Interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research

Community conceptualizations of health: implications for transdisciplinary team science

OBJECTIVE

This exploratory study set out to identify how communities in the Tufts University Clinical Translational Science Institute (CTSI) catchment area define health-related research priority areas.

METHODS

Three focus groups comprising community stakeholders were conducted in three communities. Participants were representatives from community-based organizations and health centers. A systematic content analysis was performed that involved the identification, labeling, and categorization of data followed by thematic analysis.

RESULTS

Participant conceptualizations of health and health priorities were not formulated in the context of specific disease conditions, such as diabetes, obesity, cardiovascular disease, or asthma. Instead, participants described contextual factors including social, environmental, economic, and political conditions that influence health and health behavior.

CONCLUSIONS

Respondents in the Tufts University CTSI catchment area, like many diverse urban communities, described multiple interconnected social determinants of health and well-being. As such, they were interested in research that focuses on "upstream" areas of intervention as opposed to disease prevention at the individual level. In addition, respondents were interested in research that would catalyze community change.

Prevalence of comorbid conditions with aging among patients with diabetes and cardiovascular disease

OBJECTIVES

The objectives were to develop a methodology to understand the prevalence of medically complex patients, and to apply the methodology to examine patients with one or more of hypertension, hyperlipidemia, diabetes, and heart disease.

METHODS

Prevalence was measured using insurance data by calculating the proportion of days patients in a health state of interest contributed to the total days of enrollment. Graphs summarized the prevalence patterns within age and morbidity categories. Results by age and gender were supplemented with cubic spline curves that closely fit the prevalence data.

RESULTS

The study provides basic epidemiologic information on changes with aging in the prevalence of patients with one or more comorbid conditions. Patients such as those with hyperlipidemia alone rose in prevalence at younger ages and fell at older ages, whereas the prevalence of other patients, such as patients having hypertension, diabetes, and heart disease, progressively increased with age. With straightforward extensions of the methodology other issues such as the incidence of emergency department visits and hospitalizations might be investigated.

Impact challenges in community science-with-practice: lessons from PROSPER on transformative practitioner-scientist partnerships and prevention infrastructure development

At present, evidence-based programs (EBPs) to reduce youth violence are failing to translate into widespread community practice, despite their potential for impact on this pervasive public health problem. In this paper we address two types of challenges in the achievement of such impact, drawing upon lessons from the implementation of a partnership model called PROSPER. First, we address five key challenges in the achievement of community-level impact through effective community planning and action: readiness and mobilization of community teams; maintaining EBP implementation quality; sustaining community teams and EBPs; demonstrating community-level impact; and continuous, proactive technical assistance. Second, we consider grand challenges in the large-scale translation of EBPs: (1) building, linking and expanding existing infrastructures to support effective EBP delivery systems, and (2) organizing networks of practitioner-scientist partnerships-networks designed to integrate diffusion of EBPs with research that examines effective strategies to do so. The PROSPER partnership model is an evidence-based delivery system for community-based prevention and has evolved through two decades of NIH-funded research, assisted by land grant universities' Cooperative Extension Systems. Findings and lessons of relevance to each of the challenges are summarized. In this context, we outline how practitioner-scientist partnerships can serve to transform EBP delivery systems, particularly in conjunction with supportive federal policy.

Mapping a research agenda for the science of team science

An increase in cross-disciplinary, collaborative team science initiatives over the last few decades has spurred interest by multiple stakeholder groups in empirical research on scientific teams, giving rise to an emergent field referred to as the science of team science (SciTS). This study employed a collaborative team science concept-mapping evaluation methodology to develop a comprehensive research agenda for the SciTS field. Its integrative mixed-methods approach combined group process with statistical analysis to derive a conceptual framework that identifies research areas of team science and their relative importance to the emerging SciTS field. The findings from this concept-mapping project constitute a lever for moving SciTS forward at theoretical, empirical, and translational levels.

A community-based approach to translational research addressing breast cancer disparities

Disparities in breast cancer survival rates suggest that biological processes contribute. Translational research addressing health disparities would benefit from using a community-based participatory approach (CBPR) to examine biological processes commonly seen as the proximal causes of illness as well as behavioral and social-ecological "causes of the causes" within an integrated conceptual framework. This paper describes a CBPR study that explored perceptions regarding breast cancer relevant behaviors, and the application of the study's results to develop translational research. Data from eight focus groups of African American (n = 29) and Caucasian women (n = 27) were analyzed, using the framework of the social-ecological model. Nutrition and physical activity were valued over screening and research participation. Treatment of illness was emphasized over prevention. Women's perspectives are presented within a framework that facilitated the collaborative development of translational research to examine associations among biological, behavioral, and societal processes contributing to disparities.

