Office of Special Populations
Strategic Plan To Address Racial and Ethnic Health Disparities
(May 2002)

On this page:

• Introduction
• The Challenge
• Strategic Plan To Address Racial and Ethnic Health Disparities
• Research
• Research Infrastructure
• Communications and Outreach
• Evolution and Evaluation
• Appendix I
• Appendix II

Introduction

The establishment of the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health in 1998 may prove to be a watershed in medical history in America. Not only was the founding of the Center an acknowledgment that Americans are increasingly receptive to forms of health care outside conventional medicine, it was an acknowledgment that rigorous research on these forms could enrich conventional medicine. The resulting "integrative medicine" could pay off in greater options for improving the health and well being of the American public. NCCAM has underscored this philosophy of inclusion in its description of complementary and alternative medicine (CAM) practices as "those not presently considered an integral part of conventional medicine." As evidence accrues that particular CAM therapies are safe and effective, steps will be taken to include them in the repertoire of conventional medicine interventions.

In 2001, NCCAM, with the advice of many individuals and groups within and outside government, developed a 5-year strategic plan, Expanding Horizons of Health Care, expressing the following mission and vision:

The NCCAM Mission

We are dedicated to exploring complementary and alternative healing practices in the context of rigorous science, educating and training CAM researchers, and disseminating authoritative information to the public and professionals.

The NCCAM Vision

We will advance research to yield insights and tools derived from complementary and alternative medicine to benefit the health and well being of the public, while enabling an informed public to reject ineffective or unsafe practices.

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The Challenge

The NCCAM 5-year strategic plan identified four strategic areas for implementation: Investing in Research, Training CAM Investigators, Expanding Outreach, and Facilitating Integration, each with a set of goals and objectives (see Appendix I). Within each of the four areas are objectives that address the special needs of America's most vulnerable populations, in particular, racial and ethnic minority groups. Information documenting that the health of these groups is generally poorer than that of the white majority has led the Department of Health and Human Services and the National Institutes of Health to implement research plans to reduce and eventually eliminate racial and ethnic health disparities. NCCAM is cooperating in these activities, affirming that not only must research aimed at eliminating health disparities increase, but so must efforts to expand minority participation in research as investigators and clinicians. Culturally sensitive communications and outreach activities to attract young people to health-related careers are needed, as are informational materials to keep all members of racial and ethnic minority populations informed of research findings important to their health.

At the same time, NCCAM regards America's diverse racial and ethnic groups as an invaluable resource for learning about systems of healing and health practices outside the mainstream. Many CAM practices have originated or are traditional in cultures and countries outside America and were brought here by immigrating racial and ethnic minority populations. In the new homeland, these CAM practices may have been modified over time, making them all the more interesting to study and to compare with practices in their countries of origin. There the particular system of healing may well constitute the routine system of health care for the majority of citizens. NCCAM is, therefore, implementing an international research program, where, in cooperation and collaboration with native peoples and practitioners, CAM systems can be studied on their native grounds. This international effort will complement NCCAM's domestic research program in which CAM practices are studied as used in America by racial and ethnic minority populations. These research programs can serve a dual purpose: (1) They can establish which CAM interventions—either as practiced in their countries of origin or as assimilated in this country—can benefit the health and well being of all Americans, but may be particularly useful and accepted in selected racial and ethnic minority populations, and (2) They can facilitate the integration of these practices into conventional health care in the United States, especially into programs specifically designed to address the health needs of minority populations.

Accordingly, NCCAM has created two new and interrelated offices to address these issues. The Office of Special Populations is the focus for NCCAM activities to eliminate racial and ethnic health disparities. The Office of International Health Research is the focus for the Center's international activities. Each Office has been charged to develop its own strategic plan, building on the goals and objectives in the Center's 5-year plan. What follows is NCCAM's Strategic Plan To Address Racial and Ethnic Health Disparities.

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Strategic Plan To Address Racial and Ethnic Health Disparities

The higher rates of sickness and death that many racial and ethnic minorities experience compared to the white majority not only take their toll in pain and suffering, but extract enormous social and economic costs that burden those affected, their families, and society as a whole. While such gaps in health status are sufficient cause for alarm, population trends indicate that today's racial and ethnic minority groups collectively will emerge as the majority population in America by mid-century, making the need for action urgent. Toward that end, NCCAM has created an Office of Special Populations to initiate programs to address these needs, as well as to contribute to the Strategic Plan To Reduce and Ultimately Eliminate Health Disparities, developed by the National Institutes of Health in response to an initiative of the Department of Health and Human Services. The Department has targeted the elimination of racial and ethnic health disparities in six major areas by the year 2010: infant mortality, cancer, cardiovascular disease, diabetes, HIV infection/AIDS, and immunizations. As a member of the NIH community, the National Center for Complementary and Alternative Medicine (NCCAM) can make unique contributions toward the goals of these initiatives.

