"Social and cultural factors play a central role in preventing illness, maintaining good health, and treating disease," observed Acting National Institutes of Health (NIH) Director Ruth Kirchstein, welcoming more than 1,000 participants to the groundbreaking NIH-sponsored conference, "Toward Higher Levels of Analysis: Progress and Promise in Research on Social and Cultural Dimensions of Health," held June 28 - 29 on the NIH campus. Kirchstein expressed her "delight" at being the keynote speaker at a conference centered around social and behavioral factors and their impact on health.

The conference, sponsored by NIH's Office of Behavioral and Social Sciences Research (OBSSR), was designed to: 1) highlight the contributions of social and cultural factors to health and illness to achieve a better understanding of the interdependence of social, behavioral, and biological levels of analysis in health research; 2) examine the state of science in the area of sociocultural constructs such as race, ethnicity, socioeconomic status (SES), and gender; 3) examine the influences of social and cultural factors as well as interpersonal, neighborhood, and community influences on prevention, treatment, and use of health services; 4) examine the current status of issues related to health justice/ethics and perspectives for global health; and 5) provide recommendations for future research directions.

"There Is More to Health and Life than the Genome"

Kirchstein noted that the timing of the conference was "particularly apt" given the announcement the previous day of the completion of the mapping of the human genome. "There is more to health and life than the genome," she said. The OBSSR conference puts the entire activities of the NIH biomedical, behavioral, and social science into context, allowing for a more complete picture. Kirchstein commended the Conference's co- chairs: Christine Bachrach of the National Institute of Child Health and Human Development, and David Takeuchi of Indiana University, along with the planning committee which included representatives from eleven NIH Institutes and three outside social and behavioral science organizations: COSSA, the American Anthropological Association, and the American Sociological Association.

Kirchstein emphasized that research has shown that individuals' social environment, their family, neighborhood, schools and workplaces, have a "profound impact on health." She added that individuals' socioeconomic status (SES), regardless of their economic condition, as well an their gender, race and ethnicity, have been consistently linked to health outcomes. We know that a person's social ties, the quality of social relationships, and social resources can "mediate the effect of stress on health," said Kirchstein. Further, as a result of social and behavioral science research, she continued, "we know that cultural factors influence how we view, diagnose, and treat both physical and mental illnesses."

She observed that by examining the contributions of social and cultural factors to health, "including the influence of social structures and social processes, we can attain a better understanding of how to prevent illness and treat disease." By analyzing these two factors along with behavioral and biological factors allows for a more complete picture of the total person and what contributes to positive health outcomes, she added. This multifaceted effort, said Kirchstein, will allow the Nation to better attack the most difficult health problems it faces.

Highlighting her anticipation of achieving the administration's goal of eliminating health disparities, Kirchstein underscored that "research on social and cultural factors is a vital part of [NIH's] efforts to understand health disparities, and critical to understanding the etiology of health and illness in general." She further observed that NIH's commitment to improving health for all Americans requires 1) a better understanding of the influences of the social and cultural environment on health, 2) an examination of the social processes and social structures that affect health, and 3) support of the development of an integrated understanding of how social, cultural, behavioral, and biological factors combine to produce health and illness. She concluded by calling for the preparation of more scientists for research careers in the behavioral and social sciences; the facilitation of interdisciplinary training among scientists to allow for the understanding of the different methods, procedures, and theoretical frameworks; and improving the dissemination of research to "our immensely diverse world."

"Our time is now," exclaimed the former and first OBSSR Director Norman B. Anderson. Now at Harvard University, Anderson stressed a need to galvanize the field. He reflected that upon his arrival at the NIH five years ago as OBSSR's first director many NIH leaders did not understand how social and behavioral science related to the overall mission of the agency. Basic and applied research in the social sciences, he continued, and its integration with other fields of health science, is critical to the mission of the NIH, emphasized Anderson. Although health science disciplines may be separate conceptually, methodologically, and administratively, the processes about which they are concerned are inextricably linked, he continued.

Echoing Kirchstein, Anderson underscored that social science research, and the interdisciplinary research among social, behavioral, and biomedical scientists will accelerate the progress toward understanding and improving health while ameliorating health disparities. Anderson presented what he termed the "level of analysis" framework, which would allow for such interdisciplinary research. The levels of analysis social/cultural/environmental, behavioral and psychological, organ systems, cellular, and molecular is an attempt to get beyond those artificial distinctions, said Anderson. Emphasizing that the five levels are interdependent, he stressed that an integrated multilevel approach to research may be essential to accelerating advances in understanding health.

