The National Institute on Minority Health and Health Disparities Research Framework.

We introduce the National Institute on Minority Health and Health Disparities (NIMHD) research framework, a product that emerged from the NIMHD science visioning process. The NIMHD research framework is a multilevel, multidomain model that depicts a wide array of health determinants relevant to understanding and addressing minority health and health disparities and promoting health equity. We describe the conceptual underpinnings of the framework and define its components. We also describe how the framework can be used to assess minority health and health disparities research as well as priorities for the future. Finally, we describe how fiscal year 2015 research project grants funded by NIMHD map onto the framework, and we identify gaps and opportunities for future minority health and health disparities research.

Building the Evidence Base to Inform Planned Intervention Adaptations by Practitioners Serving Health Disparity Populations.

Many evidence-based interventions (EBIs) have been developed to prevent or treat major health conditions. However, many EBIs have exhibited limited adoption, reach, and sustainability when implemented in diverse community settings. This limitation is especially pronounced in low-resource settings that serve health disparity populations. Often, practitioners identify problems with existing EBIs originally developed and tested with populations different from their target population and introduce needed adaptations to make the intervention more suitable. Although some EBIs have been extensively adapted for diverse populations and evaluated, most local adaptations to improve fit for health disparity populations are not well documented or evaluated. As a result, empirical evidence is often lacking regarding the potential effectiveness of specific adaptations practitioners may be considering. We advocate an expansion in the emphasis of adaptation research from researcher-led interventions to research that informs practitioner-led adaptations. By presenting a research vision and strategies needed to build this area of science, we aim to inform research that facilitates successful adaptation and equitable implementation and delivery of EBIs that reduce health disparities.

Design of a cluster-randomized minority recruitment trial: RECRUIT.

BACKGROUND: Racial/ethnic minority groups remain underrepresented in clinical trials. Many strategies to increase minority recruitment focus on minority communities and emphasize common diseases such as hypertension. Scant literature focuses on minority recruitment to trials of less common conditions, often conducted in specialty clinics and dependent on physician referrals. We identified trust/mistrust of specialist physician investigators and institutions conducting medical research and consequent participant reluctance to participate in clinical trials as key-shared barriers across racial/ethnic groups. We developed a trust-based continuous quality improvement intervention to build trust between specialist physician investigators and community minority-serving physicians and ultimately potential trial participants. To avoid the inherent biases of non-randomized studies, we evaluated the intervention in the national Randomized Recruitment Intervention Trial (RECRUIT). This report presents the design of RECRUIT. Specialty clinic follow-up continues through April 2017. METHODS: We hypothesized that specialist physician investigators and coordinators trained in the trust-based continuous quality improvement intervention would enroll a greater proportion of minority participants in their specialty clinics than specialist physician investigators in control specialty clinics. Specialty clinic was the unit of randomization. Using continuous quality improvement, the specialist physician investigators and coordinators tailored recruitment approaches to their specialty clinic characteristics and populations. Primary analyses were adjusted for clustering by specialty clinic within parent trial and matching covariates. RESULTS: RECRUIT was implemented in four multi-site clinical trials (parent trials) supported by three National Institutes of Health institutes and included 50 associated specialty clinics from these parent trials. Using current data, we have 88% power or greater to detect a 0.15 or greater difference from the currently observed control proportion adjusting for clustering. We detected no differences in baseline matching criteria between intervention and control specialty clinics (all p values > 0.17). CONCLUSION: RECRUIT was the first multi-site randomized control trial to examine the effectiveness of a trust-based continuous quality improvement intervention to increase minority recruitment into clinical trials. RECRUIT's innovations included its focus on building trust between specialist investigators and minority-serving physicians, the use of continuous quality improvement to tailor the intervention to each specialty clinic's specific racial/ethnic populations and barriers to minority recruitment, and the use of specialty clinics from more than one parent multi-site trial to increase generalizability. The effectiveness of the RECRUIT intervention will be determined after the completion of trial data collection and planned analyses.

Perspective: Nutrition Health Disparities Framework: A Model to Advance Health Equity.

