wine novices who can't tell much more than whether a wine is
red or white. Over a ten-year period, my lab discovered that
differences in emotional expertise translate to important outcomes.
Emotion connoisseurs are more flexible in regulating their emotions.
They are more centered, and less buffeted by slings and arrows of life.
Those with less emotional expertise, by contrast, live life as
turbulent roller coaster with more ups and downs.
These basic research findings are now being translated into
emotional literacy training programs for children (ages four to
fourteen), teachers, and school administrators (see www.ei-
schools.org). By the end of next year, 250 schools in the New York
school system alone will participate, and already the results are
promising. Children who can identify, understand, label, and regulate
their emotions effectively have fewer clinical symptoms, and are at
lower risk for violent behavior and drug and alcohol abuse. They have
better social skills, and stronger leadership skills. Perhaps most
surprisingly, hundreds of studies show that emotionally intelligent
children have higher grades in math, science, and reading, meaning that
emotional literacy must be included in educational reforms like No
Child Left Behind. These are welcome outcomes, especially given the
recent UNICEF report showing that U.S. children have the second-lowest
rate of well-being across 21 developed nations.
But emotional expertise isn't just about happiness--it translates
into economic stability and productivity for our country. The
emotionally intelligent children of today become the skilled and
productive adults of tomorrow. In a recent forum on children's
education, the noted economist and Nobel Laureate James Heckman argued
that social and emotional expertise is necessary to improve the quality
of the American workforce. A happier and socially skilled workforce
translates into an increase in the Gross Domestic Product.
Emotional expertise will even play a role in addressing some of the
Nation's most pressing problems. For example, emotional literacy may
help to prevent early retirement in adults, which costs the government
significantly in social security and health care benefits. Anecdotal
evidence shows that, regardless of their plans, people often decide to
retire on the spur of the moment, say, after a particularly bad day in
the office. So instead of retiring at age 67 (when they should), or age
65 (when they plan to), they retire, on average, at age 63. By teaching
emotional literacy to adults, we can prevent that bad day from causing
them to retire early, allowing people more financial security and
saving the government a lot of money in the process.
From a purely scientific standpoint, the discovery that not
everyone feels anger or sadness or fear has helped to ignite a paradigm
shift in the study of emotion. Emotions used to be thought of as simple
reflexes or light switches that turn on parts of your brain, and that
could be turned off by a drug or changing the right gene. But we now
know that's not the case, which is why there's no pill that cures
depression, and no single gene that controls happiness. The exact
nature of emotion is now the topic of heated debate and furious
research, and the history of science teaches us that key scientific
discoveries are made during such times. At the frontiers of science,
nothing speeds scientific progress like the clash of competing
viewpoints. This may not be comfortable, or cheap, but it is absolutely
necessary.
Science is like a food chain, with basic research at the base,
feeding translational research, which feeds applied research, which can
be used by service providers. Without a healthy base, however, the
entire ecosystem becomes weak and cannot survive. Basic research in
social and behavioral sciences is being starved in America. And without
this basic research today, there will be no critical health solutions
for tomorrow.
It takes time for basic science to feed applied solutions. In
genetics or pharmacology, the life cycle is of discovery is usually
several decades. Scientific discovery is like slowly peeling an onion--
while exploring one question, other, more nuanced questions are
revealed beneath (and sometimes, a lot of tears are shed along the
way). But here in the social and behavioral sciences, a basic finding
about emotion was translated after only 15 years--a relatively quick
outcome for science, but one that serves both public health and the
public treasury.
Science is about exploration, risk, and discovery. This means that
you cannot run scientific discovery like a business, where you set a
tangible goal and try to meet it on a strict timeline. A seemingly
trivial, everyday occurrence or a very abstract idea can, upon closer
inspection, open up a new scientific vista. The neuroscientist who
discovered that canary brains grow new cells after birth wasn't trying
to solve the puzzle of human mental illness. The physicists who
discovered quantum mechanics were not trying to build a better
computer. Social scientists who studied the evils of conformity after
World War II weren't trying to keep people from using drugs. And my own
research on emotion wasn't originally targeted at helping children and
retirees, but in the end, this is where it has led. Regardless of the
goals that motivate basic research in the first place, it is simply a
fact such research is necessary to achieve the critical, and often
surprising, results that help people live healthier and more productive
lives.
Congressman Baird, you and your colleague Congressman Kennedy
deserve a lot of credit for encouraging NIH to provide a better
infrastructure to support basic research in the social and behavioral
sciences. I know I speak for my colleagues when I say that we are all
very grateful for your efforts. I myself am fortunate that my
laboratory is well supported by federal funding agencies at the moment.
In the context of today's hearing, however, this funding success is a
bit misleading, because the majority of it pays for the neuro-imaging
side of my research on emotion. Like many labs around the country, my
lab is also struggling to move our social and behavioral research
forward. For the social and behavioral sciences to realize their full
potential in the service of this country's health and well-being, labs
like my own need four things to succeed: a well-trained scientific
workforce of sufficient expertise and diversity, more advanced
technology that is suited to the scientific questions we want to ask
(whether or not they have an applied value that is immediately
obvious), an adequate level of research funds to see our best ideas
(and perhaps riskiest) forward, and open minds that are not mired in
the habits or agendas of the past.
Biography for Lisa Feldman Barrett
Lisa Feldman Barrett, Ph.D., is currently Professor of Psychology
and Director of the Interdisciplinary Affective Science Laboratory at
Boston College, with appointments at Harvard Medical School and
Massachusetts General Hospital. Dr. Barrett received her Ph.D. in
clinical psychology in 1992, and has since received additional training
in social and personality psychology, psychophysiology, cognitive
science, neuroanatomy, and cognitive neuroscience. Her research focuses
on very basic question of what emotions are, both from both the
standpoint of the psychologist (who measures behavior) and the
neuroscientist (who measures the brain). Her work also incorporates
insights from philosophy, anthropology, and linguistics.
Dr. Barrett is an elected Fellow of the Association for
Psychological Science, the American Psychological Association, and the
Society for Personality and Social Psychology. In 2007, she received an
NIH Director's Pioneer Award for innovative research on emotion. She is
also the recipient of an Independent Scientist Research Award from the
National Institute of Mental Health, a Career Trajectory Award in
Experimental Social Psychology, the James McKeen Cattell Award, and an
American Philosophical Society Fellowship. Dr. Barrett has served as an
elected member to the governing boards of the International Society of
Research on Emotion and the Society for Experimental Social Psychology.
For the past eight years, she has continually served on grant review
panels for either the National Science Foundation or the National
Institutes of Health. She is a founding Editor-in-Chief of the journal
Emotion Review, and sits on the editorial boards of top tier journals
in both psychology and neuroscience.
Dr. Barrett's lab has been continually funded by the National
Science Foundation since 1998. In addition to NSF funding, her lab
currently receives support from the NIH Director's Pioneer Award
program in the National Institute of General Medicine, the National
Institute on Aging, and the Army Research Institute.
Dr. Barrett has published over 90 papers and chapters, including a
National Research Council white paper on the nature of emotion. She has
edited three books on the science of emotion, including the current
edition of the Handbook of Emotion. She also wrote the current entry on
emotion for World Book Encyclopedia.
Chairman Baird. Thank you, Dr. Barrett.
Dr. Jemmott.
STATEMENT OF DR. JOHN B. JEMMOTT III, KENNETH B. CLARK
PROFESSOR OF COMMUNICATION; PROFESSOR OF COMMUNICATION IN
PSYCHIATRY; DIRECTOR, CENTER FOR HEALTH BEHAVIOR AND
COMMUNICATION RESEARCH, UNIVERSITY OF PENNSYLVANIA, SCHOOL OF
MEDICINE AND ANNENBERG SCHOOL FOR COMMUNICATION
Dr. Jemmott. I am very happy to be here today to share some
of the work that I have been doing over the past 20 years or so
in the era of HIV prevention, conducting a program of research
that is designed to identify the social psychological factors
that underlie HIV risk-associated behavior. Once you identify
those factors, we develop interventions that are based on
theory and that are tailored to the population to try to change
their behavior. We then evaluate those intervention strategies
using rigorous scientific methods, usually a randomized control
trial, which is the best way to find out whether an
intervention is effective.
Along the way we try to address some practical questions
about the best way to do HIV prevention. This might be
questions about the race of the facilitator or the gender of
the facilitator or the gender, composition of the group, or the
age of the facilitator, all of these practical question about
how to do intervention.
Then if we find that an intervention is effective, we then
try to disseminate it to people who can actually use to, go
beyond publishing it in journals and get it to the end users.
Then when the end users are using it, it leads to additional
questions about whether it still works, and so we look at that
as well.
In our research we found that two of the key
characteristics of effective interventions is one, that they
are grounded in some behavior change theory, some systematic
understanding of human behavior. And second, that they are
tailored to the population, and this is usually based on
qualitative research with that population so you can understand
their beliefs and the context in which the behavior occurs.
This slide shows one of the theories that we use called the
theory of planned behavior. So it is a model of behavior. So
the behavior might be abstinence or it could be condom use, and
we basically begin at the behavior, and we work backwards in
the model. We identify an intention, which is a plan to engage
in the behavior. The best predictor of a person's behavior is a
plan to do that behavior. And then we look at different types
of beliefs that could influence those behaviors.
And those beliefs did not come from the pages of academic
journals. They come from our target population through
qualitative research. We ask them what they believe. Then once
we have their beliefs, we then try to develop interventions to
target the beliefs, to change the beliefs in ways that are
supportive of behavior.
So through a mediational change by affecting building the
intervention, affecting the beliefs, affects intentions and
changes behavior, and you can extend the model further to a
health outcome such as sexually-transmitted disease. So that is
basically how our research is done.
Our measures of success are the outcomes in terms of sexual
behaviors related to HIV infection; abstinence, condom use, and
limiting the numbers of partners. In some of our studies we are
also, where appropriate, able to collect biological specimens
that we can test for sexually-transmitted diseases such as
chlamydia, gonorrhea, herpes simplex. And because we want to
understand why the intervention works or why it didn't work, we
also look at mediator variables, the beliefs and intentions
that I mentioned earlier. Because if the intervention worked,
we want to know which beliefs were actually responsible for the
good outcome that we saw.
But on the other hand, if it didn't work, then we want to
know did we, in fact, change the beliefs that we intended to
change and also if we did change them, were they actually
related to the behavior. And then in this way we can design
better interventions in the future.
We also look at the participants and the facilitators'
evaluations of the intervention because that is important in
terms of whether it is practical and can be used in the real
world.
We have developed a number of successful interventions, the
first five that you see listed there are being disseminated now
by the Centers for Disease Control, and we have two others that
are efficacious that we hope to have disseminated soon, one of
which is in South Africa, where the HIV epidemic is having the
largest impact.
In terms of scaling up, there are a number of issues that
come into play in terms of whether success interventions are
adopted. Sometimes they are not. What are the variables that
affect that? Interventions often have to be adapted, which
means changing them, and so the question is if you change it,
does it still work? So what kinds of adaptations are useful,
and which ones are harmful?
And then the third question is if it is efficacious in a
randomized-controlled trial, is it still effective when it is
used by teachers in schools or health professionals in clinics?
And so researchers are required to look at effectiveness as
well.
We at the University of Pennsylvania and the Behavioral
Sciences Cores, we cover a lot of different populations and
research in a variety of different venues that I will not be
able to go into, and we collaborate with people in other
disciplines within the Center, in immunology, and clinical core
in particular, so we see how the different areas of science
work together with social science to address these health
problems.
And I will stop here.
[The prepared statement of Dr. Jemmott follows:]
Prepared Statement of John B. Jemmott III
1. Please describe your work to prevent the spread of HIV/AIDS among
urban youth and other populations. What social and behavioral theories
underlie your research? How do you apply those theories to design and
test interventions that may reduce risky behaviors in your target
populations? What are your measures of success?
My colleagues and I have been conducting a program of HIV/STD risk-
reduction research in urban populations. Our research program has
several objectives. First, we seek to identify the social psychological
factors that underlie HIV/STD risk behavior. Second, we seek to
identify theory-based strategies that are culturally and
developmentally appropriate. Third, we evaluate the efficacy of those
strategies using scientifically sound methodology. This usually
involves the use of a randomized controlled trial in which participants
are randomly assigned to receive the intervention or to a control
condition. A randomized controlled trial provides the most
scientifically valid evidence for the efficacy of an intervention.
Fourth, we address practical questions about the best way to implement
HIV/STD risk-reduction interventions. For instance, we have examined
whether the efficacy of an intervention varies depending on the race of
the facilitator, the gender of the facilitator, whether the facilitator
is a peer or an adult, and whether the intervention is implemented in
single-gender or mixed gender groups. Finally, if an intervention is
found to be efficacious, we seek to disseminate it so that it is
available to providers who can employ it to curb the spread of HIV
among their clients. This also leads additional research questions
regarding the adaptation of evidence-based interventions to new
settings and populations, factors affecting the adoption of
interventions by service providers, and factors affecting the
effectiveness of interventions when implemented by service providers
and in new settings or populations.
Our research as been funded since 1988 by the National Institute of
Mental (NIMH), the National Institute of Child Health and Human
Development (NICHD), the National Institute of Nursing Research (NINR),
the Centers for Disease Control and Prevention (CDC), and the American
Foundation for AIDS Research. We have conduced research with a
diversity of populations, including inner-city African American
adolescents, African American parents and their adolescent children,
African American women clinic attendees, African American and Latino
adolescent female clinic attendees, African American HIV serodiscordant
couples where one partner has HIV and the other does not, African
American men who have sex with men (MSM), middle class White college
students, English-speaking and Spanish-speaking Latino adolescents,
Xhosa-speaking South African adolescents, and Xhosa-speaking South
African men. We have conducted our studies in a variety of settings,
including schools, churches, universities, adolescent medicine clinics,
women's health clinics, community-based organizations, low-income
housing developments, and neighborhoods/communities.
To address the problem of HIV/STD in any society requires an array
of interventions that can be implemented in a variety of venues by
different kinds of facilitators. Accordingly our research has developed
many different types of interventions. A contentious debate in the area
of HIV education and sex education for adolescents has revolved around
the extent to which interventions should emphasize sexual abstinence as
opposed to condom use. We have developed safer-sex interventions
emphasizing condom use, abstinence-only interventions, and
comprehensive interventions stressing both abstinence and condom use.
Another issue has been whether peer educators are more effective than
adult facilitators in changing adolescents' sexual behavior. We have
developed both peer-led and adult-led interventions. Most of our
interventions have involved small groups of participants led by a
facilitator or a pair of co-facilitators. However, we have also
developed one-on-one individual interventions for certain
circumstances: for instance, nurses serving women in a hospital clinic
or service providers to African American MSM who may conceal their
involvement with men and consequently would be unwilling to attend a
small group intervention. We have identified several efficacious
interventions, including Be Proud! Be Responsible!, Making Proud
Choices--a Safer Sex Intervention, Making a Difference--an Abstinence
Based Approach, Cuidate, which is a Latino-tailored adaptation of Be
Proud! Be Responsible!, Sister to Sister, which is an intervention for
African American women in clinical settings, Sisters Saving Sisters,
which is an intervention for African American and Latino adolescent
girls, and Let Us Protect Our Future, which is an intervention for
South African adolescents. Of these interventions, Be Proud! Be
Responsible!, Making Proud Choices, Making a Difference, Cuidate, and
Sister to Sister have been included in dissemination initiatives of the
CDC.
Our experiences in this area teaches that two key characteristics
of effective HIV/STD risk-reduction interventions are (a) grounding in
behavior change theory and (b) tailoring to the population or culture
served. The social and behavior theories that we have employed include
the social cognitive theory and the reasoned action approach, which
includes the theory of reasoned action and its extension the theory of
planned behavior. We use social cognitive theory to suggest
intervention strategies to achieve behavior change, including skill
building, modeling, reinforcement, and activities to build self-
efficacy. We use the reasoned action approach to help identify beliefs
that should be targeted by the interventions to achieve behavior
change. We selected the reasoned action approach because it can be
tailored to a variety of populations and cultures, which facilitates
the development of contextually appropriate interventions.
Consider the theory of planned behavior. Briefly, according to the
theory, the best predictor of a specific behavior is an intention or
plan to engage in the behavior. Although it is understood that people
do not always live up to their intentions, if a person does not plan to
engage in a behavior, then it is highly unlike that he or she will
engage in the behavior. Research has demonstrated a strong longitudinal
relationship between intention and sexual behaviors, including condom
use and abstinence. The theory also suggests that a behavioral
intention is determined by attitude, subjective norm, and perceived
behavioral control or self-efficacy regarding the behavior. Thus,
people should intend to use condoms if they evaluate condom use
positively, if they believe significant others think they should use
condoms, and if they feel confident in their ability to use condoms.
A valuable feature of the theory of planned behavior is that it
directs attention to why people hold specific attitudes, subjective
norms, and perceived behavioral control or self-efficacy. Behavioral
beliefs about the consequences of engaging in the behavior determine
attitude toward using them. For instance, adolescents may believe that
sexual involvement may interfere with their ability to achieve their
educational goals. With regard to condoms, people may believe that if
they use a condom, their risk of sexually transmitted HIV infection or
pregnancy will be reduced. On the other hand, they may believe that
using a condom would interfere with sexual enjoyment. If I perceive
that the consequences of a behavior are good, then I am more likely to
engage in the behavior than if I perceive that the consequences are
bad. Normative beliefs about important referents' approval or
disapproval of the behavior determine subjective norm. These
significant referents might include peers, parents, other relatives,
church members, or sexual partners. Adolescents might be less likely to
initiate sexual involvement if they understand that their parents would
strongly disapprove of their having sexual intercourse. On the other
hand, it may be difficult for adolescents to practice sexual abstinence
it they believe that all of their friends approve of their having
sexual intercourse. Control beliefs about factors that facilitate or
inhibit condom use determine perceived behavioral control or self-
efficacy. This might include beliefs about the availability of condoms.
If people are embarrassed to purchase or carry condoms they may not
have them available when they need to use them. Impulse control beliefs
concern people's confidence that they can control themselves enough to
use condoms when sexually excited. Perhaps most emphasized in HIV
prevention research are negotiation beliefs, which concern the people's
confidence that they can persuade their sexual partners to practice
sexual abstinence or to use condoms. Technical skill beliefs concern
the people's ability to use condoms correctly and without ruining the
mood.
Several other factors may affect people's sexual risk behavior,
including prior sexual experiences, race/ethnicity, gender, age,
poverty, gender-role beliefs, parental monitoring and supervision,
parent-child communication, religiosity, and alcohol and drugs use.
According to the theory these are external variables. The effects on
intention and behavior of variables external to the theory are seen as
mediated by their effects on the attitudinal component, the normative
component, the perceived control component, or all three. In other
words, external variables, including an intervention, may affect
variables that are a part of the theory and through a mediation chain,
influence behavior. For instance, gender-role beliefs may influence a
woman's confidence that she can negotiate condom use with her partner
and may thereby affect condom-use intention and condom use. External
variables may also moderate an intervention's efficacy. For instance,
girls initiate sex at an older age than do boys, and girls have less
power over the use of condoms than do boys. Accordingly, gender may
both predict sexual debut and moderate the intervention's efficacy in
increasing condom use.
Given the way in which the theory explains the impact of external
variables, the theory offers a clear prescription for the development
of an intervention. We could design interventions to affect behavioral,
normative, and control beliefs and through a mediation process
influence intention and the targeted behavior. The theory also
suggested a strategy for identifying the relevant beliefs: namely,
target the salient behavioral, normative, and control beliefs in the
specific population. Researchers can use qualitative research methods,
including focus groups, key informant interviews, and elicitation
studies, with the population to identify the salient beliefs. By
targeting salient beliefs, an intervention may change attitude,
subjective norm, and perceived self-efficacy, which would change
intention, which, in turn, would change behavior. Identifying the
population-specific salient beliefs serves to make the theory and the
resulting intervention appropriate for the population. Perhaps most
important, the theory suggested that the relative predictive power of
the attitudinal, normative, and control components of the theory could
vary from population to population. Thus, the prediction of a
behavioral intention might be different in middle-class white college
students as compared with low-income African American women as compared
with African American MSM, but the theory might have predictive value
in each of these populations.
In developing our interventions we have conducted several phases of
research. First, we conduct qualitative research with the population or
culture, not only to identify the salient behavior, normative, and
control beliefs regarding the behaviors we seek to change, but also to
identify the contexts in which the behaviors occurs. An understanding
of the context is essential to developing an intervention that is
appropriate to the population. For example, knowing that adolescents
are more likely to have sex when they are home can help researchers
develop role-play scenarios regarding refusal to have sex that seem
authentic to the participants. The second phase of research is to
develop and employ a questionnaire to confirm that the salient beliefs
identified are, in fact, related to the behaviors of interest. The
third phase is to use the information from the first two phases to
develop an intervention. In other words, the qualitative information
about the culture or population and the quantitative information from
the survey are integrated with the theoretical framework to create an
intervention that is both grounded in the theory and tailored to the
population or culture. The fourth phase is to pilot test the
intervention, collect comments and criticisms from the participants and
facilitators, and then design the final version of the intervention.
The fifth phase is to test the efficacy of the intervention.
Randomized controlled trials provide the most scientifically sound
evidence for the efficacy of an intervention. We measure the success of
our efforts to develop efficacious interventions by examining the
quantitative and qualitative results of the randomized controlled
trials. We typically have three specific aims in testing the efficacy
of the intervention. First, we examine whether the intervention
significantly improved sexual behavior outcomes, including abstinence,
condom use, unprotected sexual intercourse, and multiple sexual
partners. In some studies, we also examine whether the intervention
influenced biological outcomes, that is, reduced the incidence of
sexually transmitted infections. A focus on STI is important because it
provides an outcome measure that is objective and less likely to be
influenced by a socially desirable responding by research participants.
In addition, it provides an actual health outcome for the intervention.
Typically, our second aim concerns moderators of intervention efficacy:
namely, whether the intervention is more effective with some
participants as compared with others. For example, does the
intervention have a better effect on adolescent boys as compared with
girls, virgins as compared with sexually experienced adolescents, or
single people as opposed to those in committed relationships? Or
perhaps the intervention has a better effect when implemented in
single-gender groups as compared with mixed gender groups or when the
facilitator is the same gender as the participant. A third aim of our
research is to test the mediation of the effects of the intervention on
behavior: namely, if it changes behavior, why did it changed behavior,
and if it did not change behavior, why it failed to change behavior.
This is very important to future research to improve the intervention.
This involves examining the theoretical mediators, that is, the beliefs
the intervention targeted. Did the intervention actually have an impact
on the beliefs it was designed to change? Were the beliefs related to
the behavior we sought to change? By conducting this kind of mediation
analysis a better understanding of why the intervention worked or did
not work will emerge. Thus, we measure our success by examining whether
the intervention changed behavior, whether it was more efficacious with
some participants or under certain circumstances, and why it was or was
not efficacious.
Here are some examples of studies we have conducted. In each study,
we followed the five phases mentioned earlier in developing and testing
the interventions. One randomized controlled trial tested the efficacy
of clinic based HIV/STD interventions. African American and Latina
adolescent girls at the adolescent medicine clinic of a children's
hospital were randomized to one of three interventions focused on HIV/
STD information, HIV/STD behavioral skill building, or general health
promotion among, with 89 percent retained at 12-month follow-up
(Jemmott, Jemmott, Braverman, and Fong, 2005). The skills building
intervention participants reported less frequent unprotected
intercourse and fewer sexual partners and were less likely to test
positive for an STD at 12-month follow up, as compared with the health-
promotion control intervention. The efficacy of the intervention did
not differ between the Latino as compared with the African American
girls. We developed the ``Sister to Sister'' HIV/STD risk-reduction
curriculum and evaluated it in a randomized controlled trial with Black
adult women at a women's health clinic in Newark, NJ (Jemmott, Jemmott,
& O'Leary, 2008). Among the 86.9 percent that returned for 12-month
follow-up, those in the Sister-to-Sister intervention had reduced
unprotected sexual intercourse and biologically confirmed STD rates as
compared with those in the health control group.
In another randomized controlled trial, Jemmott, Jemmott, and Fong
(1998) assigned 659 African American adolescents to an abstinence
intervention, a safer sex intervention, or a health-promotion control
intervention. About 98 percent attended all sessions of the two-session
interventions, and 93 percent returned for the 12-month follow-up. The
safer sex intervention significantly increased condom use compared with
the control group at three-, six-, and twelve-month follow-ups. The
abstinence intervention significantly reduced self-reported intercourse
at three-month follow-up compared with the control group. This was the
first randomized controlled trial demonstrating that an abstinence
intervention was efficacious in reducing sexual involvement. The
interventions were equally efficacious when implemented by peer co-
facilitators as compared with adult facilitators.