Barriers to Health

The reasons for health disparities among racial and ethnic groups lay not so much in a lack of scientific understanding of disease processes, but in failures to communicate and apply existing knowledge in ways that can benefit minority groups and in disparities in their access to health care. In resolving these issues, it is critical to recognize the diversity that exists within the broad categories of race and ethnicity. Among Hispanic Americans, for example, there is no reason to assume that the health problems of urban Cuban Americans living in Florida will be the same as Mexican American migrant workers in California. America's minority groups are not homogeneous, but composed of subgroups that vary in education, income, and other factors that affect health and well being. While such groups may share a common heritage of language, religion, customs, and values—including health beliefs and practices—there are individual and group differences that reflect demographic variables as well as generational changes, different degrees of assimilation and adaptation to American culture, and other factors affecting health.

In this regard, NCCAM is well-positioned to provide important information on the health beliefs and practices of various racial and ethnic subgroups, in particular, determining the extent to which a group subscribes to conventional medical care, to a particular form of CAM, or a combination of the two. For all practical purposes, CAM practices can be described as those not presently considered an integral part of conventional medicine.¹ See the NCCAM 5-Year Stategic Plan 2001-2005. While recent national surveys document a substantial and growing use of CAM by Americans as a whole (with most people using CAM in addition to conventional care), little is known about CAM use in minority populations, either by lay members or their care providers. Such research can shed light on how traditional beliefs shape health behaviors and whether they conflict with or complement conventional health care or methods of health promotion and disease prevention. In this way NCCAM can gather key information, while acting as a mediating influence: opening the door to information exchange with the groups queried and improving the understanding, cultural sensitivity, and competence of health care providers working within the conventional medical care system. These activities, as well as the integration of CAM therapies found to be safe and effective into conventional health care, will help us realize the aim of the NCCAM health disparities plan, as expressed in the vision statement:

Our Vision

The vision of the NCCAM Strategic Plan To Address Racial and Ethnic Health Disparities is a health system in which no health disparities exist between the majority population and racial/ethnic minority populations; a system in which CAM and conventional practices are integrated in promoting health and treating disease. NCCAM will contribute to the elimination of health disparities by conducting research to identify CAM practices that are effective, disseminating research findings on those practices to all groups of Americans, and enriching the diversity of the CAM research community itself.

Guiding Principles

The guiding principles of this NCCAM plan parallel those in the NIH plan: (1) support research; (2) build research infrastructure; and (3) increase public information and community outreach. From NCCAM's perspective, the Office of Special Populations will:

• Support research on the use and effectiveness of CAM in racial and ethnic minority populations. To the extent possible, such research will be community-based, enlisting community knowledge in determining the shape and direction of projects and assuring that the research process is clearly understood by community participants and outside researchers;
• Build CAM research infrastructure—both personnel and facilities—to facilitate CAM research conducted by minority investigators at minority and minority-serving institutions; and
• Increase communications and outreach activities to target minority populations and health professionals with information about CAM research opportunities and research findings.

This NCCAM plan follows the general format of the NIH health disparities plan, with NCCAM objectives and activities aligned with the objectives in the NIH plan. Cross-references link NCCAM's disparities initiatives to the four Strategic Areas in the Center's 5-year strategic plan, Expanding Horizons of Health Care. Two appendices summarize the objectives of the NCCAM 5-year strategic plan and the NIH health disparities plan. This NCCAM health disparities plan will be evaluated and updated periodically as new findings and opportunities present themselves.

The NIH Goal: To Reduce and Ultimately Eliminate Health Disparities Among Racial and Ethnic Minorities
To accomplish this goal, NCCAM will implement initiatives described under the three categories: Research, Research Infrastructure, and Communications and Outreach.

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I. Research

In general, CAM systems and practices are aimed not only at treating disease, but also at promoting general health and wellness. Defining "wellness" for the purposes of research is challenging in itself; it is even more challenging to investigate the safety and efficacy of the many highly complex and diverse therapies that constitute CAM modalities. Adding to the difficulties of conducting rigorous CAM research is the fact that CAM interventions are frequently customized for the individual patient and thus may not be as replicable for the purposes of establishing safety and efficacy as conventional medical regimens. Moreover, the research methods used to investigate CAM need to be sensitive to cultural variants within the many types of CAM systems to be studied. With the ultimate goal of identifying safe and efficacious CAM systems and practices in mind, it may be necessary initially to conduct descriptive or qualitative research to understand health behaviors and the meaning of a given approach in a given culture prior to conducting quantitative research.

Research Objective 1. Advance understanding of the development and progression of diseases and disabilities in minority populations.

NCCAM research in pursuit of this objective will entail studies of the diseases and disorders for which CAM approaches are used by various racial and ethnic minority populations. By supplementing existing surveys as well as undertaking new initiatives, NCCAM will expand knowledge of CAM use by minority populations and provide a more comprehensive view of CAM use by the entire U.S. population. In addition to one ongoing initiative, one new initiative is planned.

Ongoing Initiative: Conduct epidemiologic studies of CAM use in racial and ethnic minority populations.

In collaboration with the National Center for Health Statistics of the Centers for Disease Control and Prevention, NCCAM has developed a supplemental module on CAM use to be incorporated into the National Health Interview Survey (NHIS) for 2002. Because NHIS oversamples African Americans and Hispanic Americans, the survey will collect much-needed information on CAM use in these groups.

