Dr. Francis Collins, former director of the National Institutes of Health, recently reflected on lessons from the COVID-19 pandemic. Collins noted, “Maybe we underinvested in research on human behavior. I never imagined a year ago . . . that we would still have 60 million people [unvaccinated].”
As a public health and health behavior expert who has spent over a decade studying factors that shape human behavior and health outcomes, and whose job relies heavily on research funding from institutions like NIH, I found his remarks frustrating. Researchers in my field have been advocating for increased support of behavioral research for decades — long before the World Health Organization listed vaccine hesitancy as among the top threats to public health in 2019.
Human behavior, such as the choice not to vaccinate (or worse, actively propagate misinformation designed to stoke unsubstantiated fear), is central to the nation’s most prevalent, obstinate conditions, including heart disease and obesity. To successfully improve health outcomes, reduce costly chronic disease management, and prevent infectious disease outbreaks, it is imperative to understand the link between what drives health behavior (our thoughts) and what catalyzes behavior change (our choices). And understanding the science of human behavior means investing in it. Unfortunately, social and behavioral health scientists remain the minuscule minority in the pool of externally funded scientific investigators.
Federal funding of social and behavioral science is about $2 billion, with the Department of Health and Human Services (primarily NIH) providing the lion’s share of investment. To put that number in context, the total research budget of NIH is over $40 billion. Widening the aperture to include investments in prevention and public health (of which behavioral research closely aligns), we find that the funding allocation is actually declining. In the two decades preceding the COVID-19 pandemic, preventive care spending by the government as a share of total national health expenditures dipped below 3 percent.
This should be deeply concerning to the public.
First, all roads of medical research inevitably require some form of behavior change on the part of individuals. From the life-saving to the banal, medical interventions require people to actually engage in choices or changes. This might mean making dietary changes, scheduling an appointment for a cancer screening, swapping out smoking for a nicotine patch, taking medication as directed, or opting to vaccinate. Short of widespread strategies such as adding fluoride to drinking water or mandating seatbelt use (which, notably, still requires human adherence), improving public health means that decision-makers in government and health care need to understand and apply the science of how to shift behavior at the population level.
There are several interdisciplinary fields working fervently to maximize the impact of medical, environmental, or policy interventions through behavioral research, such as those in behavioral medicine, social epidemiology, psychology, behavioral economics, and implementation science. However, the odds of health behavioral research being funded and behavioral scientists being included at the highest levels of decision-making to promote our nation’s well-being are not in our favor.
This scant investment in behavioral research may partially stem from biases in how we speak about different fields of science. We often hear distinctions such as “hard science” or “bench science” when discussing medical research and clinical trials. Conversely, studies of human behavior are routinely minimized as the “soft” side of the discipline. Like all messaging, however, inaccurate characterization drives false perceptions of value and yields real consequences that stymy progress on efforts to promote population health.
The 60 million US adults who remain unvaccinated for COVID-19 in the third year of the pandemic are a prime example. Even with the COVID-19 vaccine development being nothing short of stunning — funded at historic levels and producing an efficacy rate over 90 percent, or 2 to 3 times the efficacy of a flu shot — 1 in 4 adults has refused to roll up their sleeves. Had even a portion of federal funding amplified behavioral research to understand and mitigate hesitancy, the United States may have been much closer to the success rates in other Organization for Economic Cooperation and Development nations (like Norway, with nearly 90 percent of adults vaccinated).
Science is science. While the content being studied may vary, the integrity and rigor of applying the scientific method should not. As we continue to grapple with the largest public health event in our lifetime, the gaps in research that led to preventable gaps in outcomes need to be questioned. How can policymakers, health care leaders, and scientific experts collaborate to facilitate uptake of successful interventions and address health inequities in real-world settings, where health care access is variable, misinformation and mistrust in medicine are pervasive, science is politicized, racism is systemic, and people make decisions based on factors beyond evidence? This kind of research is science worth the investment.
Monica L. Wang is an associate professor at the Boston University School of Public Health and associate director of the Boston University Center for Antiracist Research.