Disparities in nutrition, such as poor diet quality and inadequate nutrient intake, arise from multiple factors and are related to adverse health outcomes such as obesity, diabetes, cardiovascular disease, and some cancers. The aim of the current perspective is to present a nutrition-centric socioecological framework that delineates determinants and factors that contribute to diet and nutrition-related disparities among disadvantaged populations. The Nutrition Health Disparities Framework (NHDF) describes the domains (biological, behavioral, physical/built environment, sociocultural environment, and healthcare system) that influence nutrition-related health disparities through the lens of each level of influence (that is, individual, interpersonal, community, and societal). On the basis of the scientific literature, the authors engaged in consensus decision making in selecting nutrition-related determinants of health within each domain and socioecological level when creating the NHDF. The framework identifies how neighborhood food availability and access (individual/built environment) intersect with cultural norms and practices (interpersonal/sociocultural environment) to influence dietary behaviors, exposures, and risk of diet-related diseases. In addition, the NHDF shows how factors such as genetic predisposition (individual/biology), family dietary practices (interpersonal/behavioral), and food marketing policies (societal) may impact the consumption of unhealthy foods and beverages and increase chronic disease risk. Family and peer norms (interpersonal/behavior) related to breastfeeding and early childhood nutrition interact with resource-poor environments such as lack of access to preventive healthcare settings (societal/healthcare system) and low usage of federal nutrition programs (societal/behavioral), which may increase risk of poor nutrition during childhood and food insecurity. The NHDF describes the synergistic interrelationships among factors at different levels of the socioecological model that influence nutrition-related outcomes and exacerbate health disparities. The framework is a useful resource for nutrition researchers, practitioners, food industry leaders, and policymakers interested in improving diet-related health outcomes and promoting health equity in diverse populations.

Assessing National Institutes of Health Prevention Research on Leading Causes of Death Focused on Racial or Ethnic Minority Populations, Fiscal Years 2016-2020.

Objective: To characterize the National Institutes of Health (NIH) prevention research portfolio on leading causes of death focused on racial or ethnic minority populations. Research Design: Longitudinal analysis of NIH-funded prevention research projects from FY2016-FY2020. Measures: Project characteristics including type of prevention, study design, budget, minority health focus, and causes of death addressed. Results: Minority health projects comprised 27.0% of prevention projects and 33.1% of funding across all leading causes of death. Homicide (42.9%), diabetes (36.3%), and stroke (35.5%) had the highest proportion of minority health projects and suicide (20.2%), Alzheimer disease (18.8%), and pneumonia or influenza (8.3%) the lowest. Most minority health projects focused on identifying risk factors or on primary prevention efforts (80.3%). Most projects had an observational design (80.0%), and this predominance was observed for each cause of death. There was a significant correlation between the proportion of minority health projects for cause of death and the ratio of minorities versus non-minorities mortality rate. Conclusions: Only about one-fourth of NIH-funded prevention research on leading causes of death focused on racial or ethnic minorities, who currently comprise about 40% of the US population. Only a small fraction of minority health prevention projects included an intervention design, suggesting a limited contribution to the evidence base on effective interventions to address racial or ethnic mortality disparities. Also, we identified that the number of projects increase where mortality rate disparities are higher. This portfolio analysis provides a useful baseline to assess future progress in building the minority health prevention research portfolio, a critical component to promoting health equity in population health.

Perspectives From the National Institutes of Health on Multidimensional Mental Health Disparities Research: A Framework for Advancing the Field.

Racial, ethnic, and other mental health disparities have been documented for several decades. However, progress in reducing or eliminating these disparities has been slow. In this review, the authors argue that understanding and addressing mental health disparities requires using a multidimensional lens that encompasses a wide array of social determinants of health at individual, interpersonal, organizational, community, and societal levels. However, much of the current research on mental health disparities, including research funded by the National Institutes of Health, is characterized by a narrower focus on a small number of determinants. The authors offer a research framework, adapted from the National Institute on Minority Health and Health Disparities Research Framework, that provides examples of determinants that may cause or sustain mental health disparities and that can serve as intervention targets to reduce those disparities. They also discuss different types of mental health disparities research to highlight the need for more research testing and implementing interventions that directly modify social determinants of health and promote mental health equity.