The majority of today's research in the health sciences, however, occurs within a single level of analysis and is closely tied to specific disciplines, he continued. According to Anderson, scientists have "reified the distinction" between disciplines as if those differences reflect a true framework. Even when scientists from the different fields collaborate on the same research question, maintained Anderson, it is not always multilevel research. He observed that integrating the levels of analysis has not been completely overlooked in the health sciences, citing cognitive and behavioral neuroscience as examples where the levels of analysis has been applied quite productively.

"Ironically and paradoxically," said Anderson, the completion of the mapping of the human genome provides "incredible opportunities for the behavioral and social sciences." Ultimately, he continued, we will have to answer the question, what turns a particular gene on or off? It will become increasingly clear that the other levels affect the organ and cellular levels. The social and behavioral science community, therefore, has to be ready, "they are coming back to us," cautioned Anderson. He concluded that the conference is timely given that several factors are coming together: the Department of Health and Human Service's Healthy People 2010 initiative, the creation of strategic plans on eliminating health disparities by all of the NIH Institutes and Centers, as well as an NIH-wide strategic plan on health disparities and the Congress' call for the creation of a National Center on Health Disparities at the NIH (See UPDATE, May 15, 2000, #9).

David R. Williams of the University of Michigan provided an overview of select findings that suggest that factors related to the social environment such as socioeconomic status, race, gender, and place are closely related to the distribution of disease and death. Serval of the findings presented by Williams were counterintuitive and paradoxical, highlighting the limited understanding of the mechanisms and processes by which social structures affect health.

According to Williams, the gap in death rates between African-Americans and whites was as large five years ago as it was 50 years ago. Comparing the 1995 leading causes of death among blacks and whites to 1950 rates, Williams observed that in 1950 the death rates for African Americans was 1.6 times higher than the rate for whites identical to what it was in 1995. While the overall death rates have declined for both groups, the racial gap is wider today than in 1950 for several leading causes of death, including diabetes, cardiovascular disease, cancer, and cirrhosis of the liver.

Williams explained that racial differences in economic status play a large part of the black- white health differences. Men and women with higher household incomes have better health than those with lower incomes, explained Williams. "Moreover, the differences in health between high income and low income persons of each race are often larger than the overall differences between blacks and whites," Williams continued. He added, however, that at the same time, at every level of income, blacks tend to have higher death rates than whites. This could reflect the added effect of racism and discrimination. According to Williams "racism can affect health indirectly through institutional policies that reduce employment and educational opportunities for minorities." He also stressed that racism can affect health directly in multiple ways. The stress of experiencing discrimination, and residing in poor neighborhoods, said Williams, can also have negative effects on health, said Williams.

Williams also noted that Asian Americans, 70 percent of whom are foreign-born, have lower death rates for all 10 of the leading causes of death in the United States. He also noted that immigrants of all racial groups tend to have better health than their native-born counterparts, adding that unfortunately the health of immigrants also declines as length of stay in the United States increases.

"Advancing our understanding of the role of the social environment and health," emphasized Williams, "will require careful, theoretical, and empirical work that seeks to (1) characterize the multiple dimensions of the social context, and (2) comprehensively assess potential consequences for physical and mental health." There is a need, said Williams, for multidisciplinary research that identifies and evaluates plausible biological mechanisms for observed social processes. "This comprehensive approach is necessary to facilitate identification of the conditions under which various components of social structure are more or less consequential in predicting specific health outcomes," he concluded.

A long-standing commitment prevented the current Acting OBSSR Director Peter Kaufmann from participating in the two-day conference. In a statement read by Christine Bachrach to conference participants, Kaufmann called the NIH-sponsored conference "visionary" for its attention to the social and cultural dimensions of health. "This conference," said Kaufmann, "is a natural outgrowth of the growing recognition, among biomedical and behavioral scientists alike, that what happens inside our bodies is the result of a unique series of interactions among genetic, biological, psychological, and environmental influences. The social and cultural milieu plays a critical, and increasingly appreciated role in this equation."

"The challenge," according to Kaufmann, "is for the NIH to move beyond appreciating the importance of social and cultural influences on health to fully developing the science that elucidates them, explain how they operate, and translate this knowledge into interventions that can reduce health disparities and improve the health of all people." This, said Kaufmann, requires the development of better methods and models for understanding how social and cultural factors combine with other health determinants to produce health and disease. Biomedical scientists and social and behavioral scientists need to collaborate to develop truly integrated models of health. The work of this conference is an important step toward meeting these objectives, said Kaufmann.