Finally, we recently completed a randomized controlled trial
developing and testing the efficacy of an HIV/STD risk-reduction
intervention for young South African adolescents, ``Let Us Protect Our
Future'' (Jemmott, Jemmott, O'Leary, Ngwane et al., 2008). We randomly
selected nine matched pairs of schools and randomly allocated schools
to either a HIV/STD risk-reduction intervention or a health promotion
control intervention. Grade 6 students completed baseline, post-
intervention, three-, six-, and twelve-month follow-up surveys written
in Xhosa following translation and back-translation from English. We
found that a significantly smaller percentage of students in the HIV/
STD risk-reduction intervention reported having vaginal intercourse,
unprotected vaginal intercourse, and multiple sexual partners, as
compared with their counterparts in the health-promotion control
intervention. The intervention's efficacy did not differ significantly
between girls and boys. Thus, our intervention approach, which
integrates qualitative information about a population with behavior
change theory, can be applied successfully not only to diverse
populations in the United States, but also to populations in sub-
Saharan Africa where HIV is exacting its most devastating toll.
2. How might successful programs in behavioral interventions for AIDS
prevention be scaled up, applied to other public health challenges, or
otherwise used to better inform public policy?
Considerable evidence from studies here in the United States and
abroad documents that HIV/STD risk-reduction interventions can reduce
sexual risk behaviors in a wide range of populations, including
adolescents, women, men who have sex with men (MSM), substance users,
patients in clinic settings, and other persons at risk. To have the
most impact on the HIV/AIDS epidemic, these successful preventive
interventions must be scaled up. We would argue that interventions
would be easier to scale up if the intervention developers consider the
likely end-users of the intervention during the process of development.
In this way, they are more likely to develop an intervention that can
be widely used than if practical questions are not considered from the
very beginning. For example, if we are to develop an intervention for a
broad range of African American MSM, we should consider not only
whether it will be most efficacious when implemented by African
American MSM facilitators, but also how realistic is it to scale up an
intervention for African American MSM that must be implemented by
African American MSM facilitators. If we know that women are the most
common case managers for African American MSM, it might be more
practical to examine whether women could successfully serve as
facilitators of an intervention for the population. Clearly, an
intervention that could be implemented by either women or African
American MSM would be easier to scale up than one that must be
implemented by African American MSM. This is just one example; the
point is that efforts to scale up may be most successful if scaling up
is considered from the beginning.
Certainly, in the early years of HIV/STD risk-reduction research,
the emphasis was appropriately on discovering interventions that could
successfully change behavior. Now, that we know we can develop
interventions to change behavior it is appropriate to shift the
emphasis and focus on the development of interventions that can be
scaled up. Several issues need to be considered when we focus on
scaling up, among them are adaptation, adoption, and effectiveness of
interventions.
Research is needed on the how to adapt evidence-based interventions
to meet the needs of different communities. This is important because
to adapt is to change, and change may mean creating a new intervention
that may or may not retain the efficacy of the evidence-based
intervention. Research is needed to understand how to adapt
interventions for new populations or settings while retaining the
qualities that made the interventions efficacious. In this connection,
a distinction is sometimes drawn between core elements of an
intervention and key characteristics of an intervention. Core elements
are aspects of an intervention that are considered essential to its
efficacy and therefore should not be changed, whereas key
characteristics are not essential to achieve efficacy and therefore can
be modified. More research is needed to more fully understand which
aspects of interventions are truly core elements and which are merely
key characteristics.
Research is needed on why evidenced-based interventions are or are
not adopted. Although successful interventions are published in
scientific, medical, and public health journals and therefore brought
to the attention of researchers, academics, and professionals, the
majority of service providers who work closely with populations at risk
may remain unaware of the interventions. Thus, efforts must be made to
disseminate successful interventions to likely end-users. The question
then becomes whether these service providers decide to adopt the
evidence-based intervention. The fact that service providers know that
an intervention successfully changed behavior in a study does not
necessarily mean that service providers will immediately adopt it.
Other considerations figure in the decisions of service providers to
use a given intervention. Research is needed into these decisions in
order to devise effective strategies to encourage the adoption of
evidence-based interventions. This may include research into ways to
train service providers to implement the intervention, identifying and
providing appropriate kinds of technical assistance, identifying
barriers to adopting the intervention among all relevant
constituencies. Examples of such barriers are funding, reasonable
salaries for talented staff, high rates of turnover, organizational
mission, and inadequate organizational capacity or infrastructure.
A third type of research needed concerns the effectiveness of
evidenced-based interventions when they are disseminated. Such studies
are sometimes called Phase IV trials and distinguished from Phase III
trials designed to test the efficacy of interventions. Although
carefully controlled Phase III studies employing well trained and
monitored facilitators who adhere to the intervention protocol strictly
may demonstrate that an intervention is efficacious, it does not
necessarily mean it will be effective when implemented under less
controlled real world circumstances. Thus, Phase IV trials are needed
to identify factors that affect the effectiveness of interventions when
implemented by service providers with their client populations in their
settings. These factors could then be taken into account both in the
development of future interventions that can be more successfully
scaled up and in the training of providers in the use of interventions.
Examples of factors that might affect the effectiveness of an
intervention are characteristics of the organization, including
organizational mission, the type of training the service providers
receive, technical assistance, supervision of staff, and staff
turnover.
Here is an example of a Phase IV effectiveness trial. After
conducting several Phase III trials of the efficacy of the Be Proud! Be
Responsible! intervention, we conducted a Phase IV trial of its
effectiveness when implemented by service providers at community-based
organizations (CBOs) serving African American adolescents 13 to 18
years of age. We randomized 86 CBOs to implement ``Be Proud! Be
Responsible!'' or a control health promotion intervention on diet and
physical activity. In addition, we randomly assigned the CBOs to
receive three different amounts of training. Each CBO implemented its
assigned intervention with six groups of adolescents (N=3,448), and we
randomly selected three of the six to complete three-, six-, and
twelve-month follow-up surveys (N=1,707). We found that adolescents who
received the HIV/STD intervention were more likely to report consistent
condom use than were those who received the health-promotion control
intervention. In addition, the effectiveness of the intervention did
not improve significantly when the CBOs were given more expensive and
labor-consuming training. This finding suggests that an HIV/STD risk-
reduction intervention whose efficacy has been established can be
effective when implemented by CBOs, which play a critical role in the
delivery of HIV/STD prevention services worldwide. Moreover, the
training of the CBOs need not be especially expensive or labor-
intensive to achieve desirable outcomes.
The findings from research on behavioral interventions to prevent
HIV can be applied to other public health challenges. The leading
causes of morbidity and mortality in the United States and in most
parts of the world are health problems that are either caused by or
affected by behavior and whose treatment or course are influenced by
behavior. National health organizations throughout the world as well as
international organizations all offer similar behavioral guidelines on
how to reduce the risk of leading causes of premature death. These
include guidelines regarding not only sexual behavior but also
cigarette smoking, healthful diet, physical activity, alcohol
consumption, and other use of other substances, screening behaviors,
and treatment adherence. Given the focus on behavior, the same type of
focus on behavior change theory and tailoring to the population is
likely to be successful in efforts to address these other pressing
public health issues.
We can say this with confidence because although we are primarily
HIV/STD risk-reduction researchers, in all of our studies we also
include a control group that receives an intervention. A common control
group intervention is a health promotion intervention that focuses on
how chronic diseases can be preventing by engaging healthful behavior.
This usually involves focusing on fruit and vegetable consumption and
physical activity as a means to reduce the risk of hypertension, heart
disease, obesity, and certain types of cancer. In developing these
chronic disease prevention strategies we employ the same phases of
research as in developing the HIV/STD interventions. Thus, we conduct
qualitative research to identify salient behavioral, normative, and
control beliefs and the context of the behaviors and then integrate the
information with our theoretical framework to develop the intervention.
An example of the success of this approach is the trial we recently
completed in South Africa with grade 6 students. Our health promotion
intervention was efficacious. Students who received the health
promotion intervention reported more fruit and vegetable consumption
and more physical activity over the twelve-month follow-up period than
did those who received the HIV/STD risk-reduction intervention.
3. Please provide an overview of the range of topics addressed by the
Behavioral and Social Sciences division of the Penn Center for AIDS
Research. What is the nature of the relationship between your division
and the Center's other divisions in biological sciences and clinical
research? How might social and behavioral research be used more
effectively to guide or take advantage of biomedical research and vice
versa? Given the potential for behavioral interventions to prevent the
spread of HIV/AIDS and many other diseases, is the Federal Government
investment in behavioral research reasonable relative to its total
investment in research to prevent and treat these diseases?
The Behavioral and Social Sciences (BSS) Core of the Penn Center
for AIDS Research (CFAR) focuses on studies of risk behavior and
outcome research as well as studies of epidemiologic, economic, and
bioethical aspects of AIDS. Additional goals of this group are to
develop strong linkages with the academic community of the University
outside the Medical Center in order to establish a broad-based and
comprehensive program in AIDS research. More specifically, the BSS Core
services are guided by and designed to promote the following set of
scientific priorities and principals: 1) Contextual circumstances
(social, sexual, and drug using networks; community; geography) within
which HIV transmission occurs and infection exists are crucial factors
to understanding and responding to risk of infection, access and
adherence to treatment; 2) Behavioral sciences have a critical role to
play in the design and evaluation of clinical trials of both behavioral
and biomedical interventions (microbicides, vaccines, and
therapeutics); 3) Linkages between investigators (behavioral, clinical
and basic), locally, domestically, and internationally is critical to
the development of sustainable programs of innovative and meaningful
AIDS research.
Members of the BSS Core have an impressive history of productivity
over the past 20 years and continue to be active in the behavioral and
social science aspects of AIDS. The work of these faculty include the
development of important and widely applied theory, the design and
implementation of theoretically based prevention interventions, and
leadership and participation in multi-site clinical trials of
behavioral and biomedical interventions. The BSS Program has a rich
portfolio of active AIDS research characterized by close collaborations
among program members and between CFAR programs. The following provides
a brief overview of the current work of the program with particular
emphasis on those studies that the CFAR has been instrumental in
facilitating.
International HIV Prevention Research
BSS program members have been actively involved in an expanding
international research agenda. In collaboration with Penn
investigators, the University of Botswana was recently awarded a
capacity building grant by NICHD. Botswana has the second highest rate
of HIV/AIDS in the world. A limited capacity and infrastructure for
rigorous HIV/STD prevention research has hampered efforts to curb the
spread of sexually transmitted HIV infection among adolescents in
Botswana. Accordingly, the broad long-term objective of the grant is to
build capacity and infrastructure to develop, implement, and evaluate
culturally competent, developmentally appropriate, sustainable
interventions suitable for implementation in a variety of settings to
dissuade Botswana adolescents from engaging in behaviors that increase
their risk for sexually transmitted diseases (STDs), including HIV.
This grant is a collaborative effort of a multi-disciplinary team of
researchers at the University of Botswana and the University of
Pennsylvania to build such capacity and infrastructure at the
University of Botswana. It is directed by Bagele Chilisa at the
University of Botswana and John Jemmott at the University of
Pennsylvania. The capacity building is organized around three cores.
Qualitative and Quantitative Methodology Core, Social and Behavioral
Intervention Core, and the Administrative Core. In addition, three
research projects that draw upon the cores to address adolescents in
different settings were proposed: School-Based HIV/STD Prevention,
Church-Based HIV/STD Prevention, and HIV/STD Prevention for Adolescents
Living with HIV. The Principal Investigator of each core and research
project is a University of Botswana faculty member and the Co-Principal
Investigator is a University of Pennsylvania faculty member. Penn BSS
Core faculty involved in the Botswana project include J. Jemmott, L.
Jemmott, Metzger, Fishbein, Blank, Heeren, Teiltelman, Coleman, and
Stevenson. In addition to the University of Botswana collaboration,
Jemmott and Jemmott are implementing an NIMH funded school-based
prevention program in South Africa and an NICHD-funded cluster-
randomized controlled to test the efficacy of a HIV/STD risk-reduction
intervention among adult men in 48 randomly selected neighborhoods in
Eastern Cape Province, South Africa.
George Woody's work evaluating naltrexone treatment for high risk
heroin injectors in St. Petersburg has led to currently funded studies
of naltrexone implants in St. Petersburg and methadone treatment among
HIV positive heroin users in Ukraine. Woody is conducting a NIDA
supported randomized trial examining the efficacy of oral naltrexone
(an opiate antagonist) with and without fluoxetine for relapse
prevention to heroin addiction in St. Petersburg, Russia. This study is
being done in collaboration with investigators from the Pavlov State
Medical University and the Leningrad Regional Center for Addiction
Treatment. An important component of this research is the measurement
of HIV risk behavior since intravenous drug use is the primary route of
HIV transmission in St. Petersburg. The findings thus far suggest
significant reduction of heroin use and injection related risk
behaviors among those receiving naltrexone. Adherence rates for
naltrexone are also substantially higher than those found in prior
studies of naltrexone. A supplement to the Penn CFAR has extended the
St. Petersburg work to study co-morbidities between alcoholism, heroin
addiction, TB, hepatitis and HIV. These projects have laid the
groundwork for a CIPRA application to fund an HIV education, treatment,
prevention and research center at Pavlov. Woody has an ongoing
collaboration with researchers at the University of Rio Grande do Sul
in Porto Alegre, Brazil. This group recently reported the results of a
sero-incidence study modeled after the longitudinal work being
conducted in Philadelphia, among cocaine users in Porto Alegre. The
study estimates an HIV sero-incidence rate of 5.03/100 person years of
follow-up. The findings of the work have formed the basis further
prevention initiatives in Porto Alegre including the recent submission
of a CIPRA application to establish a collaborative HIV research
center.
David Metzger is the protocol Chair for the HPTN 058, the first
randomized trial of drug treatment (suboxone) using sero-incidence as
an endpoint. He is also an investigator on a NIDA supplement (Richard
Schottenfield PI; Yale University) to evaluate Behavioral and Drug Risk
Counseling in methadone treatment in Wuhan, China. The work in Wuhan
has evolved from and earlier collaboration with WenZhe Ho and
investigators from the Chinese CDC, which examined changes in immune
function during detoxification at a detoxification center in Wuhan.
Metzger has also completed research on ACASI risk assessments with
Brazilian collaborators during the funding period. Metzger has been
collaborating on several projects designed to develop assessments of
HIV risk behaviors in Brazil. In Porto Alegre, the Risk Assessment
Battery was adapted and evaluated for validity and reliability and in
Rio De Janeiro an ACASI risk assessment has been developed an evaluated
for use with drug using populations entering treatment.
Toorjo ``TJ'' Ghose, is a new investigator in the School of Social
Policy and Practice, having joined the Penn faculty in 2007 after
completing post-doctoral training at the Center for Interdisciplinary
Research on AIDS (CIRA) at Yale University. He has recently been funded
as part of the Penn CFAR Pilot study program to conduct a project
entitled ``Implementing PATH India: Reducing HIV risk among the dually-
diagnosed in India,'' building on the work done domestically by Blank.
This research examines HIV risk among treatment seekers at the All
India Institute of Medical Sciences (AIIMS) in New Dehli who have been
dually diagnosed with a mental health and substance use disorder. The
pilot study comprises two phases, a first phase in which knowledge,
attitudes, and risk behaviors are assessed for 200 persons, and a
second phase in which PATH is translated and pilot tested for 20
persons in a randomized pilot study. Collaborators at AIIMS have been
working with Ghose, an Indian native, for several years and have been
full partners in the development of the pilot study.
Hans-Peter Kohler, a sociologist, Susan Watkins, a sociologist, and
Jere Behrman, an economist, of the Population Studies Center, are
leading an investigation of partnership patterns among couples in
Malawi. This work, which received CFAR developmental funding initially
and is now supported with NICHD funds, is built upon a longstanding
social network research initiative Kenya. The goal of this project is
to examine the role of networks in changing attitudes and behavior
regarding family size, family planning, and HIV/AIDS in Malawi. The
project focuses on two key empirical questions: the roles of social
interactions in (1) the acceptance (or rejection) of modern
contraceptive methods and of smaller ideal family size; and (2) the
diffusion of knowledge of AIDS symptoms and transmission mechanisms and
the evaluation of acceptable strategies of protection against AIDS (69-
72). Behrman also has grant support from NICHD to examine how economic
transfers that provide support for dependent children and elderly are
affected in a context in which HIV/AIDS and poor health has weakened
traditional support networks. Tukufu Zuberi, a sociologist and
demographer in Penn's Population Research Center, directs the African
Census Analysis Project in collaboration with social scientists,
demographers, and public health specialists in 14 African countries.
This project provides CFAR investigators working in Africa with access
to university resources including survey research resources and public
health populations and HIV testing facilities. An important focus of
the Census project is the demographic impact of the HIV epidemic in
Africa. Mark Pauly, professor of economics at the Wharton School, is
funded by a Fogarty award to collaborate with colleagues at the
University of Natal in Durban, South Africa to assess the impact of
poor health and HIV/AIDS on small businesses and the local economies
where they are located in South Africa.
Health Services and Policy Research
Although much of the work described above has important
implications for HIV policy regarding prevention and care, a number of
faculty have been involved in policy specific research. Policy related
investigations by BSS program members have focused on access to care
for HIV positive individuals and the structure of health care delivery.
Dr. Barbara Turner's work has documented substantial deficiencies in
the care of HIV+ persons nationally. Linda Aiken's research group has
made important contributions to the development and evaluation of AIDS
prognostic staging measures for use in controlling for severity of
illness in the evaluation of treatment effects, in understanding the
impact of organization of AIDS services on outcomes of care, and
assessing racial disparities in AIDS health services and outcomes.
Dennis Culhane of the School of Social Work, the Population Studies
Center, and the Center for Mental Health Policy Research has examined
the relationship between AIDS and homelessness in Philadelphia by
integrating the City's administrative data bases for AIDS surveillance
and public shelter utilization. Martin Fishbein has had a major
influence on HIV prevention through the development and application of
the Theory of Reasoned Action which he co-developed. He has been very
active in research designed to test this theory in community trials
including ``Project Respect'' which has greatly influenced HIV
counseling strategies both domestically and internationally. He has
continued to urge HIV behavioral research to recognize the important
role theory in prevention and the need to integrate behavioral and
biological measures in a rational manner. Currently he is leading a
five year research effort designed to examine the link between exposure
to sexual content in the media and sexual risk behaviors among
adolescents.
The BSS program includes several key faculty who have been
important in the national and international response to the AIDS
epidemic and who, although their work is not currently centered on AIDS
research, are important resources to the program. Robert Boruch, a
social statistician in the Graduate School of Education, chaired the
National Research Council (NRC) Committee on AIDS Research and the
Behavioral, Social, and Statistical Sciences's Panel on the Evaluation
of AIDS Interventions. Boruch co-edited the NRC volume, Evaluating AIDS
Prevention Programs. He is Director of the Campbell collaborative and a
major voice in the public policy research, design and analyses. Robert
Hornik, a noted social scientist in mass media communication and
behavior change at Penn's Annenberg School of Communications, was a
central participant in the AIDS Public Health Communications Program
(AIDSCOM), and evaluated mass media interventions to prevent the spread
of AIDS in Uganda, Zambia, Ghana, and Dominican Republic. Hornik has
evaluated AIDS education and communication programs for WHO's Global
Program on AIDS. Hornik and Fishbein, at Annenberg, have evaluated the
impact of the mass media anti-drug campaign supported by the White
House Office on Drug Control Policy.
Intervention Development and Testing with Adolescents
John Jemmott's work has made significant contributions to HIV
prevention theory and practice among high-risk African American
adolescents in community-based settings. He is currently directing a
very active program of prevention research. As the director of the
Center for Behavior and Health Communications Research, Department of
Psychiatry, School of Medicine, Jemmott and his group are leading a
randomized controlled trial investigating the efficacy of abstinence
and safer sex interventions with inner-city grade six and seven African
American adolescents. One important result of that study was that a
theory-based culturally tailored abstinence-only intervention reduced
sexually intercourse during a 24-month follow-up period as compared
with a health promotion control group. This is the first study to
document an efficacious abstinence-only intervention over a two-year
follow-up.
Loretta Sweet Jemmott continues to conduct research focused on
identifying modifiable psychological factors that underlie behaviors
that lead to risk for sexually transmitted HIV infection among urban
African Americans, and on designing and testing theory-based,
culturally sensitive, developmentally appropriate interventions to
reduce those risks. She has also conducted a number of theory-based
descriptive studies that use theoretical frameworks to predict risky
sexual behaviors among adolescents. She has been funded by the NINR to
coordinate a partnership with the Hampton University School of Nursing
designed to develop and evaluate strategies intended to narrow the gap
in health disparities between American citizens of different ethnic and
racial origins. Sweet Jemmott is leading a randomized trial of a theory
based an abstinence-only intervention with parents and their adolescent
children identified through black churches in Philadelphia.
Subsequent to pilot funding through the Developmental Core, Anne
Teitelman was successful in securing a K01. This Career Development
Award will to establish a rigorous academic foundation for a research
career devoted to developing and testing novel interventions for
reducing HIV risk for adolescents. Thematically, the K01 will address
the social context of HIV risk by integrating effective theory-based
adolescent HIV prevention with promising partner abuse prevention
strategies, emphasizing promotion of healthy relationships. It uses
family planning clinics as a venue for providing a skill-based,
culturally-tailored HIV and partner abuse prevention educational and
advocacy program for African American girls living is economically
disadvantaged circumstances. Partner abuse, which significantly
increases risk for HIV, disproportionately affects low income African-
American adolescent girls, as does HIV. Critical to this project is the
candidate's demonstrated ability to conduct HIV/STD research in
partnership with minority communities, a long-term engagement in
interdisciplinary scholarship aimed at improving health and a 20-year
history as a primary care provider. The research plan is divided into
two phases, both guided by social cognitive and gender theory. In phase
1 she will conduct focus groups and individual interviews in order to
develop and tailor the HIV/partner abuse intervention for adolescent
girls and in phase 2 she will evaluate the initial acceptability and
feasibility of this intervention in a limited RCT. Dr. Tetitelman's
mentors on this project include BSS program members L. Jemmott and J.
Jemmott.
Intervention Development and Testing with Couples
J. Jemmott and his group are leading a major NIMH funded four-city
multi-site cluster-randomized intervention trial on sexually active HIV
serodiscordant African American couples. Couples in which one person
has HIV and the other does not are randomly assigned to a sexual risk
reduction intervention or a chronic disease prevention control
intervention. Participants provide biological specimens for STD assays
and compete ACASI at baseline, immediately post-intervention, and six
and twelve months post-intervention. Thus far, the study has achieved
very high retention rates in this high risk population, over 90 percent
have completed the twelve-month follow-up assessment. The project
involves BSS program members as co-investigators (Metzger, L. Jemmott,
and Maslankowski) and receives services from the Clinical Core and the
BSS Core in recruitment and assessment support. The data coordinating
center for this multi-site trial is being directed by J. Richard Landis
of the Biostatistics Core.
Intervention Development and Testing for Persons with Mental Illnesses
Michael Blank examines mental health and substance abuse and
relationships with HIV risk. His previous research with the SMI
population has demonstrated high rates of both psychiatric and general
medical comorbidity. Likewise, the HIV positive population has
dramatically elevated rates of mental illness and other physical co-
morbidities. Blank's work has been substantially impacted by the Penn
CFAR resulting in two R01 awards, and R13 to support three national
scientific meetings of the SBSRN, and a U18 from the CDC in
collaboration with investigators from the University of Maryland to
examine implementation of HIV testing in community mental health
settings. This work has evolved with investigators from the Center for
Mental Health Policy Research and the Center for Health Outcomes and
Policy Research at the School of Nursing (Aiken). These projects
evolved from analyses of Medicaid claims data that found that the
relative risk of HIV/AIDS is at least five times greater in persons
with serious mental illness (SMI) relative to the general Medicaid
population in Philadelphia and over seven times greater for those also
treated for substance abuse. A cost study linked to these data showed
that SMI with HIV had much higher health care costs than non-SMI
persons with HIV and non-HIV persons with SMI. Based in part on these
findings, and with co-investigators Aiken, Hines, Fishbein, Gross,
Rothbard, and TenHave, Blank has been conducting an NINR funded
investigation to study the effectiveness of integrating advanced
practice nursing into ongoing Targeted Case Management (TCM) to enhance
adherence to treatment regimens among persons with serious mental
illness (SMI) who are also HIV positive. The work is built around a
Public-Academic Liaison (PAL) model involving mental health services
researchers from a number of specialized research centers at the
University of Pennsylvania, with the public health and mental health
programs in the City of Philadelphia.
