For the First Time, Healthy People Initiative Focuses on Social Determinants of Health

By Nancy Breen, Ph.D.
Economist, Office of Strategic Planning, Analysis and Reporting, NIMHD and NIMHD Representative to the Healthy People Social Determinants of Health Workgroup

Healthy People Background

The Healthy People initiative is a federal program that provides “science-based, 10-year national objectives for improving the health of all Americans.” For the past 40 years, Healthy People has monitored the health of Americans and set benchmarks for how we can all be healthier. You can read more about Healthy People online at www.healthypeople.gov.

Nancy Breen, Ph.D.

Nancy Breen, Ph.D.

Healthy People provides a national 10-year framework for health promotion and disease prevention, with measurable objectives and goals, and it invites states and localities to use the national framework and objectives for their own plans. While the focus has always been health promotion and disease prevention, the Healthy People 2020 agenda is the first to use social determinants of health (SDOH) to frame the conceptual understanding of health. For 2000, an overarching goal to “reduce health disparities” was introduced, partly in response to the 1985 Report of the Secretary’s Task Force Report on Black and Minority Health (often referred to as the “Heckler Report”).1 For 2010, that goal was strengthened to “eliminate health disparities.” For Healthy People 2020, one of the overarching goals is to “achieve health equity, eliminate disparities, and improve the health of all groups.”2 The graphic from Healthy People 2020 shows that the overarching goals emphasize the determinants of health.

The mission of Healthy People 2020 includes identifying health improvement priorities; increasing public understanding of the determinants of health, disease, and disability; and engaging multiple sectors to identify opportunities for progress. Including health disparities in this framework improves the chances that federal interventions will be able to reduce health disparities and increase health equity for all Americans. The choice to highlight social determinants as a leading health indicator (LHI) is important, because LHIs are used to motivate action on high-priority health issues and challenges at the national, state, and community levels.3

One of the Healthy People initiative’s key roles is to identify research, evaluation, and data needs. The National Center for Health Statistics conducts two assessments for each 10-year initiative. These midcourse and final reviews provide an opportunity to see the initiative’s impact along the way. The 5-year review for Healthy People 2020 was released in January 2017 and can be found on the CDC website, at https://www.cdc.gov/nchs/healthy_people/hp2020/hp2020_midcourse_review.htm.

Healthy People 2020 Framework

Healthy People 2020 Framework. Graphic from www.healthypeople.gov.

Chapter 39 of the Midcourse Review focuses on SDOH, and some of the most important findings are described below. Healthy People 2020 defines SDOH as “conditions and the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”4 The 33 SDOH objectives are organized into five domains:

  1. Economic stability (9 objectives)
  2. Education (5 objectives)
  3. Health and healthcare (6 objectives)
  4. Neighborhood and built environment (10 objectives)
  5. Social and community context (3 objectives)

Highlights from the Midcourse Review

Economic Stability

How much money people spend on housing can have a meaningful impact on their well-being. Economic experts recommend that families spend no more than one third of their income on housing, so that adequate funds are available for other expenditures. Studies show that spending more than half of a family’s income on housing puts householders at high risk of losing their home. The Midcourse Review shows that more people are being affected on both measures, suggesting that, overall, Americans are not doing as well in terms of economic stability as they were 5 years before.

  • From 2007 to 2011, the proportion of households that spent more than 30 percent of their income on housing rose from 35 percent to 38 percent; in 2011, Hispanics/Latinos were the racial/ethnic group most at risk. Householders with less than a high school education, with low family income, with a disability, or who lived in metropolitan areas were also at higher risk.
  • From 2007 to 2011, the proportion of households that spent more than half of their income on housing increased from 16 percent to 18 percent. Householders who were African American had less than a high school education, were poor, or lived in nonmetropolitan areas were at higher risk.

Education

Today, having a college education is important for getting a job and staying employed. The Midcourse Review showed that, unfortunately, the percentage of young people going to college after completing high school is lower than it was a few years ago.

  • Individuals ages 16–24 who had completed high school and enrolled in college the following October decreased from 68 percent to 66 percent between 2010 and 2013. High school completers from low-income families were less likely than completers from high-income families to enroll in college right after high school graduation.

Health and Healthcare

Having health insurance is an important part of making sure that people can afford access to an ongoing source of healthcare when they get sick. The Midcourse Review showed that more people under the age of 65 have insurance now than they did in 2007 and that people of all ages are more likely to have a source of ongoing healthcare. In addition, more people than before say that they can understand their doctor or nurse’s instructions.

  • The proportion of people under age 65 with medical insurance increased from 83 percent in 2008 to 87 percent in 2014, and the proportion of people of all ages with a source of ongoing care increased from 86 percent in 2008 to 88 percent in 2014.
  • The proportion of people age 18 and over who reported that their healthcare providers’ instructions were easy to understand increased from 64 percent in 2011 to 66 percent in 2012.

Neighborhood Context and the Built Environment

Under the well-known “broken windows” theory, an orderly environment signals that an area is monitored and that criminal behavior is not tolerated: Neighborhoods with a strong sense of cohesion assert social responsibility and control by fixing broken windows and other small but visible problems. Air quality and lead levels are important indicators of a clean and safe environment, and crime rates are an indicator of social cohesion.