Screening for mental illness in a trauma center: rooting out a risk factor for unintentional injury.

BACKGROUND: Injury prevention and screening efforts have long targeted risk factors for injury recurrence. In a retrospective study, our group found that mental illness is an independent risk factor for unintentional injury and reinjury. The purpose of this study was to administer a standard validated screening instrument and psychosocial needs assessment to admitted patients who suffer unintentional injury. We aimed to prospectively measure the prevalence of mental illness. We hypothesize that systematic screening for psychiatric disorders in trauma patients is feasible and identifies people with preexisting mental illness as a high-risk group for unintentional injury. METHODS: In this prospective study, we recruited patients admitted to our Level I trauma center for unintentional injury for a period of 18 months. A bedside structured interview, including the Mini International Neuropsychiatric Interview, and a needs assessment were performed by lay research personnel trained by faculty from the Department of Psychiatry. The validated needs assessment questions were from the Camberwell Assessment of Need Short Appraisal Schedule instrument. Psychiatric screening and needs assessment results, as well as demographic characteristics are reported as descriptive statistics. RESULTS: A total of 1,829 people were screened during the study period. Of the 854 eligible people, 348 were able to be approached by researchers before discharge with a positive response rate of 63% (N = 219 enrolled). Interviews took 35 minutes ± 12 minutes. Chi-squared analysis revealed no difference in mechanism in those with mental illness versus no mental illness. Men were significantly more likely to be found to have a mental health disorder but when substance abuse was excluded, no difference was found. Four-way diagnostic grouping revealed the prevalence of mental illness detected. CONCLUSIONS: This inpatient pilot screening program prospectively identified preexisting mental illness as a risk factor for unintentional injury. Implementation of validated psychosocial and mental health screening instruments is feasible and efficient in the acute trauma setting. Administration of a validated mental health screening instrument can be achieved by training college-level research assistants. This system of screening can lead to identification and treatment of mental illness as a strategy for unintentional injury prevention.

Using increased trust in medical researchers to increase minority recruitment: The RECRUIT cluster randomized clinical trial.

While extensive literature exists on barriers and strategies to increase minority participation in clinical trials, progress is limited. Few strategies were evaluated in randomized trials. We studied the impact of RECRUIT, a trust-based, cluster randomized minority recruitment trial layered on top of four traditional NIH-funded parent trials (BMT CTN, CABANA, PACES, STEADY-PD III; fifty specialty sites). RECRUIT was conducted from July 2013 through April 2017. Intervention sites implemented trust-based approaches customized to individual sites, promoting relationships between physician-investigators and minority-serving physicians and their minority patients. Control sites implemented only parent trials' recruitment procedures. Adjusting for within-site clustering, we detected no overall intervention effect, odds ratio 1.3 (95% confidence limits 0.7,2.4). Heterogeneity among parent trials may have obscured the effect. Of the four parent trials, three enrolled more minorities in intervention versus control sites. CABANA odds ratio = 4.2 (adjusted 95%CL 1.5,11.3). PACES intervention sites enrolled 63% (10/16) minorities; control sites enrolled one participant in total, a minority, yielding an incalculable odds ratio. STEADY-PD III odds ratio = 2.2 (adjusted 95%CL 0.6,8.5). BMT CTN odds ratio < 1, 0.8 (adjusted 95%CL 0.4,1.8). In conclusion, RECRUIT findings suggest the unique trust-based intervention increased minority recruitment to intervention trials in ¾ of studied trials. Physician-investigators' participation was critical to recruitment success. Lack of commitment to minority recruitment remained a barrier for some physician-investigators, especially in control sites. We recommend prospective physician investigators commit to minority recruitment activities prior to selection as site investigators and trial funding include some compensation for minority recruitment efforts. TRIAL REGISTRATION ClinicalTrials.govNCT01911208.