Urban planning and health equity

Although the fields of urban planning and public health share a common origin in the efforts of reformers to tame the ravages of early industrialization in the 19th century, the 2 disciplines parted ways in the early 20th century as planners increasingly focused on the built environment while public health professionals narrowed in on biomedical causes of disease and disability. Among the unfortunate results of this divergence was a tendency to discount the public health implications of planning decisions. Given increasingly complex urban environments and grave health disparities in cities worldwide, urban planners and public health professionals have once again become convinced of the need for inclusive approaches to improve population health and achieve health equity. To make substantive progress, intersectoral collaboration utilizing ecological and systems science perspectives will be crucial as the solutions lie well beyond the control of any single authority. Grounded in the social determinants of health, and with a renewed sense of interconnectedness, dedicated and talented people in government agencies and communities who recognize that our future depends on cultivating local change and evaluating the results can come to grips with the enormous challenge that lies ahead to create more equitable, sustainable, and healthier cities worldwide.

Building a biomedical cyberinfrastructure for collaborative research

For the potential power of genome-wide association studies (GWAS) and translational medicine to be realized, the biomedical research community must adopt standard measures, vocabularies, and systems to establish an extensible biomedical cyberinfrastructure. Incorporating standard measures will greatly facilitate combining and comparing studies via meta-analysis. Incorporating consensus-based and well-established measures into various studies should reduce the variability across studies due to attributes of measurement, making findings across studies more comparable. This article describes two well-established consensus-based approaches to identifying standard measures and systems: PhenX (consensus measures for phenotypes and eXposures), and the Open Geospatial Consortium (OGC). NIH support for these efforts has produced the PhenX Toolkit, an assembled catalog of standard measures for use in GWAS and other large-scale genomic research efforts, and the RTI Spatial Impact Factor Database (SIFD), a comprehensive repository of geo-referenced variables and extensive meta-data that conforms to OGC standards. The need for coordinated development of cyberinfrastructure to support measures and systems that enhance collaboration and data interoperability is clear; this paper includes a discussion of standard protocols for ensuring data compatibility and interoperability. Adopting a cyberinfrastructure that includes standard measures and vocabularies, and open-source systems architecture, such as the two well-established systems discussed here, will enhance the potential of future biomedical and translational research. Establishing and maintaining the cyberinfrastructure will require a fundamental change in the way researchers think about study design, collaboration, and data storage and analysis.

Challenges in interpreting cytokine biomarkers in biobehavioral research: a breast cancer exemplar

PURPOSE

This report extends the findings of a prior study comparing the level of plasma cytokines in women with breast cancer to those of women with a benign breast biopsy with the addition of a normal comparison group. The results of this three-group comparison are presented as background for discussing several methodologic challenges for biobehavioral research in inflammatory-based conditions.

METHOD

This study used a descriptive, cross-sectional design to compare the levels of plasma cytokines in women with breast cancer, women with a benign breast biopsy, and a normal comparison group. The levels of 17 cytokines were measured using multiplex bead array assays (Bio-Plex®). Data analysis included a variety of descriptive and graphical techniques to illustrate between-group differences in cytokine profiles.

RESULTS

The levels of plasma cytokines in the sample of 35 women who had recently been diagnosed with breast cancer, 24 women with a suspicious breast mass, who subsequently were found to have a benign breast biopsy, and 33 women in a normal comparison group present a background for discussing the implications of extreme between-group differences for biobehavioral nursing research. Both the levels of individual cytokines and their patterns were distinctly different in the three groups.

CONCLUSION

The exemplar presented from the three-group comparison has implications for planning biobehavioral nursing research in patients with conditions characterized by inflammation.

An agent-based model of income inequalities in diet in the context of residential segregation

BACKGROUND

Low dietary quality is a key contributor to obesity and related illnesses, and lower income is generally associated with worse dietary profiles. The unequal geographic distribution of healthy food resources could be a key contributor to income disparities in dietary profiles.

PURPOSE

To explore the role that economic segregation can have in creating income differences in healthy eating and to explore policy levers that may be appropriate for countering income disparities in diet.

METHODS

A simple agent-based model was used to identify segregation patterns that generate income disparities in diet. The capacity for household food preferences and relative pricing of healthy foods to overcome or exacerbate the differential was explored.

RESULTS

Absent other factors, income differentials in diet resulted from the segregation of high-income households and healthy food stores from low-income households and unhealthy food stores. When both income groups shared a preference for healthy foods, low-income diets improved but a disparity remained. Both favorable preferences and relatively cheap healthy foods were necessary to overcome the differential generated by segregation.

