It is a privilege and
an honor to speak with the scientific community about the need to
integrate the behavioral and social sciences with the biomedical
sciences and how this relates to the mission of the American Heart
Association. My observations and thoughts are influenced by my
experiences as a nurse researcher and behavioral scientist at Johns
Hopkins, where I have been involved in a research program on high blood
pressure control in urban black communities.
Tremendous advances in biology are providing new knowledge about
genetics, physiology, pathophysiology, and disease, creating exciting
opportunities for clinical research. From the laboratory this research
evolves into new applications for diagnosis, therapy, and prevention in
humans. At the same time, important advances in behavioral science,
clinical outcomes, and healthcare delivery have provided needed
knowledge about prevention and treatment. This research transitions
from the healthcare setting into the community.
Individuals' lifestyles significantly impact their health, with
unhealthy habits accounting for about 54%1 of
known contributions to heart disease. Behavioral and biological
interventions can reduce morbidity, disability, and death due to heart
disease and stroke. They can improve quality of life and influence the
behavior of policy makers in their decisions, health professionals in
their practice, and people in their daily lives.
However, there is a gap between the efficacy of interventions in
studies and their effectiveness in practice, a gap between potential
and reality, intention and action, and information and behavior. This
gap illustrates the urgent need to more fully integrate the social and
behavioral sciences with the biomedical sciences. Three questions
arise:
The Gap
Despite extensive studies of strategies to prevent and treat risk
factors for heart disease and stroke, current evidence documents
disappointingly slow, and in many cases limited, implementation of
these therapies in practice and daily life. The following examples of
underdiagnosed and insufficiently treated risk factors illustrate this
point.
Adherence to National Cholesterol Education Program
treatment goals in almost 3000 postmenopausal American women with
documented coronary heart disease was reported earlier this
year by investigators from the Heart and Estrogen-Progestin Replacement
Study (HERS).2 In 1993 and 1994, baseline
measurements were made of lipids and lipoproteins, frequency of
achieving the 1988 and 1993 Adult Treatment Panel treatment goals, and
being on a regimen of lipid-lowering medication. The distribution of
plasma LDL cholesterol levels showed that 36.6% of
participants had a cholesterol level <130 mg/dL and
attained the ATP I treatment goal. In 1993, when the ATP II treatment
goals were published, 9.6% of these women had LDL
cholesterol levels <100 mg/dL
(Figure
The National Health and Nutrition Examination Surveys (NHANES)
documented impressive increases in rates of awareness, treatment, and
control of hypertension from 1960 to 1991.3 In 1960 to
1962 and 1971 to 1974, only 16% of all people with hypertension had it
controlled to <160/95 mm Hg. By 1991 64% were below this
original goal. However, with increasing evidence of the benefits of
lower blood pressure, in 1988 the Fourth Joint National Committee reset
the goal at <140/90 mm Hg.
In Phase 1 of the third NHANES, conducted from 1989 to 1991, 29% of
participants were below the treatment goal
level.3 In Phase 2, from 1991 to 1994,
analysis showed decreases in awareness, treatment, and control
rates, with only 27% below the goal level
(Table
A third example shows startling improvements in survival when social
and behavioral strategies are used at the community level. In
Rochester, Minn, survival rates after witnessed cardiac arrest
increased to 30% after public education about signals and actions for
heart attack. Because police often arrived at least 2 minutes before
other emergency personnel, they were given automatic external
defibrillators, and survival rates jumped to 49%. The major
determinants of survival were the 911-call-to-shock time and return of
spontaneous circulation after initial shocks without the need for
advanced life support.5
Why Does the Gap Exist?
There are powerful reasons why the results of clinical trials have
historically been difficult to generalize and apply to diverse and
large groups in the "real world." First, in the biomedical
community the emphasis has been on basic science and its translation
into clinical research. The struggle for funding priority between this
research and research in demonstration and education and research in
dissemination of knowledge has handicapped our understanding of how to
implement interventions shown to be effective in clinical trials. For
example, in a review of the literature on the impact of medication
nonadherence on coronary heart disease outcomes, no clinical
trials that specifically tested the impact of a compliance-enhancing
intervention were identified.6
Second, steady advances in scientific knowledge and the ability of
physicians to diagnose and intervene have generated several
expectations. One is that if experts come to a consensus and
disseminate practice guidelines to practitioners, the
recommendations will be implemented, practice will improve, and
patients will benefit. Another is that if physicians know the cause of
a patient's illness, select the appropriate therapy, and tell the
patient what to do, the patient will do it, and the problem will be
solved.