  • Between 2008 and 2012, there was a decrease in the rate of arrests of minors and young adults ages 10–24 for serious violent crimes (from 444 to 324 per 100,000 population) and serious property crimes (from 1,527 to 1,223 per 100,000 population).
  • Days when the Air Quality Index (AQI) exceeded 100 (weighted by population and AQI) decreased from 2.2 billion to 982 million between 2006–2008 and 2012–2014. Also, lead levels in blood samples among children ages 1–5 years in the 97.5 percentile decreased from 5.8 mcg/dL to 4.3 mcg/dL between 2005–2008 and 2009–2012.

Social and Community Context

Social support is especially critical for children and adolescents, who are in their formative years. New items that may be measured in the final review of Healthy People 2020 include civic participation, incarceration, and discrimination.

  • The proportion of adolescents ages 12–17 who reported having an adult in their lives with whom they could discuss serious problems rose slightly, from 76 percent in 2008 to 78 percent in 2013; however, it is striking that almost a quarter of adolescents did not report having such an adult in their lives.

Overall, the Healthy People 2020 Midcourse Review underscores a basic fact: Improving the social determinants of health and mitigating their adverse impacts on population health is complicated. Even so, trends for 15 of the 25 objectives that have targets are moving toward or have met national targets. The Midcourse Review provides an opportunity to assess progress and identify remaining opportunities for interventions so that more can be accomplished by 2020. Addressing SDOH in localities, states, and the nation is an important step toward reducing health disparities. We have made some progress, especially in healthcare and family communication, but there is still work to be done.

Learn more about NIMHD’s work to eliminate disparities and improve the health of all groups.

 

References

1. National Center for Health Statistics. Chapter 4: Leading Health Indicators. Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B04-LHI.pdf

2. National Center for Health Statistics. Chapter 39: Social Determinants of Health (SDOH). Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C39-SDOH.pdf

3. U.S. Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Volume I: Executive Summary. Washington, DC. 1985.

4. National Center for Health Statistics. Chapter 1: Introduction. Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B01-Introduction.pdf

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Introducing the Language Access Portal

By Kelli Carrington, M.A.
Director, Office of Communications and Public Liaison
National Institute on Minority Health and Health Disparities

NIMHD Office of Communications and Public Liaison Director Kelli Carrington

Kelli Carrington, M.A.

Many of us know what it’s like to feel overwhelmed during a doctor’s visit by information about health conditions, medicines, and behavior recommendations. For patients who don’t speak or understand English fluently, the situation can be more than overwhelming—it can be dangerous. Patients with limited English proficiency (LEP) are nearly three times more likely to have an adverse medical outcome.1

Language is one of the most significant barriers to health literacy, the ability to understand the basic health information needed to make good health decisions. Patients who lack health literacy are often unable to read or understand written health information or to speak with their healthcare providers about their symptoms or concerns. These patients are less likely to follow important health recommendations or be able to give informed consent.2

According to the U.S. Census Bureau, more than 1 in 5 U.S. residents don’t speak English at home. Of that group, about 4 in 10, or 25 million people, have limited English proficiency.3 Many people with limited proficiency also live in households where no one speaks English well, meaning there isn’t a translator readily available to accompany them to doctor’s visits.

The National Institute on Minority Health and Health Disparities (NIMHD) is committed to addressing these language barriers and to improving the health literacy and lives of everyone living in America. We’re excited to announce a new tool, the Language Access Portal, as a resource for the NIMHD research community, public and community health professionals, healthcare providers, and others who work with health disparity populations with LEP. The portal improves access to cross-cultural and linguistically appropriate health information produced by the National Institutes of Health (NIH), NIMHD, and other federal agencies.

The Language Access Portal pulls together health resources from across NIH in selected languages, particularly those languages spoken by populations experiencing significant health disparities. As we launch, the portal includes information in Spanish, Hindi, Tagalog, Korean, Chinese, Japanese, and Vietnamese. The portal currently has language resources for the following areas where health disparities have been identified:

The Language Access Portal is an important tool to help people working with LEP populations provide the information necessary for patients to make important health decisions. The portal will continue to evolve and incorporate new resources from NIMHD, NIH and other government agencies as they become available, so keep checking back. By working together and using tools like the Language Access Portal, we can begin to tackle these communication barriers and improve the health of every resident of this country.

 

References

  1. Divi, C., Koss, R.G., Schmaltz, S.P., Loeb, J.M. (2007) Language Proficiency and Adverse Events in US Hospitals: a pilot study. Int J Qual Health Care. 19 (2): 60-67.
  2. Lee, J.S., Pérez-Stable, E.J., Gregorich, S.E. et al. (2017). Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English ProficiencyJ GEN INTERN MED. doi:10.1007/s11606-017-3983-4
  3. U.S. Census Bureau. Table S1601: 2011-2015 American Community Survey 5-Year Estimates.