Involving consumers in the development of a psychoeducational booklet about stigma for black mental health clients.

Black individuals hold more negative views of mental illness and mental health treatment than do Whites, attitudes that are implicated in the underutilization of mental health services by Black populations. Psychoeducational interventions or materials may be one way to address attitudinal barriers to mental health treatment among Black adults, but only if the psychoeducational content is directly relevant to their beliefs and concerns. This article documents the process of developing a consumer-derived psychoeducational booklet for Black adults contemplating mental health treatment. Black mental health consumers provided the content for the booklet through qualitative interviews about their experiences and then provided feedback once it was developed. Results from this project suggest that the strategy of involving consumers is a feasible approach to develop psychoeducational materials that address treatment barriers in underserved populations.

The relationship between stigma and other treatment concerns and subsequent treatment engagement among black mental health clients.

This study examined stigma (both the perception that mental illness is stigmatized and stigma concerns about entering treatment) and other treatment concerns along with subsequent treatment engagement within three months in a sample of 42 black adults referred to public-sector outpatient treatment. Contrary to expectation, perceived stigma of mental illness was unrelated to treatment engagement; however having stigma or other concerns about treatment was associated with increased odds of engagement. Findings indicate the importance of examining stigma as a multi-dimensional construct and raise questions about the utility of addressing stigma as a way of promoting service use in black adults. More work is clearly needed to understand the complex relationship between stigma and help-seeking in black populations and other underserved groups.

Risk perception and preference for prevention of Alzheimer's disease.

OBJECTIVES: To understand how older adults perceive their risk of Alzheimer's Disease (AD) and how this may shape their medical care decisions, we examined whether presence of established risk factors of AD is associated with individuals' perceived risk of AD, and with preference for preventing AD. PARTICIPANTS: Data came from the US Health and Retirement Study participants who were asked questions on AD risk perception (N = 778). MEASUREMENTS: Perceived risk of AD was measured by respondents' estimate of their percent chance (0-100) developing AD in the next 10 years. Preference for AD prevention was measured with questions eliciting willingness to pay for a drug to prevent AD. ANALYSIS: Multivariate linear regressions were used to estimate correlates of perceived risk and preference for prevention. RESULTS: Better cognitive functioning and physical activity are associated with decreased perceived risk. Neither age nor cardiovascular disease is associated with perceived risk. African Americans have lower perceived risk than non-Latino whites; the difference is wider among people age 65 and above. Only 4% to 7% of the variation in perceived risk was explained by the model. Preference for prevention is stronger with increased perceived risk, but not with the presence of risk factors. Persons with better cognitive functioning, physical functioning, or wealth status have a stronger preference for prevention. CONCLUSION: Some known risk factors appear to inform, but only modestly, individuals' perceived risk of AD. Furthermore, decisions about AD prevention may not be determined by objective needs alone, suggesting a potential discrepancy between need and demand for AD preventive care.

Psychoeducation to address stigma in black adults referred for mental health treatment: a randomized pilot study.

Forty-two Black clients referred for outpatient treatment were randomly assigned to receive existing brochures about services or a psychoeducational booklet about stigma based on experiences of Black mental health consumers. At 3-month follow-up, clients reported that both types of information were helpful; there were no significant differences between the types of information on treatment attendance. However, individuals who reported higher perceived treatment need or greater uncertainty about treatment showed greater stigma reduction from the psychoeducation. Findings indicate the need to move beyond "customer satisfaction" to evaluate educational interventions, as well as for greater understanding of differential impact of stigma reduction interventions.

Reduction of state victim compensation disparities in disadvantaged crime victims through active outreach and assistance: a randomized trial.