In fact, the physician's behavior is influenced by many factors, a
growing number of which are beyond his or her control. The patient's
behavior is also complex and influenced by many factors. Physical and
social environments, the healthcare system, and policies are important.
They influence awareness, knowledge and desire to change behavior,
skills to change behavior, and changes in risky behavior. These are all
precursors to risk factor modification and reductions in
cardiovascular disease, disability, and death.
Third, the organizational structure, staffing, and reimbursement of
academic medical centers do not encourage interdisciplinary health
education and promotion. Yet large trials such as the Multiple Risk
Factor Intervention Trial (MRFIT)7 ; Hypertension
Detection, Follow-up, and Prevention (HDFP)8 9 ;
the Lipid Research Clinics Coronary Primary Prevention Trial
(LRC-CRRP)10 ; and the Systolic
Hypertension in the Elderly Program (SHEP)11 have
shown that patient care and risk factor management improve when nurses,
physicians, pharmacists, and other health professionals share roles and
responsibilities and when interventions are based on sound principles
of health education and behavioral science. These efficacious
interdisciplinary approaches are addressed briefly, if at all, in most
practice guidelines.12 Formal integrated
interdisciplinary teams are the exception, not the norm, in most
inpatient and ambulatory care settings.
Finally, I propose a new paradigm for risk factor management that
recognizes the importance of the social and behavioral sciences.
Boundaries are changing among those responsible for primary prevention
and secondary prevention, populations at risk and people at risk,
health promotion and health protection, as well as in individual and
societal responsibilities.
What was once considered within the purview of medicine, nursing,
or public health can be readily found in the research and practice of
the other professions. At Johns Hopkins, faculty and students from the
Schools of Medicine, Nursing, and Public Health are collaborating on
clinic- and community-based educational and behavioral interventions
implemented by a nurse practitioner-community health
worker-physician team to improve care and control of high blood
pressure. In addition, in this clinical trial, investigators from
nursing and cardiology are working together to assess
genetic and physiological factors. This
comprehensive interdisciplinary approach to improving patient outcomes
is designed to integrate the biomedical sciences with the social and
behavioral sciences.
Why Must the Gap Be Closed?
The gap between what we know and what we do must be closed if the
AHA is to meet its mission to reduce disability and death due to
cardiovascular disease and stroke.
The gap must be closed because there is an emerging global epidemic of
cardiovascular disease and
stroke,13 and these problems are, in large and
increasing part, preventable. The gap must be closed because heart
disease and stroke are the most prevalent, expensive, chronic diseases
of lifestyle, and chronic diseases are our most serious health threat.
The gap must be closed if we are to meet expectations of the community
as well as government and other regulatory authorities to improve
outcomes.14 The gap must be closed because in the
current era of cost containment we cannot afford not to close it. And
the gap must be closed because it is the right thing to do, the moral
and ethical thing to do.
What Are We, as Scientists and the AHA, Doing to Close the
Gap?
To close the gap, I propose that we, as scientists, take the
following steps.
1. Recognize the broad continuum of science
We must recognize and embrace the broad continuum of science relevant
to the AHA mission. Closing the gap calls for translation of research
not only from the bench to the bedside but from the hospital to the
ambulatory care center and into the home and community. While we
anticipate the role of genetics in prevention and treatment, we must
tap all available talent to improve health behavior in the information
age. This will require the same support, commitment, and enthusiasm
given to biomedical research.
The fundamental importance of basic science must be protected. However,
the AHA must address the entire continuum of science relevant to its
mission. Five years ago the association established the Behavioral,
Science, Epidemiology, and Prevention Study
Group and began to fund research on educational and behavioral change
strategies. The association's science activities are now organized
around three interrelated areas: laboratory, clinical, and
community/preventive. The AHA recognizes that the behavioral sciences,
including health education, focus on the many individual,
interpersonal, social, and cultural factors that can inhibit or promote
changes in health behavior.15 16
2. Identify and set science priorities and
strategies
Important challenges and questions confront us as we demonstrate
effectiveness in the real world. What kinds of studies are needed to
better understand how to prevent disease? What kind of evidence is
needed and how much? What is the problem? How can we overcome the
barriers to improving health and reducing disability and death? As we
test approaches to improving health at the individual and community
levels, we must move beyond who does it to getting it done (behavior)
and documenting the difference it makes (results/outcomes).