Blank has also has been conducting a randomized community trial of
a preventive intervention delivered by mental health case managers in a
one-on-one format for persons with SMI who also abuse substances. The
intervention entitled, Preventing AIDS Through Health (PATH) is an
evidence-based intervention that integrates features from the CDC
project Respect to encourage safer sexual practices and promote condom
use with aspect of the NIDA Community-based Outreach Model to reduce
risk of blood-borne infections resulting from substance abuse. Co-
investigators for this work include Fishbein, Metzger, Hadley, Solomon,
Rothbard, and Ten Have.
Blank has also been directing a multi-site U18 project from CDC to
increase HIV testing and improve linkage to care for HIV-infected in
community mental health settings with large numbers of numbers of
African Americans. Using a six-month longitudinal design, he will be
enrolling participants who meet inclusion criteria for assessment,
counseling, and Rapid HIV Testing at baseline. These participants will
be interviewed again at six months post intervention. The study is
designed to evaluate changes in HIV risk behaviors, linkages to HIV
care, and subsequent use of mental health services. As the primary
coordinating institution, the Penn research team will be collaborating
with a mix of three types of facilities in Philadelphia and Baltimore,
through our collaborators at the University of Maryland. Target
facilities in both cities include university-based inpatient
psychiatric units, Community Mental Health Centers (CMHCs), and
Assertive Community Treatment (ACT) programs.
Intervention Development and Testing for Persons who Abuse Substances
L. Jemmott is leading a randomized trial of a theory based sexual
risk reduction intervention targeting African American women in drug
detoxification. BSS program members who serve as co-investigators
include J. Jemmott and Metzger. The intervention will be evaluated
using STD incidence and self-reported sexual behavior as measured via
ACASI.
Philippe Bourgeois joined Pen and the CFAR BSS Program in 2007 as
the fifth Penn Integrates Knowledge (PIK) Professor. PIK Professorships
are awarded to exceptional scholars whose research and teaching
exemplify the integration of knowledge across academic disciplines. Dr.
Bourgois has earned international acclaim for his ethnographic research
with drug abusers. He has devoted much of his recent research to the
prevalence of violence and disease among homeless drug abusers in San
Francisco. Bourgois's books include In Search of Respect: Selling Crack
in El Barrio, which received the 1996 C. Wright Mills Prize from the
Society for the Study of Social Problems of the American Sociological
Association and the 1997 Margaret Mead Award from the American
Anthropological Association and the Society for Applied Anthropology.
Bourgois is currently funded to examine the HIV and HCV risk
implications of the growing phenomenon in the United States of
prematurely geriatric substance abusers by examining the aging process
among both young and older injectors. He is contributing to a socio-
culturally contextualized understanding of variance in HIV and HCV
infection rates among differentially vulnerable profiles of street
based IDUs that is informed theoretically at the macro-structural
level. A cross-generational and multi gender ethnographic team will
collect qualitative data inside the shooting/sleeping encampments and
income generating territory of two overlapping social networks of
injectors (core N = 25-40 at any given time; peripheral N = 50-70). The
project extends its ongoing collaboration with epidemiologists to
clinical researchers and researchers and caregivers who work with
comparable data sets of injectors in San Francisco in order to engage a
multi-method dialogue. An immediate applied goal is to promote
communication across the research/service interface. We will offer
providers of health care, outreach and treatment an indigenous
perspective on the effectiveness of their services among substance
abusers by age cohort through our comparative study of: 1) injectors
from the baby boom generation who are advancing from mid-life to old
age with rapidly deteriorating health and ongoing HIV risk; and 2)
homeless youth injectors (many of whom are the children of middle-aged
substance abusers) who engage in risky injection and sexual practices.
Charles Dackis, MD, an experienced researcher in substance abuse
treatment has recently been supported by NIDA to conduct a trial to
evaluate the efficacy of modafinil as a treatment for cocaine
dependence in women, and as a means of reducing high-risk behavior
(HRB) that increases the likelihood of HIV seroconversion. Modafinil, a
wake-promoting medication that is approved for narcolepsy, has a low
abuse potential despite its alerting effect. Modafinil also blocks
cocaine-induced euphoria under controlled conditions [2, 3] and may
reverse clinically significant cocaine-induced neuroadaptations. An
effective pharmacological treatment for cocaine dependence should also
reduce HIV seroconversion by diminishing unsafe sexual practices that
often accompany cocaine procurement. Cocaine enhances sexual arousal
and increases reckless sexual activity, including trading sex for
cocaine with multiple partners. Cocaine-addicted women who engage in
this dangerous practice are particularly vulnerable to HIV
seroconversion and in need of effective treatment. Needle sharing by
intravenous cocaine users is another avenue of HIV transmission that
could be targeted by effective treatment.
Intervention Development and Testing using Media Communications
Martin Fishbein is Harry C. Coles Jr. Distinguished Professor in
Communication at the Annenberg School and is internationally recognized
for his theoretical work in behavior change theory and relationships to
risk behavior such as HIV. He is currently funded to examine media
influences on risk behavior among adolescents. The media is a pervasive
institutional structure in all modern societies. It has often been
argued that the media industry encourages unsafe sex by irresponsibly
portraying sexual behaviors. As a result, it is widely claimed that
youth are negatively influenced by what they see, hear, and read in the
media. There is, however, very little evidence to either support or
refute this hypothesis. Historically, sexual portrayals in the media,
like violence, have raised the ire of advocates, policy-makers, and
parents dating back to the first mass media marketed to children.
Today, the issue remains an important agenda item and has led to public
health policy interventions such as V-chip ratings and technology
legislation, movie ratings, and video game advisories. Yet few studies
of the ``effects'' of mass media on specific behaviors are done due to
theoretical, logistic, design, and cost considerations. One specific
reason for this is that much ``media influence'' is designed to shape
and perpetuate consumer preferences and is therefore not targeted to
behaviorally-defined groups but rather to the mass consumer public. But
other kinds of media effects predicated on the principles of social
learning theory and other theories can be predicted for specific
``audiences'' and specific behaviors. This application focuses on the
media's role in presenting sexual content, implying sexual norms,
modeling sexual decision-making (``self-efficacy''), and displaying the
outcomes of sexual behaviors in relation to young adolescents, a group
whose attitudes, norms, self-efficacy, and decision-making skills are
all in flux and development. This five-year research project is the
first to combine behavioral theory, communication theory, and a state
of the art content analytic approach to investigate the relationship
between exposure to sex in the media and early initiation of sexual
intercourse and other sexual behaviors. Using this approach, the
project will develop both objective (i.e., content analytic) and
subjective, theory-based measures of (a) the quantity and content of
adolescent's exposure to sexual media and (b) adolescents' sexual
behavior and its underlying psychosocial determinants (i.e., beliefs,
attitudes, norms, self-efficacy and intention). These measures will be
tested for their reliability and validity, and they will take
developmental, gender and ethnic differences into account. Based on
this formative research, the project comprises a three-wave
longitudinal proof of concept study to investigate the empirical link
between exposure to sexual content in a broad variety of media (i.e.,
television, movies, music CDs, the Internet, video games, and
magazines) and sexual behavior. In summary, this research uses a
theoretically grounded, methodologically sound approach to more fully
examine the relationships between media exposure and AIDS-related
sexual behavior.
Intervention Development and Testing with MSM
John Jemmott is currently conducting an NIMH funded study to
develop, implement, and evaluate the efficacy of an HIV/STD risk
reduction intervention for African American MSM. This is a
collaborative effort by HIV/STI university-based researchers and Blacks
Educating Blacks About Sexual Health Issues (BEBASHI), the oldest
community-based organization (CBO) in the City of Philadelphia that has
addressed HIV in the African American community, including MSM. The
participants will be 594 African American MSM who will be randomized to
a one-on-one sexual risk reduction intervention, ``Being Responsible
for Ourselves (BRO)'' or a one-on-one health promotion intervention
that will serve as the control condition. This study will provide an
urgently needed intervention to reduce the risk of HIV and other STIs
in one of the highest risk populations in the United States.
Christopher Coleman, who holds a joint appointment with the School of
Nursing and the Medical School, is a co-investigator on John Jemmott's
MSM intervention study, has a longstanding research interest in HIV
positive MSM.
William Holmes' research has focused on modeling the relationship
between childhood abuse and risk behaviors among MSM populations. More
men with than men without childhood sexual abuse (CSA) histories report
sexual behavior that has high risk for HIV transmission. His work has
found that co-morbid post traumatic stress disorder (PTSD) and
depression acts as both a mediator and a moderator of the association
between CSA and sexual risk behavior. In his current NIMH funded study
entitled, ``Interaction of abuse, PTSD, depression on men's sex risk,''
data from a cross sectional, random-digit-dial (HDD) survey of 1,200
men from high AIDS prevalence areas of Philadelphia County will be used
to test the model he has developed to explain the mediating/moderating
pathway between CSA and lifetime sexual risk behavior in men. From this
model, multidimensional HIV risk reduction interventions can be built.
Integrated Biomedical and Behavioral Trials
David Metzger is the PI of the Penn Prevention Clinical Trials
Unit, funded by NIAID and a research site for the HIV Vaccine Trials
Network (HVTN), the Microbicide Trials Network (MTN) and the Prevention
Trials Network (HPTN). This award in 2006 was built upon its successful
involvement as a site for the HIV Network of Prevention Trials (HIVNET)
and subsequently, the HIV Prevention Trials Network (HPTN). The Penn
Prevention Clinical Trials Unit is one of 60 international and domestic
trials units selected to develop and test behavioral and biomedical
prevention interventions. The Penn Prevention CTU includes co-
investigators from the School of Nursing (Loretta Sweet Jemmott), the
Infectious Diseases Division of the School of Medicine (Ian Frank), the
Department of Immunology of the Children's Hospital of Philadelphia
(Steven Douglas), and the Annenberg School of Communication (John
Jemmott). The Penn Prevention CTU and its predecessor, the HPTU have
made significant contributions to the research agenda of the HIV
Clinical Trials Network and is currently involved in three active
protocols: 1) the HVTN 502, the ``STEP'' study testing the ; 2) HVTN
070, and 3) HPTN 035, a large international Phase IIb trial of Pro2000
(entry inhibiting gel), and Buffer Gel (a buffering gel which
inactivates virus). Penn's work in testing vaginal microbicides is led
by Lisa Maslankowski. David Metzger, the PI of the Penn Prevention CTU
also serves as the Chair of HPTN 058, a randomized trial of suboxone
treatment for opiate addiction as HIV prevention taking place in
Thailand and China.
Courtney Schrieber received a developmental award to study
pregnancy during clinical trials using a nested case-control method and
a point-of-care questionnaire. This area of inquiry is unique and
important because incident pregnancies are significant and a somewhat
unexpected finding in NIH supported Phase II and III vaginal
microbicide and vaccine trials that can serve a biomarker of risk
behavior. Further, because the teratogenicty of investigatory vaccines
and microbicides are unknown, thus pregnant women are dis-enrolled from
these studies which may introduce bias in the studies as those at
greater risk may be dis-enrolled more frequently. Reducing pregnancy
rates during trial participation will help avoid the associated
methodological complications and potential health risks. Schrieber
seeks to explore the risk factors for pregnancy among trial
participants in order to inform efforts to both identify
characteristics of women who are likely to become pregnant during the
study and to prevent pregnancy for trial enrollees.
Relation Between the Behavioral and Social Science (BSS) Core and Other
CFAR Programs: Building Research Collaborations
The BSS Program has encouraged collaborations among program members
and between CFAR programs. This was evidenced in many of the projects
already described that are led by members of the core. In addition, BSS
Core members in conjunction with members of the immunology program
(Douglas and Ho) are currently investigating the role of host factors
on viral activity HIV and HCV infected individuals. This work,
facilitated by the Penn CFAR, perhaps best exemplifies the program goal
of cross discipline collaborations and have developed a productive
program of research over the past five years. Dwight Evans' research
involving HIV infected men prior to the advent of HAART, provided the
first indication that stress was not only predictive of early HIV
disease progression but was associated with alterations in immunity,
suggesting that stress influences disease progression by altering key
aspects of cellular immunity. His study of HIV infected women conducted
in collaboration with Steven Douglas and David Metzger extended the
understanding of these relationships and provided the first evidence
that depression may alter the function of killer lymphocytes in HIV
infected women. Evans' recently completed grant entitled ``HIV in
Women: Depression and Immunity'' further explored these relationships
and the ex-vivo impact of anti depressants among HIV infected women
with depression. Metzger's research group had responsibility for
screening, recruitment, and specimen collection and Douglas's lab
conducted immunologic assays. This work demonstrated that resolution of
depression is associated with restoration of NK cytotoxicity in HIV and
found that ex-vivo treatment of lymphocytes with an SSRI enhances NK
cytolytic activity. These findings were the basis of a recent NIMH
award to Evans. This new study is designed to test whether depression
is associated with non-cytolytic, chemokine and cytokine, functional
alterations of killer lymphocytes, as well as chemokine receptor
sensitivity of macrophages and T-cells that are relevant to HIV-
infectivity. The potential for impact of alcohol and opiates on HIV
viral activity has also led to investigations of the mediating role of
substance use on immune function among well characterized HIV infected
individuals with Douglas and Ho. NIDA funded work on the relationships
among opiates, substance P and HIV viral activity have found that
methadone in vitro enhances infection of immune cells. With
supplemental funds from NIDA this work was extended to examine factors
associated with HCV activity. Using this model of collaborative
research where behavioral scientist identify and assess well defined
subject characteristics and deliver specimens for intensive and
innovative analyses, Metzger's group is working with Douglas to examine
the impact of alcohol abuse and dependence on viral activity and immune
function.
The collaborative capacity building project between the University
of Botswana and the University of Pennsylvania is organized around
three cores. Qualitative and Quantitative Methodology Core, Social and
Behavioral Intervention Core, and the Administrative Core. The project
draws upon members of the CFAR Biostatistics Core, including Dr. Susan
Ellenberg and the CFAR Administrative Core, including Dr. James Hoxie.
This partnership is committed to developing a creative, comprehensive
and interdisciplinary HIV/STD prevention research program on
adolescents that is fully integrated within the research and education
mission of the University Botswana and dedicated to addressing the
urgent need to stem the devastating impact of HIV on one of the highest
risk adolescent populations in the world.
Effective Use of Social and Behavioral Research
HIV/AIDS remains the most important public health problem facing
our global community. Since the first cases of AIDS were reported in
1981, infection with HIV has grown to pandemic proportions, with an
estimated 65 million infections and 25 million deaths. To be sure, we
now have effective treatment of HIV infection with highly active anti-
retroviral therapy (HAART) even in countries with limited resources.
Still, these treatments do not reach all who need them, especially in
low-resource countries and prevention is more cost effective than is
treatment. Accordingly, there is a great need for effective behavioral
strategies to reach and serve all persons who could benefit from
treatment and prevention services.
As with many health problems today, behaviors--for instance,
practicing abstinence, limiting sexual partners, using condoms, using
clean IDU equipment, and adhering to treatment regimens--are central to
the spread of HIV and to the efficacy of treatment. Accordingly, an
approach that integrates the lessons from behavioral and biomedical
science is likely to be most effective in stemming the HIV pandemic. As
biomedical advances are made, social and behavioral science
contributions will be required to ensure the success of new biomedical
prevention technologies and treatments, including microbicides and
vaccines. For example, social and behavioral science research would
contribute to an understanding of whether the technologies and
treatments are acceptable to populations, whether new behaviors will be
adopted, and the facilitators and barriers to optimal treatment
adherence.
Adequacy of Federal Funding
The Federal Government's investment in behavioral research on HIV
has not been sufficient. Although the CDC has a number of dissemination
initiatives, not enough funding has been allocated to result in the
widespread use of interventions that we know are efficacious. If these
interventions are effective when disseminated and if they were widely
disseminated then we would not be witnessing the high rates of HIV that
we are still seeing in the United States. Second, there are still
important gaps in the portfolio of intervention strategies. African
American MSM have the highest rates of HIV in the United States.
Indeed, the rates of HIV among African American MSM rivals those seen
in countries in sub-Saharan Africa, the region with the highest rate of
HIV in the world. The CDC still does not have interventions for African
American MSM with evidence of efficacy in reducing risk behavior and
STD from randomized controlled trials to offer service providers who
work with this population. Thus, additional funding is needed urgently
for behavioral research on dissemination of efficacious interventions,
including the adaptation, adoption, and effectiveness of those
interventions. In addition, funding is also needed for interventions
for populations, including African American MSM, where efficacious
interventions are lacking.
The present funding environment for behavioral research on HIV is
tough. It is extremely difficult for investigators to receive funding
for scientifically meritorious proposals when insufficient funds are
available and strong proposals must be set aside unfunded. The is a
problem for established researchers who may have to dismantle their
research teams and lose their infrastructure because of a lack of
funds. It is especially damaging for young scientists who are unable to
secure the funding needed to launch their careers and may have to seek
other careers because they are unable to produce the body of research
required to earn tenure at leading universities.
Biography for John B. Jemmott III
John B. Jemmott III received his Ph.D. in Psychology from the
Department of Psychology and Social Relations at Harvard University.
From 1981 to 1999, he served as Instructor, Assistant Professor,
Associate Professor, and Professor of Psychology at Princeton
University. He currently holds joint faculty appointments at the
University of Pennsylvania as the Kenneth B. Clark Professor of
Communication in the Annenberg School for Communication and as
Professor of Communication in Psychiatry in the School of Medicine. He
also directs the Center for Health Behavior and Communication Research
in the School of Medicine at the University of Pennsylvania.
Dr. Jemmott is a Fellow of the American Psychological Association
and the Society for Behavioral Medicine. He has served as a regular
member of several National Institutes of Health (NIH) panels, including
the Behavioral Medicine Study Section, the AIDS and Immunology Research
Review Committee, and the Office of AIDS Research Advisory Council. Dr.
Jemmott has published numerous articles and has been the recipient of
many grants from the National Institutes of Health to conduct research
designed to develop and test theory-based, contextually appropriate
HIV/STD risk reduction interventions for inner-city African American
and Latino populations. He was identified in the 25 July 2008 issue of
Science magazine as one of the 10 researchers whose work into HIV/STD
risk reduction interventions received the most investigator-initiated
(R01) grant funding from the NIH (fiscal year 2007).
The Centers for Disease Control and Prevention have identified as
effective and have disseminated three curricula based on his HIV
prevention research with adolescents: ``Be Proud! Be Responsible!
Empowering Adolescents to Reduce their Risk of HIV,'' ``Making a
Difference! An Abstinence Approach to HIV/STD Risk Reduction,'' and
``Making Proud Choices! A Safer Sex Approach to HIV/STD Risk
Reduction.'' Dr. Jemmott is currently conducting research on HIV/STD
prevention strategies for couples where one partner is living with HIV,
African American men who have sex with men, and adolescents and adult
men in sub-Saharan Africa, where the HIV pandemic is taking its
heaviest human toll.
Chairman Baird. Thank you.
Dr. Kenkel.
STATEMENT OF DR. DONALD S. KENKEL, PROFESSOR OF POLICY ANALYSIS
AND MANAGEMENT, COLLEGE OF HUMAN ECOLOGY, CORNELL UNIVERSITY
Dr. Kenkel. Thank you for the opportunity to testify. I am
convinced that the social sciences in general and economics in
particular have much to offer to improve our nation's health.
Nobel Prize winning economist Gary Becker has argued that,
``Economic theory is not a game played by clever academicians
but is a powerful tool to analyze the real world.'' To inform
public health policy, empirical health economists like myself
combine economic theory with careful analysis of data to try to
quantify the impact of various real world influences on
individual health behaviors.
In these comments I will try to overview some research on
the economics of health behaviors and provide a few examples of
their relevance for public policy and then make a few comments
about the importance of NSF and NIH support for health
economics.
Some health economics research focuses on the health care
sector. The research I will overview uses the tools of
economics to better understand the determinance of these health
behaviors outside the health care sector like smoking and
obesity.
The economic approach to human behavior emphasizes that
people respond to incentives. Consequences for their health can
provide people with very strong incentives to quit an unhealthy
behavior like smoking or to start a healthy behavior like
regular exercise. The history of smoking in the U.S. is a good
example. Since the 1964, Surgeon General's Report on the health
consequences of smoking, the prevalence of smoking among U.S.
adults has dropped from over 40 percent to about 21 percent.
Econometric studies suggest that improved consumer information
about the risks of smoking helped lead to part of this drop.
When people learned smoking was unhealthy, many people quit
smoking, and others didn't start smoking in the first place.
My colleagues and I recently completed an empirical study
of the impact of pharmaceutical industry advertising on smoking
cessation decisions, another important source of health
information. Based on our results, we estimate that if the
smoking cessation product industry increased its expenditures
on magazine advertising by 10 percent, the result would be
about 225,000 new attempts to quit smoking each year and 8,000
successful quits each year.
This is part of a growing body of evidence that direct-to-
consumer ads increased consumer demand for a variety of
pharmaceutical products. Easing regulation on ads for smoking
cessation products could exploit more fully the industry's
profit incentives to promote public health.
More generally, when crafting public policy, it is
important to keep in mind the private incentives to improve
public health. People want to live healthier, longer lives, and
private sector firms can make profits helping them do so.
Public policies should be structured to facilitate the public
health gains enjoyed when firms pursue their private profits.
The prices consumers pay for health-related goods also
provides important incentives that influence health behaviors.
Dozens of econometric studies estimate the price responsiveness
of demand for alcoholic beverages and cigarettes. I have
contributed to both lines of research. In research funded by
the National Institute on Alcohol Abuse on Alcoholism, I found
evidence that even heavy drinking falls when the prices of
alcoholic beverages increase.
Research funding from the National Cancer Institute helped
my colleagues and I launch a series of studies on the effects
of higher prices on youth smoking. The Guide Tax Policy, the
NIAAA special reports to Congress on alcohol and health and the
Surgeon General's reports on tobacco and health regularly
review econometric studies of the price or tax responsiveness
of alcohol and cigarette demand.
Health economics research takes on hard research questions
about the impact of public policies on health behavior. While I
believe health economics research provides useful guidance for
policy, it is important to keep in mind how hard the questions
are. For example, over the past few decades the Federal
Government and the states have launched massive and varied
public policy campaigns to reduce smoking. As various policies
have been enacted, it is clear that smoking rates have fallen
and public anti-smoking sentiment has grown. Yet teasing out
the direction of causality and the contribution of specific
policies is extremely difficult.
Social science research also contributes to public policy
when it reminds us of the wisdom of the old comment, ``It ain't
so much the things we know that get us into trouble, it is the
things we do know that just ain't so.'' This in turn reminds me
of the almost inevitable comment at the end of an academic
paper, ``More research is needed.'' This comment is probably
not what you want to hear, but it is not an admission of
failure but reflects how science progresses. Answers to hard
research questions are re-examined and probed, leading to new
answers and better questions.
Research on the economics of health behaviors requires data
on health behaviors and on the factors that influence them.
Federal and State governments' data collection efforts are a
very valuable resource for this research. The NIH and the NSF
Foundation, the NSF, also provide important resources for
health economics research supporting investigator-initiated
date collection.
An applied field like health economics also relies on
insights from economic theory and uses tools and methods
developed in econometric theory. NSF support for even seemingly
esoteric research topics in economic and econometric theory
improves health economics research over time. The NIH, of
course, provides support for many economics projects with more
immediate significance for public health.
I believe a source of missed research opportunities is the
gap between economists and some of the other social and
behavioral scientists including my colleagues here, who design,
implement, and evaluate public health interventions. For
example, some emerging research is exploring the use of
monetary incentives to reduce smoking and illicit drug use.
Increasingly, behavioral economists integrate insights from
psychology into standard economic models of consumer behavior.
Data from intervention research could provide a rich source to
testing predictions from behavioral health economics.
I will stop with my comments there. Thank you very much.
