National Institutes of Health
Bethesda, Maryland
The behavioral and social sciences are integral to oral health research and in a system approach to address health issues. No one who attended the NIH honorary symposium for Dr. Lois K. Cohen on December 11, 2006, would dispute this fact. Indeed, the symposium was a tribute to Dr. Cohen for her leadership in engaging the social sciences in dental research and expanding interdisciplinary oral health research around the globe. This summary conveys the importance of behavioral and social sciences in oral health and directions for future research.
Lois K. Cohen, Ph.D., founded and directed the NIDCR Office of International Health. When she retired from NIDCR in June 2006, she had served the Federal government for 42 years. At NIDCR for 30 years, she advised five NIDCR directors and two interim directors about the relationship between oral health and the social and behavioral sciences. Early on, she directed the NIDCR Office of Planning, Evaluation, and Communications. In 1989, she became director of the NIDCR Extramural Research Program. At the same time, she was named the first NIDCR associate director for international health, a position she held until her retirement.
Approximately 100 people came to hear eight oral health researchers and public health experts describe the development and future directions of behavioral and social science research in oral health. The aim of the symposium, at Dr. Cohen's request, was to address and stimulate integration of the behavioral and social sciences into a systems approach to oral, dental, and craniofacial health and research. As the speakers noted, Dr. Cohen leaves a substantial legacy of both fostering interdisciplinary research collaborations among scientists and engaging national and international partners in the construction of programs to support and encourage this research.
The Social Sciences Are Intertwined with Dentistry
Opening the symposium, Dr. Lawrence A. Tabak, Director of NIDCR, remarked on the intertwining of his and Dr. Cohen's careers as a reflection of the connection between dentistry and the social and behavioral sciences. Dr. Cohen, a sociologist, has helped to bring the broad purview of social science research into dentistry, while Dr. Tabak, a dentist, has helped to bring dentistry into the broad purview of biomedical research .
The Social and Behavioral Sciences Are Integral to Health Research
Statistics show that health is largely a behavioral phenomenon and that interventions to change behavior are effective and can dramatically improve health. Dr. David B. Abrams, of the Office of Behavioral and Social Sciences Research (OBSSR), NIH, noted that up to 70 percent of the risk factors for diseases is broadly behavioral, social, and environmental in nature—whereas only about 30 percent is genetic. Furthermore, most of the increase in life expectancy since 1900, amounting to more than 35 years in the United States, is due primarily to changes in life circumstances including socioeconomic development. Two examples of the great effects possible by changing behaviors are the major reductions in the incidence of human immunodeficiency virus infection in the United States in less than 25 years and lung cancer among males as a result of cutting by more than half the population prevalence of tobacco use behaviors since the 1960's. Especially within the last 30 years, advances in biomedical research in terms of early detection and better therapeutics are increasingly contributing to longevity and wellbeing. One example of these biomedical benefits is an estimated 6 years of additional life expectancy attributed to the medical management of cardiovascular diseases. As scientists now probe genetic contributions to health and disease, behavior, at the individual and societal levels, must be viewed as the "leading edge" of gene–environment interactions.
Behavior is the bridge between biology and society, and the biomedical "causes" of disease and the socio-ecological "causes of causes" must be seen as two sides of the same coin. Behavioral and social sciences research already has made significant contributions to health and health research, and even greater contributions are possible as scientists confront the many public health challenges that remain—from emerging threats (e.g., obesity and type2 diabetes, pandemic flu, aging populations) to persistent problems (e.g., health disparities, continued tobacco use, toxic environments). These problems are complex, multilevel, multideterminant, and contextual, and they cannot be adequately addressed unless behavioral and social sciences research is integrated into a full systems model of health and disease that embraces a continuum from the micro biological level to the macro social level across the human lifespan and generations. A dramatic example of unintended "systems level" consequences is how population increases in obesity, type 2 diabetes and widening health disparities, are threatening to undermine the gains made in life expectancy and advances made in treating chronic disease. Basically a complex interaction of biological vulnerabilities, behavioral, socio-cultural, economic and policy forces have conspired to create an epidemic rise in obesity and related to complex causal pathways such as mass marketing of inexpensive "fast foods", decreases in physical activity, and changes in family dynamics, schools, neighborhoods and worksites.