Through the Office of Communications and Public Advocacy in Washington,
DC, the AHA works to incorporate cardiovascular disease
and stroke science into Congressional report language for the National
Institutes of Health (NIH). This year's efforts to highlight
scientific opportunities focused on the origins of
atherosclerosis, congestive heart failure, congenital
heart disease, and healthful lifestyle. The AHA is also working to
ensure enactment of the 7.1% increase over current funding agreed to
by the House-Senate conference and is actively involved in efforts with
Research!America and other organizations to double the NIH budget by
the year 2002.
Each of us has the responsibility to communicate with our congressional
representatives. Please, take action now. Write the
President. Join the AHA grassroots network.
3. Develop health promotion skills of health
professionals and the public
We can close the gap faster if we encourage patients, providers, and
the healthcare system to work together as partners and develop the
necessary skills. Providers need help in knowing what to do and how to
do it, and patients need help in making decisions about treatment and
developing strategies to meet their goals.
Professional and patient education now requires active learning
techniques and consideration of cultural and environmental factors.
This is where interdisciplinary teams with the appropriate mix of
expertise and competencies can maximize patient outcomes. We have an
opportunity to influence the evolution of the healthcare system. If
managed care is to be successful, it must support prevention activities
in humanistic ways.
The AHA continues to bring together different disciplines with
expertise in the behavioral as well as biological sciences to guide us
in the development of policy and scientific statements that are the
basis for its patient and public education information. Some examples
are
The AHA is developing a comprehensive approach to risk factor
management, "The Compliance Action Program," which will involve
patients, providers, and the healthcare system. The Women's Health
Campaign is another major new program aimed at women and their
healthcare providers.
These programs are based on expanded interdisciplinary
health-focused models. They recognize the importance of the public's
growing use of self-help materials as well as cultural and ethical
issues in communities and patients' lives. The professional education
components address new realities in practice settings and the
advantages of new technologies.
4. Reach out to a broader constituency
To close the gap, we must broaden our reach to provide increased access
to our messages. One way the AHA is doing this is by renewing previous
partnerships while forming new ones. Other stakeholders include
These collaborations need our thought and support. To succeed, we
must reach further into diverse and disadvantaged communities and form
more effective partnerships.
Even with all of this focused activity, much remains to be done.
The AHA has the talent and resources to bridge the gap and accelerate
its closing by developing and implementing new interdisciplinary
knowledge.
The AHA is expanding the scope of its research program. A new
initiative is planned to promote cutting-edge research in behavioral
science and health services to improve patient care and outcomes. The
call for proposals will be available March 1, 1998.
This initiative is made possible by the new members of the AHA
Pharmaceutical Roundtable. Through their generosity, the AHA will be
able to fund not only this new initiative but also its established
research program.
I pledge my commitment to retain the AHA's world-class reputation in
science and its position as the American public's most credible source
of cardiovascular and stroke information. This will
require the involvement of the very best behavioral and biological
scientists, funding of only the most meritorious research, and
dissemination of the most valid and useful information. Our mission
challenges us to use more effective strategies to improve the health of
populations and individuals, especially those at high risk, so that
they can benefit in their daily lives. I urge you to join the AHA and
me in closing the gap between what we know can work and what we do.
Let us begin by recognizing that behavior and biology are the sciences
basic to AHA action.
Footnotes
The president's address is being published simultaneously in the March issue of Stroke.
A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71–0132. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or . To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400. (Circulation. 1998;97:807-810.)
References
© 1998 American Heart Association, Inc.
AHA President's Address
Behavior and Biology: The Basic Sciences for AHA Action
Presented at the 70th Scientific Sessions of the American Heart Association November 9, 1997 Orlando, Florida
Key Words: AHA Medical/Scientific Statements • risk factors • prevention • lifestyle
). Forty-seven percent of
participants were taking lipid-lowering medications. Almost two thirds
of women with LDL cholesterol levels <130 mg/dL were
treated with lipid-lowering drugs. Only one third of the women with LDL
cholesterol levels >160 mg/dL were taking a lipid-lowering
agent.
View larger version (18K):
[in a new window]
Figure 1. Distribution of low-density lipoprotein
cholesterol (LDL-C) levels. ATP-I indicates 1988 Adult
Treatment Panel; ATP-II, 1993 Adult Treatment Panel. From Schroft et
al.2 Copyright 1997 by the American Medical Association.
Reproduced with permission. ).4 These are
two of many examples of how much work remains to be done in risk factor
management.
View this table:
[in a new window]
Table 1. Trends in the Awareness, Treatment, and Control of High Blood
Pressure in Adults: United States, 1976-19941
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