[The prepared statement of Dr. Kenkel follows:]
Prepared Statement of Donald S. Kenkel
Thank you for the opportunity to testify about ``The Role of Social
Sciences in Public Health.'' I am convinced that the social sciences in
general, and economics in particular, have much to offer to help
improve our nation's health. Nobel Prize-winning economist Gary Becker
has argued that: ``Economic theory is not a game played by clever
academicians but is a powerful tool to analyze the real world.'' To
inform public health policy, empirical health economists like myself
combine economic theory with the careful analysis of data to try to
quantify the impact of various influences on individual health
behaviors.
Health economics is a relatively young sub-field of economics, and
in its early days was sometimes instead called ``medical economics'' or
``health care economics.'' Today, many health economists continue to
focus on the financing and delivery of health care. These economists
explore important questions about physician behavior, the hospital
industry, and private and public health insurance, to name just a few
areas of health care sector research. However, many key health
behaviors are outside the health care sector. Current estimates suggest
that almost half of all deaths in the U.S. can be traced to cigarette
smoking, sedentary lifestyles and obesity, and alcohol consumption.\1\
An exciting and productive line of research uses the tools of economics
to better understand the determinants of these health behaviors. To
give an idea of how productive: my colleague John Cawley and I recently
co-edited a collection of the most important and interesting papers in
the economics of health behaviors.\2\ The collection runs to three
volumes and includes 85 academic studies written by health economists
from the U.S. and across the world.
---------------------------------------------------------------------------
\1\ Mokdad, A.H., Marks, J.S., Stroup, D.F., and Gerberding, J.L.
(2004). Actual Causes of Death in the United States: 2000. JAMA 291
(10): 1238-1245.
\2\ Cawley, John and Donald Kenkel, co-editors (2008). The
Economics of Health Behaviours, Volumes I-III. The International
Library of Critical Writings in Economics, An Elgar Reference
Collection. Edward Elgar Publishing: Northampton, MA.
---------------------------------------------------------------------------
Another way to view the field of health economics is that health
care sector economics is mainly about ``cure,'' while the economics of
health behaviors is mainly about ``prevention.'' There is an old saying
that an ounce of prevention is worth a pound of cure. Health economists
have not been able to quantify the benefits of prevention quite so
precisely. In fact, investing in prevention will not necessarily reduce
aggregate health care spending. But our public policy goal is not
simply to contain health care costs, but to spend our health care
dollars well. Preventing deaths due to smoking, obesity, and other
unhealthy behaviors can help the U.S. get the most value from the
societal resources we invest in health.
The economic approach to human behavior emphasizes that people
respond to incentives. The consequences for their health can provide
people with strong incentives to quit an unhealthy behavior like
smoking or to start a healthy behavior like regular exercise. However,
the health consequences only matter if people know about them. I've
contributed to a line of health economics research that studies how
health information shapes health behaviors. The history of smoking in
the U.S. is a good example. Since the 1964 Surgeon General's Report on
the health consequences of smoking, the prevalence of smoking among
U.S. adults has fallen from over 40 percent to about 21 percent.\3\
Econometric studies suggest that improved consumer information about
the risks of smoking led to part of this drop: when they learned
smoking was unhealthy, many people quit smoking, and others didn't
start in the first place. These studies exploit information
``shocks''--discrete events like the publication of the 1964 Surgeon
General's Report that provided people with more health information.
International studies suggest that similar information shocks also
reduced smoking in other countries.\4\ In a study I completed earlier
in my career, I found that information appears to be an important
incentive to adopt healthier behaviors related to smoking, drinking,
and exercise.\5\
---------------------------------------------------------------------------
\3\ Rock, V.J., A. Malarcher, J.W. Kahende, et al. (2007).
``Cigarette Smoking Among Adults--United States, 2006.'' Morbidity and
Mortality Weekly Report 56 (44): 1157-1161.
\4\ Kenkel, Donald and Likwang Chen (2000). ``Consumer Information
and Tobacco Use.'' In: Jha P and FJ Chaloupka, Editors. Tobacco Control
in Developing Countries. Oxford University Press, pp. 177-214.
\5\ Kenkel, Donald (1991). ``Health Behavior, Health Knowledge, and
Schooling,'' Journal of Political Economy 99 (2): 287-305.
---------------------------------------------------------------------------
My colleagues and I recently completed an empirical study of the
impact of pharmaceutical industry advertising on smoking cessation
decisions.\6\ Although many smokers quit `cold turkey' without
assistance, medical research shows that smokers are more likely to
successfully quit if they use a pharmaceutical smoking cessation
product such as a nicotine replacement therapy. The cessation product
industry's estimated retail sales are nearly $1 billion annually. In
recent years the industry has spent between $100 to $200 million
annually advertising these products. In other health-related markets,
producer advertising has been shown to be an important source of health
information that prompted people to consume more dietary fiber and less
saturated fat.\7\ Similarly, we find that the more magazine
advertisements smokers see for products like the nicotine patch, the
more likely they are to try to quit smoking and to be successful. Based
on our results, we estimate that if the smoking cessation product
industry increases its average annual expenditures on magazine
advertising by 10 percent, the result would be about 225,000 new
attempts to quit and 80,000 successful quits each year.
---------------------------------------------------------------------------
\6\ Avery, Rosemary, Donald Kenkel, Dean Lillard, and Alan Mathios
(2007). ``Private Profits and Public Health: Does Advertising Smoking
Cessation Products Encourage Smokers to Quit?'' Journal of Political
Economy 115 (3): 447-481.
\7\ Ippolito, Pauline M. and Alan Mathios (1990) ``Information,
Advertising and Health Choices: A Study of the Cereal Market.'' RAND
Journal of Economics 21 (3):459-480. Ippolito, P. and Mathios, A.,
(1995) ``Information and Advertising: The Case of Fat Consumption in
the United States,'' American Economic Review: Papers and Proceedings,
85 (2) May.
---------------------------------------------------------------------------
The prices consumers have to pay for health-related goods also
provide important incentives that influence health behaviors. Dozens of
econometric studies estimate the price-responsiveness of demand for
alcoholic beverages and cigarettes. I've contributed to both lines of
research. In research funded by the National Institute on Alcohol Abuse
on Alcoholism, I found evidence that even heavy drinking falls when
alcoholic beverage prices increase, although there may be a subset of
very heavy drinkers who are not responsive.\8\ This is consistent with
other research that shows that higher prices reduce alcohol-related
consequences including liver cirrhosis death rates and drunk driving.
Research funding from the National Cancer Institute helped my
colleagues and I launch a series of studies on the effects of higher
cigarette prices on youth smoking.\9\ Higher cigarette prices
potentially reduce smoking through three channels: by preventing youth
from starting; by encouraging smokers to quit; and by encouraging
smokers to cut down their daily consumption. Our research, and research
in several other countries, call into question whether higher prices
are really very effective in preventing youth from starting. Although
the implications of our findings are still controversial, they tend to
suggest that the main effect of higher prices is through encouraging
smokers to either cut down or quit.
---------------------------------------------------------------------------
\8\ Kenkel, Donald (1993). ``Drinking, Driving, and Deterrence: The
Effectiveness and Social Costs of Alternative Policies,'' Journal of
Law and Economics, pp. 877-913. Kenkel, Donald (1996). ``New Estimates
of the Optimal Tax on Alcohol,'' Economic Inquiry 34: 296-319.
\9\ DeCicca, Philip, Donald Kenkel, and Alan Mathios (2002).
``Putting Out the Fires: Will Higher Taxes Reduce the Onset of Youth
Smoking?'' Journal of Political Economy 110 (1): 144-169. DeCicca,
Phillip, Donald Kenkel, Alan Mathios, Yoon-Jeong Shin, and Jae-Young
Lim (2008). ``Youth Smoking, Cigarette Prices, and Anti-Smoking
Sentiment.'' Health Economics 17 (6): 733-749. DeCicca, Philip, Donald
Kenkel, and Alan Mathios (2008). ``Cigarette Taxes and the Transition
from Youth to Adult Smoking: Smoking Initiation, Cessation, and
Participation.'' Journal of Health Economics 27 (4): 904-917.
---------------------------------------------------------------------------
By providing new insights about what influences health behaviors,
health economics research helps shape public policies such as marketing
restrictions or taxes that have broad effects on consumers and thus on
public health. In contrast, other social and behavioral sciences study
more targeted interventions, such as an individual-level intervention
to help smokers quit, or a school-level intervention to prevent
adolescents from abusing alcohol. Targeted interventions play an
important role in public health and can yield highly visible success
stories of individuals whose health was improved. Broad public policies
can also yield important health improvements, but the success stories
are found in data that might show that the population rate of smoking
cessation increased over time, or that the population rate of drunk
driving fell.
Health economics research on the role of health information has
important implications for broad public policies. In addition to
directly providing information, other policies such as marketing
regulations affect the flow of health information to consumers. Our
study of smoking cessation product advertising is part of a growing
body of evidence that direct-to-consumer ads increase consumer demand
for a variety of pharmaceutical products. The U.S. and New Zealand are
the only countries that allow DTC advertising of prescription
pharmaceutical products. Even in these two countries, DTC ads are
strictly regulated. In the U.S. this had led to an ironic situation: in
some ways, ads for prescription pharmaceutical products for smoking
cessation have been more heavily regulated than cigarette
advertisements. Food and Drug Administration (FDA) regulations require
prescription smoking cessation product ads in magazines to include at
least an extra page of disclosures about side effects and
contraindications; cigarette ads are only required to carry a short
warning label. Easing regulations on ads for smoking cessation products
could exploit more fully the profit incentives to promote public
health. Ads for other pharmaceutical products, such as statins to treat
high cholesterol, have similar potential. Because the potential gains
and harms from advertising vary widely across products, it might make
sense for the FDA to adopt a more flexible approach to regulate DTC
advertising.
More generally, when crafting public policy it is important to keep
in mind the private incentives to improve public health. People want to
live healthier and longer lives, and private sector firms can earn
profits helping them do so. Public policies should be structured to
facilitate rather than impede the public health gains enjoyed when
firms pursue private profits.
As mentioned above, many econometric studies estimate the price-
responsiveness of consumer demand for alcoholic beverages and
cigarettes. Because prices can be manipulated by imposing excise taxes,
these estimates also have implications for public health policy. The
National Institute on Alcohol Abuse and Alcoholism's Special Reports to
Congress on Alcohol and Health and the Surgeon General's Reports on
Tobacco and Health regularly review econometric studies of the price-
or tax-responsiveness of alcohol and cigarette demand.
Health economics research takes on hard research questions about
the impact of public policies on health behaviors. Typically we use
observational data and try to identify natural quasi-experiments
created, for example, by events or changes in policies. While I believe
health economics research provides useful guidance for policy, it is
important to keep these limitations in mind. For example, over the past
few decades the Federal Government and the States have launched massive
and varied public policy campaigns to reduce smoking. As various
policies have been enacted, smoking rates have fallen and public anti-
smoking sentiment has grown. Yet teasing out the direction of causality
and the contribution of specific policies is extremely difficult. An
example is the controversy I mentioned earlier about the price-
responsiveness of youth smoking. Youth smoking rates remain higher in
the tobacco-producing states, which until recent years have rarely
increased cigarette taxes. Are youth smoking rates high in these states
because cigarette taxes are low? Or are cigarette taxes low because
smoking is part of the culture in these states?
Social science research also contributes to public policy when it
reminds us of the wisdom of the comment: ``It ain't so much the things
we don't know that get us into trouble, it's the things we do know that
just ain't so.'' \10\ This in turn reminds me of the almost inevitable
comment at the end of academic papers: ``More research is needed.''
This academic comment is not an admission of failure, but reflects how
science progresses. Answers to hard research questions are re-examined
and probed, leading to new questions and better answers.
---------------------------------------------------------------------------
\10\ Attributed to Artemus Ward, American humorist, 1834-1867.
---------------------------------------------------------------------------
Because it is still a young field, it is not surprising that basic
research questions on the economics of health behaviors remain
unanswered. Recently, some of the questions receiving the most
attention concern health disparities related to socioeconomic status.
Again, smoking provides a stark example--it is increasingly true that
smokers are more likely to have lower incomes and less schooling. For
example, in 2006 about 35 percent of high school dropouts smoked,
compared to only about 10 percent of college graduates and less than
seven percent of those with graduate degrees. Why is this the case? One
hypothesis is that people with more schooling are better able to gather
and process information about the health risks of smoking. This
explanation is supported by the fact that in the 1950s--before medical
research firmly established the health risks of smoking--college
graduates were about as likely to smoke as those with less schooling.
But this explanation is hard to reconcile with the persistence of the
schooling gap in smoking 50 years later, when virtually everyone
understands that smoking kills. Health economists are exploring other
explanations, such as the idea that there are other hard-to-observe
differences between people with different levels of schooling.
Understanding the schooling-smoking link might provide a case study
for understanding the links between schooling and health more
generally. If schooling helps people make healthier choices,
investments in schooling could also pay off in the form of reductions
in obesity or other health problems. If other hard-to-observe factors
are the root causes of both low schooling attainment and unhealthy
choices, investments in more schooling may not be enough.
Research on the economics of health behaviors requires data on
health behaviors and on the factors that influence them. Federal and
State governments' data collection efforts are a very valuable resource
for this research, including the National Health Interview Survey, the
Behavioral Risk Factor Surveillance Surveys, the Youth Risk Behavior
Surveillance System, and the Tobacco Use Supplements to the Current
Population Survey. Federal support for ongoing longitudinal studies--
including the Panel Study of Income Dynamics, the Health and Retirement
Survey, the National Longitudinal Surveys of Youth, and the National
Longitudinal Study of Adolescent Health--provides especially useful
data to follow individual health behaviors over time. Health economists
often use data from ongoing collections to study health behaviors
before and after a natural quasi-experiment in policy or circumstances.
Innovations in data collection, such as the collecting biomarkers,
present opportunities to move health economic research in exciting new
directions.
The National Institutes of Health and the National Science
Foundation also provide important resources for health economics
research through supporting investigator-initiated data collection. The
National Institute of Health's data sharing policy ``expects and
supports the timely release and sharing of final research data from
NIH-supported studies for use by other researchers.'' Data sharing is
essential for the scientific process. With data sharing, NIH and NSF
support help not only the funded investigators, but can also prompt
other researchers to replicate and extend the original data analysis,
and to use the data in new ways to ask different questions.
An applied field like health economics relies on insights from
economic theory and uses tools and methods developed in econometric
theory. NSF support for even seemingly esoteric research topics in
economic and econometric theory improves health economics research over
time. The NIH provides support for many economics projects with more
immediate significance for public health. Unfortunately, sometimes
important research falls in between the cracks. For example, developing
new econometric methods for the analysis of data on health behaviors
might seem ``too applied'' to NSF reviewers but at the same time seem
``too theoretical'' to NIH reviewers. Educating NSF and NIH reviewers
about each other's missions could help better integrate federal funding
for health economics research.
Another source of missed research opportunities is the gap between
economists and the social and behavioral scientists who design,
implement, and evaluate public health interventions. It is increasingly
common for health economists to be involved near the end of these
research projects, when they conduct cost-effectiveness analyses of the
interventions. This is an encouraging trend, and the results of cost-
effectiveness analyses help to maximize the health benefits from
limited budgets for interventions. As social scientists, however,
economists could also be usefully involved earlier in the research
design. For example, some emerging research is exploring the use of
monetary incentives to reduce smoking and illicit drug use. Behavioral
economists integrate insights from psychology into standard economic
models of consumer behavior. Data from intervention research could
provide a rich source to testing predictions from behavioral health
economics.
Biography for Donald S. Kenkel
Donald S. Kenkel is a Professor in the Department of Policy
Analysis and Management at Cornell University, and a Research Associate
of the National Bureau of Economic Research. His expertise is in areas
of health economics and public sector economics. Broadly speaking, most
of his research is on the economics of disease prevention and health
promotion. He is the author of the chapter on ``Prevention'' in the
Handbook of Health Economics. He has conducted a series of studies on
the economics of public health policies, including: alcohol taxes and
other policies to prevent alcohol problems (Journal of Applied
Econometrics 2001, American Economic Review Papers & Proceedings 2005);
cigarette taxes to prevent youth smoking (Journal of Political Economy
2002); and advertising to promote smoking cessation (Journal of
Regulatory Economics 2007 and Journal of Political Economy 2007).
Another area of research and teaching interest is in cost-benefit
analysis of public policies, especially policies that affect health.
His research has been funded by the National Institute on Alcohol Abuse
and Alcoholism, the National Cancer Institute, the National Institute
on Child Health and Development, as well as private foundations.
Chairman Baird. Thank you.
Dr. Koenig.
STATEMENT OF DR. HAROLD G. KOENIG, PROFESSOR OF PSYCHIATRY AND
BEHAVIORAL SCIENCES; ASSOCIATE PROFESSOR OF MEDICINE; DIRECTOR
OF THE CENTER FOR THEOLOGY, SPIRITUALITY, AND HEALTH, DUKE
UNIVERSITY
Dr. Koenig. Thank you, Mr. Baird.
I am going to speak on religion, spirituality, and public
health. In overviewing this topic I would like to say that the
United States is a very religious and spiritual nation. Stress
and depression are common and increasing in our country. Stress
affects physical health and need for health services. Many turn
to religion when stressed, facing sickness, or disability.
Religion and spirituality may reduce stress, reduce depression,
enhance quality of life, may be related to less alcohol and
drug abuse, less crime, delinquency, related to better health
behaviors, healthier lifestyles, better physical health, faster
recovery, and less need for health services. May also enhance
the community's resiliency after disaster or terrorism.
Implications for public health and patient care, I will
make some of those and make some recommendations as well.
Ninety-three percent of Americans believe in God or a higher
power. Eighty-nine percent report a religious affiliation.
Eighty-three percent say it is--that religion is very, is
fairly or very important to them. About two-thirds of Americans
are members of a church or synagogue or mosque. Fifty-eight
percent pray every day, and 75 percent pray at least weekly.
Nearly half of the country attends church at least monthly, and
42 percent weekly.
We know that there is increased stress due to the recent
economic downturn. We know that depression is increasing due to
loss of jobs and homes. We know that debt is increasing, and
people are not saving. We know that youth are facing many, many
choices with very few absolute guides by which to guide their
behavior and their choices. The population is aging, facing
increasing health problems, fewer saving for retirement, and
that is creating fear.
We know that stress and depression affect physical health
and use of health services, that diseases like heart attacks,
hypertension, stroke, infection, wound healing, the aging
process itself appears to be affected by stress and depression,
and all of that increases hospital stays and need for health
services.
Many in the U.S. turn to religion to cope with stress and
illness. After September 11, 90 percent of Americans turned to
religion. That was reported in the New England Journal of
Medicine. Ninety percent of hospitalized patients rely on
religion to cope, and nearly half in some areas of the country
say that it is the most important factor that keeps them going.
Hundreds of quantitative and qualitative studies report similar
findings.
Research on religion, spirituality and health is increasing
dramatically. Prior to the year 2000, if you did an online
search, you would find that there were about 6,282 scientific
articles on the topic. In the last seven to eight years that
has increased to over 7,000 articles. Just in the last seven to
eight years those are the number of articles. About 20 percent
of those are original research studies. So to date there are
nearly 3,000 studies looking at these relationships. More
research has been conducted recently than in a long time
previous to the year 2000.
Now, religious involvement can buffer stress, reduce
depression, enhance quality of life. Of 324 studies looking at
depression, 204 find significantly less depression or faster
recovery from depression in those who are more religious. Of
359 studies looking at well-being, happiness, meaning, purpose,
hope, 278 show significantly more positive emotions in the
religious. With regard to increased quality of life, 20 of 29
recent studies showing that.
Here is just an example of some of the research showing
that religious involvement affects the recovery rates for
depression over time when you follow people.
Religion is also related to less drug and alcohol use,
especially among the young. Of 324 studies, 276 show
significantly lower rates, less delinquency and crime found in
40 of 52 studies. These are all peer review studies
quantitative, original research published in science journals.
Religion is related to less cigarette smoking, especially
among the young. Fifty of 58 studies show that. Religious
persons are also more likely to exercise. Unfortunately, it is
not related to diet and weight. So whatever reason that is, but
also religion is related to less extra-marital sex and safer
sexual practices with regard to fewer partners. So 45 of 46
studies show those relationships.
Here is a slide I don't show in North Carolina, but I will
show it here. Religious attendance and cigarette smoking.
Clearly people attending services more aren't as likely to
smoke. Religion is related to better physical health and
recovery from illness. Here is a list of the different diseases
which are less frequent among those who are more religious.
This is just an example of survival after open heart surgery.
This is out of Dartmouth. You can see that those with high
religious support and high social support have much lower rates
of death during the six months after surgery.
This is a national sample of twenty thousand people looking
at life expectancy. Among whites the length of survival is
seven years longer among those attending services compared to
those who aren't. Among African-Americans it extends to 14
years longer. Religious persons need and use less health care
services as well. Because there is greater marital stability,
there is more social support, they are healthier, and that
translates into shorter hospital stays, fewer hospital days,
and less time spent in nursing homes because people are kept in
the community longer.
Here is an example just of the length of hospital stay at
Duke Hospital based on religious affiliation alone. Here is
looking at days spent in long-term care after hospital
discharge. In African-Americans that means fifty days in the
10-month period following discharge compared to five days.
Religion enhances community resiliency to disaster and
terrorism, helps people to cope with stress from an individual
level, helps long-term adaptation. At the community level
religious organizations are present in every community. Clergy
are oftentimes the first responders. Religious communities are
often present over the long-term after many other agencies
leave, and many national religious organizations are active in
disaster response.
So what? So what? You can't convert everybody or make them
religious, but there are numerous direct public health and
patient care implications which have nothing to do with
prescribing religion, endorsing religion, or overstepping the
bounds of church-state separation guaranteed by the First
Amendment.
Here are some implications for public health. More research
is needed, we don't understand the mechanisms. Even small
health effects are likely to lead to big, public health impact,
given that there are 200 million church members, 125 million
weekly attenders.
While not ethical or desirable to change a person's
religion or spirituality, we need to know this information for
planning health services. They also discover information that
are useful for enhancing health interventions in non-religious
people, using secular interventions. Congregations are one of
the few places where persons of all ages and races, and
economic levels meet regularly. You can do screening there, and
health education. Ideal place to educate youth with regard to
substance abuse; stress reduction and healthy lifestyle
education for the middle-aged; and training for volunteering
and mentorship for the elderly. Altruism is a basic value for
churches, and here is potential volunteers to support programs
in the community during disasters and non-disaster periods.
Many implications for patient health. Religion may help
patients to cope with illness, may affect their health
outcomes. Many patients want their religion acknowledged,
patients have spiritual needs, and patients are often isolated
from sources of religious help. Religious beliefs influence
medical decision-making and compliance with treatment.
Religious communities support patients in the community. We
want health care professionals to take a brief spiritual
history, support the patient's beliefs and practices, identify
their spiritual needs, and refer them to appropriate people.
Chairman Baird. Dr. Koenig, I am going to ask you to
conclude at this point, because we are about four minutes over.
We will get to some of these issues in a second. If you one or
two final comments but----
Dr. Koenig. Okay. There are many recommendations as you can
see for Congress here in terms of research, in terms of
supporting congregational health programs, in terms of
educating the public, and in terms of integrating faith-based
organizations in disaster response.
Thank you very much.
[The prepared statement of Dr. Koenig follows:]
Prepared Statement of Harold G. Koenig
Religion, Spirituality and Public Health: Research, Applications, and
Recommendations
Summary
This report reviews original research published in social,
psychological, behavioral, nursing and medical journals since the 1800s
that has examined relationships between religion/spirituality (R/S) and
the health of individuals and populations. I describe (1) the
prevalence of religious beliefs and practices in United States; (2) the
increasing stress in America and negative effects on physical health;
(3) the role R/S play in coping with stress and physical illness; (4)
the relationships between religious involvement, stress, and
depression; (5) the relationships between religion, substance abuse,
and health behaviors; (6) the relationships between religion and
physical health; (7) the impact on need for medical care and use of
health services; and (8) the effects on community resiliency following
natural disasters and acts of terrorism. This review suggests that as
many as 3,000 quantitative studies have now examined relationships
between R/S and health (mental and physical), the majority reporting
positive findings. I examine the implications this research has for
public health and patient care, and make recommendations that could
lead to a better understanding of these relationships and to
applications that may improve public health, promote community
resiliency, enhance patient care, and lighten the ever-increasing
economic burden of providing health care and protecting our population.