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Addressing Mental Health in African Americans Through FAITH

By Dr. Tiffany Haynes, Ph.D.
Assistant Professor, Department of Health Behavior and Health Education
Fay W. Boozman College of Public Health
University of Arkansas for Medical Sciences, Little Rock, AR

Rural African Americans are disproportionately exposed to numerous stressors, such as poverty, racism, and discrimination,1–that place them at risk for experiencing elevated levels of depressive symptoms.6 Elevated levels of depressive symptoms can lead to a host of negative outcomes, including poor management of chronic illnesses (e.g., hypertension, diabetes), poor social and occupational functioning, and development of clinical depression.7 Although effective treatments for decreasing depressive symptoms exist, structural barriers (e.g., lack of available services, transportation) and perceptual barriers (e.g., stigma, fear of misdiagnosis) impede the use of traditional mental health services within these communities, resulting in a significant unmet psychiatric need. Failure to develop culturally appropriate strategies to provide adequate, timely care to rural African Americans can result in a significant public health crisis.

Dr. Tiffany Haynes, Ph.D.

Dr. Tiffany Haynes, Ph.D.

African American churches have been identified as potential venues for providing depression education and treatment for rural African Americans.8 Within the African American rural community, churches represent a key portal through which as much as 85% of the community can be reached.9 Churches have been used to address physical health outcomes in those communities, but few have focused primarily on addressing mental health outcomes10-11. Through the NIMHD-funded project entitled “Faith Academic Initiatives to Transform Health (FAITH) in the Delta,” our partnership, consisting of faith community leaders and University of Arkansas for Medical Science researchers, conducted formative work in the Arkansas Delta. Data suggested that community members consider elevated depressive symptoms to be a significant unmet need. Furthermore, community members suggested that attempts to improve depressive symptoms should do the following:

  1. Provide education about depressive symptoms. Recognizing when depressive symptoms become a clinical problem is the first step toward receiving adequate treatment. However, rural African Americans report difficulties in differentiating between normal sadness and clinically significant depressive symptoms. Providing education about depressive symptoms allows rural African Americans to make informed treatment decisions.
  2. Address the role that stress from social inequities plays in the development and maintenance of depressive symptoms. Rural African Americans correctly realize that prolonged exposure to stress caused by social inequities is a significant factor in the development and maintenance of depressive symptoms. Treatments that conceptualize depressive symptoms as normal reactions to stress are more culturally acceptable in rural African American communities.
  3. Find ways to increase social support for those experiencing depressive symptoms. Stigma is a significant concern in rural communities. Rural African Americans experiencing depressive symptoms tend to socially isolate themselves, which, in turn, can worsen depressive symptoms.
  4. Provide mental health interventions in community-based settings. Residents suggest that offering mental health services in community settings, such as churches, would allow residents to receive treatment in less stigmatizing places and improve access to mental health care.

    (from left to right): Pastor Johnny Smith, Community PI; Dr. Tiffany Haynes, Academic PI; Dr. Karen K. Yeary, PhD, Academic Co-PI; and Pastor Jerome Turner, Community PI.

    From left to right: Pastor Johnny Smith, Community PI; Dr. Tiffany Haynes, Academic PI; Dr. Karen K. Yeary, PhD, Academic Co-PI; and Pastor Jerome Turner, Community PI

Using this data as a base, researchers worked closely with the faith community to culturally adapt an evidence-based behavioral activation intervention for use with rural African American churches. This eight-session behavioral activation intervention, REJOICE (Renewed and Empowered for the Journey to Overcome in Christ Everyday), was adapted to include faith-based themes, scripture, and other aspects of the rural African American faith culture (e.g., Bible studies, interweaving faith-based messages throughout the intervention materials).

Currently, we are testing the effectiveness of REJOICE and obtaining pilot data about the best ways to implement this intervention in rural African American churches. Collecting data from this project is the first step in providing timely and appropriate care to high-need and underserved communities.

 

References

  1. Harris, R. P., & Worthen, D. (2003). African Americans in rural America. In D. L. Brown & L. E. Swanson (Eds.), Challenges for rural America in the twenty-first century (pp. 32-42). University Park, PA: The Pennsylvania State University Press.
  2. U.S. Department of Agriculture, Economic Research Service (2016). Rural Poverty and Well-Being: Geography of Poverty. Retrieved from https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/
  3. Fitchen, J. M. (1992). On the edge of homelessness: rural poverty and housing insecurity. Rural Sociology, 57, 173-193.
  4. Kusmin, L. (Ed.). (2012). Rural America at a glance, 2012 edition. Washington, DC: U.S. Department of Agriculture, Economic Research Service.
  5. Odom, E. C., & Vernon-Feagans, L. (2010). Buffers of racial discrimination: links with depression among rural African American mothers. Journal of Marriage and the Family, 72, 346-359.
  6. Kusmin, L. (Ed.). (2011). . Rural America at a glance, 2011 edition. Washington, DC: U.S. Department of Agriculture, Economic Research Service.
  7. Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201-225.
  8. Taylor RJ, Chatters LM, Levin J. Religion in the Lives of African Americans: Social, Psychological, and Health Perspectives. Thousand Oaks, CA: Sage Publications, 2004.
  9. Reeves RR, Adams CE, Dubbert PM, Hickson DA, Wyatt SB. Are Religiosity and Spirituality Associated with Obesity Among African Americans in the Southeastern United States (the Jackson Heart Study)? J Relig Health. 2011.
  10. DeHaven MJ, Hunter IB, Wilder L, Walton JW, Berry J. Health programs in faith-based organizations are they effective? Am J Public Health. 2004; 94(6): 1030-6. 1448385
  11. Hankerson, Sidney H., and Myrna M. Weissman. “Church-based health programs for mental disorders among African Americans: a review.” Psychiatric Services 63.3 (2012): 243-249.
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New Funding Opportunity Announcement for Research Centers in Minority Institutions

By Eliseo J. Pérez-Stable, M.D.
Director, National Institute on Minority Health and Health Disparities

It’s been 5 years since the last funding opportunity announcement (FOA) for the Research Centers in Minority Institutions (RCMI) was issued. Today I’m pleased to share news that the National Institute on Minority Health and Health Disparities (NIMHD) is releasing a new FOA that will capitalize on the program’s capacity to generate new scientific discoveries in minority health and health disparities research and to stimulate the next generation of researchers from underrepresented populations in institutions that are committed to this mission.