The leading diseases, such as cardiovascular disease, diabetes, and cancer, are good examples of problems that cannot be understood or treated without integrating social and behavioral sciences research into a systems approach. These leading diseases share common risk factors, which are mostly behavioral and environmental, and they are chronic in nature, requiring long-term, integrated models of public health and health care .
Social and Behavioral Research in Oral Health Has a Long Tradition
Over the past 40 years and more, social and behavioral research in dentistry has grown from a fledgling, small group of researchers into a substantial number of scientifically focused investigators who are integrated into oral health research and whose work is viewed as being essential to advancing oral health. Dr. Judith E. N. Albino, of the University of Colorado Health Sciences Center, described this evolution and the emergence of the field of social and behavioral research in oral health.
In the early years, dentistry served as the setting for empirical psychological, sociological, and anthropological research, and researchers applied social and behavioral science methods to practical problems of dentistry, dental education, and patient care. In 1971, the behavioral and social sciences were definitively linked with dentistry in the Fédération Dentaire Internationale's publication of Social Sciences and Dentistry (N. D. Richards and L. K. Cohen, eds.). Beginning in the mid-1970s, NIDCR undertook a series of structural changes to incorporate behavioral and social sciences into the research portfolio, as researchers continued to address two major concerns: where to publish, and who should review behavioral research applications. In the 1980s, researchers began to emphasize the behavioral and social aspects of oral health and the integration of biological and behavioral perspectives (i.e., social and behavioral oral health).
Over the past 40 years, the research approaches to fluoridation, dental education, and treatment of dental-facial malformations changed. Beginning in the 1970s, added interests included pain and related topics (e.g., dental fear and anxiety), epidemiology of oral health and disease, and changes in health behavior changes (e.g., compliance and adherence). In the mid-1990s, new topics not even dreamed of before became major research areas—for example, oral health-related quality of life, oral health disparities, community-based participatory research, oral health literacy, and biobehavioral approaches (including psychoneuroimmunology) to oral health and disease. Social and behavioral researchers in oral health are now poised to contribute to systems approaches in oral health research to continue to build new knowledge, enhance dental practice, and promote better oral health for individuals and populations .
Oral Conditions Are "Placeholders" for Systems Research on Complex Diseases
Oral health research now and for the future must be interdisciplinary and reach beyond dentistry and medicine—for example, to engineering, statistics, economics, and physics. This change is already under way at NIDCR. In addition, fundamental understanding of the intersection of behavior and biology must be enhanced if NIH is to radically change the translation of research results and the delivery of medicine from a curative paradigm to predictive, personalized, and preemptive health care—a vision voiced by Dr. Elias Zerhouni. To uncover the socio-ecological causes of the biological "causes" of disease and to assess the efficacy and effectiveness of treatments, behavioral and social sciences research must be integrated into the evolving systems approach to oral health research.
Dr. Samuel F. Dworkin, of the University of Washington, highlighted these imperatives and emphasized the need for an ecological (i.e., biopsychosocial) model and an integrated systems approach to understand all the factors contributing to health and disease and to solve the puzzle of complex diseases and conditions. Five domains of social and behavioral research in oral health offer prime opportunities for applying a brain–mind–body systems approach to understand individual differences in risk for and protection from disease. NIDCR is a leader in each of these research areas. By focusing on these as "placeholders" for complex diseases and problems, NIDCR can enhance its contributions and recognition at NIH in interdisciplinary biobehavioral systems research. The placeholder research domains are:
- Inherited and acquired craniofacial defects and malformations—NIDCR has long recognized the need for and has supported systems research on the genetics, psychosocial, and developmental aspects of these complex conditions.
- Inflammatory disease—Periodontal disease is an excellent placeholder for studying how stress "gets into" the body and how the psyche may influence the development of a chronic disease.