Introduction
Until recently, scientists have largely avoided studying the
relationship between religion and health. A young faculty member
wishing to examine these relationships was often told that conducting
such research amounted to an ``anti-tenure'' factor. Furthermore, there
was little if any funding from NSF/NIH to support such research.
Religious beliefs and behaviors were largely thought of as too
subjective, not quantifiable, unscientific, and based in fantasy and
infantile projections or illusion (Freud). As a result, health
professionals today ignore their patients' religious or spiritual
needs, and have little appreciation for their relationship to health.
Times are changing. There has been a tremendous surge in research
examining relationships between religion, spirituality, and health (95
percent conducted without funding). Research on this subject carried
out prior to the year 2000 has been systematically reviewed in the
Handbook of Religion and Health (Oxford University Press, 2001). That
review uncovered over 1200 studies published in a wide array for
psychological, behavioral, medical, nursing, sociological, and public
health journals. During the time since publication of this book, the
amount of research on the subject has increased dramatically. An online
search using the keywords ``spirituality'' and ``religion'' between
2000 and 2008 in PsychInfo (the American Psychological Association's
online database of research in the psychological, social, and
behavioral sciences) recently uncovered 7,145 scientific articles
(about 20 percent reporting original research). Repeating the same
search but restricting the years to 1806 to 1999, uncovered 6,282
articles. Thus, more research on religion, spirituality and health has
been published in the past seven to eight years than was published in
the nearly 200 years before that. Covering this massive research base,
then, is a daunting task.
The present report reviews original research conducted in the
social, psychological, behavioral, and medical sciences that has
examined relationships between religion/spirituality (R/S), and health.
Where individual studies are cited, these represent some of the best
work on the topic in terms of research design. They often utilize large
representative population-based or clinical samples, control for
relevant confounders, and employ distinctive, uncontaminated measures
of religion/spirituality (R/S). Most studies are observational in
research design, although a small number of clinical trials are
included. Some aspects of this review are systematic (for example,
studies on depression, positive emotions, substance abuse, delinquency,
health behaviors), while others are not. For example, studies reported
on physical health outcomes have been chosen to illustrate the kinds of
studies published, but the review is not systematic. A complete
systematic review of this area is now underway (Handbook of Religion
and Health, 2nd edition, Oxford University Press, 2011).
Below I examine (1) the prevalence of religious beliefs and
practices in the United States; (2) the increasing stress in our
population and the negative effects of stress/depression on physical
health; (3) the role that R/S plays in coping with stress and physical
illness; (4) the relationships between religious involvement, stress,
and depression; (5) the relationships between religion, substance
abuse, and health behaviors; (6) the relationships between religious
involvement and physical health; (7) the impact on need for medical
care and use of health services; and (8) the effects that religious
involvement has on community resiliency following natural disasters and
acts of terrorism. Next, I examine the implications of this research
for public health and clinical practice. Finally, I make a series of
recommendations for Members of Congress to consider.
Facts to Ponder
The United States is a very religious nation:
Fact #1: 93 percent of Americans believe in God or a higher power,
according to a Gallup Poll conducted in May 2008, (see website: http://
www.gallup.com/poll/109108/Belief-God-Far-Lower-Western-US.aspx).
Fact #2: 89 percent of Americans report affiliation with a religious
organization (82 percent Christian, i.e., Protestant or Catholic),
according to a representative national survey conducted by Baylor
Institute for Studies of Religion in September 2006 (see website:
http://www.baylor.edu/content/services/document.php/33304.pdf). Same
figures reported by Gallup Poll in December 2007 (see website: http://
www.gallup.com/poll/103459/Questions-Answers-About-Americans-
Religion.aspx)
Fact #3: 83 percent of Americans say religion is fairly or very
important to them, according to a September 2006 Gallup Poll (latest
data available) (see website: http://www.gallup.com/poll/25585/
Religion-Most-Important-Blacks-Women-Older-Americans.aspx)
Fact #4: 62 percent of Americans say that they are members of a church
or synagogue, according to a December 2007 Gallup Poll (latest data
available) (see website: http://www.gallup.com/poll/103459/Questions-
Answers-About-Americans-Religion.aspx)
Fact #5: 58 percent of Americans pray every day (and 75 percent at
least weekly), according to a 2008 U.S. Religious Landscape Survey (see
website: http://religions.pewforum.org/)
Fact #6: 42 percent of Americans attend religious services weekly or
almost weekly (and 55 percent attend at least monthly), according to
aggregate Gallup Pools in 2007 (see website: http://www.gallup.com/
poll/105544/Easter-Season-Finds-Religious-Largely-Christian-
Nation.aspx).
Stress and depression are common in American society,
especially due to the recent economic downturn. Both stress and
depression worsen when people develop medical illness and health
problems.
Fact #1: Stress levels, and likely stress-related disorders, are
increasing in the United States, based on Associated Press-AOL poll
(see website: http://www.aolhealth.com/healthy-living/debt-stress; also
see: http://www.usatoday.com/news/health/2007-10-23-
stress-N.htm)
Fact #2: Rates of significant depression in the community are about
five to ten percent, and place a substantial burden on the economy due
to cost of treating depression and time lost from work due to
depression-related disability (Journal of the American Medical
Association 2002, 287:203-209; Journal of Clinical Psychiatry 2003m
64:1465-1475; PharmacoEconomics 2007, 25:7-24)
Fact #3: Nearly 50 percent of hospitalized medical patients develop
depressive disorder, usually due to the prolonged stress and life
changes caused by medical problems (American Journal of Psychiatry
1997; 154:1376-1383)
Stress and depression have effects on physical health and
need for health services
Fact #1: Psychological stress and depression adversely affect health.
This applies to a wide range of medical outcomes (hypertension,
myocardial infarction, stroke, speed of wound healing, etc.), and may
even affect the aging process itself (based on changes at the DNA
level) (Lancet 1996, 346:1194-1196 (wound healing); New England Journal
of Medicine 1998, 338:171-179 (general review); Lancet 2003, 362:604-
609 (prognosis after myocardial infarction); Proceedings of the
National Academy of Sciences 2004,101:17312-5 (cellular aging) )
Fact #2: Depression increases length of hospital stay and cost of
medical services, in addition to adversely affecting the quality of
life of the patient and their family (American Journal of Psychiatry
1998, 55:871-877; Social Psychiatry and Psychiatric Epidemiology 2004,
39:293-298; for more recent information, see the following NIH report:
http://www.nih.gov/news/pr/jan2007/nimh-19.htm)
Many in the United States turn to religion for comfort when
stressed or sick.
Fact #1: Religion is often used to cope with stress. Following the
terrorist attacks on September 11, 2001, research shows that nine out
of ten Americans turned to religion to cope (New England Journal of
Medicine 2001, 345:1507-1512)
Fact #2: Religion is often used to cope with mental/physical health
problems. Research shows that in some areas of the United States, nine
out of ten hospitalized patients say they use religion to cope with
illness, and over 40 percent say that it is the most important factor
that keeps them going. (Handbook of Religion and Health, 2001; Oxford
University Press). Since the year 2000, over 130 separate quantitative
studies have documented high rates of religious coping in a range of
health conditions, especially in minority groups and in women. This
number does not include hundreds of peer-reviewed published qualitative
studies (in the words of patients) that support these findings.
Religious involvement may help to reduce stress, minimize
depression, and enhance quality of life.
Fact #1: Because of its effectiveness as a coping behavior, religious
involvement may reduce psychological stress, buffer against depression,
and speed recovery from emotional disorders (American Journal of
Psychiatry 1992, 149:1693-1700; American Journal of Psychiatry 1998,
155:536-542; Journal of Nervous and Mental Disease 2007, 195:389-395).
Of studies examining religion and depression prior to the year
2000, 64 of 101 studies (64 percent) reported less depression or faster
recovery from depression among the more religious (Handbook of Religion
and Health, ibid). Since the year 2000 (past seven to eight years), 140
of 223 studies (63 percent) reported less depression or faster recovery
from depression in the more religious (unpublished review).
Fact #2: Religious involvement is associated with positive emotions
(greater well-being, happiness, optimism, hope, meaning and purpose in
life) and higher quality of life.
Well-being: Of research conducted prior to the year 2000, 106 of
131 studies (81 percent) reported that religious persons experienced
more positive emotions (Handbook of Religion and Health, ibid). Since
the year 2000 (past seven to eight years), 172 of 228 studies (75
percent) have reported this same finding (unpublished review). Quality
of Life: Since the year 2000, 20 of 29 studies on R/S and quality of
life reported that they were positively associated.
Religious involvement is related to lower rates of alcohol
and drug abuse, less crime and delinquency, and better grades in
school.
Fact #1: Religious involvement predicts lower rates of alcohol and drug
use, particularly in high school students, college students, and young
adults (Prevention Science 2001, 2(1):29-43; Social Science Research
2003, 32:633-658; Psychology of Addictive Behaviors 2003, 17:24-31;
Social Science & Medicine 2003, 57:2049-2054; Journal of Adolescent
Health 2006, 39:374-380; Journal of Adolescent Health 2007, 40:448-455;
Alcoholism: Clinical and Experimental Research 2008, 32:723-737).
Concerning research published prior to the year 2000, 124 of 138
studies (90 percent) reported less alcohol and drug use/abuse in those
who were more religious (Handbook of Religion and Health, ibid). Since
the year 2000 (past seven to eight years), an incomplete review
indicates that 152 of 186 studies (82 percent) reported this same
finding (unpublished review). Thus, 276 of 324 studies report
significant inverse relationships between religious involvement and
substance abuse.
Fact #2: Delinquency rates and crime are less frequent in those who are
more religious (Journal of Adolescent Research 1989; 4:125-139;
Sociology of Religion 1996; 57:163-173; Social Forces 2004; 82:1553-
1572; Journal of Family Issues 2008; 29:780-805).
Prior to the year 2000, 28 of 36 studies (78 percent) reported that
delinquency or crime rates were lower among the more religious
(Handbook of Religion and Health, ibid). Since the year 2000 (past
eight years), an incomplete review indicates that 12 of 16 studies (75
percent) report similar findings.
Religious involvement is related to healthier lifestyles and
fewer risky behaviors that could adversely affect health
Fact #1: Religious involvement is associated with better health
behaviors, including less cigarette smoking and more exercise
(Cigarette smoking: Journal of Gerontology, Medical Sciences 1998,
53:M426-434; Prevention Science 2001, 2:29-43; Social Science &
Medicine 2003, 57:2049-2054; Families in Society 2004, 85:495-510;
Nicotine & Tobacco Research 2006, 8:123-133; Journal of Adolescent
Health 2007, 40:506-513; Exercise: American Journal of Public Health
1997, 87:957-961; Activities, Adaptation & Aging 2002, 26:17-26; Family
& Community Health 2006, 29:103-117)
Smoking: Prior to the year 2000, 22 of 25 studies (88 percent)
indicated that religious persons are less likely to smoke cigarettes
(Handbook of Religion and Health, ibid). Since the year 2000, an
incomplete review indicates that 28 of 33 studies (85 percent) reported
this finding. Exercise: Four of six studies have reported that
religious persons are more likely to exercise. Weight, however, is
another issue; only one of eight studies show that religious persons
weigh less than those who are less religious (probably because of those
potluck suppers!).
Fact #2: Religious involvement is related to less extra-marital sex and
safer sexual practices (fewer partners) (Social Psychology Quarterly
1985; 48:381-387; American Journal of Public Health 1992; 82:1388-1394;
Journal of the American Medical Association 1997, 278:823-832; Social
Science & Medicine 2003, 57:2049-2054; American Journal of Community
Psychology 2004, 33(3-4):151-161; Pediatrics 2006, 118:189-200).
Prior to the year 2000, 37 of 38 studies reported this finding.
Since 2000, an incomplete review indicates that eight of eight studies
(100 percent) report this.
Fact #3: Religious involvement is related to a lower risk, healthier
lifestyle, particularly among youth. This includes greater likelihood
of wearing seat belts, better sleep quality, regular vitamin use,
regular physical and dental visits, etc. (Psychological Reports 1991;
68:819-826; Health Education and Behavior 1998; 25:721-741; European
Journal of Pediatrics 2005; 164:371-376; Preventive Medicine 2006;
42:309-312; Journal of the National Medical Association 2006, 98:1335-
1341).
Religion is related to better physical health and faster
recovery
Fact #1: Religious involvement is associated with less cardiovascular
disease, improved outcomes following cardiac surgery, lower rates of
stroke, less cardiovascular reactivity and lower blood pressure, better
immune/endocrine functioning, improved outcomes for patients with HIV/
AIDS, lower risk of developing or better outcomes from cancer, and less
susceptibility to infection:
Coronary artery disease: International Journal of Cardiology 1986,
10:33-41; Cardiology 1993, 82:100-121; American Journal of Cardiology
1996, 77:867-870; Journal of Clinical Epidemiology 1997, 50:203-209.
Cardiac surgery: Psychosomatic Medicine 1995, 57:5-15; Health
Psychology 2004, 23:227-238.
Cardiovascular reactivity: International Journal of Neuroscience
1997, 89:15-28; Annals of Behavioral Medicine 2004, 28:171-178; Journal
of Health Psychology 2005; 10:753-766.
Blood pressure: Hypertension 1988; 12:457-461; Hypertension 1995;
26:820-829; International Journal of Psychiatry in Medicine 1998,
28:189-213; Behavioral Medicine 1998, 24:122-130; Psychosomatic
Medicine 2001, 63:523-530; Journal of Gerontology 2002, 57B: S96-S107;
Journal of Biosocial Science 2003, 35:463-472; Psychosomatic Medicine
2006, 68:382-385.
Stroke: American Journal of Epidemiology 1992, 136:884-894; Stroke
2000, 31:568-573.
Metabolic problems: Diabetes Care 2002, 25(7):1172-1176; Archives
of Internal Medicine 2006, 166:1218-1224; Psychosomatic Medicine 2007,
69:464-472.
Immune/endocrine: Psychology and Health 1988, 2:31-52;
International Journal of Psychiatry in Medicine 1997, 27:233-250;
Journal of Psychosomatic Research 1999, 46:165-176; Breast Journal
2001, 7:345-353; Annals of Behavioral Medicine 2002; 24:34-48; Journal
of Biological Regulators & Homeostatic Agents 2003, 17:322-326; Health
Psychology 2004, 23:465-475; International Journal of Psychiatry in
Medicine 2004, 34:61-77; Journal of General Internal Medicine 2006,
21:S62-68; Journal of Psychosomatic Research 2006, 61:51-58.
Cancer: Journal of the National Cancer Institute 1989, 31:1807-1814
(misc. cancers); Journal of the Royal Society of Medicine 1993, 86:645-
647 (colorectal); Social Indicators Research 1996, 38:193-211 (misc.
cancers); International Journal of Psychiatry in Medicine 2002, 32:69-
89 (gastrointestinal); International Journal of Psychiatry in Medicine
2003, 33:357-376 (breast); American Journal of Epidemiology 2003;
158:1097-1107 (colon); Oral Oncology 2006, 42:893-906 (oral).
Infection susceptibility: British Medical Journal 2006,
332(7539):445-450.
For reviews of the research before 2000, see Handbook of Religion
and Health, ibid. For a more recent review, see Medicine, Religion and
Health (2008, Templeton Press). For a critique of this research, see
Lancet 1999, 353(9153):664-667, and Blind Faith (2006, St. Martin's
Press).
Fact #2: Religious involvement predicts greater longevity and lower
mortality, with religious attendance being the strongest predictor (and
associated with seven to fourteen years of additional life) (American
Journal of Public Health 1996, 86:341-346; American Journal of Public
Health 1997, 87:957-961; Demography 1999; 36:273-285; Journal of
Gerontology, Medical Sciences 1999, 54:M370-M37; Journal of
Gerontology, Medical Sciences 2000, 55:M400-405; Archives of Internal
Medicine 2001, 161:1881-1885; Annals of Behavioral Medicine 2001,
23:68-74; Research on Aging 2002; 22:630-667; American Journal of
Epidemiology 2002, 155:700-709; Journal of Health and Social Behavior
2004, 45:198-213; Annals of Epidemiology 2005, 15:804-810;
International Journal of Epidemiology 2005, 34:443-451; Journal of
Clinical Epidemiology 2005, 58:83-91; Journal of Gerontology 2005,
60:S102-S109; Journals of Gerontology 2006, 61:S140-S146).
Fact #3: Religious activity predicts slower progression of cognitive
impairment with aging, and may be associated with a slower progression
of Alzheimer's disease (Journal of Gerontology 2003, 58B:S21-S29;
Journal of Gerontology 2006, 61:P3-P9; Neurology 2007, 68:1509-1514
(Alzheimer's); Journal of Gerontology, Medical Sciences 2008, 63:480-
486)
Fact #4: Religious involvement predicts less functional disability with
increasing age, and faster functional recovery following surgery
(American Journal of Psychiatry 1990, 147:758-759; Journal of
Gerontology 1997, 52B:S306-S316; Journal of Aging and Health 2004,
16:355-374; Research on Aging 2008, 30:279-298).
All things being equal, religious people need and use fewer
health care services; this is because they are healthier, more likely
to have intact families to care for them, and have greater social
support
Fact #1: Religious involvement is related to greater marital stability
and social support, particularly in minority communities. This affects
the kind of support and monitoring a person with chronic illness will
have in the community (which may keep them out of the hospital or out
of a nursing home). Marital stability: Journal of Health and Social
Behavior 1989, 30:92-104; Behavior Genetics 1992, 22:43-62; Journal for
the Scientific Study of Religion 1997, 36:382-392; Addiction 2007,
102:786-794. Enhanced family relationships: Sociological Quarterly
2006; 47:175-194. Social support: Research on Aging 1991, 13:144-170;
Journal of Gerontology 1997, 52B:300-305; American Journal of Geriatric
Psychiatry 1997, 5:131-143; Health Care for Women International 2001,
22:207-227; Journal of Palliative Medicine 2006, 9:646-657; Journal of
Health Psychology 2007, 12:580-596). Prior to the year 2000, 19 of 20
studies found that religious persons had significantly more social
support.
Fact #2: Religious involvement is associated with lower rates of health
services use (medical), both acute hospitalization and long-term care
(Social Science & Medicine 1988, 27:1369-1379; Southern Medical Journal
1998, 91:925-932; International Journal of Psychiatry in Medicine 2002,
32:179-199; Archives of Internal Medicine 2004, 164:1579-1585).
Communities with high percentage of religious involvement
recover more quickly from natural disasters and acts of terrorism
Fact #1: After the police, firefighters, and emergency medical
technicians, religious communities are often the first responders and
often the most enduring responders following disasters. The extensive
literature (both research studies and popular articles) documenting
this fact is described in two books, In the Wake of Disaster: Religious
Responses to Terrorism and Catastrophe (Templeton Press, 2006), and
Tend My Flock: Emergency Planning for Faith Communities (forthcoming,
2009).
Fact #2: Religious involvement is related to better mental health,
greater community resilience, and higher social capital following
disasters (Journal of Community Psychology 2000, 28:169-186; Annals of
the New York Academy of Sciences 2006, 1094:303-307; Journal of Health
Care for the Poor & Underserved 2007, 18:341-354; Social Science &
Medicine 2008, 66:994-1007).
Implications for Public Health and Patient Care
So what? Should we try to make people more religious? There are
numerous direct public health and clinical applications for all of the
above that have nothing to do with prescribing religion, endorsing
religion, or over-stepping the bounds of church-state separation that
the 1st Amendment guarantees. I divide the implications of this
research into two categories: implications for public health and
implications for clinical care.
Implications for Public Health
(1) More research is needed. Although there is every reason based
on existing research to suggest that religious involvement is related
to better health, we don't really understand why this is the case.
Religion can certainly have negative health effects as well, but
certain aspects of religion (cognitive, behavioral, or social) appear
have positive effects on health and well-being. Is this not relevant to
the health of our population and resiliency of our communities? The
problem is that we don't know what aspects of religion are particularly
healthy, or how these health benefits occur in terms of behavioral and
physiological mechanisms. We also don't fully know how religion impacts
the health of communities, or their resiliency to crime, poverty,
teenage pregnancy, school performance, venereal disease transmission,
natural disasters, etc. Given the widespread prevalence of religious
beliefs and activities (with nearly 200 million church members, and
over 125 million weekly church attendees), even small effects on either
individual or community health could have enormous public health
impact.
(2) Although it is not ethical or desirable to change or increase
religious involvement for health reasons, it is important for social
and behavioral scientists to learn how R/S is affecting health and then
inform the public about this. People, then, will need to make their own
choices in this regard, free from coercion or manipulation.
Furthermore, doesn't the majority of the U.S. population for whom
religion is important deserve to know what effect their religious
beliefs and practices are having on their health? This is particularly
true since certain religious practices in some settings may actually
worsen health (about five to ten percent of studies find negative
correlations between religion and health). For religious beliefs,
practices, and rituals that are shown to improve health, knowing this
may help to boost the health effects that these beliefs/practices have
for religious people (since it may encourage them to continue these
practices, or may help them to utilize their beliefs to help them
change unhealthy lifestyles). Thus, education of the public and
dissemination of research findings about factors that may affect health
is an important role for both health professionals, as well as for
government agencies interested in maintaining and enhancing the health
of the population.
(3) There are many human characteristics that we study in the
social and behavioral sciences that we cannot change, but need to
understand what impact they are having on health for planning purposes
(i.e., anticipating health care needs of the population). These include
age, gender, race, ethnic background, sexual preference, political
belief, etc. There are also characteristics that we may be difficult to
change, and yet we need to know how these factors affect health and use
of health services. These include the effects of poverty, personality,
level of social involvement, health habits, obesity, and so forth. This
doesn't prevent us from conducting research to better understand how
these factors affect health. For some reason, however, religion seems
to be placed in a different and separate category. Currently, there is
widespread bias in the mainstream scientific community against research
on the health effects of traditional religious beliefs and practices
[just take a look at the portfolio of NSF/NIH grants and see how many
grants in the psychological, social, and behavioral sciences are
focused this area of research].
(4) What about one-third of the U.S. population who are not
religious? It may be that they too will benefit from research on
religion, spirituality and health. By learning about how R/S affects
health, we can apply this knowledge to non-religious settings and to
non-religious people using secular techniques. For example, how does
religious involvement convey meaning and purpose, hope, self-esteem,
protection from depression, and buffer against stress (and perhaps
consequently reduce blood pressure, heart attacks, and stroke, or slow
the development of cognitive impairment and disability with age)? If we
know the mechanisms, we could use them to enhance the way secular
beliefs and behaviors provide these healthy effects. This would benefit
everyone.
(5) There is even some research that suggests that communities
where high proportions of the population are members of religious
groups have better health in general, even the non-religious people who
live in those communities (see Annals of Epidemiology 2005, 15(10):804-
810; American Journal of Sociology 2005, 111:797-823). Shouldn't public
health experts be interested in why and how this occurs? Would such
research not provide clues on how to enhance the health of entire
populations?
(6) There are few places where people of all ages (young, middle-
aged, and elderly), all socioeconomic levels, and all ethnic
backgrounds congregate on a regular basis as happens in religious
communities. This makes religious organizations an ideal route by which
to provide health screening, health education, and other disease
detection and prevention services. A few studies have shown that health
education programs in churches can affect diet, weight, exercise, and
other health behaviors, and this is particularly true for minority
communities who often do not have easy access to such information or to
preventative health care services. Religious communities may also be an
ideal place to provide alcohol and drug education, as well as inculcate
moral values and character that could affect future decisions that
impact health, pro-social behaviors, and even affect the ability to
afford health insurance during adulthood. More research is needed and
effective programs developed. Again, such efforts could have a direct
impact on public and community health.
(7) Religious communities often have altruism as one of their basic
values. Thus, members of churches, synagogues and mosques represent an
army of potential volunteers to assist with social programs, mentoring,
and direct service provision. This is perhaps most evident with regard
to disaster preparation and response. Why are we not supporting and
nourishing this role that many faith communities are already engaged
in? Instead, faith groups often meet resistance from formal emergency
management services when they try to help, since they are not
integrated into these efforts. Without the volunteer help that faith
communities provide, it is not hard to imagine what the additional cost
to FEMA might be. The health of our communities, particularly when
affected by natural disasters or acts of terrorism, may depend on
whether religious communities are fully prepared and involved in
response efforts.