CONCLUSIONS

The model underscores the challenges of fostering favorable behavior change when people and resources are residentially segregated and behaviors are motivated or constrained by multiple factors. Simulation modeling can be a useful tool for proposing and testing policies or interventions that will ultimately be implemented in a complex system where the consequences of multidimensional interactions are difficult to predict.

Making sense of polarities in health organizations for policy and leadership

Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense-Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense-Making schema is proposed.

From "one medicine" to "one health" and systemic approaches to health and well-being

Faced with complex patterns of global change, the inextricable interconnection of humans, pet animals, livestock and wildlife and their social and ecological environment is evident and requires integrated approaches to human and animal health and their respective social and environmental contexts. The history of integrative thinking of human and animal health is briefly reviewed from early historical times, to the foundation of universities in Europe, up to the beginning of comparative medicine at the end of the 19th century. In the 20th century, Calvin Schwabe coined the concept of “one medicine”. It recognises that there is no difference of paradigm between human and veterinary medicine and both disciplines can contribute to the development of each other. Considering a broader approach to health and well-being of societies, the original concept of “one medicine” was extended to “one health” through practical implementations and careful validations in different settings. Given the global health thinking in recent decades, ecosystem approaches to health have emerged. Based on complex ecological thinking that goes beyond humans and animals, these approaches consider inextricable linkages between ecosystems and health, known as “ecosystem health”. Despite these integrative conceptual and methodological developments, large portions of human and animal health thinking and actions still remain in separate disciplinary silos. Evidence for added value of a coherent application of “one health” compared to separated sectorial thinking is, however, now growing. Integrative thinking is increasingly being considered in academic curricula, clinical practice, ministries of health and livestock/agriculture and international organizations. Challenges remain, focusing around key questions such as how does “one health” evolve and what are the elements of a modern theory of health? The close interdependence of humans and animals in their social and ecological context relates to the concept of “human-environmental systems”, also called “social-ecological systems”. The theory and practice of understanding and managing human activities in the context of social-ecological systems has been well-developed by members of The Resilience Alliance and was used extensively in the Millennium Ecosystem Assessment, including its work on human well-being outcomes. This in turn entails systems theory applied to human and animal health. Examples of successful systems approaches to public health show unexpected results. Analogous to “systems biology” which focuses mostly on the interplay of proteins and molecules at a sub-cellular level, a systemic approach to health in social-ecological systems (HSES) is an inter- and trans-disciplinary study of complex interactions in all health-related fields. HSES moves beyond “one health” and “eco-health”, expecting to identify emerging properties and determinants of health that may arise from a systemic view ranging across scales from molecules to the ecological and socio-cultural context, as well from the comparison with different disease endemicities and health systems structures.

Developing partnerships to reduce disparities in cancer screening

BACKGROUND

Interventions in scientific settings to improve the well-being of women who are not regularly screened for cancer have failed. Consequently, community-based prevention and control efforts are needed.

COMMUNITY CONTEXT

From 2003 through 2007, three federal agencies and 1 nongovernmental agency collaborated with county-level public health counterparts from 6 states to address screening disparities in cervical and breast cancer in counties with the highest prevalence. This case study describes lessons learned from Team Up, a model pilot program.

METHODS

We conducted a descriptive qualitative case study including 5 Southern states and 1 Midwestern state: Alabama, Georgia, Kentucky, Missouri, South Carolina, and Tennessee. The 6 states underwent a 5-step process to adopt, adapt, and implement 1 of 3 evidence-based interventions designed for cervical and breast cancer screening.

OUTCOME

The 6 participating states had various levels of success. Participating states formed and sustained viable interorganizational public health partnerships throughout the pilot program and beyond.

INTERPRETATION

Although this innovative pilot faced many difficulties, participants overcame substantial obstacles and produced many key accomplishments. Team Up brought together 2 challenging public health strategies: the translation of evidence-based approaches to communities and populations, and partnerships among diverse people and organizations. Case study results suggest that using a mix of approaches can promote the transference of evidence from research into practice through local, regional, and national partnerships.