The RCMI will continue to serve as a flagship program aimed at the development and enhancement of institutional research infrastructure necessary to conduct world-class biomedical, behavioral, and clinical research and to produce well-trained investigators from underrepresented populations who will help enhance diversity in the biomedical research enterprise.

We have modified the RCMI program to make it even stronger in the future, with more flexibility and a three-tiered research structure opportunity for basic, clinical, and/or behavioral research. Eligible institutions must award doctoral degrees in the health professions or health-related sciences, have a historical and current commitment to serving students from underrepresented populations, and receive less than $50 million in average annual NIH funds within the 3 years prior to the time of application.

Given that the single most important predictor of choosing a scientific career is whether an individual participates in a rigorous, mentored research experience, the RCMI program now enables all levels of investigators, especially new and early career investigators, to experience rigorous, mentored research experiences focused on diseases that disproportionately affect minority and other health disparity populations. At least one research project will be included, as well as funds allocated to support pilot projects by postdoctoral fellows and assistant professors.

These program changes support NIMHD’s vision to advance the science of minority health and health disparities, and I encourage eligible institutions to apply. Click here to learn more about the new RCMI FOA.

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Apply Now to the 2017–2018 NIH Medical Research Scholars Program

By Eliseo J. Pérez-Stable, M.D.
Director, National Institute on Minority Health and Health Disparities

The National Institutes of Health (NIH) Medical Research Scholars Program (MRSP) is an excellent research enrichment opportunity for promising students from diverse backgrounds to gain real-life experience in NIH laboratories and patient care areas. NIMHD is proud to participate with other NIH Institutes and Centers in the MRSP. Our goal is to introduce the MRSP to medical, dental, and veterinary students from diverse racial and ethnic backgrounds and encourage them to consider biomedical research as a career.

A medical researcher at work.

A medical researcher at work.

The U.S. population continues to increase in diversity, and there is an urgent need to ensure that the scientific talent which is key to our nation’s success is nurtured, recognized, and supported across all demographic groups. We need more researchers from diverse backgrounds to contribute minority perspectives and priorities to the research agenda, and advance the likelihood that underserved or health disparity populations participate in and benefit from health research.

However, minorities are seriously underrepresented in the biomedical workforce. In a recent study of U.S. citizens applying for investigator-initiated NIH research funding, African Americans were 13 percentage points less likely to receive awards, compared with Whites. African Americans/Blacks, American Indians and Alaska Natives, Hispanics/Latinos, and Native Hawaiians and other Pacific Islanders make up a disproportionately small component of the NIH Principal Investigator (PI) pool.

MRSP works to address this deficit in the research workforce by providing a comprehensive, year-long residential program designed to attract the most creative, research-oriented medical, dental, and veterinary students to the NIH intramural campus in Bethesda, Maryland. Student scholars in their second, third, or fourth year of study engage in a closely mentored basic, clinical, or translational research project that matches their research interests and career goals.

150930_dr_perez-stable_ps2_032_medIn addition to pursuing a rigorous research agenda, MRSP scholars participate in career development activities, lectures, journal club seminars, patient rounds, and clinical research coursework. They also highlight their research in formal presentations to the NIH community and at professional conferences. Each scholar is assigned an advisor who provides guidance in defining a well-articulated career development plan and selecting a dedicated NIH research mentor. Mentors are full-time NIH investigators with established and successful basic, translational, or clinical research programs.

The mentorship of students and early-career scientists is essential to professional success and the future of the biomedical research enterprise as a whole. The availability and quality of mentoring support for graduate students and newly graduated doctorates is important to increasing the proportion of underrepresented minority students who will ultimately obtain an independent position in a research university, medical school, or independent research institute, and finally, successfully compete for R01 grants.

As part of NIH’s mission to train the next generation of clinician-scientists and biomedical researchers, this program is designed for U.S. citizens and permanent residents currently enrolled in an accredited medical, dental, or veterinary program who have completed their core clinical rotations. This does not preclude students with strong research interests from applying before they complete their clinical rotations. Medical and osteopathic students may participate after completing their first year of clinical rotations (i.e., third year of medical school). Dental and veterinary students may participate in the MRSP after completing their second or fourth year of study, due to the integrated nature of the third and fourth (clinical) years.

MRSP scholars experience the full continuum of biomedical research—the bench, the bedside, between the two, and beyond. So this is a comprehensive, integrated, rich opportunity for students ready to build a solid foundation for their careers in biomedical research.  I encourage students who are ready to take this competitive, yet rewarding next step to apply.

Applications for the 2017–2018 program will be accepted from October 1, 2016, through January 13, 2017. Interviews will be held in early March 2017, and selections will be announced in mid-March.