NCCAM will also solicit applications for additional in-depth studies to determine CAM use by racial and ethnic populations and subpopulations. Investigators will be encouraged to collect and analyze data on demographics, health and social characteristics, race/ethnicity, pre-existing illnesses, and CAM utilization by these populations in order to support statistically reliable estimates of CAM patterns of use. Further, in conjunction with NCCAM's international initiatives, this information may lead to studies in which CAM use by immigrant minority populations is compared with the use of these approaches in their countries of origin, elucidating the impact of American culture and local environmental and psychosocial factors on the use and effectiveness of CAM. Overall, these projects will permit NCCAM to collect nationwide information on CAM use by minority populations as well as targeted information on use by specific minority subgroups.
(Note: Implementation Strategy and Timeframe are included only for those initiatives that are or will be open for applications.)


• Implementation Strategy: NCCAM will utilize an Intra-Agency Agreement (IAA) to fund the NHIS CAM module and solicit in-depth minority population studies as well as secondary data analyses through Program Announcements (PA).
• Timeframe: FY 2002-2006 (IAA: 2001-2003; PA: 2003-2005; PA for data analysis: 2004-2006)

New Initiative: Develop research methods for the study of CAM use in minority populations.

NCCAM will hold a workshop to identify:

• the challenges of conducting research on CAM beliefs and use in culturally diverse populations;
• gaps in the knowledge base; and
• appropriate research methods for closing the gaps.

The scope of the workshop is designed to go beyond ethnographic studies and cultural determinants of disease. It is expected that a number of issues that will be raised will apply across the range of minority populations and will be open to discussion by the workshop as a whole. For those issues identified as unique to various subpopulations, breakout groups may be used. NCCAM anticipates publication of an executive summary from this workshop in an appropriate peer-reviewed journal. The summary may be used as the basis for a subsequent program announcement. By addressing methodological issues up front and proposing ways to resolve them, this initiative will guide other research activities and policies aimed at the elimination of health disparities.

• Implementation Strategy: Sponsored Workshop; Program Announcement (PA)
• Timeframe: Workshop in FY 2003; PA FY 2004-2006

The above initiatives relate to the NCCAM 5-year strategic plan Objective 3 (support research to address health disparities among women, minorities, children, and other underrepresented populations), under Goal 2 (expand the scope of the NCCAM extramural research portfolio and participation by research subjects) in Area 1, Investing in Research.

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Research Objective 2. Develop new or improved approaches for treating diseases and disabilities based on investigations of CAM systems of care.

Some CAM modalities practiced in the United States have arisen from the traditional healing practices of other nations or cultures (e.g., Hmong, Hispanic), while others have evolved or have been adapted to work in American society, often in parallel with conventional medical practices (e.g., traditional Chinese medicine, Native American medicine). These practices/systems are not well documented, either within the context of their native communities (transplanted or indigenous), or understood within the context of American culture. Research to detail these practices will provide important insights into how particular CAM systems are utilized and their impact on the health of U.S. minority populations. In addition to one ongoing initiative, one new initiative is planned.

Ongoing Initiative: Study the use of traditional, indigenous systems of medicine.

Examples of CAM systems practiced in the United States that may differ from how they are applied in their places of origin include Native American medicine and Curanderismo, a folk healing system native to Latin America and used in the United States by many Hispanic Americans. Much Native American medicine involves the use of botanicals, "sweats," and other ways of dealing with illness. Knowledge of the specific healing techniques and rituals used by a given tribe may be acquired by novice healers directly from elder healers, from spirits encountered during vision quests (spiritual journeys involving altered states of consciousness), and other initiation ceremonies. A wide range of studies of these traditional systems will be needed—from descriptive to outcomes/effectiveness studies—to understand any changes between the traditional and the adapted systems. The inclusion of ethnic healers as collaborators with NCCAM researchers should be encouraged to facilitate this research. As feasible, attention should be given to the heterogeneity of tribes and their healing traditions as well as to regional differences in adapting systems.

With these examples in mind, the purpose of this initiative is to support developmental studies to establish the methodological feasibility and strengthen the scientific rationale for proceeding to large randomized clinical trials on the use of traditional, indigenous systems of medicine as practiced in the United States. The intent of the research is to develop study designs that will enable the determination of safety and efficacy of interventions within a particular CAM system. The studies must address the difficult methodological and design issues characteristic of complex medical interventions, as well as allowing for the development of culturally sensitive research into aspects of CAM care that reflect current practice in the United States.


• Implementation Strategy: Existing Program Announcement: Traditional, Indigenous Systems of Medicine
• Timeframe: FY 2002-2003
New Initiative: Conduct outcomes research on CAM in minority populations.

This initiative can use as a basis for outcome studies the results of the CAM module from the National Health Interview Survey and additional indepth projects funded under Research Objective 1, above. These studies will provide information on the extent and types of CAM use by minority populations. In particular, if research findings indicate that certain CAM therapies are used to treat diseases targeted by NIH and DHHS in their plans for eliminating health disparities, NCCAM can propose studies comparing outcomes for a group of patients receiving conventional care for the condition to outcomes for a group of patients receiving a CAM treatment for the same condition. In this way, NCCAM research may determine the potential benefits of CAM modalities.


