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Social and Cultural Factors in Health
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Health Disparities
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Home > PublicationsReports > Health Disparities


Strategic Plan for Health Disparities Research, FY 2002-2006

Background

Scientific research supported by the National Institutes of Health (NIH) has been of great benefit to the health of the population in the United States. Research to improve diagnosis, treatment, and prevention has led to improvements in health care for most Americans, and significant declines in morbidity and mortality from numerous diseases. As a result, the population can expect not only to live longer but to be more productive and to enjoy a higher quality of life. However, these gains have not affected all segments of the population equally. Minority populations in the United States continue to experience substantial disparities in the burden of disease and death when compared to the majority population.

Because the existence of racial and ethnic health disparities are to a large extent due to the influence of behavioral and social, rather than biological factors, the Office of Behavioral and Social Sciences Research (OBSSR) is committed to developing better knowledge of their specific causes and participating in finding solutions. The projects described in the OBSSR Strategic Plan for Health Disparities Research are the result of discussions with the extramural research community and the NIH Behavioral and Social Sciences Research Coordinating Committee, and represent important areas of investigation or development which may not be highlighted in the Institutes’ strategic plans. The projects represent directions that OBSSR would like to pursue in the next five years as funding allows. The projects fall into broad categories of background or risk factors, intervention research,training and communications, and are not listed in priority order. In addition, the OBSSR may pursue projects not identified here if opportunities for collaboration with the NIH Institutes arise.

OBSSR welcomes comments on its Strategic Plan for Health Disparities Research. Please send your remarks to Dr. Ronald Abeles at abeles@nih.gov.

Racial Bias and Health

Life expectancy of members of many minority groups in the United States continues to be significantly shorter than that of white Americans. Although significant gains have been made in recent years to increase longevity and decrease the impact of chronic diseases, minority populations have benefited much less than the white population. These disparities in health exist for many reasons but racial bias appears to contribute significantly to differences in health care. For example, a recent study of racial factors that contribute to differentials in diagnosis and treatment demonstrated that racial bias is a significant influence on the likelihood that cardiac catheterization will be recommended for patients with chest pain.

The influence of racial bias is not limited to access to health care. Prejudice and discrimination can be sources of acute and chronic stress which have been linked to conditions such as cardiovascular disease and alcohol abuse. Discrimination can restrict the educational, employment, economic, residential and partner choices of individuals, affecting health through pathways linked with what psychosocial scientists refer to as human capital. Environmental influences from industry, toxic waste disposal sites, and other geographic aspects linked with poverty and minority status can result in serious disadvantages to minority groups' health.

Evidence is insufficient to evaluate the magnitude of the relationship between racial biases and health. In addition, much of the empirical work investigating the effects of prejudice and discrimination and health has focused on African Americans. Few studies have addressed systematically how prejudice and discrimination affect other racial minority groups such as Native Americans, Asian Americans and Latinos. Prejudice and discrimination have helped shape the social position of each racial and ethnic group in the U.S. and, consequently, they may have unique associations with health for each group. Finally, an insufficient focus on the impact of societal forces has hindered our ability to understand and effectively address the influence of racial biases on health disparities. The growing evidence that health, socioeconomic status, and macro-economics are inextricably linked emphasizes the importance of undertaking a program of research to examine the relative magnitude of the influence racial bias in the context of the other factors thought to affect minority health.

The OBSSR plans to assess the state-of-the-science on racial bias and health and stimulate research on areas identified as gaps in knowledge.

Racial/Ethnic and Socioeconomic Inequalities in Health

Both socioeconomic status (SES) and race/ethnicity have been found to relate to a variety of health outcomes. The disparities in life expectancy and health status have been found to be widest between blacks and whites, with blacks having disproportionate mortality from cardiovascular and cerebrovascular diseases, cancer, homicide, infant death, diabetes, and AIDS. Health disparities also have been consistently found for individuals different in socioeconomic status. However, while it is well known that minority groups are disproportionately represented in low socioeconomic strata in the United States, less recognized is that at most levels of SES, morbidity and mortality rates are higher for blacks than for whites.

If black-white differences in health are not simply attributable to group differences in SES, research is needed to understand race and health and the role of SES in this relationship. Reasons for the continued excess risk for poor health among black versus white Americans, even within the “same ” socioeconomic strata, may be two-fold: (a) limitations and errors of measurement and/or (b) real differences. Still undetermined is how best to conceptualize and measure socioeconomic position in general, and within racial/ethnic groups. Indeed classification of race/ethnicity is far from straightforward, e.g., the new Census approach includes the option of checking more than one box. Also in need of study are the roles of environment, family, workplace, and community context as they interact with SES, race/ethnicity, and health. Another largely unexplored area is the way that psychosocial, biological, familial, community and environmental risk factors can be utilized as potential targets for interventions designed to disrupt the negative effects of low SES or race/ethnicity on health.

The OBSSR plans to assess the state-of-the-science in measuring SES and race/ethnicity, and examine current research on the SES/race context as it affects health. Subsequently, it will develop initiatives to stimulate research on racial/ethnic and socioeconomic inequalities in health.