Visit the NIH MRSP website at http://cc.nih.gov/training/mrsp/index.html to learn more and submit your online application.

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Health Disparities Among American Indians and Alaska Natives: Enormous Hurdles and Opportunities to Advance Health Status

By Linda Burhansstipanov, M.S.P.H., Dr.P.H.
Founder, Native American Cancer Research Corporation and President, Native American Cancer Initiatives, Inc., Pine, Colorado

Linda U. Krebs, RN, Ph.D., AOCN, FAAN
Associate Professor (retired), College of Nursing, University of Colorado at Denver, Anschutz Medical Campus

American Indians and Alaska Natives (AI/ANs) have long experienced lower health status than other U.S. populations do. AI/ANs born in 2011 have a lower life expectancy than all other U.S. populations (73.7 years vs. 78.1 years).[1] The poverty level among AI/ANs is nearly twice that of the overall U.S. population, and only half as many AI/ANs have health insurance.

linda-b-1

Dr. Linda Burhansstipanov

The socioeconomic conditions where people live and work have a substantial influence on health, and effects are cumulative over a lifetime.[2],[3] In the United States, educational attainment and income are the indicators most commonly used to measure the effect of socioeconomic status on health.3 Compared with other populations, AI/ANs are more likely to have lower socioeconomic status and to live in poverty, leading to less access to cancer prevention and screening and other healthcare services. Additionally, 20 percent of AI/ANs have not completed high school, compared with 8 percent of non-Hispanic Whites. Not completing high school has been associated with unhealthy and risk-taking behaviors.

Adult AI/ANs have behaviors and co-morbidities that increase their risk for cancer and other chronic conditions. They are more likely to be obese, use commercial tobacco, and have diabetes or high blood pressure.[4] Centers for Disease Control and Prevention (CDC) data reported that more than ¼ (29.5 percent) of AI/ANs reported having no healthcare provider, compared with 18.9 percent for whites and 24.2% of AI/ANs report having no healthcare coverage as compared with 12.5 percent for whites.[5]

 

Dr. Linda U. Krebs

Frequently, AI/ANs are also physically inactive. For example, one third of participants in the Education and Research Towards Health Study did not meet current physical activity recommendations; a high proportion were completely sedentary during leisure time.[6]

The Indian Health Service (IHS) reported that AIAN cancer screening rates were significantly lower than in the overall population, with only 59 percent receiving cervical screening, 48 percent breast screening, and 37 percent completing colorectal screening, leading to increased risk of late diagnosis and decreased survival from cancer.[7]

 What does this mean for AI/ANs? These data tell us we need:

  • Tobacco prevention programs and interventions, starting early with pregnant mothers as well as elementary school students
  • Tobacco control and cessation programs targeting adolescents and adults
  • Physical activity/exercise programs, starting with pregnant mothers
  • Environmental safety programs (e.g., safe well water, pollution and contamination reduction)
  • Cancer screening programs
  • Cancer survivorship programs, including resources that are culturally relevant for AI/AN cancer survivorship plans
  • Palliative care and end-of-life programs that are culturally and geographically relevant
  • Genetic studies on molecular markers or alleles that may contribute to or interfere with cancer medicines and treatments
  • Clinical trial recruitment and retention protocols that address barriers to participation (e.g., high blood pressure, cost of medications, lengthy travel to in-person clinic sessions)

Although AI/ANs continue to struggle with health inequities, they have many strengths. AI/ANs need interventions that build upon these strengths rather than repeatedly focusing on weaknesses. This community has survived hundreds of years of invasion and has the potential to continue to thrive as strong Native Peoples. Their traditions honor and respect their elders and families (despite historical trauma and community dysfunction). Their communities have strong foundations and emphasize the need to be healthy again like their ancestors by continuing to use native languages, consuming traditional foods, reserving tobacco for ceremonial uses only, and taking part in daily prayers, healing rituals (e.g., sweat lodges), and formal ceremonies (e.g., Green Corn, Stomp Dance, Sun Dance) as part of organized religions. These strengths affect AI/AN spirits, minds, emotions, bodies, and social interactions and contribute to the balance of these for health and wellness.

References

[1]     IHS. IHS fact sheets. Indian Health Service website. https://www.ihs.gov/newsroom/factsheets/disparities/ Published 2016.

[2]     Beckles GL, Truman BI, CDC. Education and income—United States, 2009 and 2011. MMWR Suppl. 2013; 62(3): 9-19.

[3]     CDC. CDC health disparities and inequalities report—United States, 2013. MMWR Suppl. 2013; 62(3): 1-187. http://www.cdc.gov/MMWR/pdf/other/su6203.pdf

[4]     Yurgalevitch SM, Kriska AM, Welty TK, Go O, Robbins DC, Howard BV. Physical activity and lipids and lipoproteins in American Indians ages 45-74. Med Sci Sports Exerc. 1998; 30(4): 543-549.

[5]     Cobb N, Espey D, King J. Health behaviors and risk factors among American Indians and Alaska Natives, 2000-2010 [published online April 22, 2014]. Am J Public Health. 2014; e1-e9. doi:10.2105/AJPH.2014.301879.