Implications for Patient Care
(1) If future research confirms that religious involvement
significantly affects mental and physical health, then health
professionals need to be educated about this and need to consider this
in their treatment of patients. In fact, one could argue that there is
already sufficient research evidence to begin to do this. Furthermore,
there are other reasons why health professionals should be integrating
spirituality into patient care. Here are a few (see Spirituality in
Patient Care, 2007, for a complete description):
Many patients are religious or spiritual, and would
like it addressed in their health care. Because religious
beliefs are used to cope with illness (either mental or
physical), religious patients would like their spiritual needs
to be acknowledged and addressed by their physicians (and by
nurses who provide more direct and personal care)
Patients, particularly when hospitalized or
imprisoned by chronic illness, are often isolated from their
religious communities. Our country has recognized that when
people are prevented from practicing their religious faith
because of circumstances imposed on them, we have provided the
resources necessary for them to practice their faith (based on
the principle of religious freedom). This is why we have
chaplains in the army, and in federal and state prisons and
psychiatric facilities. Hospitalized patients with medical
problems or the chronically ill are no different. Many people
are hospitalized far away from their religious communities of
support (this is especially true for nursing homes, where
contact is minimal even when religious communities are nearby).
Religious beliefs affect medical decisions, and may
conflict with medical treatments. This is a very practical
reason why health professionals need to communicate with
patients about religious or spiritual beliefs. Studies find
that 45 percent to 73 percent of seriously ill patients
indicate that their religious affect their medical decisions
(Archives of Internal Medicine 1999, 159:1803-1806; Journal of
Clinical Oncology 2003, 21:1379-1382; Family Medicine 2006,
38:83-84). Yet 90 percent of physicians do not take a spiritual
history or discuss these matters with patients, and 45 percent
of physicians say that it is not appropriate to do so (Medical
Care 2006, 44:446-453). How can physicians practice competent
medicine if they don't have knowledge about factors that will
affect compliance with the treatments they prescribe?
Religious struggles or spiritual conflicts over
medical issues have been shown to predict increased mortality
and worse medical outcomes (see Archives of Internal Medicine
2001, 161: 1881-1885). If left undetected and not addressed,
these struggles may adversely affect disease course despite the
best of medical treatments.
Religion influences health care in the community.
Because of the rising costs of health care, most health care is
now shifting out of the hospital and into the community.
Hospital stays are becoming shorter and shorter (since
hospitalization is the most expensive form of medical care),
and people are being discharged sicker and sicker into the
community. If patients are involved in a religious community,
they will have a ready support system that can provide
emotional support, monitor compliance, and provide practical
services (meals, home-maker services, respite care, rides to
physician office). If they are not, then they are dependent on
family members for support, and if no family is available, then
they are forced to rely on the government. This will become a
real issue as our population ages and the medical needs
escalate (Faith in the Future: Healthcare, Aging, and the Role
of Religion--see Further Readings).
(2) What are some sensible ways that clinicians can integrate
spirituality into patient care, without prescribing religion or
coercing patients to believe or practice? First of all, most of their
patients are already religious to at least some degree (recall that up
to 90 percent of seriously ill patients in some parts of the U.S. use
religion to cope), so clinicians don't have to promote religion. It's
already there. What they do need to do, however, is to recognize it,
support it, and consider it when making medical decisions and
developing treatment plans. Here are some ways to do that:
For patients admitted to the hospital or those with
serious or chronic medical illness, physicians should take a
brief, screening spiritual history that identifies if spiritual
beliefs are (1) important to the patient, (2) helping the
patient to cope (or, alternatively, are causing spiritual
struggles), (3) influence medical decisions or conflict with
treatments prescribed, (4) membership in a supportive spiritual
community, and (5) whether there are any spiritual needs that
someone should address (see Journal of the American Medical
Association 2002, 288:487-493). This takes about two minutes to
conduct.
Support (verbally and non-verbally) the religious or
spiritual beliefs of patients if those beliefs are helping the
patient to cope.
If spiritual needs or conflicts are identified, refer
patients to professional chaplains or trained pastoral
counselors to address these needs.
If patients are not religious, then the spiritual
history should focus on what gives patients lives meaning and
purpose in the setting of illness (grandchildren, hobbies,
etc.), and then those activities supported. Religion should
never be prescribed, forced, or even encouraged in patients who
are not already religious, so as not to add guilt to the
already heavy burden of illness. Inquiry and support in this
area must always be patient-centered and patient-directed.
(3) Health professionals in hospital and outpatient settings should
be willing to accommodate the religious or spiritual beliefs and
traditions of patients. Examples: For the American Indian, this may
involve altering the environment (or providing alternative
environments) so that traditional spiritual ceremonies concerning
sickness and death may be performed (if requested by the patient or
family). For the Muslim patient, the environment should be altered so
that the patient can perform his or her daily prayers, and care
arranged so that only gender-matched health professionals give personal
care. Religious and cultural sensitivity will help both the patient and
the family to cope better with illness, will improve patient and family
satisfaction with care, and thereby will likely enhance medical
outcomes.
(4) Efforts should be made to ensure that there are adequate
numbers of chaplains available so that patients' spiritual needs can be
adequately addressed. A recent study conducted by Harvard investigators
documented that three-quarters (72 percent) of patients dying of cancer
said that their spiritual needs were minimally or not at all met by the
medical system (i.e., doctors, nurses, or chaplains) (Journal of
Clinical Oncology 2007, 25:555-560). Currently, there are only enough
chaplains in U.S. hospitals to see about 20 percent of patients (one in
five) (International Journal of Psychiatry in Medicine 2005, 35:319-
23). There are typically no chaplains in outpatient settings and no
chaplains in nursing homes. Who meets these patients' spiritual needs?
Recommendations
Recommendations for Members of Congress emphasize their providing
support for research on R/S and health (support for both research
training and research projects); public education of the role of
religion in health and wellness; health professional education on why
and how to integrate spirituality into patient care; and motivating
health care systems to allow health professionals the time necessary to
address the spiritual needs of patients. Finally, recommendations are
provided for supporting and integrating efforts by religious
organizations in disaster preparation and response.
I. Support Research
(1). Because research on the effects of religious/spiritual beliefs and
behaviors is a substantial need, current barriers at NSF/NIH to funding
research on the effects of traditional religious beliefs/behaviors need
to be overcome. This could be done by (1) assigning a specific branch
at NSF/NIH to review such grants, (2) ear-marking funds to support such
research, (3) establishing review sections at NSF/NIH with the specific
expertise and sensitivity to this topic so as to give such grants a
fair chance of being awarded.
(2). Provide NSF/NIH training grants to support the development of
young researchers on university faculty to conduct research in this
area, or to help senior investigators to transition their research into
this area. There are currently models at NSF/NIH of junior and senior
investigator awards, but none focus on supporting the training of
researchers to study the health effects of R/S.
(3). Urge NSF/NIH to develop a ``request for proposals'' (RFP) in the
area of the effects of traditional religious beliefs and behaviors on
mental, physical, and social/community health. The John Templeton
Foundation may be willing to partner with the NSF/NIH to provide
support for such a competitive grants program.
(4). Establish an intramural research program at the NSF/NIH to examine
the impact of religious beliefs and practices on public health, the
cost-savings that this might produce, and the effectiveness and
acceptability of disease detection and prevention programs within (or
in cooperation with) religious organizations, especially in minority
congregations.
II. Support Congregational Health Programs
(1). Consider partial government support for parish nurse programs
within religious congregations that provide disease screening, health
education, lifestyle change, and volunteer recruitment and training for
service delivery. If that latter keeps members of religious communities
in their homes and out of hospitals or nursing homes, then this could
represent a substantial cost savings for Medicare and Medicaid.
(2). Along these same lines, encourage the development of health care
system-religious congregation partnerships. This would involve closer
working relationships between local hospitals or medical systems and
religious communities for the purposes of providing early disease
detection and referral for treatment, volunteer recruitment and
training, and the teaching of health promotion activities that
encourage self-care, keep people healthy, and reduce the need for
expensive medical services (Florida Hospital is a good model to
follow). Such efforts could also be expanded outside of congregations
to persons in the general community who need services, but have fallen
through the cracks of the current health care system.
III. Educate the Public
(1). Develop a public education campaign to help disseminate research
findings (both past research and new research) on the role that R/S
plays in maintaining health and well-being. There is already great
public interest in this topic as exemplified by multiple cover stories
on spirituality and health in popular magazines such as Reader's
Digest, Newsweek, Time, Prevention, and others.
(2). Support/encourage adult education classes at State and federally
funded universities to teach the public about relationships between R/S
and health, and how people can take advantage of these relationships to
prevent disease, overcome addiction, and enhance their health and well-
being. These classes should also emphasize the seeking of timely
medical care, and the important role that allopathic medicine plays in
health and wellness. Religion and medicine should complement each
other, not compete or conflict.
(3). The public should be taught how to talk with their doctors about
R/S. If religion is important to a patient, should this be a
consideration in their selection of a physician? What are some ways
that patients can communicate with their physicians about the important
role that religion plays in their lives and how it could influence
their medical decisions? A recent article by Elizabeth Cohen on CNN.com
illustrates such an approach (see website: http://www.cnn.com/2008/
HEALTH/09/11/ep.faith.medicine/index.html?iref=newssearch).
(4). The public should also be taught how to talk with their clergy
about initiating a health programs within their local religious
congregation. If the 500,000 religious congregations in America all had
such programs, then two-thirds of the U.S. population would be exposed
to disease detection, disease prevention, and health promotion efforts.
Since persons of all ages participate regularly in religious
congregations, this means that health education efforts would occur at
all ages, from the young (focused on substance abuse prevention and
character development) to the middle aged (focused on healthy eating,
exercise, stress-reduction, etc.) to the elderly (focused on
volunteering, mentoring and generative types of activities).
IV. Include Faith Communities in Disaster Preparation and Response
Part of maintaining public health involves protecting communities
who may be in constantly threat of natural disasters and even terrorist
attacks, and helping them to recover if those events occur. Religious
organizations already play a big role in this regard, both at the
individual level in helping persons cope with the stress of the event
and on the community level in helping communities minimize their losses
in the short-term and recover over the long-term. What can the
government do to support faith-based efforts? Here are some
recommendations (see In the Wake of Disaster for more details):
(1). Research and Education. Research is needed to determine the
prevalence of spiritual needs and the extent to which they are met (and
by whom) during each phase of a disaster. Further research on the
relationship between addressing spiritual needs and long-term mental
health outcomes following disasters is critically needed. Systematic
data are needed on the activities of clergy and non-clergy volunteers
from the faith community following disasters. Although more research is
clearly needed, much is already known that justifies a major
educational initiative. Education is needed for Emergency Management
Services (EMS) agencies/personnel, mental health authorities, and
faith-based groups to help dispel myths and misconceptions about each
other, to define the unique roles that each group serves, and to
emphasize the consequences of not valuing and not including each other
in the disaster response.
(2). Leadership. Government supported EMS agencies should take the lead
in inviting Faith-Based Organizations (FBOs) to participate in disaster
planning and response. Government agencies should encourage interested
FBO's to identify the types of resources they wish to contribute to the
disaster response effort. This may involve efforts to coordinate
disaster response; mobilize and train clergy and congregational
volunteers to provide psychological, social and spiritual support;
raise funds or material necessities to assist victims during their
recovery; or many other potential activities.
(3). Organize and coordinate. Government supported EMS agencies need to
take the initiative to establish a body to coordinate FBO efforts. Once
established, it could organize itself into national and local networks.
(4). Include in Planning Phase. On the local level, EMS agencies should
include deployment of FBO resources as part of their response protocol.
As noted above, this would require that the leaders of local FBOs are
included in disaster response planning.
(5). Encourage teamwork, partnership and collaboration. Partnerships
should be encouraged between mental health workers and local faith-
based groups. Local mental health workers should be encouraged to visit
or participate on local ministerial associations or church councils. In
this way, the two groups could develop working relationships and
establish referral patterns before a disaster strikes. Mental health
counseling services could offer a spiritual component by developing a
referral network with local pastoral counselors or clergy. Faith-based
groups, in turn, could refer members who need specialized mental health
care to mental health professionals. Furthermore, mental health
professionals could provide education to faith-based communities on how
to identify mental disorders, which kinds of interventions might be
helpful, and when to refer.
(6). Consider making trained clergy ``first responders.'' Besides
offering necessary spiritual support, local clergy are ideally
positioned to serve as first responders in meeting the psychological
needs of disaster survivors and triaging those with more complex needs
to mental health professionals--enhancing the efficiency with which
scarce specialized mental health services can be delivered. In many
communities, clergy serve this function anyway following disasters (by
default). However, making this part of the formal EMS response would
help to systematize and coordinate the effort.
(7). Credential. There needs to be a way of screening clergy before
sending them out into the field to ensure that they are adequately
trained. Basic national standards should be established for
credentialing clergy, as well as methods of identifying clergy
credentialed in disaster response prior to a disaster. This needs to be
done as part of pre-disaster planning to ensure that it is part of a
coordinated response.
(8). Fund. First, provide greater flexibility in support mechanisms by
offering more grant options than SAMHSA currently offers. The options
should address the pastoral care needs of disaster victims during long-
term recovery extending beyond the first few months after the event. It
is during recovery, as people begin to put their lives back together,
that issues of meaning and purpose in life begin to surface and
pastoral care services are most needed. Second, make it easier for FBO
groups to apply for available funding to help support their preparation
and response.
V. Educate Health Professionals
(1). Physicians, nurses, social workers, counselors, and hospital
administrators need to be informed of the existing research on R/S and
health, and the rationale for integrating spirituality into patient
care. Most health professionals did not receive training on how to do
this, and many are nervous about doing so and feel unprepared. They
don't know how to take a spiritual history or what to do with the
information they learn from it. They don't know what a chaplain does,
the type of training a professional chaplain receives, or how the
chaplain can be useful to them or their patients. They don't know what
benefits might result from their addressing the spiritual needs of
patients and ensuring that those needs are appropriately addressed.
Many medical schools are now developing courses on religion,
spirituality and medicine for medical students. In fact, nearly 100 of
the 141 medical schools in the U.S. and Canada now have such courses
(70 percent of which are a required part of the curriculum).
(2). These medical courses, however, are a relatively new development.
In 1992, only three medical schools had such courses. As a result, most
physicians in practice today have no training in this regard. The same
is true for nurses and other health professionals. This means that CE
(continuing education) programs are needed to train current health
professionals about how to sensitively and sensibly address spiritual
issues with patients. These CE programs could be held at regional
medical centers or in local hospitals, with several institutions linked
by video-conferencing or Internet-based methods.
VI. Initiate Health Care System Changes
(1). Even with adequate education and training, health professionals
need time to address the spiritual needs of patients. Administering a
screening spiritual history, supporting patients' beliefs, and referral
to pastoral care all take time, precious time that most health
professionals don't have in the busy clinic or hospital setting. While
freeing up such time will be modestly expensive in the short-term,
there is every reason to think that it will be cost-effective in the
long-term. If patients have their spiritual needs addressed, this will
likely influence their health over the long-term and reduce their need
for future health services (as well as enhance satisfaction and help
them move more smoothly through the health system). In the only
clinical trial that has examined this possibility, researchers found
that physicians taking a spiritual history (which added 2.1 minutes to
the visit) resulted within three weeks in oncology patients
experiencing less depression, greater functional well-being, and a
strengthening of the doctor-patient relationship (see International
Journal of Psychiatry in Medicine 2005, 35:329-347).
(2). Government-funded health programs should emphasize the importance
of health professionals addressing the spiritual needs of patients and
need to free them up from other responsibilities to do so (this is true
for physicians, but perhaps even more true for nurses). This may
require providing monetary or some other types of incentive for
hospitals to free up time for physicians, nurses, social workers, and
chaplains to address these issues. Perhaps tying this to Medicare/
Medicaid reimbursement based on post-hospitalization patient
satisfaction surveys might be one route to go. This would require that
all hospitals include post-hospitalization surveys that assess patient
satisfaction with spiritual care, which few such survey currently do.
Suggested Readings
Medicine, Religion and Health. Templeton Press (September, 2008)
The latest review and discussion of research on religion,
spirituality and health (including both mental and physical health),
written in a reader-friendly, non-researcher format (updates the
Handbook of Religion and Health, 2001). Length: 235 pages. To order, go
to website: http://www.templetonpress.org/
book.asp?book-id=124
Spirituality in Patient Care, 2nd Edition. Templeton Press (2007)
This book is for health professionals interested in identifying and
addressing the spiritual needs of patients. It addresses the whys,
hows, whens, and whats of patient-centered integration of spirituality
into patient care, including details on the health-related sacred
traditions for each major religious group. This book provides health
care professionals with the training necessary to screen patients
sensitively and competently for spiritual needs, begin to communicate
with patients about these issues, and learn when to refer patients to
trained spiritual-care professionals who can competently address
spiritual needs. Sections specifically address mental-health
professionals, nurses, chaplains and pastoral counselors, social
workers, and occupational and physical therapists. A ten-session model
course curriculum on spirituality and health care for medical students
is provided, with suggestions on how to adapt it for the training of
nurses, social workers, and other health professionals. Length: 264
pages. To order, go to website: http://www.templetonpress.org/
book.asp?book-id=105
Handbook of Religion and Health. Oxford University Press (2001)
This is a comprehensive review of history, research, and discussion
of religion and health. Its 35 book chapters span mental and physical
health, from well being to depression to immune function, cancer, heart
disease, stroke, chronic pain, disability, and others. Appendix lists
1200 separate scientific studies on religion and health that are
reviewed and rated on 0-10 scale, and followed by 2000 references and
extensive index for rapid topic identification. This is the most cited
of all references (books, book chapters, and peer review articles) on
religion and health. Length: 714 pages.
The Link Between Religion and Health: Psychoneuroimmunology and the
Faith Factor. Oxford University Press (2002)
Edited volume (15 chapters) examines the role of
psychoneuroimmunology as an explanation for the link found between
religion and physical health. Leaders in psychoneuroimmunology discuss
their respective areas of research and how this research can help
elucidate the relationship between religion and health. This volume
reviews research on religious involvement, neuroendocrine and immune
function, and explores further research needed to better understand
these relationships. Length: 304 pages
Faith in the Future: Healthcare, Aging and the Role of Religion.
Templeton Press (2004)
This book presents a compelling look at one of the most serious
issues in today's society: health care in America. How will we provide
quality health care to older adults who will need it during the next
30-50 years? Who will provide this care? How will it be funded? How can
we establish effective, comprehensive, and cost-effective systems of
care as demographic and health-related economic pressures mount?
Innovative programs created and maintained by volunteers and religious
congregations are emerging as pivotal factors in meeting health care
needs. Summarizing decades of scientific research and providing
numerous inspirational examples and role models, the authors present
practical steps that individuals and institutions may emulate for
putting faith into action. Length: 200 pages. To order: http://
www.templetonpress.org/book.asp?book-id=63
In the Wake of Disaster: Religious Responses to Terrorism &
Catastrophe. Templeton Press (2006)
Based on White Paper produced for the Center for Mental health
Services (CMHS) of the U.S. Department of health and Human Services
(DHHS). Examines psychological responses to natural disasters and acts
of terrorism, outlines the emergency response system in the United
States, and describes that role that individual religious faith plays
in coping with disaster. However, the main focus of the book is
describing the role that faith-based organizations play in responding
to disasters, and discusses the many ways that they are involved at all
stages whenever a disaster strikes. See pp. 109-119 for recommendations
to public policy-makers. Length: 162 pages. To order: http://
www.templetonpress.org/book.asp?book-id=84
Faith and Mental Health: Religious Resources for Healing (Templeton
Press, 2005)
This book is also based on White Paper produced for the Center for
Mental health Services (CMHS) of the U.S. Department of health and
Human Services (DHHS). It provides an updated review of the history,
research, and interventions related to religion and mental health. The
focus is on examining faith-based delivery of mental health services.
Five faith-based organizations are discussed: clergy and local
religious congregations, networking and advocacy groups for the
chronically mentally ill, national religious organizations that deliver
mental health services, and groups that deliver faith-based mental
health services but do not belong to a national religious group
(religious counselors, chaplains, pastoral counselors). See pp. 255-275
for recommendations to public policy-makers. Length: 342 pages. To
order: http://www.templetonpress.org/book.asp?book-id=80
Handbook of Religion and Mental Health. Academic Press (1998)
Due to our religiously diverse society, The Handbook of Religion
and Mental Health is a useful resource for mental health professionals,
religious professionals, and counselors. The book describes how
religious beliefs and practices relate to mental health and influence
mental health care. It presents research on the association between
religion and personality, coping behavior, anxiety, depression,
psychoses, and successes in psychotherapy, and discusses specific
religions and their perspectives on mental health. Chapters address
clinical considerations when treating Protestants, Catholics, Mormons,
Unitarians, Jews, Buddhists, Hindus, and Muslims. Length: 408 pages.
Biography for Harold G. Koenig
Dr. Koenig completed his undergraduate education at Stanford
University, his medical school training at the University of California
at San Francisco, and his geriatric medicine, psychiatry, and
biostatistics training at Duke University Medical Center. He is board
certified in general psychiatry, geriatric psychiatry and geriatric
medicine, and is on the faculty at Duke as Professor of Psychiatry and
Behavioral Sciences, and Associate Professor of Medicine. He is also a
registered nurse (RN).
Dr. Koenig is founder and former Director of Duke University's
Center for the Study of Religion, Spirituality and Health, and is
founding Co-Director of the current Center for Spirituality, Theology
and Health at Duke University Medical Center. He has published
extensively in the fields of mental health, geriatrics, and religion,
with over 300 scientific peer-reviewed articles and book chapters and
nearly 40 books in print or in preparation. He is the former Editor-in-
Chief of the International Journal of Psychiatry in Medicine and of
Science and Theology News. His research on religion, health and ethical
issues in medicine has been featured on over 50 national and
international TV news programs (including The Today Show, ABC's World
News Tonight, and several times on Good Morning America), over 80
national or international radio programs (including multiple NPR and
BBC interviews), and hundreds of national and international newspapers
or magazines (including cover stories for Reader's Digest, Parade
Magazine, and Newsweek). Dr. Koenig has given testimony before the U.S.
Senate (September 1998) and the U.S. House of Representatives
(September 2008) concerning the effects of religious involvement on
public health. He has been interviewed by James Dobson on Focus on the
Family and by Robert Schuller in the Crystal Cathedral on the Hour of
Power. Dr. Koenig has been nominated twice for the Templeton Prize for
Progress in Religion.
His books include The Healing Power of Faith (Simon & Schuster,
2001); The Handbook of Religion and Health (Oxford University Press,
2001); and his autobiography, The Healing Connection (2004); Faith and
Mental Health (2005); In the Wake of Disaster (Templeton Press);
Kindness and Joy (2006); Spirituality in Patient Care, 2nd edition
(2007); and Spirituality and Medicine (2008) published by Templeton
Foundation Press. Dr. Koenig travels widely to give workshops and
seminar presentations (see
http://www.dukespiritualityandhealth.org/about/
speaking-engagements.html).
Discussion
Chairman Baird. Thank you, Doctor, and thanks to all our
witnesses for outstanding comments and observations and most
informative.
We will proceed now in the questioning. I will yield
myself, recognize myself for five minutes, and then we will
follow with my colleagues.
First of all, I want to thank you all. As a social
scientist, some of the friends here from the social science
community will recognize that I have been one of the most
passionate advocates and harshest critics of my own
disciplines, and the reason is I believe we have so much to
offer, and we so often don't offer it as well as we can. And
the exception to that is illustrated by the testimony today.
And I congratulate you.
What I find most impressive is that we are talking about
rigorous empirical designs, followed by applications in the
real world, followed by testing those applications with real
world impacts. And all of this stemming in many cases from
basic research that then gets moved up as science is supposed
to. And with real world impacts.
What I would like to do is follow up on each of the
examples, and we will probably have a second round of questions
as well.
Let me start, we will just follow in order. Dr. Barrett,
when you talk about the example of teaching emotional, I am
blanking on the word. Literacy. Thank you. So I may, give us an
example of how you would do that with a person and with what
impact that might have. How would it change things?
Dr. Barrett. Sure. Well, I mean, first of all, I should
point out that I don't personally do work on emotional
literacy. That work is actually being done by other people. I
did the basic research, and my lab pretty much continues to do
basic research on emotions.
Chairman Baird. Well, let me jump to the basic research
then.
Dr. Barrett. But I can answer that question----
Chairman Baird.
Dr. Barrett.--for you. So basically, I mean, my husband
tells a joke. Right. The joke he tells is that when he first
met me, he knew three emotion words; happy, sad, and hungry.
And----
Chairman Baird. My kind of guy.