In the months to come, according to Kaufmann, the OBSSR will develop a research agenda to build on the "recommendations and vision" of conference participants. Noting that a draft of the research agenda will be posted on the NIH/OBSSR website (www1.od.nih.gov/obssr/obssr.asp) in the Fall for public comment, Kaufmann encouraged the social and behavioral science community to provide additional comments.

This is part one of a two part article that will continue next issue.

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NIH SOCIAL AND BEHAVIORAL SCIENCE RESEARCH CONFERENCE: PART TWO

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The National Institutes of Health (NIH) held the first ever conference "Toward Higher Levels of Analysis: Progress and Promise in Research on Social and Cultural Dimensions of Health," June 28 and 29 on the NIH campus. The two-day conference covered the full range of social and behavioral sciences, and provided participants with a wealth of information. The following is a sample of the presentations given at the conference. (This is the second of a two part series. See UPDATE, July 10, Number 13, for the first story.)

Race and Health

Robert Hahn of the Centers for Disease Control and Prevention discussed the use of race and ethnicity and social science in Federal policy. To illustrate, he noted that a goal of the U.S. Public Health Service in its Healthy People 2010 initiative is the elimination of health disparities based on race and ethnicity. Hahn noted that there are a number of problems associated with the way the Federal government collects racial and ethnic information, including: categories that are not well defined and not used consistently among Federal agencies, the possibility that categories are not well understood by many respondents, response rates and miscounts that differ substantially among racial and ethnic groups, and persons who report different racial and ethnic identities in different surveys at different times (See UPDATE, 6/2/97, 7/1/97, 9/29/97, 11/10/97).

He stressed that despite substantial Federal effort and some advances in the collection of racial and ethnic information, fundamental problems remain unresolved which hinder efforts to understand and monitor health equity. He concluded that, notwithstanding the difficulty of collecting this information, many anthropologists question the use of race.

Anthropologist Janis F. Hutchinson, University of Houston, explained that the definition of "race" and the identification of different races has been problematic since the inception of the concept. Although discrete biological races cannot be identified, everyone identifies with race, said Hutchinson. Social meanings are articulated through racial identities. Power is also embedded in the construction of racial identities, said Hutchinson.

She observed that racial identities are constructed in five ways: 1) the intersection of race, class, gender, and nationality; 2) the construction of racial identities by those in power; 3) the formation of racial identities in opposition to those in power — a form of resistance; 4) sociality, creates a comradery among people; and 5) everyday experiences. She further noted that since colonial days, racial variation in health has been dominated by a genetic model that views race as a function of biological homogeneity and black-white differences in health as mainly genetically determined. There are no qualitative differences between populations, she argued. Ninety-nine percent of the human genome is common to all people. Further, the definition and meaning of race are not the same everywhere, stressed Hutchinson.

Socioeconomic Status (SES) and Health

"SES is a pervasive and consistent predictor of health," emphasized Ichiro Kawachi, Harvard University. While the socioeconomic distribution of illnesses can sometimes change directions, and various risk factors come and go in the population, the poor have always suffered higher rates of premature mortality and morbidity, said Kawachi. The SES/health relationship, he continued, "occurs as a gradient, and is not confined to poverty." The lower one's position on the socioeconomic hierarchy, the worse one's health status, he said. Adding that there has always been a health gradient, Kawachi emphasized that SES is a neglected dimension in official sources of health statistics. Even when the data is collected, observed Kawachi, it tends to be underreported.

According to Kawachi, there are many different pathways through which socioeconomic advantage "confers better health." Both material and psychosocial factors play a role in giving rise to the SES gradient, he underscored. New advances in biology, he concluded, have contributed to a better understanding of how socioeconomic conditions "get under the skin" to produce health disparities.

Gender and Health

We are born with a biological sex, said Paula England, Department of Sociology and Population Studies Center, University of Pennsylvania. Gender, she continued, arises in part because of social interaction and because people are treated differently because of their sex. This "gender system," said England, operates at many levels, from the micro to the macro. At the micro level, one's sex is transformed into gender because it affects the expectations one encounters throughout the lifecycle. The flow of information and opportunities received across the lifecycle are affected by sex-segregated social networks. Cultural meanings, England continued, about what is valued in men and women appear in jokes, stories, and the mass media. At the macro level, said England, corporate, military, and social welfare policies are affected by gendered assumptions. As an example, England noted that the schedules and demands of many jobs were devised on the assumption that the worker had a full-time homemaker at home.