[6]     Duncan Glen E, Goldberg, Jack, Buchwald, Dedra, Wen, Yang and Henderson, Jeffrey A. Henderson. Epidemiology of Physical Activity in American Indians in the Education and Research Towards Health Cohort. American Journal Preventive Medicine, 2009. December 37(6): 488-494. Doi: 10.1016/j.amerpre.2009.07.13

[7]     https://www.ihs.gov/default/assets/File/GPRA/2010_12AreaReport_FINAL.pdf (cited   11/21/2016)

 

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Mental Health Risk Factors and Interventions for American Indian and Alaska Native People

By Spero M. Manson, Ph.D.
Distinguished Professor of Public Health and Psychiatry; Director, Centers for American Indian and Alaska Native Health; and The Colorado Trust Chair in American Indian Health and Associate Dean for Research at the Colorado School of Public Health, University of Colorado Denver

Over the past 20 years, as research on alcohol, drug, and mental health disorders has advanced, scientific inquiry among American Indian and Alaska Native (AI/AN) people has shifted from a primary focus on describing the prevalence of such problems to explorations of ways to address well-documented health disparities.

smmanson_portraitOne example involves detecting and managing depression and subsequent alcohol and substance abuse, risk of suicide, and, more recently, trauma among patients in large primary care settings operated by tribal health programs. In 2001, the Southcentral Foundation’s Primary Care Center in Anchorage, Alaska, initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) among Alaska Native patients age 18 and older.1 Their efforts, which integrated masters-level behavioral health clinicians within the care teams, demonstrated that such evidence-based practices could be tailored to this population in scientifically sound and clinically meaningful ways.2 Over a 5-year period beginning in 2004, 55 percent of the 8,000 patients who scored positive for alcohol use disorder agreed to follow-up treatment. Thanks to those results, the state of Alaska authorized Medicaid reimbursement for SBIRT, leading to the service becoming fully self-sustainable. This approach has been expanded to other tribal primary care settings in Alaska and in rural, reservation, and urban clinics in the lower 48 states. It now includes AI/AN youth ages 12 to 17 and covers other conditions, notably suicide risk and trauma.3

A second example arose in response to the widespread lack of access to mental healthcare in rural, isolated Native communities. In 1999, I co-developed a pilot project with funding from the Veterans Health Administration that deployed real-time, interactive videoconferencing to increase tribal veterans’ access to treatment resources.4 The effort proved remarkably successful and was singled out by Telehealth Magazine as one of the 10 best telemedicine programs in the United States, well before use of such technologies to address the mental health needs of disadvantaged populations became common. Research sponsored by the National Institute on Minority Health and Health Disparities documented the effort’s organization, process, clinical reliability, treatment, and cost outcomes and justified its expansion across the country.5 The U.S. Department of Veterans Affairs now funds 12 telepsychiatry clinics co-located in tribal veterans centers and Indian Health Service primary care clinics that serve hundreds of patients and family members.

A third example reflects increasing attention to the role of anxiety, depression, and trauma in the risk, prevention, and treatment of chronic physical health conditions such as diabetes and cardiovascular disease, which occur with alarming frequency among Native people. Supported by the National Institute of Diabetes and Digestive and Kidney Diseases, my colleagues and I examined the association of psychological distress, coping skills, family support, trauma exposure, and spirituality with initial weight and weight loss among participants in the Special Diabetes Program for Indians’ Diabetes Prevention Program, which was implemented at 36 Indian health care programs across the country.6 Psychological distress and negative family support were linked to greater weight at the beginning of the study, while cultural spirituality was correlated with lower weight. Furthermore, over the course of the intervention, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporation of additional intervention components.

These exciting advances, all supported in part by the National Institutes of Health (NIH), illustrate how the emphasis and scope of alcohol, drug, and mental health research among Native people have evolved over the last two decades. They represent the continued marriage of good science with local benefit, consistent with the expectations of NIH and tribal communities.

References

1Dillard DA, Muller CM, Smith JJ, Hiratsuka VY, Manson SM. The impact of patient and provider factors on depression screening of American Indian and Alaska Native people in primary care. J Prim Care Community Health. 2012; 3:120-124.

2Hiratsuka VY, Smith JJ, Norman SM, Manson SM, Dillard DA. Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care. Int J Circumpolar Health. 2015; 74: 28315. doi: 10.3402/ijch.v74.28315

3Hiratsuka VY, Moore L, Dillard DA, et al. Development of a screening and brief intervention process for symptoms of psychological trauma among primary care patients of two American Indian and Alaska Native health systems. J Behav Health Serv Res. 2016 doi: 10.1007/s11414-016-9519-6.

4Shore JH, Brooks E, Anderson H, et al. Characteristics of telemental health service use by American Indian veterans. Psychiatr Serv. 2012; 63(2): 179-181.

5Shore JH, Brooks E, Savin D, Manson SM, Libby A. An economic evaluation of telehealth and in-person data collection with rural and frontier populations. Psychiatr Serv. 2007; 58(6): 830-835.

6Dill EJ, Manson SM, Jiang L, et al. Psychosocial predictors of weight loss among American Indian and Alaska Native participants in a diabetes prevention translational project. J Diabetes Res. 2016; 1546939. doi: 10.1155/2016/1546939.

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Apply Now to NIMHD Loan Repayment Programs

UPDATE: Click here to access the Loan Repayment Program Technical Assistance webinar that NIMHD hosted on September 15, 2016.