Dr. Barrett.--that usually gets laughs but, you know, but
the point being that what you do, what emotional literacy
programs do is they turn people into emotional experts who have
a large emotion vocabulary, so they have a lot of different
words for emotion, and they understand the distinctions between
those words. So they understand the difference not just between
anger and sad but between irritation and anger and rage. And
they use those words to help them to better see emotion, you
know, more precisely see emotion in other people, to more
precisely label their own responses, and to better know how to
act.
So if I just feel bad, that doesn't tell me very much about
what to do next. However, if I understand that I am feeling
irritated as opposed to enraged, then I can plan something
more, my response a little bit more precisely.
So it basically has to do with using words to shape the
experience of emotion and the perception of emotion, to be able
to see emotions in others. And this sort of sounds like just
word play until you realize that actually words have, are a
constitutive rule in emotion, that is, emotions, you know,
there was just an article in Newsweek this week about emotion,
that, you know, fear can be found in this part of the brain,
and anger can be found in that part of the brain, and you know,
that is, it is an unfortunate article, because there isn't a
tremendous amount of science to back up those claims.
And so if you take a model like that, then it seems like
this is just wordplay. But if you believe that the words that
people use and the language that they speak actually has some
real informing emotions and in grounding emotion perception,
then it becomes a completely common-sensical thing to do.
Chairman Baird. And your research and that of our
colleagues in the field has been able to empirically identify
that people differ in how they process their own emotional
experience and communicate their own emotional experience, and
that that difference then relates to a host of other variables.
Dr. Barrett. Yes.
Chairman Baird. And by educating people about these issues,
you can then influence other variables.
Dr. Barrett. Yes. Exactly. So in our lab we spent almost a
decade doing research that was funded both by the, mainly
actually by NSF with some support from NIH but mostly it came
from NSF, where we did something called, we call it experience
sampling, but basically people almost, over 700 people took
little palm pilots out into the world with them, and we
measured a number of things about their emotional experiences
and then brought them back into the lab and did very controlled
measurements there of their body, of their faces, and so on. We
actually also did some brain imaging with these people, and
what we found really clearly was there is no question that
people vary in, not just in the words that they know for
emotion but actually in the precision of their experiences and
that these have effects in peoples' ability to perceive emotion
in others and to regulate their own responses and so on.
Chairman Baird. Great. Thank you.
I am going to go over my time just a little bit, because I
want to follow up with Dr. Jemmott. I want to compliment you
for your courage. In this institution over the last few years
anything dealing with sexuality has been a target for reverse
earmarking. By that I mean Members of Congress during an
appropriations debate target studies based solely on their
title. Dr. Ehlers and I both have been enraged by this in the
past, knowing nothing about the study. They just say, oh, this
deals with sex. We don't think we should spend any money on
sex, therefore, we are going to cut the budget.
What you have done is stepped forward and said, look. We
can make a research-based effort to identify how to intervene
in a deadly behavior and disease system and apparently with
good results.
Could you give it some sense of outcome? Just, you talked
about the various metrics against which you measure. Just give
us a sense of, you know, you got these various intervention
programs. What are the outcome? What have we seen in terms of
outcome for these things?
Dr. Jemmott. Well, one study that we, we have done two----
Chairman Baird. Make sure, please make sure your mic is on
up there. Maybe. That is hard. You might want to lower the mic
a little bit to yourself. Okay.
Dr. Jemmott. Okay. We did two studies that were done in
clinics, and when you are working in a clinic, it is possible
to have actual sexual outcomes in terms of sexually-transmitted
diseases. One study was with African-American women in Newark,
New Jersey, and the educators in that study were nurses. We
developed a very, very brief intervention that is appropriate
in that setting, 20 minutes, and it dealt with the skills
necessary to use condoms and to reduce your number of partners,
et cetera. And----
Chairman Baird. It is not just how to put a condom on. It
is how to convince your partner that a condom is the way you
are going to go.
Dr. Jemmott. Absolutely. And it is using it correctly as
well. And we followed the women who received the intervention
for a year, and we found that those who received the
intervention had a lower rate of chlamydia, gonorrhea, and
trichomoniasis compared to a control group of women who also
received an intervention from nurses that dealt with chronic
disease prevention.
We did a similar study in Philadelphia with African-
American and Latino adolescent girls who were 15, about,
approximately 15 years of age. They were all sexually
experienced. They were in the adolescent medicine clinic. They
received a skill-building intervention. Some of them received
an intervention that dealt with chronic disease prevention, and
we followed them for a year. We found significant reductions in
their number of partners, increased use of condoms, and a lower
rate of chlamydia, gonorrhea, and trich, trichomoniasis in that
study as well.
So we have been able to have outcomes in terms of sexual
behavior as well as sexually-transmitted disease. Obviously
when you work with younger populations it is not really
feasible to look at sexually-transmitted disease as an outcome,
so in those populations you want to look at self-recorded
behaviors, especially abstinence.
We have a study that we just completed in South Africa that
is currently under review where they were grade six students in
South Africa, hardly any of them were sexually active at the
beginning of the study. Their average age was about 12, and
only three percent were sexually active. We followed them for a
year after the intervention, and fewer of them reported sexual
intercourse over that period, unprotected sex, and reported
fewer partners, you know, again, compared to a control group
that received the chronic disease prevention, intervention.
So we have had some positive outcomes, you know, not just
here in the United States, with a variety of populations but
also overseas.
Chairman Baird. And especially given that you are speaking
today on the HIV capital of the United States of America.
Dr. Ehlers.
Mr. Ehlers. Thank you, Mr. Chairman. Just a quick follow
up. Did I understand you correctly to say that your abstinence
program actually worked?
Dr. Jemmott. Yes.
Mr. Ehlers. Because we have a lot of debate about that here
in the Congress.
Dr. Jemmott. Yes. We have an abstinence program that works.
It worked in a study that we did here. We have had two of them.
One worked briefly for three months, but then in a second
study, which is also under review right now, we followed the
adolescents for two years and found a significant effect of our
abstinence intervention in reducing initiation of sexual
involvement.
And the participants were grades six and seven African-
American adolescents in Philadelphia, and again, it was
compared to a control group of adolescents who learned about
chronic disease prevention.
Mr. Ehlers. Thank you. And Dr. Kenkel, you mentioned some
studies on how increasing costs led to reduction of use. I
assume that applies only for non, the beginning of use of non-
addictive substances, or would that also apply to someone who
is smoking or someone who is using hard drugs? Did the cost
increase result in less use, or is it beyond help simply
because it is an addictive behavior?
Dr. Kenkel. No. Actually the research suggests that a
number of addictive behaviors, addicts do seem to respond to
higher prices. There is a controversially-named theory at least
developed by Gary Becker and Kevin Murphy at the University of
Chicago called model of rational addiction. Now, I know to a
lot of people that almost sounds like an oxymoron, but the
basic idea is simply that addicts still respond to the same
kind of incentives that non-addicts do, and it may be
difficult, and it certainly is more difficult to change
behavior, but, again, there is evidence that shows that when
the price of cigarettes go up, people are more likely to quit
smoking. My research found pretty heavy drinking responded.
Maybe not the heaviest drinking but some very heavy drinking
seemed to respond to higher prices. And there has been some
research that looked into the same kind of price responsiveness
of illicit drugs, including heroin. And all of those find some
evidence that higher prices can reduce consumption of these
goods, even by the addicts.
Mr. Ehlers. And even for hard drugs then?
Dr. Kenkel. The hard drug, there has been some studies. I
mean, that is a very, very difficult----
Mr. Ehlers. Yeah.
Dr. Kenkel.--thing to study. I mean, basically on the data
we don't know that much about the use, nor do we know exactly
about what prices people are paying. So trying to figure out
how much prices affect use, it is a doubly difficult challenge.
But there have been some studies that indicate that, yes, even
the heroin----
Mr. Ehlers. And Dr. Koenig, I really enjoyed your
presentation, perhaps because I am a religious person, but I
suspect most everyone just drives themselves that way in some
fashion.
But what, are there any implication you can draw? You can't
somehow instill religion in a person to try to improve their
health.
Dr. Koenig. Yes.
Mr. Ehlers. And another question is is it perhaps the
health outcomes are related to the fact that a number of
religious behaviors are related to health? For example, for
years some denominations have strongly discouraged smoking,
long before the Surgeon General's report. Others discouraged
drinking very strongly.
Is it related to that, or is it, in fact, intrinsic to the
belief of the person, him or herself?
Dr. Koenig. It is related to as you described, better
health behaviors, less cigarette smoking, more exercise, et
cetera, et cetera. The religious, you know, beliefs that say
you shouldn't over drink, et cetera, et cetera, so that is a
major factor.
Also, there is the social factor, the fact that people have
more support in religious congregations, and then also there is
the cognitive, the beliefs themselves. They oftentimes are
positive or optimistic about coping with stress, about deriving
meaning to the negative experiences which help people to cope
better.
In terms of the applications, there are practical
applications. Because it is so common, so frequent that people
have religious beliefs and behaviors, how are those affecting
health? And how as people become more secular in this country,
how will that affect the increase in health problems? And so
those are just some of the issues. Clinically there is the
issue of people have spiritual needs, and doctors aren't
addressing them. Ninety percent of doctors never even talk to a
patient about their religious beliefs, and yet those are
affecting their compliance, their coping with illness, et
cetera.
So those are the issues.
Mr. Ehlers. Okay. Thank you. I was just reading the Old
Testament recently and the early part of it, and it is just
striking reading through all the rules and restrictions that
Moses put in place, how many of them are really health related.
So this goes back a long way.
Chairman Baird. Dr. Lipinski.
Mr. Lipinski. I would like to thank the Chairman for
holding this hearing and the hearings that we have held and
probably most importantly right now is last year in the fight
where there was a threat to NSF funding for social sciences,
and Dr. Baird really stepped up there, and I gave a little bit
of help there, but we made sure that that wasn't, we made sure
we took care of that in the America COMPETES Act.
And Chairman Baird is the only one who I allow to call me
Dr. Lipinski, and this is the only place he is allowed to do
it, here in this Subcommittee. I do have my Ph.D. from Duke in
political science, so I have fond memories of Duke, a great
university. I spent maybe too many years in school. One of the
classes that I remember more from than any other perhaps, when
I was at Stanford I took a, got a degree in engineering
economic systems. Decision analysis was something that was, I
was very interested in. I took a class from Amos Diversky, and
you know, decision theory, and really the fact that the risk
aversion that people have and how people make choices not
really necessarily based on what economically would seem to be
the clearer choice.
So I really think that so much of that could be used,
utilized in making public policy, and Dr. Kenkel, I know you
were, you know, you were talking about incentivising. We do a
lot of that in public policy, although sometimes we don't like
to admit that. But I think a lot of the research that you were
doing you are talking about in terms of smoking, some of that
is obviously economic when you are talking about whether or not
the economics actually impacts people who are addicted to
drugs. And I think that is very important work, but also
looking at, beyond the economics of what psychology tells us
about choices that people make.
What you, I just want to ask you, Dr. Kenkel, what else,
what do you think we should be doing more of here in terms of
helping to, you know, put the question aside of what policy
should we be doing to incentivise what behavior we want to see
more of or less of here in this country, but what should we be
doing in terms of funding? How could we better fund, you know,
the type of research that would be helpful to us in making
public policy?
Dr. Kenkel. That is a tough question obviously. In the kind
of social science research that health economists use relies
very heavily on secondary data sets, and so as I said,
mentioned before, you know, the continued support and expanded
support for the ongoing data collection efforts of both the
Federal Government and also, you know, investigator-initiated
data collections. You know, I am thinking about these ongoing,
longitudinal data sets like the Michigan Panel Survey of Income
Dynamics or the Fireman Health Surveys, provide incredibly rich
resource for health economists and other social scientists to
both explore the questions that, you know, the data sets were
designed to answer but also a lot of times to exploit them to
answer some new questions. So I think a lot of times the, a lot
of the economics research actually wasn't planned necessarily
to be used in these data sets, but we suddenly realized we
could exploit the natural experiment that was created in the
data, using ongoing data collection.
With that, I think providing a support for some of the new
developments in data collection, biomarkers, for example, are
an exciting idea to connect some of the traditional social
science kind of variables about schooling and income and
socioeconomic status with data actually on a much more health-
related, even genetic-related information, something they are
beginning to use.
The same types of innovations would really also be
possible, I think, and should be encouraged in kind of trying
to provide those links between economics and the other social
science. New sub-field of economics known as behavioral
economics, which exactly tries to do what you suggest, that is,
import the insights from psychology and improve the economic
models to explore when is it going to be the case where the
economic model isn't really capturing fully what is going on.
And can we get to an improved understanding and therefore, also
maybe improve public policies by kind of combining our forces
with psychological data.
And, again, I guess it just shows, you know, the kind of
research I do, I keep on coming back to sort of facilitating
data collections and facilitating cooperations between social
scientists of different disciplines. Some of the most important
ways I think you could support the type of research where I
think it needs to go.
Mr. Lipinski. Thank you. I thank all of you for the work
that you are doing in multi-disciplinary research. I found when
I was a political scientist that there wasn't nearly enough of
them. It seems like there is more of a push in recent years to
do that, so I think that is very helpful.
Chairman Baird. Thank you, Dr. Lipinski.
Mr. Lipinski. I yield.
Chairman Baird. And that, actually that issue of
interdisciplinary work is part of what was included in the
America COMPETES Act, of course, and I would note on the issue
of behavioral economics that cognitive economic work really of
Canaman and Diversky and that group, in my judgment certainly
could help us understand the collapse that this country is
experiencing right now.
If you look at the cognitive biases and decision-making
confirmation bias, for example, is one area. Maybe we have a
hearing, which would be, hindsight is 20/20, but if you look at
the role of confirmation bias, that simple cognitive error is
so profound in getting people to believe that this market
couldn't do what it has done, we might be able to somehow
prevent prophylactic measures, cognitive prophylactics in the
financial markets would be an interesting topic for somebody's
dissertation at some point.
We will have another round, so if you have other comments,
I see Dr. Barrett has something, but I want to make sure we get
to Dr. Bartlett, and then we will come back around.
Mr. Bartlett. Thank you very much. Dr. Barrett, thank you
for your concern about the amount of money that goes into basic
research. We are starving almost everywhere. I regret that we
require you to indicate in your grant application for basic
research where it might have a societal payoff. We ought to be
pursuing knowledge. There will be societal payoff. There is no
way of knowing ahead of time where that societal payoff will
be. But the average American doesn't understand that, and we
have a truly representative Congress.
Dr. Jemmott, your comments were very interesting. HIV AIDS
is a very unique disease. It is essentially universally fatal.
We can slow the process down. It is the only disease I know in
a very long time which would totally disappear in one
generation with appropriate behavioral change. Isn't that true?
Dr. Jemmott. Yes. Ultimately it would.
Mr. Bartlett. So your research is enormously invaluable.
Let us get there. It is very unique. Kills everybody who gets
it, but it would disappear totally in a generation with
appropriate behavioral changes. So thank you very much for your
contributions.
Several years ago I was driving and over the radio there
were three reports. Two people had died in New York City from
something that might have been citicosis, and if it was
citicosis, it might have come from dried pigeon manure, so
there was a fairly serious suggestion we might ought to kill
all the pigeons in New York City because two people died.
That same radio report said that there was a report of the
deaths that occurred in cigarette smoking. The last in which I
saw a date was 472,000. By the way, it took cigarettes less
than three days to kill as many people as the terrorists killed
on 9/11. And in that same report there was a report of flying
saucers over Oklahoma.
Well, I thought, gee. If I was coming here from somewhere
else, and I saw a society where two people died in New York
City that might have had citicosis, and if it was citicosis, it
might have come from dried pigeon manure, therefore, we are
going to kill all the pigeons in New York City. And 472,000
people died from cigarette smoking, and they were still
advertising cigarettes. I think I would want to fly around a
bit, too, before I landed.
This is just insane, isn't it? You know, I can't yell fire,
fire in a crowded theater because somebody might get hurt
leaving. And yet they can advertise cigarettes to my grandkids
and my great-grandkids when it kills 472,000. Is there any
logic in that?
I just can't see the--see, I don't, if you want to smoke,
you go ahead and smoke, but I want no cigarette advertising. If
I can't yell fire in a crowded theater, you can't have
cigarette advertising. Buy it if you wish, but it is dispensed
from under the counter in a brown paper wrapper with skull and
cross bones on it. A rational society I think would do that.
Dr. Koenig, you mentioned the increase in lifestyle from
those who are religious. I am a Seventh Day Adventist, and we
and Mormons live seven years longer than the average. I don't
know that other people are less religious than we. Don't you
think lifestyle has a whole lot to do with that? Because we
have a very different lifestyle.
Dr. Koenig. Yes. Absolutely. Lifestyle, behaviors, and it
starts from childhood on, the way kids are taught and the
decisions that they make with regard to their sexual practices,
their drinking, their smoking, everything. Studies show that
religious youth are more likely to sleep better, more likely to
take vitamins, more likely to get regular health care, regular
dental care. Religion impacts in so many ways in terms of their
health, their healthy lifestyles, their health behaviors, their
decisions.
Mr. Bartlett. Then why are we so hesitant politically to
talk about religion when it has so many positive benefits? Why
are you kind of relegated to the, well, not lunatic fringe, but
some fringe, and if you talk about religion and you are in
politics.
Dr. Koenig. It's the same way in health care. You talk
about religion, you are immediately marginalized.
Mr. Bartlett. Yeah. Why is that?
Dr. Koenig. I don't know.
Mr. Bartlett. Any of the rest of you have any observations
why you are marginalized wherever your discipline is when you
talk about religion?
Dr. Barrett.
Dr. Barrett. Well, you know, a couple of years ago a major
social, the major research conference in social psychology,
people asked this question exactly. They asked the question of
you could count, why is it that you can count on one hand the
number of social science, social psychologists who study
religion when it is, you know, a foundational aspect of many,
in fact, now we hear most people's lives certainly in the
United States. And, you know, I think that the answer that
people came up with at this meeting was multi-faceted.
First of all, it is often, you know, science often
overlooks the most obvious things. I mean, overlooks the things
that are right in front of you and that seem most obvious.
Right? Nobody, very few people actually do research on the
psychological impact of touch, yet we touch each other all the
time. We shake hands, we pat people on the back, we hug our
children. You know, there is not a lot of research on this
topic even though it is a very, very basic thing.
But also for some reason it, you know, there is a certain
stigma to, there has been a certain stigma, the same kind of,
to religious, to public discourse about religion in the same
way that there is stigma for lots of things that seem natural
and obvious. I mean, paradoxically like sex. And so the reason
why there is stigma I don't think anybody really understands,
although people are interested in this topic and are starting
to study it. But there is, you know, sociologists and social
psychologists have a lot of understanding about stigma and how
it influences behavior.
The irony, of course, is that the federal funding agencies
are not funding that. They don't fund research on stigmas so
much anymore, and if they do, it is in very limited pockets.
But it is a topic that has been around in social psychology
both from a social standpoint and from sociology for, really
for 100 years.
Mr. Bartlett. Thank you, Mr. Chairman. We might look to
Hollywood for a little of the problem.
Chairman Baird. And for the problem with smoking, Dr.
Bartlett. It is amazing the implicit message about smoking that
has come through Hollywood in recent years. You can't advertise
cigarettes on television, but you can sure show every actor
that the kids look up to smoking a cigarette in almost every
scene anymore.
Dr. Kenkel, I particularly appreciated your comment, I will
recognize myself for five minutes. We will do a second round
and then--about it is not what you know that is so much
trouble, it is what you know that ain't so. One of the great
values of the social science research is the counter-intuitive
finding. I remember some years back there was the program
called Scared Straight. This was the idea that we were going to
take kids and put them in, kids, juvenile offenders, we were
going to take them to the really hardcore, I think they did
this in Rahway, New Jersey. They were going to take them and
scare them to death, and this was, got a national TV show about
it and there were programs initiated in State Legislatures
across the country. And then, thank goodness, some social
scientist actually did some follow-up research, and if my
recollection serves correctly, the kids who had gone through
the Scared Straight Program had a higher recidivism rate than
the kids who hadn't.
And the counter-intuitive was a lot of people thought,
well, we will take those kids there, and we will scare them to
death. The kids apparently thought, gee, I want to be a bad,
tough guy like those guys in prison, and the case is true in
some of our interventions. There is some fascinating research
about on the economic, behavioral economic realm recently about
if people have paid a certain amount, does that provide a
disincentive or a justification.
And so I commend you for raising this issue, because
sometimes it is not confirming what we think it would be but
disconfirming the so-called common sense assumption.
Tell us a little more about this advertising of smoking
cessation products. Flush that out a little bit for us. It is
apparently illegal to advertise these things, but if we did, we
could save a lot of lives. Again, back to Dr. Bartlett's
paradox, I am sure that was a negotiated deal with the
cigarette companies probably but----
Dr. Kenkel. Well, it is no longer illegal. Actually, the
irony of the advertising situation was one of the first things
that attracted us to the topic. We are looking at magazine
advertisements for these products back in the 1990s when most
of these products were by prescription only. And because they
were by prescription only, when, a company could advertise say
the nicotine patch, but then they would have to have a full
page of fine print disclosure of all the contraindications
about how bad nicotine was for you.
At the same time in the same magazine, the next page, you
could have an advertisement for Marlboro's, anther nicotine
delivery system, and they only had to have that tiny little,
you know, Surgeon General's box. And so we looked at this
thing, you know, why is it that we seem to be regulating the
ads for the products that will help us quit smoking and making
it more difficult to advertise them than we are advertising for
the actual products we are trying to get rid of, you know, in
the public health approach.
So we actually looked at sort of two aspects of our
research on the smoking cessation advertising. One that I
mentioned in the testimony earlier was that when people see
more of these ads on, in magazines at first, and we are
extending the research to look at television ads, it really
does seem to be, help stimulate them to think about quitting.
And interestingly enough a lot of the times when they think
about quitting after they use, they see the ads, they don't
necessarily even use the product, which in economic jargon is
sort of a positive externality, the idea that some of the
social gains from the advertisements, the firms are not
managing to gather as higher profits, but they are doing,
improving public health.
Now, the earlier part of our research also looked at the
effect of the regulations on the firms' decisions to advertise
themselves, and we found that when products went from
prescription to over the counter, this changed the way the
advertisements are regulated and made it a lot easier to
advertise, and therefore, the firms advertised a lot more. So
when you start putting those two things together, you realize
that the way we were regulating prescription products for
smoking cessation actually probably worked to discourage
smoking cessation.
Chairman Baird. But you now can see, so that is no longer
an issue.
Dr. Kenkel. Yes. So now most of the products are over the
counter----
Chairman Baird. Okay.
Dr. Kenkel.--and that is why they are all, but you see the
same thing going on now, you know, another possibility, we
haven't done this research yet, would be on things like the
statins for cholesterol reduction. A lot of the statin drugs
are going to still be by prescription only, and therefore, they
are relatively difficult to advertise. And it is not clear that
perhaps the public health goals might be better served if we
made it easier to advertise things like statins as easy as it
is to advertise the Big Macs that give us the cholesterol in
the first place.
Chairman Baird. Dr. Koenig, I appreciate your testimony
very much, and I think there has been attention in the social
sciences, pro and con. I mean, it is also true that some of the
criticism of studies, for example, in the realm of Dr.
Barrett's research and literacy, emotional literacy, can also
be opposed on the religious side. In other words, there are
some religious institutions that pass out to their parishioners
lists of key terms that say if your child is going to school
and they use the word, emotional literacy, well, that is
covert, secular humanism, and I mean, these things, a little
less so today, but some real counter attacks and issues of Dr.
Jemmott's type of research. Using a condom is implied to
instill, to promote sexual behavior, so, therefore, it is
abstinence only. The debate is not about whether, the real
debate, the substantive debate is not about whether abstinence
can prevent sexually-transmitted disease. By definition it can.
The question is does abstinence only have superior outcomes to
abstinence with education about responsible decision-making,
appropriate use of prophylactics, et cetera.
Can you comment on the dual nature of that tension and how
we can be sort of more respectful of the positive contributions
on both sides.
Dr. Koenig. Yes. There are plenty of negative effects that
religion can potentially have, and those are really
understudied as well as the positive effects. There has been
such a resistance, though, within the field of science to study
anything about religion at all because of this conflict between
religion and science. And to try to better understand part of
it in the mental health field, as you may know, you know, our
profession has, if anything, been negative towards religion. It
has excluded it. Freud said it was a neurotic obsession, and it
was unhealthy, and you did, you got psycho-analyzed so that you
would get rid of it, and you would be healthier.