- Patients' demand, adherence, compliance, and expectations with regard to treatments—NIDCR research on consumers' demand for treatment, oral health-related quality of life, and bioengineering of dental restorations is applicable to broad research on the complexity of treatment-associated issues.
- Health disparities—An estimated 50 million Americans have extreme oral health disparities, which must be studied using a comprehensive, systems approach. The interdisciplinary NIDCR Centers for Research on Oral Health Disparities are taking the lead in this effort.
- Acute and chronic pain—NIDCR is the focal point at NIH for studies of pain, including behavioral and intervention research. Some key findings in NIDCR studies point to the powerful synergies between behavior and pharmacology, the lifetime-lasting effects of behavioral interventions, patients' history as the best predictor of chronic pain, and the complexity of genotype–phenotype relationships among psychiatric traits and chronic illnesses associated with pain. Yet, even though chronic pain is a major public health problem, why it persists, fluctuates, or resolves are still largely undetermined .
Reducing the Burden of Oral Diseases Depends on Intervention Research
Behavioral and social science researchers have made great strides in understanding behavioral factors that predict and explain individuals' oral health status. In descriptive and relational studies, researchers have identified predictors of oral health outcomes in populations across the lifespan (e.g., infants/toddlers, schoolchildren and adolescents, middle-aged and older adults) and in users vs. nonusers of dental services, patients undergoing dental and surgical procedures, and patients with chronic pain. This research is grounded in social, psychological, and behavioral theories of, for example, individuals' action, attitude, coping, self-efficacy, response to stress, and social support.
Dr. H. Asuman Kiyak, of the University of Washington, described this research and the next steps needed. The findings of descriptive and association studies are generally consistent regarding "best predictors," which are both individual (e.g., perceived need for dental care, self-efficacy) and demographic (e.g., age, gender, socioeconomic status, ethnicity). With these data, behavioral and social scientists in oral health now can and need to target populations that have the greatest oral health needs, test interventions for modifying predictors of oral health behaviors, and adapt theories and methods from their home fields to continue to build the theory base in behavioral oral health.
Behavioral and social science interventions offer great promise for reducing the burden of oral disease. Future research on behavioral interventions for individuals needs to be integrated into a systems approach that spans the basic-to-clinical continuum and relates oral health to systemic health and disease and quality of life. Interventions need to be interdisciplinary, long-term (12–24 months), and embrace the new technologies available (e.g., online learning, video imaging, compliance monitors). And, both negative and positive results should be published .
Social and Community-based Research Can Counter the Dilemma of Disparities
The persistent and increasing disparities in health are among the highest priorities in public health and public health policy. Yet, the dominant research agenda in social and behavioral oral health has been focused narrowly on dental disease, individuals' behavior, and high-risk lifestyles. Limited attention has been given to social, "upstream" factors influencing disparities and to interventions to reduce oral health inequalities. Dr. Richard G. Watt, of University College, London, England, made these observations and proposed an agenda for future research.
Already endorsed in the United Kingdom and by the World Health Organization, this agenda emphasizes clarification of the social determinants of oral health inequalities and development and evaluation of "upstream" interventions. Understanding the social determinants begins with having a life-course perspective (i.e., from early life to death) and studying the influence (i.e., context) of community, environmental, and political conditions in interaction with psychosocial, behavioral, and biological factors. Longitudinal, population-based surveys are essential for investigating the linking pathways and processes.
Upstream interventions are those that promote healthy public policy—through national and/or local policy initiatives, legislation and regulation, and fiscal measures. They derive from community efforts and are linked to downstream interventions such as public and professional health education and clinical prevention. By developing and evaluating upstream interventions, social and community-based researchers can help to address the underlying causes of the "causes" of oral disease and foster integration of oral health into general health. They also can promote appropriate local, national, and even international oral health policy .