By Dorothy M. Castille, Ph.D.
Health Scientist Administrator, NIMHD Division of Scientific Programs

Education is the foundation of our nation’s biomedical research enterprise. But a college education is expensive, and a post-graduate education is even more expensive, with the average cost of medical, veterinary, and dental school totaling more than $200,000. In exchange for a commitment to conduct biomedical or behavioral research, the National Institutes of Health (NIH) will repay up to $70,000 of student loan debt (over two years) per two-year contract through the NIH Loan Repayment Programs (LRPs).

If you are a qualified health professional who agrees to engage in NIH mission–relevant research for at least 20 hours per week at a nonprofit or government institution, you may be eligible to apply to one of the five extramural LRPs:

  • Clinical Research Extramural LRP: Patient-oriented research conducted with human subjects
  • Clinical Research for Individuals from Disadvantaged Backgrounds Extramural LRP: Research conducted by clinical investigators from disadvantaged backgrounds
  • Contraception and Infertility Research Extramural LRP: Research on conditions affecting the ability to conceive and bear young
  • Health Disparities Research Extramural LRP: Research that focuses on minority and other health disparity populations
  • Pediatric Research Extramural LRP: Research that is directly related to diseases, disorders, and other conditions in children

The National Institute on Minority Health and Health Disparities (NIMHD) funds two of these LRPs. The objective of the Health Disparities Research Extramural LRP is to recruit and retain highly qualified health professionals for research careers that focus on minority health disparities or other health disparities to engage and promote the development of research and research programs that reflect the variety of issues and problems associated with disparities in health status. This requirement highlights the need for the involvement of a cadre of culturally competent health professionals in minority health disparities and other health disparities research.

The objective of the Clinical Research for Individuals from Disadvantaged Backgrounds Extramural LRP is to recruit and retain highly qualified health professionals from disadvantaged backgrounds for clinical research careers. The emphasis on clinical research and individuals from disadvantaged backgrounds highlights the need for the involvement of a cadre of competent health professionals in clinical research.

Approximately 1,500 scientists benefit from the $70 million that NIH invests each year through the extramural LRPs. On average, nearly 50 percent of all new LRP applications are funded, and these awards are competitively renewable (for a one- or two-year period) until all educational debt is repaid.  The LRPs are unique programs with tremendous benefit to young researchers, so we strongly encourage researchers that were not successful in getting their applications funded to apply again.

dr-castilleTo qualify, an applicant must be a U.S. citizen or a permanent resident, possess a doctoral-level degree (with the exception of the Contraception and Infertility Research LRP), and have educational loan debt equal to or exceeding 20 percent of his/her annual institutional base salary.

Thinking of applying this year? There are a few updates that you should keep in mind:

  • All applicants (new and renewal) are required to have an eRA Commons ID to submit an LRP application. If you don’t have an eRA Commons ID, act quickly, because it could take several weeks to get one! Check with your grants administrator and visit the eRA Commons website for more information.
  • We have a newly redesigned, easier-to-use online application! All applicants (new and renewal) will be required to create a new log-in account. Check out the new application and application guide (online and as a PDF) at lrp.nih.gov.
  • All application components, including the LRP application, recommendations, and institutional support documentation, are due by December 1, 2016.

Please contact any of these NIMHD program staff for assistance with a new application or feedback on a previous application:

Visit www.lrp.nih.gov for more details and to apply. For additional assistance, call or email the LRP Information Center at 866-849-4047 or lrp@nih.gov, Monday–Friday, 9 a.m. to 5 p.m. ET. You can also follow the NIH Division of Loan Repayment on Twitter and Facebook for more information and cycle updates. Get started on your application today!

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NIH Begins Recruitment for Landmark Adolescent Brain Cognitive Development Study

By Eliseo J. Pérez-Stable, M.D.
Director, NIMHD

logo of NIH's adolescent brain cognitive development study

Today I’m delighted to share some exciting news. The National Institutes of Health (NIH) is launching recruitment for the Adolescent Brain Cognitive Development (ABCD) Study. This is the largest long-term study of brain development and child health in the United States. NIMHD is one of eight NIH institutes, centers, and offices along with the Centers for Disease Control and Prevention (CDC) supporting this landmark study.

Adolescence, the transitional stage between childhood and adulthood, is an important period in human development. While major physical and psychological changes are happening, teenagers are testing their independence and exploring their self-identity. All the while, the brain is undergoing dramatic changes in structure and function.

For the ABCD Study, researchers will follow the biological and behavioral development of more than 10,000 children ages 9-10 through adolescence into early adulthood. It is critically important that the participants in this study reflect the U.S. population, as almost half of all children are now from a minority racial or ethnic group. In addition, the study will strive to recruit children from different levels of socioeconomic status and living environments. To accomplish this goal, recruitment will be done through partnerships with public and private schools near 19 research sites in the continental U.S. and Hawaii, as well as through registries of identical and fraternal twins.

