The Economic Burden of Racial, Ethnic, and Educational Health Inequities in the US.

Importance: Health inequities exist for racial and ethnic minorities and persons with lower educational attainment due to differential exposure to economic, social, structural, and environmental health risks and limited access to health care. Objective: To estimate the economic burden of health inequities for racial and ethnic minority populations (American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander) and adults 25 years and older with less than a 4-year college degree in the US. Outcomes include the sum of excess medical care expenditures, lost labor market productivity, and the value of excess premature death (younger than 78 years) by race and ethnicity and the highest level of educational attainment compared with health equity goals. Evidence Review: Analysis of 2016-2019 data from the Medical Expenditure Panel Survey (MEPS) and state-level Behavioral Risk Factor Surveillance System (BRFSS) and 2016-2018 mortality data from the National Vital Statistics System and 2018 IPUMS American Community Survey. There were 87 855 survey respondents to MEPS, 1 792 023 survey respondents to the BRFSS, and 8 416 203 death records from the National Vital Statistics System. Findings: In 2018, the estimated economic burden of racial and ethnic health inequities was $421 billion (using MEPS) or $451 billion (using BRFSS data) and the estimated burden of education-related health inequities was $940 billion (using MEPS) or $978 billion (using BRFSS). Most of the economic burden was attributable to the poor health of the Black population; however, the burden attributable to American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander populations was disproportionately greater than their share of the population. Most of the education-related economic burden was incurred by adults with a high school diploma or General Educational Development equivalency credential. However, adults with less than a high school diploma accounted for a disproportionate share of the burden. Although they make up only 9% of the population, they bore 26% of the costs. Conclusions and Relevance: The economic burden of racial and ethnic and educational health inequities is unacceptably high. Federal, state, and local policy makers should continue to invest resources to develop research, policies, and practices to eliminate health inequities in the US.

National Institutes of Health Advancing Multimorbidity Research.

BACKGROUND: Multimorbidity, the co-occurrence of 2 or more chronic diseases, is more common than having a single chronic disease, especially among persons age 65 years and older. The routine measurement of multimorbidity can facilitate a better understanding of potential causes and interactions and promote more effective treatment and improved outcomes. OBJECTIVES: To present a multimorbidity research framework and identify gaps in the research literature related to multimorbidity. DESIGN: In preparation for an expert panel workshop convened in September 2018, planning committee members reviewed the literature and developed a guiding framework that informed the selection of topics and speakers. RESULTS: The framework, grounded in a patient-centered approach, incorporates the concept of concordant and discordant comorbidity, and includes potential causes, interactions, and outcomes. This work informed workshop presentations and discussion related to identifying and selecting the best available multimorbidity instruments and determining future research needs. CONCLUSIONS: Multimorbidity research can be advanced by addressing gaps in study design and target populations, and by increasing attention to universal outcome measurement.

Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source.

BACKGROUND: Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE: The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN: Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS: Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS: The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

The Importance of Evaluating Health Disparities Research.

Health disparity populations are socially disadvantaged, and the multiple levels of discrimination they often experience mean that their characteristics and attributes differ from those of the mainstream. Programs and policies targeted at reducing health disparities or improving minority health must consider these differences. Despite the importance of evaluating health disparities research to produce high-quality data that can guide decision-making, it is not yet a customary practice. Although health disparities evaluations incorporate the same scientific methods as all evaluations, they have unique components such as population characteristics, sociocultural context, and the lack of health disparity common indicators and metrics that must be considered in every phase of the research. This article describes evaluation strategies grouped into 3 components: formative (needs assessments and process), design and methodology (multilevel designs used in real-world settings), and summative (outcomes, impacts, and cost). Each section will describe the standards for each component, discuss the unique health disparity aspects, and provide strategies from the National Institute on Minority Health and Health Disparities Metrics and Measures Visioning Workshop (April 2016) to advance the evaluation of health disparities research.

Behavioral Interventions Using Consumer Information Technology as Tools to Advance Health Equity.

