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
Martha N. Hill, PhD, RN
I
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ments 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 EstrogenProgestin 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 lipidlowering 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). 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 lipidlowering drugs. Only one third of the women with LDL
cholesterol levels .160 mg/dL were taking a lipid-lowering
agent.
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).4 These are two of many examples of
t 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:
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Why does the gap exist?
Why must it be closed?
What are we, as scientists and the AHA, doing to close it?
The Gap
Despite extensive studies of strategies to prevent and treat risk
factors for heart disease and stroke, current evidence docu-
The president’s address is being published simultaneously in the March issue of Stroke.
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(Circulation. 1998;97:807-810.)
© 1998 American Heart Association, Inc.
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AHA President’s Address
808
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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.
how much work remains to be done in risk factor
management.
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
Trends in the Awareness, Treatment, and Control of High
Blood Pressure in Adults: United States, 1976-1994*
NHANES II
(1976-1980)
NHANES III
(Phase I)
1988-1991
NHANES III
(Phase 2)
1991-1994
Awareness
51%
73%
68.4%
Treatment
31%
55%
53.6%
Control†
10%
29%
27.4%
*Data are for adults aged 18 to 74 years with systolic blood pressure
$140 mm Hg, diastolic blood pressure $90 mm Hg, or taking antihypertensive
medication.
†Systolic blood pressure .140 mm Hg and diastolic blood pressure
.90 mm Hg.
From the Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure3,4 and published data (NHANES III, Phase 2, Centers for
Disease Control and Prevention, National Center for Health Statistics).
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
Hill
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?
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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
809
(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
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The Expert Panel on Awareness and Behavior Change,
chaired by Richard Carleton16
Optimal Risk Factor Management in the Patient After
Coronary Revascularization, chaired by Thomas Pearson
and Elliott Rapaport17
Preventing Heart Attack and Death in Patients With Coronary Disease, chaired by former AHA President Sidney
Smith18
Guide to Primary Prevention of Cardiovascular Disease,
chaired by Scott Grundy19
The Multilevel Compliance Challenge, cochaired by Nancy
Houston Miller and Martha Hill20
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
AHA President’s Address
810
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
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Research!America
The American College of Cardiology
The North American Vascular Biology Organization
The Centers for Disease Control and Prevention
The Health Care Finance Administration
The Health Employers Data Information Set
The National Committee for Quality Assurance
The High Blood Pressure, Cholesterol, and Heart Attack
Alert Education Programs of the National Heart, Lung, and
Blood Institute
Members of the AHA Pharmaceutical Roundtable
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.
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KEY WORDS: AHA Medical/Scientific Statements
prevention n lifestyle
n
risk factors
n
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
Martha N. Hill
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Circulation. 1998;97:807-810
doi: 10.1161/01.CIR.97.8.807
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1998 American Heart Association, Inc. All rights reserved.
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