• Implementation Strategy: Program Announcement (PA)
• Timeframe: FY 2004-2006

The above initiatives address the NCCAM 5-year strategic plan Objective 1 (establish programs of research on traditional and indigenous health practices in the United States and in those countries in which the most promising opportunities for CAM research are identified) under Goal 4 (establish a global NCCAM research enterprise) in Area 1, Investing in Research.

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Research Objective 3. Determine the safety and efficacy of CAM interventions for the treatment of specific diseases.

The prospect of utilizing CAM to contribute to the elimination of health disparities will require identification of those conditions for which CAM systems and modalities are safe and effective. Through existing research projects and new initiatives, NCCAM will study the use of CAM to treat cardiovascular disease, prostate cancer, diabetes, and HIV/AIDS—four of the six priority conditions from the DHHS Initiative. Some research projects may permit integration of traditional and conventional medicines into the research approach.

Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death and a leading cause of disability in the United States. In 1998, the death rates for African Americans due to CVD on the average were 43 percent higher than the rates for whites. CVD accounts for between one-fourth and one-third of deaths in all minority populations.

Ongoing Research: Vedic Medicine and CVD

NCCAM currently is funding the Center for Natural Medicine and Prevention at Maharishi University of Management. This Center focuses on the use of Vedic Medicine, a form of traditional Indian medicine that incorporates herbal formulations and meditation to treat cardiovascular disease (CVD) in older African American populations. Three specific research projects are associated with the Center: Basic Mechanisms of Meditation and CVD in Older Blacks, a project that attempts to identify the physiologic mechanism of action by which Transcendental Meditation (TM) might reduce hypertension; Clinical Trial of Meditation for CVD in Older Black Women, a study of the effects of TM on hypertension and carotid artery thickness; and Effects of Herbal Antioxidants on CVD in Older Blacks, a placebo-controlled trial evaluating the effects of a traditional Vedic herbal preparation on pathophysiologic markers of CVD in high-risk, older African Americans. These projects are funded through FY 2004.

Prostate Cancer

Prostate cancer is more prevalent in African American men than in any other population worldwide. The mortality rate for African American men is twice as high as that for white men. Clinical treatments for prostate cancer are limited to surgery, radiation, hormonal, and cytotoxic chemotherapies. The need for testing novel approaches and compounds in the fight against prostate cancer is acknowledged.

Ongoing Research: PC SPES and Prostate Cancer

NCCAM currently supports the Center for Cancer Complementary Medicine at the Johns Hopkins University. The research goals of this center are directed at gender-specific cancers, such as breast and prostate cancer. Currently, the center is conducting a phase II randomized, placebo-controlled clinical trial evaluating the efficacy and safety of PC SPES, a Chinese herbal preparation, versus estradiol alone, in white and African American men with hormone-refractory prostate cancer. The trial also includes a subset of Chinese men at Johns Hopkins Singapore. This project is funded through FY 2005.

Ongoing Research: Selenium and Vitamin E Cancer Prevention Trial (SELECT)

NCCAM is collaborating with the National Cancer Institute on a multicenter randomized clinical trial on the use of selenium and vitamin E, alone and in combination, in preventing prostate cancer. Secondary findings from different clinical trials suggest that selenium and vitamin E may have independent, as well as synergistic chemopreventive effects. This is a 12-year trial that will seek to enroll 20 percent African American men—equal to their proportion of prostate cancer cases among the U.S. population. Information from this trial will inform the delivery of care for men with prostate cancer and contribute to the elimination of health disparities.

Breast Cancer

The stress of breast cancer may alter natural neuroendocrine-mediated immunoprotective mechanisms and increase the likelihood of tumor recurrence. African American women have a poorer prognosis at every stage of breast cancer diagnosis and are more vulnerable to the stress associated with the attendant diagnosis and treatment.

Ongoing Research: Prayer in Black Women with Breast Cancer

This project, also at the Johns Hopkins University Center for Cancer Complementary Medicine, is evaluating the impact of personal and group prayer interventions on neuroendocrine and immune responses in African American women 1 to 2 months after surgery and radiation. The prayer intervention is being compared to a randomly assigned wait-listed control group with measurement of changes in neuroendocrine markers of stress, immune response, perceived stress, psychosocial functioning, and quality of life. This cohort will be followed long term for tumor surveillance and compared with a matched reference group. This project is funded through FY 2005.

Diabetes Mellitus

Twenty-five percent of all type II diabetic patients in the United States are from minority populations. African Americans, Hispanic Americans, and Native Americans have rates of disease that are significantly greater than the rates for non-Hispanic whites. Complications such as retinopathy and end-stage renal disease are two-to-four times more prevalent in minority populations than in non-Hispanic whites. Diabetes is also an example of a disease that can benefit from an integrative medical response emphasizing prevention and the role of diet and nutrition. NCCAM's ongoing research projects on CAM and diabetes may benefit minority patients, even though minority patients are not targeted by the research. Three ongoing studies and one ongoing initiative are described.