The digital divide related to consumer information technologies (CITs) has diminished, thus increasing the potential to use CITs to overcome barriers of access to health interventions as well as to deliver interventions situated in the context of daily lives. However, the evidence base regarding the use and impact of CIT-enabled interventions in health disparity populations lags behind that for the general population. Literature and case examples are summarized to demonstrate the use of mHealth, telehealth, and social media as behavioral intervention platforms in health disparity populations, identify challenges to achieving their use, describe strategies for overcoming the challenges, and recommend future directions. The evidence base is emerging. However, challenges in design, implementation, and evaluation must be addressed for the promise to be fulfilled. Future directions include (1) improved design methods, (2) enhanced research reporting, (3) advancement of multilevel interventions, (4) rigorous evaluation, (5) efforts to address privacy concerns, and (6) inclusive design and implementation decisions.

Structural Interventions to Reduce and Eliminate Health Disparities.

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance 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.

Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities.

Multilevel interventions can be uniquely effective at addressing minority health and health disparities, but they pose substantial methodological, data analytic, and assessment challenges that must be considered when designing and applying interventions and assessment. To facilitate the adoption of multilevel interventions to reduce health disparities, we outline areas of need in filling existing operational challenges to the design and assessment of multilevel interventions. We discuss areas of development that address overarching constructs inherent in multilevel interventions, with a particular focus on their application to minority health and health disparities. Our approach will prove useful to researchers, as it allows them to integrate information related to health disparities research into the framework of broader constructs with which they are familiar. We urge researchers to prioritize building transdisciplinary teams and the skills needed to overcome the challenges in designing and assessing multilevel interventions, as even small contributions can accelerate progress toward improving minority health and reducing health disparities. To make substantial progress, however, a concerted and strategic effort, including work to advance analytic techniques and measures, is needed.

Decreases in adolescent weekly alcohol use in Europe and North America: evidence from 28 countries from 2002 to 2010.

BACKGROUND: This study examined trends in adolescent weekly alcohol use between 2002 and 2010 in 28 European and North American countries. METHODS: Analyses were based on data from 11-, 13- and 15-year-old adolescents who participated in the Health Behaviour in School-Aged Children (HBSC) study in 2002, 2006 and 2010. RESULTS: Weekly alcohol use declined in 20 of 28 countries and in all geographic regions, from 12.1 to 6.1% in Anglo-Saxon countries, 11.4 to 7.8% in Western Europe, 9.3 to 4.1% in Northern Europe and 16.3 to 9.9% in Southern Europe. Even in Eastern Europe, where a stable trend was observed between 2002 and 2006, weekly alcohol use declined between 2006 and 2010 from 12.3 to 10.1%. The decline was evident in all gender and age subgroups. CONCLUSIONS: These consistent trends may be attributable to increased awareness of the harmful effects of alcohol for adolescent development and the implementation of associated prevention efforts, or changes in social norms and conditions. Although the declining trend was remarkably similar across countries, prevalence rates still differed considerably across countries.

Longitudinal relationship between drinking with peers, descriptive norms, and adolescent alcohol use.

Descriptive norms are consistently found to predict adolescent alcohol use but less is known about the factors that predict descriptive norms. The objective of this study is to test if drinking with peers predicts later alcohol consumption and if this relationship is mediated by a change in the descriptive norms of peer alcohol use. Data are from a nationally representative cohort of high school students surveyed in the 10th and 11th grade (N = 2,162). Structural equation modeling was used to test a mediation model of the relationship between drinking with peers (T1) on later alcohol use (T2) and mediation of the relationship by descriptive norms (T2). Descriptive norms significantly mediated the relationship between drinking with peers and alcohol use for both males and females with a somewhat larger effect for males compared to females. These results support a continued focus on the development and evaluation of interventions to alter descriptive norms of alcohol use.

Trends in Substance Use Among 6th- to 10th-Grade Students From 1998 to 2010: Findings From a National Probability Study.

Of the handful of national studies tracking trends in adolescent substance use in the United States, only the Health Behavior in School-Aged Children (HBSC) study collects data from 6th through 10th graders. The purpose of this study was to examine trends from 1998 to 2010 (four time points) in the prevalence of tobacco, alcohol, and marijuana use among 6th through 10th graders. Differences in trends by grade, gender, and race/ethnicity were examined for each substance use behavior, with a primary focus on trends for sixth and seventh graders. Overall, there were significant declines in tobacco, alcohol, and marijuana use from 1998 to 2010. The declines were largest for the younger grades, which suggest promise for future declines among high school students as these cohorts age into high school.