Boosting population quits through evidence-based cessation treatment and policy

Only large increases in adult cessation will rapidly reduce population smoking prevalence. Evidence-based smoking-cessation treatments and treatment policies exist but are underutilized. More needs to be done to coordinate the widespread, efficient dissemination and implementation of effective treatments and policies. This paper is the first in a series of three to demonstrate the impact of an integrated, comprehensive systems approach to cessation treatment and policy. This paper provides an analytic framework and selected literature review that guide the two subsequent computer simulation modeling papers to show how critical leverage points may have an impact on reductions in smoking prevalence. Evidence is reviewed from the U.S. Public Health Service 2008 clinical practice guideline and other sources regarding the impact of five cessation treatment policies on quit attempts, use of evidence-based treatment, and quit rates. Cessation treatment policies would: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based state-sponsored telephone quitlines; (3) support healthcare systems changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments. This series of papers provides an analytic framework to inform heuristic simulation models in order to take a new look at ways to markedly increase population smoking cessation by implementing a defined set of treatments and treatment-related policies with the potential to improve motivation to quit, evidence-based treatment use, and long-term effectiveness.

Researching a local heroin market as a complex adaptive system

This project applies agent-based modeling (ABM) techniques to better understand the operation, organization, and structure of a local heroin market. The simulation detailed was developed using data from an 18-month ethnographic case study. The original research, collected in Denver, CO during the 1990s, represents the historic account of users and dealers who operated in the Larimer area heroin market. Working together, the authors studied the behaviors of customers, private dealers, street-sellers, brokers, and the police, reflecting the core elements pertaining to how the market operated. After evaluating the logical consistency between the data and agent behaviors, simulations scaled-up interactions to observe their aggregated outcomes. While the concept and findings from this study remain experimental, these methods represent a novel way in which to understand illicit drug markets and the dynamic adaptations and outcomes they generate. Extensions of this research perspective, as well as its strengths and limitations, are discussed.

Introduction to special issue on social ecological approaches to community health research and action

We have the potential to make new, substantive contributions to resolving our most pressing community health problems. However, to do so we must adopt a philosophy of science that is directed towards understanding the dynamic complexity and full contextual reality surrounding these issues. A social ecological approach to science is ideally suited to this challenge. This framework is systems-oriented and defines research problems in terms of structures and processes, generating research outcomes that give insight into the dynamic interaction of individuals with their environment across time and space. Though community psychology is built upon social ecological principles, researchers from other disciplines have also noted its utility and implemented interventions based on this framework. In our introductory article to this special issue on social ecological approaches to community health research and action, we present a brief review of the theoretical foundations of the social ecological approach, present highlights from our selected manuscripts, and conclude with some reflections about the need to build further capacity to conduct effective social ecological research to foster community health and well-being.

Prediction and prevention of musculoskeletal injury: a paradigm shift in methodology

Traditional methods employed to study musculoskeletal injury mechanisms and joint biomechanics utilise in vivo or in vitro techniques. The advent of new technology and improved methods has also given rise to in silico (computer modelling) techniques. Under the current research paradigm, in vivo, in vitro and in silico methods independently provide information regarding the mechanisms and prevention of musculoskeletal injury. However, individually, each of these methods has multiple, inherent limitations and is likely to provide incomplete answers about multifactorial, complex injury conditions. The purpose of this treatise is to review current methods used to study, understand, and prevent musculoskeletal injury and to develop new conceptual-methodological frameworks that may help create a paradigm shift in musculoskeletal injury prevention research. We term the fusion of these three techniques in simulacra amalgama, or simply in sim, meaning a "union of models done on the likeness of phenomena." Anterior cruciate ligament (ACL) injury will be employed as a model example for the utility and applicability of the proposed, synthesised approach. Shifting the current experimental paradigm to incorporate a multifaceted, multidisciplinary, integration of in vivo, in vitro and in silico methods into the proposed in sim approaches may provide a platform for a more comprehensive understanding of the relationships between complex joint biomechanics and observed injury mechanisms.

Suicide prevention as a community development process: understanding circumpolar youth suicide prevention through community level outcomes

OBJECTIVES

Community-based models have become increasingly prominent in prevention, and have special relevance for suicide prevention in circumpolar Indigenous communities. It follows that outcomes from circumpolar suicide prevention programs might be more completely understood at the community level. We present here a methodology for analysis at this level. This paper seeks to understand a cultural prevention program for rural Yup'ik youth in Alaska targeting suicide and co-occurring alcohol abuse as a community development process through changes at the community level.

STUDY DESIGN

Quasi-experimental design with assessment at pre- and post-intervention or at 4 time points. The community development process for this project began in October 2004. The first program baseline assessment began in November 2006, prior to prevention activities with youth and parents, and the post-intervention assessment concluded in March 2008.