Ongoing Research:

NCCAM is funding (through FY 2002) a study investigating the potential utility of the botanical product, ginseng, as a therapeutic agent for type II diabetes. Ginseng is thought to produce its effect by regulating blood glucose levels. The project is examining the ability of ginseng to modulate the expression of genes involved with glucose metabolism. Such mechanistic studies may eventually lead to definitive clinical trials examining the efficacy of ginseng. Another project, funded through FY 2003, is a double-blind, randomized crossover study to determine the ability of the biofield modality, Reiki, to reduce pain levels and improve glycemic control in type II diabetes patients. A third project is studying the effect of the herb Ginkgo biloba on glucose metabolism and the mechanism by which it increases pancreatic function. The results of this study, funded through FY 2004, should also provide valuable information for designing new therapeutic strategies for the treatment of diseases in the insulin resistance syndrome.

Ongoing Initiative: Chromium To Treat Diabetes

There is accumulating evidence suggesting that chromium supplementation can alleviate symptoms associated with type II diabetes and reduce the need for exogenous insulin. The NIH Office of Dietary Supplements, NCCAM, and the National Institute of Diabetes and Digestive and Kidney Diseases have issued a Program Announcement for studies on product formulation, dosing, and study population requirements. While not exclusively targeting minority populations, this initiative will generate information on the role of chromium in the treatment of diabetes in minority populations, and may contribute to the elimination of health disparities in minority populations.


• Implementation Strategy: Existing Program Announcement: Chromium As Adjuvant Therapy for Type II Diabetes and Impaired Glucose Tolerance
• Timeframe: FY 2002-2004

HIV/AIDS

The devastation of this epidemic is focusing increasingly on minority communities. In 1999, African American adults had AIDS rates that were more than 2.4 times the rates for Hispanic adults, over 7 times the rates for American Indians and Alaska Natives, and more than 9 times the rates for non-Hispanic whites. Many HIV-infected people of color utilize CAM approaches either in association with, or instead of, conventional medical therapy. The range of treatments is as varied as the cultures from which the people come. Studies on the range of CAM modalities may contribute to understanding the cultural nuances of health behaviors and potentially identify useful integrative approaches to treating HIV/AIDS.

New Initiative: CAM and HIV in Minority Populations

This initiative will support a workshop on the CAM treatments used by racial and ethnic minority populations in treating HIV/AIDS. In addition to identifying treatments in widespread use and cataloging therapeutic regimens, data will permit development of a research agenda on CAM use by minority populations for the treatment of HIV/AIDS. The inclusion of minority participants in other NCCAM HIV/AIDS initiatives will provide supplemental information regarding the use of CAM to treat HIV/AIDS that will inform the research agenda. A program announcement will support research investments into the issues identified through the workshop.


• Implementation Strategy: Program Announcement (PA)
• Timeframe: FY 2004-2006

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Research Objective 4. Expand Minority Participation in CAM Research

In addition to the disease-specific studies discussed above, NCCAM will pursue efforts to increase the involvement of minority participants in all its CAM research projects. This objective is consistent with NIH policy and will facilitate identification of demographic variables that may influence clinical outcomes resulting from use of CAM.

New Initiative: Recruitment of Minority Subjects for CAM Research

This initiative is aimed at establishing fruitful partnerships between investigators, health care facilities, and community-based organizations and leaders to enhance minority accrual in CAM research studies in a culturally sensitive manner. In particular, collaborations between minority physicians and academic health centers serving large numbers of minority patients are needed. NCCAM staff will consult with investigators about recruiting strategies used to target minority participants and in some cases NCCAM may consider supplemental funding for outreach if routine efforts are unsuccessful. Currently, NCCAM is collaborating with the Health Resources and Services Administration (HRSA) to explore possible linkages between NCCAM Research Centers and Community Health Centers and Migrant Health Centers (funded by HRSA and serving large numbers of minority patients).


• Implementation Strategy: Intra-Agency Collaboration; Grant Supplements
• Timeframe: FY 2002-2005

The above initiatives relate to the NCCAM 5-year strategic plan Objective 3 (support research to address health disparities among women, minorities, children, and other underrepresented populations), under Goal 2 (expand the scope of the NCCAM extramural research portfolio and participation by research subjects) in Area 1, Investing in Research.

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II. Research Infrastructure

Studies document the underrepresentation of racial and ethnic minority investigators in biomedical research and the lack of research funding at minority institutions. Building a diverse CAM research community requires not only support of programs to increase the number of minority researchers in general, but also investment in those minority institutions that continue to train a large share of minority researchers. A variety of NIH programs provide research training opportunities for minority students at various educational levels. In addition, there are programs to enhance the research capability of faculty at health professions schools. However, no program specifically targets the development of minority investigators trained to conduct CAM research. In view of the ever-broadening cultural diversity of the American population and the wealth of CAM traditions, NCCAM's ongoing and planned initiatives are aimed at increasing the number of minority investigators in the CAM research community and building research infrastructure at minority and minority-serving institutions.

Infrastructure Objective 1. Support minority CAM research training and career development.

Several factors, to varying degrees at various times, contribute to the dearth of individuals from racial and ethnic minority groups receiving training in CAM research: a lack of CAM research resources at their home institutions; a lack of opportunities to develop the research skills necessary to investigate CAM; and a lack of interactions with CAM research scientists. However, increasing the number of minority students preparing for careers in CAM research—at majority as well as minority institutions—is critical to any plan to eliminate health disparities of minority groups. Toward that end, NCCAM will target minority student and faculty programs and provide new extramural funding to build the necessary diversity in the CAM research community. The inclusion of presentations on CAM research at national conferences of minority researchers and care providers will aid recruitment efforts. The initiation of intramural research at NCCAM provides additional opportunities to train minority investigators, both independently and collaboratively with other NIH programs. NCCAM also recognizes the importance of retaining CAM-trained researchers within minority communities, a goal that can be facilitated if research training is also community-based. Two ongoing and two new initiatives are described.