Health Communications Research Can Improve Patients' Oral Health Outcomes
Behavioral and social scientists are engaged in a broad spectrum of research on health communications. The research includes understanding and improving the use of mass media and social marketing to advance health, issues of health literacy, and interpersonal exchanges between patients and providers and in community and professional networks. The challenges in this research, which are philosophical, bioethical, pedagogical, theoretical, and methodological, relate to the responsibilities and practice of all oral health professionals. Dr. Debra L. Roter, of Johns Hopkins University, described these challenges and several research studies.
Communication is key to any significant future improvements in health care—a recognition that is documented in reports on the nation's health and by organizations accrediting and certifying health professionals. Practitioners must be able to communicate competently and to understand the bioethics involved in making health decisions, particularly with vulnerable populations. Growing evidence links health communications (e.g., patient education/activation, relationship building) with outcomes for patients (e.g., satisfaction, compliance, utilization of services, functional status), as well as providers (e.g., satisfaction).
Behavioral and social science research is needed to document oral health communications between clinicians and patients and to explore and understand the communication variables contributing to health outcomes. Although many studies of dental students have been conducted, few have examined the professional maturation and skill development of students, or clinicians, over time or in relation to their competence in communication and bioethics. Recent NIDCR research, using videotapes, links dental students' competencies in communication (in both cognitive and affective domains) to their patients' quality of care, health disparities, and outcomes (i.e., satisfaction, intent to comply with recommendations). This research needs to be expanded. Additional innovative, interactive video- and computer-based methodologies (e.g., simulation, analog, and virtual studies) could be utilized, as is being done in other studies assessing patient–provider dynamics and training physicians.
Research Capacity, Design, and Infrastructure Are Major Challenges
Three key methodological issues for integrating behavioral and social science research into a systems approach to oral health research are research capacity, research design, and research infrastructure. The opportunities and challenges in each of the three areas reflect the special research needs of a systems approach (e.g., integration of disciplines and of units of observation) and relate to the expected research outcomes, which are both intermediate (e.g., production of appropriate practitioners and therapies; effective translation of research results) and ultimate (e.g., oral health status, access to care, reduction of oral health disparities). Dr. Ronald M. Andersen, of the University of California, Los Angeles, described the systems context of these methodological issues and elaborated on the challenges.
Regarding development of research capacity, various models exist (e.g., small-scale research, focused research centers, long- and short-term training programs, mentoring), but need to be validated in terms of systems research. The specific challenges include assuring that behavioral and social scientists are well integrated into interdisciplinary research and bring to this research theoretically grounded methods and techniques. Who will provide training in systems research is unclear, and new training materials are needed.
The research designs for systems approaches are proliferating, but how they will coexist with traditional research designs is a question. The opportunities for systems research include use of nonlinear models, mathematical and simulation models, longitudinal surveys, geographic maps, social networks, Internet and video research, and international replication. The challenges include the operationalization of systems at different levels of interaction, the accounting of different assumptions made when using different methods (e.g., case studies, social surveys, simulations), and the necessity for replication and comparison.
The emphasis on systems research that is broadly interdisciplinary makes this particular time ripe for developing the infrastructure (i.e., organization, financing, facilities) of behavioral and social sciences research. NIH has various funding and research mechanisms that offer opportunities for support of clinical and translational science, dissemination and implementation research, interdisciplinary research centers, health promotion and behavioral research, and informatics approaches. Overcoming the comfort and safety of discipline-oriented research "silos" remains a challenge and, in dentistry and oral health research, the behavioral and social sciences still suffer from benign neglect. And, eventually, the new systems researchers will need legitimization and jobs.
Global Research Elucidates Key Social and Policy Issues in Oral Health
Social equity has become a dominant force internationally, and nations are responding to this challenge by developing social policies that assure population's rights, education, and health. Global health comparisons and research, such as the World Health Organization's International Collaborative Study of Dental Manpower Systems (ICS-I and ICS-II), bring to light important social and policy issues that need to be addressed. The ICS study, in particular, demonstrated tremendous disparities in oral health in relation to cultures and health systems. Specific data which related tooth loss to social status generated enormous international debate about oral health disparities and social equity within countries.