OBJECTIVES: We examined whether providing active outreach and assistance to crime victims as part of comprehensive psychosocial services reduced disparities in access to state compensation funds. METHODS: We analyzed data from a randomized trial of injured crime victims (N = 541) and compared outcomes from comprehensive psychosocial services with usual community care. We examined the impact of outreach and assistance on disparities in applying for victim compensation by testing for interactions between victim characteristics and treatment condition in logistic regression analyses. RESULTS: Victims receiving comprehensive services were much more likely to apply for victim compensation than were victims receiving usual care. Comprehensive services decreased disparities associated with younger age, lower levels of education, and homelessness. CONCLUSIONS: State-level victim compensation funds are available to help individuals recover physically, psychologically, and financially from crime victimization. However, few crime victims apply for victim compensation, and there are particularly low application rates among young, male, ethnic minority, and physical assault victims. Active outreach and assistance can address disparities in access to victim compensation funds for disadvantaged populations and should be offered more widely to victims of violent crime.

The experience of stigma among Black mental health consumers.

Little is known about how stigma affects Black people receiving mental health treatment. For a project to develop a consumer-based stigma intervention, qualitative interviews were conducted with public-sector Black mental health consumers (N=34). Primary themes from the interviews regarding stigma concerns, experiences, and coping strategies were examined. Concerns about stigma prompted most consumers initially to avoid or delay treatment; once in treatment, consumers commonly faced stigmatizing reactions from others. Consumers identified numerous strategies to deal with stigma, including seeking support from accepting members of their existing social networks, and viewing their own health as more important than the reaction of others. These consumer perspectives may be valuable to Black individuals who are contemplating seeking mental health treatment.

Characteristics and psychosocial needs of victims of violent crime identified at a public-sector hospital: data from a large clinical trial.

OBJECTIVE: This study explores the feasibility of recruiting acutely injured public-sector crime victims into a research protocol and identifies baseline characteristics associated with posttraumatic distress in the enrolled sample (N=541). METHOD: Assertive research tracking methods were used to enroll participants, who completed baseline interviews. Descriptive statistics were used to define characteristics of the sample and prevalence of psychosocial problems and posttraumatic distress. Multiple regression analysis was performed to identify predictors of posttraumatic distress. RESULTS: A high percentage (78%) of eligible victims completed baseline interviews within 1 month of victimization. The sample was largely male, ethnic minority, unemployed and living below the poverty level. Trauma symptoms were highly prevalent, with three quarters having significant posttraumatic distress. Female gender, preexisting psychiatric disorder, trauma history, case management needs and employment status were predictive of greater symptomatology. Stabbing victims had lower distress. CONCLUSIONS: Comprehensive mental health and case management services that proactively engage disadvantaged victims are needed to meet the complex problems of this population.

Research issues for improving treatment of U.S. Hispanics with persistent mental disorders.

This article reports on the outcome of an expert consensus meeting in August 2005 sponsored by the National Institute of Mental Health, which assembled 15 senior researchers with a background in treatment and services research with the Hispanic population. The purpose of the workshop was to identify research issues most pertinent for improving quality and effectiveness of treatment for Hispanics experiencing persistent mental disorders, defined as psychiatric syndromes that are of sufficient severity and duration to cause long-term impairment in social and occupational functioning and significant disability. The spectrum of ideas and recommendations advanced at the one-day meeting was wide and overlapping; therefore, the rich body of material was subsequently organized into five topics: diagnosis, quality of care and culturally appropriate services, psychosocial intervention development, psychopharmacologic interventions, and access to care. Although the authors recognize that the review was broad and the agenda presented is ambitious and in many instances generalizes to priority areas in overall mental health services and treatment research, the recommendations are intended to stimulate research for addressing the unique problems and research deficits that affect Hispanics with persistent mental disorders.

Mental health provider perspectives on co-occurring substance use among severely mentally ill clients.

This qualitative study explores strategies used by mental health providers (N = 17) to address substance use problems among seriously mentally ill (SMI) clients and their perspectives on barriers to treatment and how treatment can be improved. Providers identified numerous strategies, yet these were countered with perceptions of multiple obstacles, leaving them frustrated, helpless, and hopeless about their clients' substance use. Results suggest that, in addition to improving access to quality dual-diagnosis treatment, larger issues of poverty and social isolation must also be addressed. Not doing so limits what providers can do for SMI clients and could reduce the effect of larger system-level improvements.