According to England, links between gender and health defy simple summary. Women suffer from some physical illnesses and from depression, yet they live longer than men and suffer less from other types of ill health. "These seemingly contradictory patterns make sense, given the gendered pattering of opportunities and social structural roles," she said. For example, said England, sex discrimination in labor markets, as well as childcare responsibilities, lead women to have lower earnings and be under-represented in positions of authority. For single mothers, this often means household poverty. For married women, it lowers their bargaining power in marriage. Low power and resources can often lead to stress, depression, and physical ill health.

Socially approved notions of masculinity as "power" and "daring," said England, encourage men to engage in risky behaviors such as violence and substance abuse. This risky behavior, she said, leads to men's higher mortality. On the other hand, England noted that women's embeddedness in networks of emotional support is health-inducing and is a buffer to many stressors.

Culture and Health

Culture, stressed W. Penn Handwerker, University of Connecticut, consists of the knowledge people use to live their lives and the way in which they do so. It is what is in one's head and influences what one does. What is in our head is unique to us. It is shared in specific ways with specific people. Culture makes up a major component of the behavioral ecosystems in which we live our lives. Handwerker said that unfortunately he could not say how this happens. Consciousness comes after behavior, he said.

A "culture," in contrast with culture, said Handwerker, consists of the intersection of sets of labels, definitions, and meanings that we "variously share" with other people. The emotional tone to experience comes from the danger and opportunity signaled by our stress response. Stress thus shapes cultural meaning and induces specific choices that generate cultural replication or evolution. Childhood experiences, said Handwerker, may induce specific forms of adult brain structure and function. Stress-induced "morbidity" may consist of adaptive responses to ecosystems in which children find themselves subject to predation and denial of access to resources. "Resilient" children, he stressed, may exhibit high mortality.

Further research, said Handwerker, is needed to identify and characterize 1) the stressor dimensions and specific health effects of social relations and interaction predicated on power inequalities between and among individuals and social groups; and 2) the effect of various forms of stressors and social supports on children's brains and behavior, particularly their relation to the familiar litany of depression, substance use and abuse, suicide and other forms of violence, sexually transmitted diseases, HIV/AIDS, and teen pregnancy.

Social Capital and Health

According to John Hagan, Northwestern University and American Bar Foundation, "individuals acquire at birth and accumulate through their lives unequal shares of human and social capital that incrementally alter and determine their life chances." Hagan explained that these shares of human and social capital are acquired through the resources of surrounding social institutions — families, schools, and neighborhoods. Because individuals vary in their access to these resources, they must adapt themselves to the institutional and structural circumstances they inherit and inhabit. In less advantaged community and family settings, without abundant institutional resources, parents are less able to supply or transmit opportunities to their children. Using violence as an example, Hagan noted that young people who come from disrupted families or who are failing in educational settings have increased risk of exposure to various kinds of violence — not only neighborhood or street violence, but also self-destructive violence (e.g., suicidal behavior) and intimate partner violence (e.g., romantic relationships).

Gary Sandefur, University of Wisconsin, discussed families, social capital and health, and said that social relationships can provide resources that lead to the enhancement of the well-being of individuals. These relationships — parent-child, spousal, friends, neighbors, coworkers, teachers, among others — provide resources to individuals, including social support and encouragement, access to larger social networks, role modeling, and opportunities to learn and develop. Sandefur also noted that the availability of data, such as the National Longitudinal Survey of Adolescent Health (Add Health), creates opportunities to look at the effects of social capital and parental investments in social capital on the physical and mental well-being of adolescents, as well as other social and behavioral outcomes.

"It is widely recognized that social relationships, social integration, and affiliation have powerful effects on physical and mental health," echoed Lisa Berkman, Harvard School of Public Health. People who are isolated, she said, are at increased risk from dying from many causes of death, she continued. Berkman further explained that social networks and the degree to which individuals are embedded in supportive social relationships are related to many different outcomes, most likely for many different reasons, that need examination.

Religion, Spirituality, and Health

"A large and growing research base indicates that religious involvement typically has beneficial effects on physical health, mental health, and survival itself," noted Linda K. George, Duke University. George observed that currently the most important research in this area is focused on identifying the mechanism by which religious involvement affects health. The search to do so is important for a number of reasons, she emphasized. First, from the perspective of basic science, the search for mechanisms is a hallmark of causal inference. Second, from a public health perspective, if we can identify the mechanisms that account for the relationships between religion and health, it may be possible to "package" those mechanisms in forms other than religion — an important goal because not everyone finds religious involvement palatable, said George.