Over the next decade, leading researchers in the fields of child development and neuroscience will use extensive baseline interviews, psychological and behavioral testing, and cutting-edge technology in brain imaging, to determine how childhood experiences interact with a child’s changing biology to affect brain development and—ultimately—social, behavioral, academic, and other health outcomes. Experiences such as playing video games, participating in extracurricular activities like organized sports, insufficient sleep or poor sleep habits, cigarette smoking, other use of tobacco products, and drinking alcohol. For example, we know that adequate hours of sleep is essential for normal growth and brain development, yet studies show that children from minority and economically underserved communities are more likely to experience shorter sleep times compared to their White and economically advantaged counterparts. As a result, these children are disproportionately affected by the adverse health and quality of life consequences of poor sleep.

When it comes to physical activity, the overall lifelong health benefits are clear. Yet children who participate in certain sports and recreational activities are exposed to various injury risks. The CDC estimates that 1.6 to 3.8 million concussions occur in sports and recreational activities annually. Understanding the relationships among these experiences and their effects on the growing brain will provide answers that can inform educational practices and policy and, ultimately, may help improve the health and well-being of our youth.

At NIMHD, our mission is to lead scientific research to improve minority health and reduce health disparities. We know that increased diversity in participants of clinical research studies is both a crucial part of achieving health equity and an essential component to advance scientific knowledge. For example, we cannot know if a treatment will be effective for certain race/ethnic minority groups if they are not part of clinical research. Greater diversity allows researchers to identify differences between populations and formulate appropriate treatments and contributes to understanding the interactions of individual behavior and biology with the social and physical environment. Diverse representation among study participants in the ABCD study will help us gain a better understanding of development across all groups and ensures that the study results are relevant for all children.

You can learn more about the ABCD Study at www.ABCDStudy.org. Help us spread the word about this important study so diverse communities will not only be represented, but can share in, and benefit from, the medical advances gained from this critical research.

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Welcome to NIMHD Insights, the New NIMHD Blog

By Eliseo J. Pérez-Stable, M.D.
Director, NIMHD

At the one-year anniversary of my appointment as director of NIMHD, I’m excited to welcome you to our new blog, NIMHD Insights.

NIMHD leads scientific research in two distinct but overlapping areas: minority health and health disparities. But first of all, what do these terms mean?

Minority health concerns the health of the five U.S. racial and ethnic minorities who have historically faced discrimination and social disadvantage. These groups are defined by the U.S. Census and include African Americans/Blacks, Latinos/Hispanics, Asians, American Indians/Alaska Natives, and Native Hawaiians/other Pacific Islanders. All of these populations are usually not included as participants of all types of biomedical research and most are also underrepresented as members of the scientific workforce. At NIMHD, we are committed to addressing health issues within each of the minority groups independent of whether the outcome is worse, better or similar to that of the White comparison group. We value research that emphasizes mechanisms by which health differs within these race/ethnic groups, as well as comparisons to each other and Whites.

Health disparities are differences in health outcomes that negatively affect racial and ethnic minorities, persons of less privileged socioeconomic status, and underserved rural populations. All of these persons have historically been subjected to system and individual discrimination that results in social disadvantage and leads to worse health outcomes. NIMHD is focusing on outcomes that reflect a higher incidence/prevalence of diseases, higher or premature mortality from specific causes, a higher burden of illness as reflected by global measures such as disability-adjusted life years (DALYs) and worse results on standardized measures of function, well-being or symptoms. NIMHD postulates that the mechanisms that lead to these health disparities have determinants in the behavioral, biological, social, environmental, and clinical health care system that results in these worse outcomes. Understanding these mechanisms is precisely what will lead to development of interventions to reduce health disparities.

Although social disadvantage is at the core of factors that result in health disparities, it is not the only cause. Behavior and lifestyle affect individual and social outcomes especially in interactions with the biological factors of each person. For example, stress associated with early life adverse events may trigger biological mechanisms that may lead to chronic diseases in adults and this has great implications of how we attend to the health of children. Known carcinogen exposure such as tobacco smoke has an increased risk of causing lung cancer in some populations by race/ethnic category and may help us understand different factors that cause cancer, which would not be possible if only one race/ethnic group was included. Poor persons living in one urban environment appear to live an average of four years more than poor people in a different urban environment and this emphasizes the importance of place and systems in the wellbeing of the most vulnerable members of society. Treatment outcomes for persons with diabetes varies by socioeconomic status, race/ethnicity, and health literacy; interventions need to be attentive to these differences. Understanding the factors that explain these observations will advance our knowledge of minority health and health disparities. Health disparities research seeks to understand the causes and effects of these differences and to use this knowledge to determine the best approaches to improve health outcomes in affected populations.

NIMHD shares and interprets minority health and health disparities research findings, fosters innovative collaborations and partnerships, spearheads NIH’s efforts to increase the racial and ethnic diversity of the scientific workforce, and promotes the inclusion of minorities in clinical trials and registries. “Inclusion” of minorities in and of itself is not an issue of minority health or health disparities. Rather, it is an issue of social justice and good science that clinical studies need to have diverse populations that represent today’s American demographics.

This blog will feature posts by me and NIMHD research and program staff, along with guest contributors from within and outside NIH who represent the many disciplines that contribute to minority health and health disparities. Topics will look at the Institute’s research priorities and programs, scientific discoveries, and research policies and practices that impact program operations, among other related areas.

I look forward to engaging with you to share new insights and raise intriguing questions that encourage scientific discussion as we work to build an America in which all populations will have an equal opportunity to live long, healthy, productive lives.

Visit www.nimhd.nih.gov to learn more about NIMHD and subscribe to our blog.

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