Social Determinants of Health Research at NIMHD: An Analysis of Studies Funded During 2019-2023.

INTRODUCTION: Social determinants of health (SDOH) contribute to differences in health outcomes and exacerbate health disparities. This study characterizes the National Institute on Minority Health and Health Disparities' (NIMHD) portfolio of funded grants in SDOH research, identifies gaps, and provides suggestions for future research. METHODS: Using the National Institutes of Health's SDOH Research, Condition, and Disease Categorization, research projects funded from 2019 to 2023 were identified and linked with NIMHD's internal coding system to extract in-depth study characteristics, including sociodemographics of study participants, disease and condition focus, and alignment with strategic priorities. Natural Language Processing methods were used to categorize projects into five Healthy People 2030 SDOH domains. RESULTS: The resulting sample included 675 unique research projects. Most projects included racial and ethnic minority groups (89%), followed by people with lower socioeconomic status (33%), underserved rural communities (16%), and sexual and gender minority groups (13%). Most projects focused on the Etiology of health disparities (61%), followed by Interventions (54%), and Methods and Measurement (39%). Of the Healthy People 2030 domains, Social and Community Context had the greatest representation (61%) whereas Education Access and Quality had the least (6%). Variation in research project characteristics across SDOH domains is also presented. CONCLUSIONS: This study documents characteristics of SDOH research funded by NIMHD and explores how they differ across Healthy People 2030 SDOH domains. Findings highlight how study characteristics and foci align with strategic priorities and suggest opportunities for future research.

Disparities in violent fatal injury among racial and ethnic minorities, 2009-2019: a portfolio analysis of United States-National Institutes of Health.

The excess mortality burden due to violent fatal injuries is an urgent public health issue for adolescents and young adults, especially those from racial and ethnic minority populations. We examined the research portfolio of the United States National Institutes of Health (NIH) related to violent fatal injuries between 2009 and 2019 to focus on adolescents and young adults from NIH-designated populations experiencing health disparities and to identify trends and research gaps. We analyzed funded projects by populations covered, geographic location of the study population, type of research (etiology, intervention, methodology), type of determinants, and publications generated. In 10 years, NIH funded 17 grants that produced 90 publications. Researchers used socioecological frameworks most to study violent crime, except in rural locations. Research gaps include the direct impact of violent crime among those victimized and health care (the least studied determinant) and premature mortality disparities caused by hate crimes.

Ethnic differences in perceptions of body satisfaction and body appearance among U.S. schoolchildren: a cross-sectional study.

BACKGROUND: Perceived body appearance and body satisfaction are potentially related to weight problems and poor health. The purpose of this study was to examine how gender, and ethnic differences in body satisfaction, perceived body appearance and weight status change by age in a representative sample of U.S. adolescents 11-17 years old. METHODS: We used the US Health Behavior in School-Aged Children (HBSC) 2001 survey which assessed perceived body appearance, body satisfaction, self-reported body mass index (BMI) and socio-demographic indicators. The associations between age and perceived appearance, age and body satisfaction, and between z-transformed BMI and body satisfaction were analyzed using separate non-parametric regression models for both genders and the three ethnic groups. RESULTS: Body satisfaction did not vary significantly by age except for an increase with age in the proportion of Non-Hispanic White girls who perceived themselves as too fat. Although boys did not report being too fat unless their BMI was above the age- and gender-specific median, one third of Non-Hispanic White girls felt too fat at or below the age- and gender-specific median. Compared to other ethnicities, African-American students' perceived appearance was significantly more positive and they were less likely to perceive themselves overweight at higher BMI scores. However, during adolescence, the positive self-reported perceived appearance of African-American boys dropped substantially while it remained relatively stable in African-American girls. CONCLUSIONS: There were substantial differences in body satisfaction and perceived appearance across the three largest ethnic groups of school-age children in the U.S. Stability across age indicates that these perceptions are most likely established before the age of 10 and underline the importance of primary schools and parents in prevention. Special attention should be directed to the dramatic loss of positive perceived appearance among African-American boys.