Behavioral Change Interventions to Diminish Racial/Ethnic Health Disparities

While several interventions to improve health-enhancing behaviors in the areas of smoking, drinking, physical activity, and diet have been developed, most previous research has targeted easy-to-reach populations. The effectiveness of these interventions for vulnerable populations in diverse racial/ethic groups is still undetermined. While a variety of theoretical models (health belief model, theory of reasoned action, trans-theoretical model and stages of change, etc.) have been developed to describe the process of health behavior change, still unknown is the relevance of different theories for changing particular behaviors in various minority populations. In addition to research on individual level behavior change, gaps remain in the development and testing of community level interventions for a diversity of racial and ethnic communities.

Currently underway are 15 studies supported by an OBSSR- coordinated, trans-NIH RFA to evaluate theory-based interventions targeting initiation and long term maintenance of change in two or more health-related behaviors. Special encouragement is needed to extend this work with respect to the relative effectiveness of theory-based interventions for population groups differing in race and ethnicity.

OBSSR plans to examine current research on barriers to intervention availability, delivery and effectiveness as a function of racial/ethnic group membership, as well as the mechanisms of intervention which best manage the health outcomes of particular ethnic or racial groups.

The Office will develop initiatives to stimulate research on behavioral interventions for different ethnic/racial groups.

Health Disparities and Health Care Systems

Differences in the quantity and quality of health care provided to members of racial/ethnic groups are critical to understanding disparities in health. Members of minority racial/ethnic groups are less likely than majority group members to receive health-care services. For example, blacks are less likely than whites to receive common diagnostic procedures and treatments or to receive intensive interventions such as by-pass surgery. Furthermore, racial disparities exist in important qualitative aspects of medical care, e.g., receiving care from a private physician vs. hospital outpatient or emergency departments.

Increased conceptual and empirical efforts are needed to identify and understand the processes leading to differentials in health care and to develop intervention strategies. Disparities in the quantity and quality of health care may result from the interaction of several factors. Among these are:
  • Differential mix of health care services available to and accessible by racial/ethnic communities. Physicians may tend to avoid areas with large minority populations when establishing private practices; distances to health care services may be greater for those living in minority communities; outreach and health promotion activities of agencies may be less effective. A related question is how the currently evolving health care system, e.g., HMOs, is affecting health disparities.
  • Inadequate economic resources may result in foregoing or postponing medical services. For example, Hispanic adults are substantially more likely to be uninsured than white or black adults.
  • Cultural, attitudinal, or communication-style differences between minority individuals and health-care providers may lead to miscommunication, misunderstanding, and deficiencies in health care.
  • Minority individuals may express their disease symptoms in different ways from majority individuals, which may lead to errors in diagnoses and treatment.
  • Prejudice and discrimination may influence decisions about providing health care services.
OBSSR plans to assess the state-of-the-science and develop an agenda for research on racial/ethnic group health discrepancies and health care systems. Research initiatives arising from this assessment are likely to address gaps in both basic and intervention research on racial/ethnic group interactions with health care systems.

Infrastructure Development: Training and Developing Scientists, Including Minority Scientists

In order to understand and address health disparities, it is critical that we build a cadre of scientists who can approach scientific questions from a multidisciplinary perspective, and who possess a thorough understanding of the influence of behavioral and social science factors on health and illness. OBSSR will continue its support for the multidisciplinary training of scientists with a focus on health disparities research. In addition, OBSSR will increase its activities to expand the pipeline of minority researchers in the behavioral and social sciences, especially students interested in research on health disparities.

OBSSR is establishing goals to increase the number of scientists who study health disparities from a multidisciplinary perspective and increase the pool of minorities interested in pursuing research careers in the behavioral and social sciences in general, and health disparities in particular. Efforts to accomplish these goals include reviewing the literature to determine what factors are important in keeping minority students interested in research careers; developing an outreach program to encourage participation of high school and college students in the Research Supplements for Underrepresented Minorities program; and exploring training opportunities for minorities in NIH behavioral and social science intramural labs.

Public Information/Outreach: Improving NIH Public Health Messages

Critical to the mission of NIH is ensuring that research findings and health messages are clearly communicated to all segments of the public. NIH health messages are a powerful tool for diminishing health disparities through education.

Working in cooperation with the NIH Office of Communications and Public Liaison (OCPL), OBSSR will draw on the experience of the Institutes and Centers to determine how the OBSSR might be helpful in improving health communications targeted to various racial/ethnic populations.

The first step toward improving health communications is to assess the state-of-the-science in communicating health information to diverse racial and ethnic populations. Working in cooperation with the Institutes and Centers, OBSSR will organize a task force to review relevant communication theory and research and identify knowledge gaps in developing health communications for specific populations. Following an assessment of the current scientific literature and a review of the recommendations of the task force, OBSSR will work with NIH Institutes and Centers to implement the recommendations. If significant knowledge gaps are identified, OBSSR, in collaboration with the Institutes and Centers, will develop an initiative to stimulate research in the needed areas.
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Health Disparities