While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
The Problem. Lloyd Johnston, PhD, has worked to stack the deck in favor of children throughout his long career. Years of groundbreaking research have taught him that individual health behaviors result from complex interactions among individuals, the environments that surround them and the laws that govern them—and that sound public policies need to consider each of those influences. Johnston also knows from experience that high-quality health research must inform those policies.
That commitment to good science is essential to confront smoking, drinking and illicit drug use—all of which are pervasive health, social and economic challenges that have defied many strategies intended to alleviate their impact. Rigorous data are also the foundation for addressing the more recent epidemic of childhood obesity, in which almost one in three young children and adolescents are either overweight or obese.
Health behaviors are formed early, making Johnston's focus on children especially valuable. For example, studies have shown that most cigarette smoking, drinking and illicit drug use begins in adolescence. Other research demonstrates that early experiences shape food preferences and attitudes about how much to eat.
Choosing psychology over a corporate career. From a young age, Johnston wanted to make a social contribution, inspired perhaps by the example of his parents. "My father was always concerned about doing good in the world," he says.
Although he completed a Masters of Business Administration at Harvard University, Johnston discovered along the way that he was not a good fit for corporate life. "I took as many social science courses as I could within the MBA program and then applied to several schools to study psychology. I got rejected by every one of them. That was a humbling experience."
Johnston may have been humbled, but he was not deterred: "I thought I had to get 'retreaded'" he says. He convinced a Harvard professor in the field of organizational behavior to hire him as a research assistant, and he helped to design and administer a graduate course on human behavior using simulated organizations. He also read a book by a professor at the University of Michigan's Institute for Social Research, which introduced him to the analytical perspective—and the place that would soon become his intellectual and professional home.
A year later, Johnston reapplied to several graduate programs in psychology and this time, he was accepted by all of them. He chose the University of Michigan, earned his master's degree, and then a PhD in social psychology in 1973, and chose to remain there ever since. For more than a decade, he has held the title of Distinguished Research Scientist.
Tracking youth behaviors to improve health outcomes. Soon after entering the University of Michigan, Johnston and Jerald Bachman, PhD, developed a proposal for a study that became the nation's landmark National High School Senior Survey, now known as Monitoring the Future: A Continuing Study of American Youth. Monitoring the Future has collected, analyzed and disseminated information about the beliefs, attitudes and behavior of more than a million young people in the United States, conducting surveys every year since 1975.
By 2010, Monitoring the Future was surveying about 50,000 eighth, tenth and twelfth grade students in a nationally representative sample of about 420 public and private secondary schools each year. The federal National Institute on Drug Abuse (NIDA) has funded the survey since its inception.
Through Monitoring the Future, Johnston has emerged as a pre-eminent researcher and thinker about adolescent health behaviors and the forces that influence them. Researchers, policy-makers and advocates have drawn on his journal articles and policy papers to design solutions to the problem of youth substance use. He has won various awards, including the National Institute on Drug Abuse National "Pacesetter Award" in 1982 and the Regents' Award for Distinguished Public Service from the University of Michigan in 1998. The Institute for Scientific Information lists him among the "most highly cited authors in the social sciences (top 0.5%)."
Kenneth E. Warner, PhD, Avedis Donabedian Distinguished University Professor of Public Health and former dean of the University of Michigan School of Public Health describes Johnston's contribution to the substance abuse field, "Monitoring the Future has served as the nation's barometer on licit and illicit drug use by youth for more than 30 years. It is an extraordinarily valuable resource, one that Lloyd and his colleagues have enriched consistently. Lloyd's contribution to the national debate on drug use and to the formulation of national drug policy has been invaluable."
Making the connection with the Robert Wood Johnson Foundation (RWJF). When RWJF turned its grantmaking efforts to substance use in the 1990s, Johnston had all the right credentials to become involved. RWJF soon pulled him in to help guide Bridging the Gap: Research Informing Practice and Policy for Healthy Youth Behavior, one of its major national programs.
Bridging the Gap began in 1997 with the goal of understanding environmental factors and policies that affect adolescent decisions to smoke, drink or use drugs. Prior studies had focused on individuals, and generally ignored the context within which they made their choices. According to RWJF's Senior Scientist C. Tracy Orleans, PhD, "We realized Lloyd's Monitoring the Future data would show us how drug use among kids was changing. RWJF could then create a strategy to monitor the drivers of those changes—the policies that might have prompted them."
Johnston was interested in becoming involved, but also cautious. Although he had urged RWJF to seek out an existing survey, rather than design a new one, he had mixed feelings about using his own. Taking on the commitment added to the scope of an already ambitious study, and required sign-off from NIDA.
But after further discussion, Johnston agreed to become involved. "I knew we had a great deal of data about kids and their substance use. We also had data about how students viewed their schools' drug policies and their perceptions of school norms. It would be a shame to let the opportunities go by and not have learned from them," he says.