Ongoing Initiative: CAM Research Training for Minority Researchers

This initiative will help develop a cohort of minority scientists investigating CAM and enhance the ability of minority institutions and minority-serving institutions to support CAM research. The NCCAM Institutional Research Training Program for Minority Researchers is a National Research Service Award (NRSA) Program (T32) intended to support pre- and post-doctoral trainees and short-term research training for health professions students at minority and minority-serving institutions having the potential to develop meritorious training programs in CAM research. It is designed to attract students in their developmental stages, to increase their awareness of CAM research, and to encourage them to pursue research career opportunities in this area. The initiative funds training for individuals, selected by the grantee institutions, in specified areas of biomedical and behavioral research related to CAM. In addition, the inclusion of short-term summer training opportunities for health professions students will assist in developing the pipeline of minority students interested in pursuing research careers in CAM-related fields. Applications for this initiative were limited to minority institutions and minority-serving institutions (e.g., Hispanic Serving Health Professions Schools)--institutions that have demonstrated a commitment to the education and training of racial and ethnic minority individuals. The two grants awards, to Morgan State University and to Florida International University, are funded through FY 2006.

Ongoing Initiative: Minority Research Supplements

NCCAM participates in the NIH program, Research Supplements for Underrepresented Minorities, which supports training of minority students by supplementing selected research grants. Through this program, NCCAM may support minority students from high-school through pre-doctoral levels, as well as post-doctoral individuals and junior faculty working under the supervision of an NIH-funded investigator. NCCAM routinely notifies its funded investigators of the availability of minority supplements at the time of grant award. Ongoing collaboration with other NIH Institutes and Centers also will enhance NCCAM's participation in NIH-wide activities to help NCCAM investigators identify eligible minority trainees.

• Implementation Strategy: Existing NIH-wide Program Announcement: Research Supplements for Underrepresented Minorities
• Timeframe: Ongoing

New Initiative: Minority Summer Internships

NCCAM will provide funding to support summer internships for minority students interested in careers in CAM. Several minority student organizations have long-standing programs to identify undergraduate and graduate students interested in exploring health research and policy careers. The range of opportunities available through NCCAM's facilities will offer selected students rich experiences and exposure to the forefront of CAM activities.

• Implementation Strategy: Cooperative Agreements through the Office of Minority Health
• Timeframe: FY 2003-2006

New Initiative: Minority Youth Initiatives

Building the community of minority investigators requires informing minority youth of the career opportunities available to them in CAM research. To this end, NCCAM participates in ongoing DHHS summer programs for minority high-school youth that expose students to potential research careers in CAM.

• Implementation Strategy: Cooperative Agreements through the Office of Minority Health
• Timeframe: FY 2002-2006

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Infrastructure Objective 2. Provide support for institutional resources.

As noted above, building a diverse CAM research community requires investment in those minority institutions that train a large share of minority researchers. In addition to supporting increased diversity of the CAM research community, NCCAM's ongoing research and planned initiatives are aimed at building research infrastructure at minority and minority-serving institutions. One ongoing and one new initiative are described.

Ongoing Research Activity: Center for CAM, Minority Aging and CVD

Drew University, Howard University, and Morehouse School of Medicine, all recognized minority institutions, have research subcontracts with the Maharishi University of Management to collaborate on the cardiovascular disease projects noted above. Such CAM research collaborations are another vehicle by which NCCAM is helping to build the capacity to conduct CAM research at minority institutions. These projects are funded through FY 2004.

New Initiative: Academic Partnerships

This initiative, to begin in FY 2003, will seek to facilitate collaborative interactions between investigators at minority and minority-serving institutions and CAM research centers, botanical research centers, and NCCAM-funded investigators at research-oriented institutions. The intent is to enable minority researchers to establish productive collaborations that will help them compete successfully for peer-reviewed research support. The program will support improved access to NCCAM resources, such as CAM and botanical centers, so that research can be focused on issues that affect minority populations. These NCCAM resources will be used for promoting training opportunities for minority researchers and students.


• Implementation Strategy: Intra-Agency Agreements; Grant Supplements
• Timeframe: FY 2003-2006

Initiatives in the above section relate to the NCCAM 5-year strategic plan Objective 5 (increase the number of trainees from underrepresented populations), under Goal 1 (increase the number, quality, and diversity of CAM investigators) in Area 2, Training CAM Investigators.

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III. Communications and Outreach

The growth of print and electronic media coverage of health issues has enhanced opportunities for communication with consumers and with the health research and practitioner communities, allowing widespread distribution of CAM information. While NCCAM will make optimal use of electronic formats to communicate with leading institutions, the Center recognizes the need to target print communications to optimize dissemination of CAM information to minority populations that may lack access to electronic media. Three new initiatives are described.