Early Adolescent and Peer Drinking Homogeneity: Similarities and Differences Among European and North American Countries.

This study examined associations between perceived peer and adolescent alcohol use in European and North American countries. Self-reported monthly alcohol use and adolescents' report of their peers' alcohol use were assessed in nationally representative samples of students aged 11.5 and 13.5 years (n = 11,277) in Greece, Scotland, Switzerland, and the United States who participated in the 2005/2006 Health Behavior in School-Aged Children survey. Cross-national associations between perceived peer and adolescent alcohol use were examined using logistic regressions and interactions by gender and country. Perceived peer and adolescent alcohol use were positively associated in all countries, but the association was notably weaker in Greece than in Scotland (boys), and in Greece compared to Switzerland (girls). Further examination of the underlying processes that explain stronger and weaker associations between perceived peer and adolescent alcohol use in some settings could guide the development of effective, culture-specific interventions.

Inadequate Data Limit the Analysis of Health Disparities and Causes: A Call for Research on Youth Interpersonal Violence.

Interpersonal violence among racial and ethnic minority youth is of great concern in health disparity research. Child maltreatment (CM), adolescent dating abuse (ADA), sexual abuse, and polyvictimization are key forms of interpersonal violence that require surveillance and national epidemiological data. However, national data systems and published evidence do not depict this health burden for all racial and ethnic populations. Prevalence and incidence rates for American Indians, Eskimo, and Asian youth are absent from most estimates. This commentary provides a brief overview of the gaps in the literature and offers suggestions for addressing these gaps.

NIH Portfolio of Unintentional Injury Research Among Racial and Ethnic Minority Children: Current Landscape and Future Opportunities.

Unintentional injuries (UIs) caused by accidental suffocation, burns, drowning, falls, poisoning, and motor vehicle accidents are the leading causes of morbidity and mortality among children (Dellinger and Gilchrist. Am J Lifestyle Med; 2017). Notable racial and ethnic disparities exist in accidental suffocation among infants and in motor vehicle injuries (MVI) among youth. The purpose of this study is to examine the National Institutes of Health's funded research projects addressing UIs, using a socioecological framework, and to determine whether funded projects align with key priorities for unintentional injuries among racial and ethnic minorities as identified by the research community. Between 2011 and 2018, a total of 130 grants that examined UIs were identified, thirty-four of which focused on UI research among children. Of those 34 grants, eight focused on UIs among racial and ethnic minority children. The analyses suggest four areas of opportunities, where more research is needed to (1) prevent accidental suffocation among American Indians and Alaska Natives; (2) strengthen the role of the health care sector to prevent UIs; (3) promote the use of an integrative multilevel social ecological approach to characterize UIs and help shape interventions; and (4) promote the collection and dissemination of local injury-specific data to develop interventions in community settings. Identifying gaps and opportunities for reducing the health burden of UI among racial and ethnic minorities can inform prevention efforts and guide the development of interventions that target these populations.

Early adolescent sexual initiation and physical/psychological symptoms: a comparative analysis of five nations.

Although most people in developed countries experience sexual initiation during adolescence, little is known about inter-country variability in the psychosocial correlates of early initiation. Population-based samples of 15-year-olds (n = 6,111, 52% female) who participated in the Health Behaviors in School-Aged Children Study (Finland, Scotland, France and Poland, 1997/1998) or the National Longitudinal Study of Adolescent Health (United States, 1996) self-reported sexual intercourse experience and physical (headaches, trouble sleeping) or psychological (unhappiness, loneliness, sadness, moodiness) symptoms. Analyses were conducted stratified by gender. Sexual initiation prevalence and symptoms scores varied significantly across nations. In adjusted models, sexual initiation was not related to symptoms among boys in any nation, but significantly positively related to symptoms among girls in Poland and the US. Results support variability by gender and nation in the relationship between adolescents' sexual initiation and physical/psychological symptoms. Empirically investigating specific features of national contexts that generate these differences should be explored further.