James R. Knickman, PhD, RWJF's former vice president for research and evaluation (now president of the New York State Health Foundation) knows the match between RWJF and Johnston was a good one. "Lloyd has played a key role helping our nation understand the dynamics of drug use across time and across communities. His Monitoring the Future surveys are the nation's key source of information about patterns of drug use.
"What is exciting about RWJF's relationship with Lloyd is that Bridging the Gap steered Lloyd towards modeling the causes and solutions to drug use behavior, adding to his seminal work on documenting the patterns and trends in substance use. Lloyd's pivotal leadership within the Bridging the Gap research group helped make this first-rate team of grantees productive and rigorous in its important research agenda," says Knickman.
Bridging the Gap was structured with two distinct components in order to fully capitalize on the strengths of its leadership. Johnston directs YES! (Youth, Education and Society), the student and school component of the study, while his colleague and collaborator, Frank J. Chaloupka at the University of Illinois at Chicago, directs ImpacTeen, the community and state component. Their two teams work in close partnership.
Based on their analyses of student, school, community and state data, Johnston and Chaloupka concluded that:
The first of these findings was important to RWJF's tobacco-control funding, which focused on increasing taxes on cigarettes and other tobacco products through work with many partners in its SmokeLess States initiative.
Johnston knows that research takes time to influence behavior, but he believes that making connections between behavior and environmental factors has made a difference. "Fewer kids are smoking today than at any time in the 35 years since Monitoring the Future started. I know what that means in terms of the human consequences."
Adding childhood obesity to his profile. As RWJF shifted its focus away from substance use and towards preventing childhood obesity, it decided to use Bridging the Gap in new ways. Orleans was intent on persuading Johnston and Chaloupka to make the same shift. "It was a natural next step for the program, and for Lloyd's and Frank's well-honed and phenomenally productive research partnership."
After spending more than 30 years analyzing adolescent substance use patterns, Johnston was the more ambivalent, pausing when Orleans asked if he would be willing to direct some of his efforts to childhood obesity. He reflects, "I had to think about making the switch. It wasn't anything I had planned on, and I didn't know anything about obesity."
Ultimately, Johnston's commitment to health consequences for young people trumped his concerns about having limited expertise in the fields of diet and physical activity. "Back in the 1980s, we added questions in Monitoring the Future regarding height, weight, eating habits and exercise, so we had a history of those factors for thousands of students. I didn't want to lose a chance to learn from those data. And, obesity has enormous health consequences. I realized if we could make a contribution in this area similar to the one we made on smoking that would be significant."
Since 2005, Johnston and Chaloupka have done for nutrition and physical activity what they did for substance use: to seek out the connections between individual behavior and broader influences, such as school, community, and state and federal policies.
Johnston sees important similarities between substance use and the nutritional factors that promote obesity. "The environment is an important part of both behaviors. Americans started with a cultural assumption that both substance use and obesity are based on individual will. In both, we seriously under-appreciated factors like the importance of price, media, laws and other environmental factors."
A future and a legacy. Johnston remains committed to both prongs of his research. Monitoring the Future is a continuing survey, with NIDA providing the funding to study substance use patterns, while the RWJF-funded YES! (Youth, Education and Society) project draws on his data to build a foundation for obesity initiatives.
Looking back on the approach he developed with Monitoring the Future and continued with Bridging the Gap, Johnston hopes that the connections among research, policy and health outcomes endure: "I want the lines of research I do to continue beyond my career—these should remain American institutions. I will do what I can to be sure that happens."
Many substance abuse advocates have no doubt that Johnston's work will endure. Tom Hedrick, senior communications officer and founding member of the Partnership at Drugfree.org (formerly the Partnership for a Drug Free America) says, "Lloyd is that rare combination of respected, independent scientist and committed and passionate activist for helping reduce drug, alcohol and tobacco use among kids. It is hard to overstate his importance to our field. Lloyd's independent and expert point of view have significantly influenced the Partnership's strategies and programs.
"His leadership and credibility as principal investigator of Monitoring the Future brought much-needed attention from policy-makers, the media and the public to the levels and trends in substance abuse among adolescents. Perhaps even more importantly, Lloyd's work has given us insights into why adolescents are moving in the direction they are, and what action is needed to help them."
RWJF perspective: RWJF has committed $57 million to Bridging the Gap. It has become "one of RWJF's most productive and influential policy research initiatives, far exceeding the aims we first envisioned for it," according to RWJF's Orleans.
"There is no other program I know of, anywhere, that can link individual behavior, school policy, community policy, state policy and federal policy. Nothing anywhere. Lloyd and Frank did that for adolescent substance use, and they are now leading the field in understanding how policies affect childhood obesity. Without Lloyd's extraordinary personal and scientific leadership, this would not be happening."
This has influenced RWJF as well. Orleans observes, "I think Bridging the Gap has transformed the field in connecting policy to behavior, and RWJF has used this model for our work in childhood obesity. This model has been transformative for the Foundation and for the field: addressing the policy and environmental determinants of adolescent health and health behaviors is now regarded as essential."
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