Dr. Peter Davis, of the University of Auckland, New Zealand, noted these effects and discussed the role of oral health as a diagnostic tool for illuminating underlying social conditions and raising important policy questions and equity issues. The concerns that arise reflect macrolevel trends (e.g., demographic transitions) and outcomes (e.g., rate of adverse health events) that cannot be addressed unless the mechanisms underlying them are identified and fully understood. Behavioral and social science researchers have the tools and skills to "unpack" these macro effects and to study social and policy implications.
The underpinning mechanisms are behavioral, situational, and transformational. The occurrence of adverse health events, for example, cannot be understood without knowing the context for patients' safety—that is, the behavioral effects of practitioners (e.g., constraints, performance), the situational impact of organizations (e.g., settings, institutional arrangements), and the transformational processes (e.g., patients' receipt of care).
Behavioral and social scientists need to apply this analytical "toolkit" to explain and to intervene in the mechanisms and the relationship among macrolevel "precursors," individuals' states and actions, and macrolevel outcomes. As such, they have essential roles in basic and applied global health research and public and policy guidance .
_____________________________________________________
For copies of the powerpoint presentations, please contact:
Dr. Maria Teresa Canto
maria.canto@nih.gov
Telephone: 301-594-5497
AGENDA
The Integral Role of Behavioral and Social Sciences
in a Systems Approach to Oral Health Research: A Tribute to Dr. Lois K. Cohen
December 11, 2006 • 8:30am - 12:00pm
Lipsett Amphitheater, Building 10
NIH Bethesda Campus
8:30-8:45
Introduction and Welcome
Lawrence A. Tabak, D.D.S., Ph.D.
Director, National Institute of Dental and
Craniofacial Research
National Institutes of Health
8:45-9:15
The Imperative for Social and
Behavioral Sciences as an Integral
Part of Health Research
David B. Abrams, Ph.D.
Director, Office of Behavioral and Social
Sciences Research, Office of the Director
National Institutes of Health
9:15-9:45
Social and Behavioral Research in
Oral Health: Where have we been?
Judith E. N. Albino, Ph.D.
President Emerita and Professor,
Departments of Psychiatry and
Craniofacial Biology
University of Colorado Health
Sciences Center
9:45-10:15
Biobehavioral Research in the Oral
Health Sciences: Current Status and
Future Opportunities
Samuel F. Dworkin, D.D.S., Ph.D.
(Hon: D. Sci., D. Odont.)
Professor Emeritus, Departments of
Oral Medicine and Psychiatry and
Behavioral Sciences, Schools of Dentistry
and Medicine
University of Washington
10:15-10:30 Break
10:30-10:40
Panel: Research Needs
and Opportunities
Introduction
Moderator, Helen C. Gift, Ph.D.
Ruth Stafford Conabeer Distinguished
Service Professor of Sociology and
Organizational Systems; Chair, Division
of Social Sciences
Brevard College
10:40-10:50
Studies Focused on Individual Health
H. Asuman Kiyak, Ph.D.
Professor, Oral & Maxillofacial Surgery, School
of Dentistry; Director, Institute on Aging, Health
Sciences Administration
University of Washington
10:50-11:00
Family and Community-based Research*
Richard G. Watt, Ph.D., M.Sc., B.D.S., M.F.PH.
Professor, Dental Public Health, Department of
Epidemiology and Public Health
University College London, England
11:00-11:10
Communications Research
Debra L. Roter, M.P.H., Dr.P.H.
Professor, Department of Health Policy and
Management, Johns Hopkins Bloomberg
School of Public Health
Johns Hopkins University
11:10-11:20
Research Capacity, Design
and Infrastructure
Ronald M. Andersen, Ph.D.
Wasserman Professor Emeritus,
School of Public Health
University of California, Los Angeles
11:20-11:30
Social, Health Policy and Global
Health Research
Peter Davis, Ph.D.
Professor, Department of Sociology
University of Auckland, New Zealand
11:30-12:00 Open Discussion
12:00 Adjournment
*Co-authored by: Aubrey Sheiham, Ph.D.
Professor, Dental Public Health, Department
of Epidemiology and Public Health
University College London, England