METHODS

Five key informants pre- and post-intervention completed a community readiness assessment, which is a structured procedure assessing a community's awareness of suicide as an issue and its, organizational readiness for prevention programming. Forty-three adult caregivers or sponsors of youth in the prevention program completed an assessment of behaviours that contributed to community protective factors from youth suicide and alcohol abuse at 4 time points before, during and after the intervention. The 54 youth who participated in the prevention program completed an assessment of community protective factors, also at 4 time points before, during and after the intervention. The community protective factors from suicide that were assessed included safety, enforcement of alcohol prohibitions, role models, support and opportunities for youth.

RESULTS

Community readiness for the prevention efforts increased to new developmental stages of readiness post-intervention, and a trend in the data suggested community protective factors increased in the amount of protective behaviours performed by adults (slope estimate = 0.0162, 95% CI--0.0028-0.0351, d=.55) and in the perceptions of youth (slope estimate=0.0148, 95% CI--0.0004-0.0291, d=.45), in a dose response relationship to the number of prevention program sessions attended by adults and youth.

CONCLUSIONS

Using data from a feasibility study, this paper demonstrates the feasibility and potential utility of methodological approaches that use community-level variables beyond individual level outcomes in circumpolar suicide prevention research.

Cancer communication: status and future directions

On November 7, 2005, the directors of the National Cancer Institute's (NCI's) Comprehensive Cancer Centers met to identify ways of accelerating success against cancer using current knowledge. Not surprisingly, cancer communication was identified as a focal point of research that needed to be conducted to extend the benefits of cancer knowledge throughout the population. There were three foci of communication research identified by the directors: (a) research designed to extend awareness of prevention and early detection, (b) research designed to improve the accuracy and usability of cancer science as portrayed in national news media, and (c) research designed to support behavior through individual and community-level interventions. Each of these foci takes on new meaning when considered in the context of a rapidly changing communication environment. Behavioral science must evolve to keep up with these changes and to offer new evidence-based approaches for extending the reach, effectiveness, and efficiency of cancer communication in order to do its part in accelerating successes against the disease.

Team processes and team care for children with developmental disabilities

Professionals who work with children and adolescents who have developmental disabilities find themselves working with several other professionals on various "teams." These teams are typically composed of practitioners from more than one discipline working toward the single goal of providing comprehensive patient care. Research on medical and psychosocial teams confirms the overwhelming importance of clarity, commitment, and close positive exchanges among team members to promoting successful teamwork. The effectiveness of teams largely depends on how the professionals work to accomplish meeting the needs of their patients. This article reviews multidisciplinary, interdisciplinary, and transdisciplinary approaches to delivering health care to children and adolescents who have developmental disabilities.

The science of team science: overview of the field and introduction to the supplement

The science of team science encompasses an amalgam of conceptual and methodologic strategies aimed at understanding and enhancing the outcomes of large-scale collaborative research and training programs. This field has emerged rapidly in recent years, largely in response to growing concerns about the cost effectiveness of public- and private-sector investments in team-based science and training initiatives. The distinctive boundaries and substantive concerns of this field, however, have remained difficult to discern. An important challenge for the field is to characterize the science of team science more clearly in terms of its major theoretical, methodologic, and translational concerns. The articles in this supplement address this challenge, especially in the context of designing, implementing, and evaluating cross-disciplinary research initiatives. This introductory article summarizes the major goals and organizing themes of the supplement, draws links between the constituent articles, and identifies new areas of study within the science of team science.

The collaboration readiness of transdisciplinary research teams and centers findings from the National Cancer Institute's TREC Year-One evaluation study

Growing interest in promoting cross-disciplinary collaboration among health scientists has prompted several federal agencies, including the NIH, to establish large, multicenter initiatives intended to foster collaborative research and training. In order to assess whether these initiatives are effective in promoting scientific collaboration that ultimately results in public health improvements, it is necessary to develop new strategies for evaluating research processes and products as well as the longer-term societal outcomes associated with these programs. Ideally, evaluative measures should be administered over the entire course of large initiatives, including their near-term and later phases. The present study focuses on the development of new tools for assessing the readiness for collaboration among health scientists at the outset (during the first year) of their participation in the National Cancer Institute's Transdisciplinary Research on Energetics and Cancer (TREC) initiative. Indexes of collaborative readiness, along with additional measures of near-term collaborative processes, were administered as part of the TREC Year-One evaluation survey. Additionally, early progress toward scientific collaboration and integration was assessed, using a protocol for evaluating written research products. Results from the Year-One survey and the ratings of written products provide evidence of cross-disciplinary collaboration among participants during the first year of the initiative, and also reveal opportunities for enhancing collaborative processes and outcomes during subsequent phases of the project. The implications of these findings for future evaluations of team science initiatives are discussed.