Chairman Baird. Well, Williams James didn't.
Dr. Koenig. Williams James. No. He was in favor of or he
described the phenomena in positive ways. And that created this
whole negative view towards religion, and even within medicine
today the only time it comes up is when there is a conflict,
when there is an issue of abortion or a Jehovah Witness refuses
blood products, and then it comes up in the discussions in the
teaching centers. But otherwise these positive effects that we
have been talking about are ignored largely because there is
fear to talk about it, to get involved in it.
And so we need education. Education is critical for health
professionals, for researchers to help them study this area
that is so common and has an impact one way or the other on
public health.
Chairman Baird. I really appreciate your presence and
compliment Dr. Ehlers for identifying this aspect of the
hearing today.
And would recognize Dr. Ehlers for five minutes.
Mr. Ehlers. Thank you, Mr. Chairman, and just continuing on
that topic, it has always been a real puzzle to me since I came
to Washington, if you read the documents on which this nation
is founded, it is very striking, and not just the documents
founded on but the writings of Jefferson, Adams, and so forth.
Very explicit references to the religious faith constantly.
And today it is the opposite attitude, and I don't know
whether to blame Freud or someone else. But it is, you know,
the founders were so eager to defend religion they had the
First Amendment guaranteeing freedom of religion. Today is
seems to be trying to have freedom from religion. And I don't
understand the phenomenon myself.
I have to comment on Dr. Bartlett's comments, my good
friend, who, when he talks about religious stigma and then
Hollywood, reminds me of a friend of mine who is a movie, in
the movie industry in Hollywood and frequently is asked to come
to cocktail parties generally on a Saturday night, and one of
his favorite things to do is to go around the room and talk to
the actors and directors and all those and ask them a simple
question. What percentage of the people in America do you think
will be in church tomorrow morning? And then a number of years
of doing this the highest percentage that was ever given him
was 10 percent. The average was two percent. As you said it is
over 50 percent.
There is an incredible disconnect between the Hollywood and
reality. But it is not just Hollywood. It is a lot of people
who feel the same way.
In relation to your comments about the relationship of
religion and health, we have a mental hospital in my district,
which was founded by the denomination I happen to belong to.
That is neither here nor there, but they started it years ago
and was designed to take into account this relationship between
religion and mental health. They are now, I believe, the second
largest mental hospital in the United States. And they don't,
they are not restricted to religious people coming there, but
they have a lot of people coming there just because they
provide such excellent care. And that is one the factors, and I
thought you might be interested in that.
Dr. Barrett, oh, I have to comment, too, about the pigeons.
I suspect the real reason everyone wanted to kill the pigeons
had nothing to do with the disease carried. I live in an
apartment building. It is just, my balcony is constantly
littered.
In any event, back to work. Dr. Barrett, this morning I
heard on NPR a story about, which relates to what you are
saying, about treating ADD, and that they found very frequently
doing it without medication worked better as long as you, they
say use the sorts of things you talked about. And so it is
interesting to see that idea reinforced right here in your
discussion. Just dealing with, and I wouldn't call it emotional
literacy so much as just helping students cope with the real
world, which is so different from their imagined world. So I
thank you for reinforcing that.
I had one other question, which slips my mind at the
moment, and so I will simply pass at this point. Thank you.
Chairman Baird. Dr. Lipinski.
Mr. Lipinski. I am sitting here, and I have somewhere else
I was supposed to be at 11:00, but I couldn't drag myself away
here.
So I am going to come back and ask everyone else. I asked
Dr. Kenkel about his recommendations for what we should be
doing in terms of funding and where we should be at, you know,
funding for what research would be helpful. But I wanted to
start out, you know, it can't be, we can't have some social
scientists without having any questions about measurement and
about variables.
I want to ask Dr. Koenig about, I know you are looking at a
lot of different studies, but I keep coming back to you, how
exactly do they measure whether, is this a dicogless variable,
someone is religious or spiritual or they are not? Or is there
a, you know, is this some sort of scale of how religious or
spiritual someone is? That sort of thing really stuck out. I
was wondering how is this, how is it usually considered?
Dr. Koenig. There are many ways of measuring religious and
spiritual involvement. There is a book called, Measures of
Religiosity, that has literally hundreds of measures with
psychometric properties, all in this one place. It is
oftentimes measured by church attendance, which seems to be a
proxy for level of involvement in religion community. It can be
measured in terms of a very simple question of how important
religion is to you: very important, somewhat important, or not
important.
It can be measured with multi-item scales. There are many
different scales. There is an intrinsic religiosity scale that
has ten items that tries to capture to what extent the person's
faith the object of their ultimate concern? Does it inform
their decisions in life? To what extent does it direct their
life and their life's decisions?
So there are measures of quantifying, and it ranges from 10
to 50, and you can then look at relationships with all sorts of
mental and physical health outcomes.
Mr. Lipinski. So, obviously that is going to have a big
impact on, well, the measure is going to be based on probably
the theory of what the mechanism may be and then that is going
to have a big impact. It is hard to bring all of those together
and sort of make a summary and try to talk about mechanisms
when you have all these different measurements that are out
there. And I just want to throw that question out there. I am
not trying to, you know, knock down. I just wanted to get some
sense from you about that.
So let me turn back to the other question, if anyone else
has any comments. Dr. Barrett.
Dr. Barrett. Thank you very much. I have a lot of comments
about this, so I will just try to keep it brief. I mean, I
think that money, you know, investing money in individual labs
or in research centers that tries to enhance social and
behavioral research is great. You know, I work with economists.
I collaborate with neuroscientists. I collaborate with
neurologists, so creating spaces for people to have
interdisciplinary discussions is great and important.
But I think that there are other ways in which the Federal
Government can invest that are really important and are
lacking. For example, just having a well-trained, well-educated
workforce, scientific workforce, we no longer really have that
anymore in America. Most of the people that I know and this is
also true for my own lab, have difficulty getting the post-
doctoral fellows that we need to work on research projects,
whether it is within a discipline or across disciplines, from
the United States.
Right. I just recently hired four post-doctoral fellows,
one of whom is from the U.S., and one is from Japan, and one is
from China, and one is from France. Now, I am all for
diversity, and I think it is wonderful, and I am not, you know,
saying that we shouldn't have these kinds of collaborations
across boundaries, national boundaries, but we really, there
are just not enough people who are trained. There are not
enough people who are trained within a discipline, let alone to
be able to cross disciplines easily. And we don't pay people
sufficiently so that the best minds come to science instead of
going into finance, although the current situation might change
things.
But, you know, in addition to which I think some of the,
there are real technological issues that have to be addressed
that will allow basic social and behavioral sciences to
interface with other disciplines, let us say for example
neuroscience. So right now if you are interested in
understanding how the brain creates behavior, you can measure
behavior outside a scanner and then you put somebody into a,
you know, a scanner that will image their brain where they have
to lie completely and utterly still. Right. You can, and you
can get really good measure of where neurons are activating in
the brain, but you can't measure the time course of the
activation. And it turns out that, you know, it, the brain,
neurons don't turn on and off like light switches. There is
this constant, you know, over milliseconds the pattern of
neuronal activity changes, and these, you know, millisecond to
millisecond changes are really important for understanding how
the brain is producing particular behaviors.
So these are challenges that, you know, our country faces
if we want to move forward in a significant way, and I would
also point out that, you know, I live in Boston, where there
are a total of 12 research magnets that can do neuro-imaging,
and there are, you know, I don't know, probably a thousand
people who do research on this topic where they are trying to
understand how the brain produces behavior. And there is very
little access, you know. Even at an institution where, you
know, there, I have a lot of federal funds and people's desire
to be helpful, I have trouble actually getting access to the
machinery that I need.
So it is not just about funding labs. It is about creating
a workforce and creating the tools, and I think we have a lot
of work to do on both of those fronts.
Mr. Lipinski. Anyone else have any, want to add anything?
Dr. Jemmott. I would like to add something with regard to
the area of HIV. I think there are three different things that
are needed. One is more research on dissemination. We have been
conducting HIV prevention research for quite a while in the
United States, and we have a large number of efficacious
interventions, but yet we are still seeing very high rates of
HIV.
And part of the problem is that these efficacious
interventions are not being used in the community. And so we
need to understand why. We have to understand why interventions
are adopted and why they are not adopted. We need more research
on that.
We need more research on how a community can take an
intervention and adapt it so that it is more suitable for their
population, and that will include an understanding of what are
the critical ingredients of an intervention that cannot be
changed and which things can be changed.
And then the third thing is to look at the issue of the
effectiveness of the intervention when it is outside of sort of
the social science laboratory where you have highly-trained
facilitators, and it is very tightly controlled. In a real-
world environment is it still going to be effective and what
are the factors that determine whether it is going to be
effective in those settings or not. So that is a whole area,
dissemination.
The other thing I would say is even though we have a lot of
interventions, we don't have interventions for one critically-
important population, and this is the population that is the
population that is the highest-risk population in the United
States. It is African-American men who have sex with men. They
have rates of HIV that rival those that we see in sub-Saharan
Africa. And yet to this day we still don't have an intervention
for them that is based on a randomized, clinical-controlled
trial. So we need more research on that.
And then the third thing I would say is a controversial
area that has come up, and that is the issue of abstinence
only. We are spending tremendous amounts of money for
abstinence only programs, but the data are just not there. We
have a lot more data on efficacious, sort of comprehensive
education programs. Where on abstinence only there is hardly
any. And I believe that it is possible to develop abstinence-
only interventions that can be efficacious, but the problem is
there is not much research going on right now on that issue. So
there really needs to be a lot more research on abstinence-only
interventions, especially given that they are so widely used
and so widely encouraged.
Mr. Lipinski. Is there a reason there isn't that research,
abstinence-only?
Dr. Jemmott. I think that most researchers haven't really
been interested in it. They are of the mindset that, you know,
young people are going to have sex. It is impossible to get
them to stop. I think that is probably part of the reason. Some
people promote abstinence from a religious perspective, and
many researchers are not very religious, you know, so that is
not going to motivate them to promote abstinence.
So it is not seen as an efficacious strategy, but it
actually hasn't been tested very rigorously.
Mr. Lipinski. Thank you. Dr. Koenig, anything to add there
if the Chairman will allow?
Dr. Koenig. Yes. I appreciate exactly what you are saying,
particularly about the fact that scientists are not very
religious, and so when you are looking at the NIH or the
National Science Foundation, you are looking at review sections
that are made up of scientists who are in many respects biased
against any traditional form of religious practice or activity.
If you have a kind of a new age spirituality or a fringe area
of alternative or complimentary medicine, they will fund those
in a heartbeat. But if you even mention the word of God or
anything related to God, it, immediately it turns sour. So I
think in some respects making some interventions in order to
overcome some of the bias on the review sections at the NIH and
at NSF would be very helpful.
Also, having awards or having programs where you train
young investigators or senior investigators to conduct research
in this area, provide them with the expertise to conduct the
research. I think that would have big payoff in terms of them
being able to write adequate grants that are competitive for
funding.
Mr. Lipinski. Thank you.
Chairman Baird. I will recognize Dr. Bartlett. I would just
note, though, in the context of this discussion, the vast
amount of federal money that has been going towards abstinence-
only education based on scant research. We tend, and when Dr.
Ehlers was saying earlier, a little bit too much, in my
judgment, of this argument that there is an anti-religious
sentiment certainly in the Presidential debate of late, and
always the religious factor plays heavily. And I would say the
abstinence-only advocacy and the vast funding that is going
towards it in this country and internationally is driven not
based on empirical basis but based on religious belief.
And so on the one hand to say, well, we discriminated
against religion in our scientific practice, and yet we mandate
taxpayers to fund an intervention strategy that has at present
relatively scarce demonstrated efficacy but is driven by a
largely philosophical/religious. And then so we mandate that
funding but then we say there is an anti-religious bias. That
is a bit inconsistent. I would just, for the record suggest,
and while we ought to study the efficacy, if those studies of
efficacy give us differential results, we might want to modify
our policy in some way, and that is a difficult thing. If the
basis for the policy advocacy was not an empirical position but
an ideological one, that is a challenge for us.
Dr. Bartlett.
Mr. Bartlett. Thank you very much. Dr. Kenkel, you
mentioned that half the deaths in our country come from
tobacco, sedentary lifestyle, and obesity. One would suspect a
cause-effect relationship between the last two of these. I
think some very bad trends started in our country when the
economy and keeping up with the Jones drove the mother out of
the home, into the workplace and replaced her with the
television set.
The first thing that happened was that there is a very
positive relationship between the number of television sets in
the country and the degree in SAT scores over 24 years. They
still rattle around in the basement, and they are not coming.
They are not coming up. Of course, as the kids sat in front of
the television set and nibbled on fast foods, obesity became a
problem.
I understand that the next generation of Americans for the
first time ever may live less long than this generation,
primarily because of obesity. I tell audiences, this is a
really great country we live in. The biggest health problem of
our poorest people, those on welfare, is obesity. Now, isn't
that a great country? That is really sad, isn't it, that we
have that relationship.
When you ask Americans do you think your kids are going to
live as well as you lived, and a vast majority of them say, no.
And when you ask people, do you think your country is on the
right track or wrong track, more people than ever in our
history today think that their country is on a wrong track.
What can we in Congress do about these things? Which is why
we are here today. Let us just start with Dr. Barrett. If you
have a comment on the last exchange, I would be happy to have
that, too.
Dr. Barrett. I have comments on almost every comment that
has been made. I am trying to sit here and not make them. I
would suggest, I mean, the comment that you just made, you
know, it seems to me that the fact that obesity is a major
health challenge in the United States and that the children,
our children are not going to live as well as we do may have
something to do with the fact that mothers are no longer at
home or the fact that fathers don't stay home.
But it also has to do with the fact that if you walk into a
supermarket, you, you know, there is a very narrow strip of
fresh fruit at one end, and at the other, and the rest of the
supermarket is filled with things that are bad for you.
And my understanding from, you know, scientists who study,
social and behavioral scientists who study obesity is that this
problem has a lot to do with the fact that, the way that food
is marketed, what food is available, and the fact that
carbohydrates apparently, you know, which are very, you know,
very bad for you, you know, actually trigger the same kind of
process as an addiction to other kinds of things that are bad
for you.
So it seems to me that this example is an example of a
problem that isn't going to have a quick fix, that there are
multiple causes and multiple factors that need to be addressed
and that there is not going to be any single kind of quick fix,
which I think brings to the forefront the point that a lot of
us have been making today and that I think is a sympathetic,
people are sympathetic to, and that is that, you know, sciences
have to work together, no science can solve the problem. Right.
There is not going to be a pill that, you know, solves, that
cures obesity. You are not going to find a gene that cures
obesity. It is not going to just be providing people with
cheap, you know, produce that will, you know, cure obesity. I
mean, none of those things in and of themselves are going to
solve that particular problem.
I would say that I think as a general rule one of the
reasons or at least what I see is that this is a country that
is anti-intellectual compared to other countries but doesn't
understand science. It doesn't, really deeply just does not
understand the value of science for producing better outcomes
in life. And some of that has to do with education and, you
know, at all levels, just, you know, how well do we train our
students about science, how well do they understand what
science can really do for you?
Some of it has to do with, you know, actually what I have
been hearing today a little bit, which is, you know, I have to
disagree, Dr. Koenig. I sat on review panels, grant review
panels for the past 10 years. I sit on the editorial boards of
almost every major psychology journal in my field, and I have
never seen bias against questions of religion. What I do see is
what I also see here today, which is that all of us are the
product of the Enlightenment. You know, we are all the product
of the belief that faith is something different than reason,
that reason has, it is not Freud's fault. I mean, a lot of
things are Freud's fault, but that, this isn't Freud's fault. I
mean, you know, it goes all the way back to Descartes and even
further, that, you know, we believe that reason is something
different than faith, that cognitive things, you know, that we
could solve the current economic crisis by looking at cognitive
mechanisms, when, in fact, we know that within the brain
cognition and emotion are intimately entwined and that some of
the things that Canaman and Diversky discovered are actually
emotional effects, that, you know, we just, we don't, that we
use these kind of common sense beliefs in the kinds of
questions we ask and the kinds of things that we fund, and it
has consequences in, for, you know, in the end, for the
outcomes of our children.
Mr. Bartlett. Mr. Chairman, thank you very much for a good
hearing, and thank you, panel. What we really need, of course,
is a cultural change, a culture gets what it appreciates. You
might ask yourself how often does the White House invite an
academic achiever there to slobber all over them the way they
do sports figures and entertainers.
Thank you very much for a good hearing, sir.
Chairman Baird. Thank you, Dr. Bartlett, for your insight.
We are almost finished, but if there is any final comments
anyone wants to make, I would like to open that up very
briefly. We don't have--Dr. Koenig.
Dr. Koenig. I have actually a comment with regard to Mr.
Bartlett's question about obesity future lifespans.
You know, it is interesting that the demographic that you
are talking about with the highest rates of obesity is also the
same demographic that has the highest rates of religious
attendance. These people are at all ages in churches, half of
them, more than half every Sunday. So what a marvelous place
potentially to take advantage of some of this science that,
with regard to health education within churches concerning
diet, concerning exercise, concerning lifestyle changes.
And you cut your populations right there. How can you
motivate churches to develop these faith, health ministries
where they address these issues in the congregation that could
extend longevity, that could reduce the need for health
services. Religion and medicine and health care are parallel
ways of enhancing health in many respects, but they are just
not communicating.
Chairman Baird. Dr. Kenkel.
Dr. Kenkel. Actually I would like to also say something
very quickly, and I think it actually compliments several of
the other comments here about the role of information as
providing consumer incentives. We, and how that could play out
with obesity and perhaps, you know, with the religion education
or with various other dissemination of information.
And I was struck a few years ago when the Atkins Diet came
out how quickly all of a sudden there were all sorts of low
carb products just all over the place. And this is an example
of, you know, the economist sees this as an example of how the
market responds with what consumers want. What happens, though,
is we have to be sure that the consumers get the information
that helps them want healthy things.
And one of the comments made earlier by Mr. Bartlett was
that the high prevalence of obesity among low socioeconomic
status, you know, among the poor, that is also very true for
smoking, and we are coming up with a situation where, you know,
increasingly some of these big health problems like obesity and
smoking and others are really confined to people with low
education, low income, and at the same time for people at the
higher incomes who have access to all these great products and
all the great information, we can become increasingly healthy.
And so this, a lot of interest in disparities in health
linked to these kinds of behaviors and trying to figure out
interventions, again, that could help eliminate those
disparities and motivate people that are, the groups that are
in the most need of getting this information to use these new
products I think is a very exciting area for public policy and
research.
Chairman Baird. It has interesting foreign policy
implications in the developing world we have gone in many
cases, there is still starvation, but in many developing
countries we have gone from the leading death cause is not
starvation but the non-communicable diseases like diabetes,
obesity, cardiovascular, and things.
Dr. Jemmott, did you have a final comment?
Dr. Jemmott. I would just say that I agree that we should
focus on obesity and sort of food consumption, nutrition, et
cetera, but I think we should also remember that physical
activity is very important as well. And I think a lot of
Americans know a lot about, you know, food and what they should
eat and shouldn't, and should not eat, but when it comes to
physical activity, they don't know how they can fit it into
their daily routine, yet it is so important.
So it seems like we need to have more focus on that as
well.
Chairman Baird. Again, I thank the panelists and the folks
in attendance today. Thank my colleagues. With that the hearing
stands adjourned. I am grateful for your presence. Thank you.
[Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]
Appendix:
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Additional Material for the Record
Statement of David B. Abrams
Executive Director
The Steven A. Schroeder Institute for
Tobacco Research and Policy Studies
American Legacy Foundation
There is strong evidence that half of all deaths in the U.S. can be
attributed to behavioral factors such as smoking, poor diet,
overeating, and physical inactivity. In addition, behavioral and social
factors contribute to the staggering costs of preventable morbidity and
mortality.
Even with the dramatic contributions that behavioral and social
sciences research has made to date, much more needs to be done to
understand the role of behavioral and social factors in disease and, in
turn, to use that knowledge to improve the Nation's health.
Behavioral and social sciences research is critical to improving
public health overall, but is especially important in addressing youth
smoking prevention and adult tobacco cessation. Tobacco use is the
single most avoidable cause of disease, disability, and death in the
United States. Eighty percent of all smokers have their first cigarette
before age 18 and 90 percent start smoking before age 20. Within days
or weeks of smoking your first cigarette, symptoms of nicotine
dependence may appear. Although nearly half of all smokers attempt to
quit each year, less than five percent are successful, with the
majority going back to smoking within just seven days.
As we examine how to reverse the tobacco epidemic in this country,
we must pay special attention to the role of behavior change. Young
people are especially vulnerable to the advertising tactics of the
tobacco industry and their power to affect behavior is undeniable.
Last month, a new report from the National Institutes of Health,
Monograph 19: The Role of the Media in Promoting and Reducing Tobacco
Use, concluded that much tobacco advertising targets the psychological
needs of adolescents, such as popularity, peer acceptance and positive
self-image. Advertising creates the perception that smoking will
satisfy these needs.
The report also concludes that mass media campaigns can reduce
smoking, especially when combined with other tobacco control
strategies, lending further credibility to existing media campaigns
that have been proven to curb youth smoking, such as the American
Legacy Foundation's award-winning truth campaign. In its first two
years, truth was credited with 22 percent of the overall decline in
youth smoking, but the annual budget for truth is less than the $36
million our competitors in the tobacco industry spend in just 24 hours
to market their deadly products to consumers in the U.S.
Behavioral and Social Sciences have also provided effective smoking
cessation treatments for tobacco dependence as well as for other
addictions and mental illnesses like depression and anxiety. The
national smoking cessation campaign called EX is geared to taking what
we know and reaching the 45 million current smokers--the majority of
whom want to quit, but have not accessed the available effective
resources in previous quit attempts. Despite the concerns of the
obesity epidemic and the escalating costs of health care, we should not
forget that tobacco use is still the single biggest preventable cause
of death, suffering and excess cost to our health care system.
Investments in behavioral and social sciences have paid off. We
have contributed to child health and human development, to improving
quality of life as we age, and we have cut HIV-AIDS incidence in half
in less than 20 years, and many other examples, using principles and
practices of Behavioral and Social Science. We know a great deal about
how to reverse the type 2 Diabetes epidemic. However, putting what we
know into practice and policy has fallen far short of what is needed
and could be achieved to improve our nation's health. If we put all of
what we know in behavioral and social sciences into practice and policy
at every level of health care and public health delivery, we could
dramatically reduce chronic disease burden, disability, death and huge
preventable expenses to our nation. We can do this with what we know
today.
Despite considerable success over the past decade in tobacco
control, tobacco use still accounts for nearly one-third of cancer
deaths in the U.S. and worldwide, and tobacco-attributable mortality is
predicted to increase in the coming decades if current smoking patterns
continue. Tobacco use is also a major contributor to heart disease,
pulmonary disease and it complicates and makes worse almost any other
disease. If this trend is to be reversed, an in-depth understanding of
the behavioral and social factors that underlie tobacco use as well as
effective prevention and treatment efforts must inform the debate and
guide the way to effective policy changes. Behavior change is at the
center of the translation of new discoveries in the biomedical, socio-
behavioral, and population sciences into practices and policies to
improve our nation's health.
The Steven A. Schroeder National Institute for Tobacco Research and
Policy Studies at the American Legacy Foundation advances the science
behind social marketing, smoking cessation and tobacco control policy
to facilitate the translation of empirical findings to practical public
health interventions. The American Legacy Foundation is dedicated to
building a world where young people reject tobacco and anyone can quit.
Located in Washington, D.C., the Foundation develops programs that
address the health effects of tobacco use, especially among vulnerable
populations disproportionately affected by the toll of tobacco, through
grants, technical assistance and training, partnerships, youth
activism, and counter-marketing and grassroots marketing campaigns. The
Foundation's programs include truth, a national youth smoking
prevention campaign that has been cited as contributing to significant
declines in youth smoking; EX, an innovative public health program
designed to speak to smokers in their own language and change the way
they approach quitting; research initiatives exploring the causes,
consequences and approaches to reducing tobacco use; and a nationally-
renowned program of outreach to priority populations. The American
Legacy Foundation was created as a result of the November 1998 Master
Settlement Agreement (MSA) reached between attorneys general from 46
states, five U.S. territories and the tobacco industry. Visit
www.americanlegacy.org.