New Initiative: Professional Communication and Outreach

NCCAM will expand its participation in and linkages with minority health professions organizations and minority components of research organizations. The purposes are three-fold:


• To increase the participation of minority investigators in CAM research;
• To educate conventional health professionals about the widespread use of CAM and encourage their interaction with patients in an open, non-judgmental manner; and
• To facilitate communication between the conventional medical community and the CAM community.
The development of integrative systems of health care delivery can lead to improved health outcomes for patients as well as foster collaborative opportunities for CAM research.


• Implementation Strategy: Professional Interactions and Staffing of Exhibits at Scientific Meetings
• Timeframe: FY 2002-2006
New Initiative: Public Communication and Outreach

Many CAM practices are widely used even though they have not been shown in clinical studies to be effective. NCCAM supports research on a range of CAM practices and is building the knowledge base regarding effective CAM practices, those that remain unproven or are shown to be ineffective, and potentially dangerous CAM practices. This scientific information needs to be disseminated broadly to minority communities in culturally appropriate ways. The NCCAM Office of Communications and Public Liaison will work with community organizations and institutions to encourage the appropriate use of CAM and the integration of CAM with the conventional health care delivery system.


• Implementation Strategy: Collaboration with community-based organizations to enhance the dissemination of NCCAM findings and related CAM information.
• Timeframe: FY 2002-2006
New Initiative: Community-Based Participatory Research

NCCAM is part of an NIH workgroup, coordinated by the National Institute of Environmental Health Sciences (NIEHS), that is identifying relevant steps regarding community-based participatory research. Through involvement in this workgroup, NCCAM anticipates greater input by racial and ethnic minority populations into its planning processes and research activities, as well as greater dissemination of its research information and findings.


• Implementation Strategy: Adapt recommendations of workgroup to NCCAM activities
• Timeframe: FY 2002-2006

The initiatives above relate to the NCCAM 5-year strategic plan Objective 1 (develop and disseminate reliable scientific information that is culturally sensitive, engaging to the reader, and updated frequently to reflect the pace of change in the field), under Goal 1 (enhance NCCAM's capacity to provide information to consumers, practitioners, and investigators), and to Objective 3 (exhibit NCCAM-funded discoveries and opportunities at conventional scientific meetings and those of our CAM constituents), under Goal 2 (establish an effective dialogue with CAM stakeholders), in Strategic Area 3, Expanding Outreach.

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Evolution and Evaluation

The NCCAM Strategic Plan To Address Racial and Ethnic Health Disparities represents the Center's initial efforts to articulate its commitment to the DHHS and NIH goals of eliminating racial and ethnic health disparities. Although resource constraints, the limitations of science in a developing field such as complementary and alternative medicine, and the kinds of applications NCCAM receives may limit its ability to attain results as scheduled, NCCAM remains committed to accomplishing the ambitious objectives of this plan. This plan should be considered an evolving document. NCCAM will modify the plan and correct the course to take account of new findings and opportunities as feasible. To facilitate the integration of the proposed initiatives into NCCAM research plans and to monitor their progress over time, NCCAM is establishing a Minority Health Coordinating Committee, consisting of representatives from each NCCAM division. The committee's task will be to coordinate planning and implementation of activities, make periodic evaluations of progress, and recommend changes that will better serve the objectives in support of the NCCAM and NIH Health Disparities Plans and the DHHS Initiative.

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Appendix I
Goals and Objectives of the NCCAM 5-Year Strategic Plan

(Note: Those objectives referenced in the NCCAM Strategic Plan To Address Racial and Ethnic Health Disparities are in bold type.)

Strategic Area 1: Investing in Research

Goal 1: Stimulate submission of high-quality applications in CAM priority areas by both CAM and conventional investigators.

Objectives:


• Exhibit NCCAM information at professional meetings and conduct grant-writing workshops.
• Sponsor interdisciplinary conferences to stimulate broad-based research.
• Assist extramural CAM researchers and practitioners to develop and participate in high-quality research applications.

Goal 2: Expand the scope of the NCCAM extramural research portfolio and participation by research subjects.

Objectives:


• Emphasize investigator-initiated research as the time-proven vehicle for advancing science on broad fronts.
• Support a broad base of rigorous CAM research, including, but not limited to, studies of basic biology and disease pathogenesis, elucidating mechanisms of action, outcomes research, pharmacologic investigations, epidemiology, and all phases of intervention trials (I-III).
• Support research to address health disparities among women, minorities, children, and other underrepresented populations.
• Solicit applications and proposals in areas for which the opportunities for impact are great and there is a paucity of investigator-initiated research.

Goal 3: Create an NCCAM intramural research program.

Objectives:


• Design, conduct, analyze, and report rigorous CAM research, including, but not limited to, studies elucidating basic biology and pathogenesis mechanisms of action, outcomes research, pharmacologic investigations, epidemiology, and all phases of intervention trials (I-III).
• Conduct clinical and laboratory-based CAM research studies in close collaboration with extramural CAM scientists and with intramural staff of the other NIH Institutes and Centers.
• Provide an environment for training scientists and clinicians from diverse backgrounds in the health care professions in the conduct and analysis of CAM research studies, employing the highest standards of trial design and ethics.