Neighborhoods and Health

The short term consequences of urban renewal in the second half of the 20th century, said Mindy Thompson Fullilove, New York State Psychiatric Institute, were dire and included the loss of money, loss of social organization, and psychological trauma. The long term consequences, continued Fullilove, "flow from the social paralysis of dispossession and, most importantly, a collapse of political action." This has important implications for the well being of African-Americans. Blacks, as a people, believe themselves to be a group and because of segregation were only able to live in certain areas, she said.

The structure of a city provides the substrate of individuals lives. The issue is to understand what happens socio-geographically during urban renewal. Where do the people go and what happened to them? The bulldozing that accompanies urban renewal, continued Fullilove, displaces people and destabilizes the ecosystem. Showing before and after slides of renewal of such cities as Memphis (Tennessee) St. Louis, (Missouri), and Pittsburgh (Pennsylvania), Fullilove underscored that urban renovation causes destabilizing events, including confusion, disorder, and nonsense. With the tearing apart of the structure you weaken the group. What does this have to do with health?, asked Fullilove. The bulldozing of communities destroys health because individuals are not able to go it alone, she answered.

Robert Sampson, University of Chicago, emphasized the need to study the effects of environment on health. Social characteristics of neighborhoods vary widely by family structure, lifestyle, stability, and SES, said Sampson. Research suggests that multiple dimensions of poor health are ecologically concentrated in disadvantaged neighborhoods. Sampson discussed research that depicts the spatial clustering of health-related outcomes such as violence, infant mortality, and low birth weight. There seems to be a direct link between moving to better neighborhoods and health outcomes. The research, he said, is fairly consistent — inequality in neighborhood is reflected in health outcomes.

Sampson posed the question that if there is clustering, what is it about neighborhoods, above and beyond the attributes of the individuals who inhabit them, that might contribute to various health outcomes? Current research seeks to identify both the individual selection and social causation processes hypothesized by theory to account for why community disadvantages and poor health are seemingly intertwined, said Sampson.

Sociocultural Process and Prevention

There is consistent evidence that social norms affect health-related behaviors such as violence and drug use, noted J. David Hawkins, University of Washington. There is also evidence that broad social norms among adolescents change significantly over relatively short periods of time, and that such changes are accompanied by changes in the prevalence of relevant health behaviors. Further, there is consistent evidence, he continued, that interventions in schools and communities can have beneficial effects in changing norms regarding alcohol and other drug use among middle school students and in preventing drug use during adolescence across a wide range of racial, cultural, and socioeconomic groups.

Noting that obesity, physical inactivity, negative body image, and disordered eating are on the increase among American youth, Mimi Nichter, University of Arizona, emphasized that in order to design appropriate prevention and intervention programs to address these important public health concerns, it is necessary to understand the social and cultural contexts in which these problems arise. Ethnographic studies of adolescents attentive to notions of culturally appropriate body size, patterns of consumption, and attitudes to physical activity, said Nichter, have provided important insights into the experiences of teens. According to Nichter, prevention programs need to heighten girls' awareness of unrealistic body images and discuss the possibilities for more realistic body shapes. She further observed that considering the diversity that exists across cultures, there is much that can be learned by bringing girls of different ethnic groups together to articulate cultural differences and reflect upon the cultural underpinnings of how girls and women feel about their bodies.

Culture Change and Health

Immigrants to the United States, even those from very destitute origins, exhibit superior morbidity and mortality outcomes compared to U.S. minorities, noted William A. Vega, University of Medicine and Dentistry of New Jersey. According to Vega, immigrants' frequency of practicing various risky health behaviors (e.g, criminal, domestic abuse, and substance abuse) are lower as well. This is "especially paradoxical," said Vega, "because their children will become U.S. minorities."

"Regrettably," he continued, these "positive outcomes deteriorate the longer they are in the U.S." Their rates "normalize" to the U.S. population rate in subsequent generations. The evidence for this "immigrant adjustment" effect is widespread. The primary mechanisms responsible for this adjustment, however, are not known, said Vega.

Questions for further research, said Vega, include: How do we explain the superior immigrant health profile? How do income and education interact with culture? What can we learn about social structure and health?

In the Fall, the Office of Behavioral and Social Science Research (OBSSR) will develop a research agenda based on the conference's presentations and recommendations. A draft of the agenda will be posted on the NIH/OBSSR website (www1.od.nih.gov/obssr/obssr.asp), to allow the social and behavioral science community to provide comments and suggestions.