Goal 4: Establish a global NCCAM research enterprise.

Objectives:


• Establish programs of research on traditional and indigenous health practices in the United States and in those countries in which the most promising opportunities for CAM research are identified, in coordination with international organizations, and with all due respect to the heritage and practices of indigenous peoples.
• Align these programs with existing NIH-funded international research programs to ensure the immediate availability of research expertise in the field and the infrastructure to support them.

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Strategic Area 2: Training CAM Investigators

Goal 1: Increase the number, quality, and diversity of CAM investigators.

Objectives:


• Stimulate collaborations between CAM practitioners and investigators in the conventional academic medical community.
• Develop programs to train individuals in CAM-related laboratory and epidemiological research.
• Train doctors of medicine, osteopathy, chiropractic, and naturopathy, and others with advanced degrees in relevant clinical disciplines, to conduct CAM-related clinical research.
• Initiate quality research training programs.
• Increase the number of trainees from underrepresented populations.
• Establish an interdisciplinary, intramural NIH research training program.

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Strategic Area 3: Expanding Outreach

Goal 1: Enhance NCCAM's capacity to provide information to consumers, practitioners, and investigators.

Objectives:


• Develop and disseminate reliable scientific information that is culturally sensitive, engaging to the reader, and updated frequently to reflect the pace of change in the field.
• Respond with compassion and understanding to inquiries from consumers, directing them as appropriate, to a network of resources.
• Collaborate on information dissemination with other NIH entities and government agencies, international organizations, and foreign government and nongovernment agencies.

Goal 2: Establish an effective dialogue with CAM stakeholders.

Objectives:


• Sponsor regional Town Hall Meetings to provide a forum for the public to contribute input and for NCCAM to share information regarding important research efforts and findings with the community.
• Seek ongoing, substantive input from leaders of CAM practice communities, CAM training institutions, advocacy groups, the mainstream academic and scientific communities, industry, partners in other NIH Institutes and Centers, and Federal agencies.
• Exhibit NCCAM-funded discoveries and opportunities at conventional scientific meetings and those of our CAM constituents.
• Develop media opportunities and strategies to disseminate research information and increase public understanding of NCCAM's mission.

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Strategic Area 4: Facilitating Integration

Goal 1: Facilitate development of health education curricula that respect and incorporate insights and opportunities afforded by safe and effective CAM and conventional practices.

Objectives:


• Fund educational grants to develop model curricula regarding CAM practices for schools of medicine and allied disciplines.
• Fund educational grants to develop model curricula regarding conventional medical practices and research methods for schools of complementary and alternative medicine disciplines.

Goal 2: Facilitate coupling of effective CAM and conventional practices within a coordinated, interdisciplinary health care delivery system.

Objectives:


• Sponsor national meetings, consensus conferences, and workshops on validated CAM therapies to enable practitioners and all other concerned parties to identify effective interventions for use in treating patients.
• Disseminate CAM research findings to health care providers.
• Identify and develop methods to overcome barriers to the integration of safe and effective CAM practices.
• Support demonstration projects focusing on how most effectively to translate CAM research findings into practice. These projects will emphasize the development of partnerships between researchers and health care systems and organizations that have incorporated CAM practices into the delivery of clinical care.
• Facilitate integration of effective CAM practices into routine health care delivery for NIH Clinical Center patients.
• Support enhanced communication and partnership-building between conventional and CAM health care institutions.

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Appendix II
NIH Strategic Plan To Reduce and Ultimately Eliminate Health Disparities

Research Goal

To advance the understanding of the development and progression of diseases and disabilities that contribute to minority health and other health disparities.

Research Objectives

• Advance understanding of the development and progression of diseases and disabilities that contribute to health disparities.
• Develop new or improved approaches for detecting or diagnosing the onset or progression of diseases and disabilities that contribute to health disparities.
• Develop new or improved approaches for preventing or delaying the onset or progression of diseases and disabilities that contribute to health disparities.
• Develop new or improved approaches for treating diseases and disabilities that contribute to health disparities.

Research Infrastructure Goal

To increase minority health and health disparity research training, career development, and institutional capacity.

Research Infrastructure Objectives

• Increase the number of participants in clinical trials from minority and ethnic populations and other special populations experiencing health disparities.
• Expand opportunities in research training and career development for, and provide research supplements to, research investigators from minority and other populations experiencing health disparities.
• Increase funding support for construction and renovation of research facilities across the nation aimed at enhancing the ability of these institutions to conduct health disparities research.
• Provide increased funding at institutions across the country for resources, new equipment, and shared equipment programs for use in health disparities research.
• Increase representation in peer review from minority and ethnic populations and other populations experiencing health disparities.

Public Information and Community Outreach Goal

To ensure the public, health care professionals, and research communities are informed and educated concerning the latest advances in minority health and health disparities research.

Outreach Objectives

• Provide the latest research-based information to health care providers to enhance the care provided to individuals within populations experiencing health disparities.
• Facilitate the incorporation of science-based information into the curricula of medical and allied health professions schools, and into continuing education activities of health professionals.
• Maintain ongoing communication linkages and dialogue with minority, ethnic, and other populations, including the underserved, who experience health disparities.
• Develop computer databases and Internet resources to disseminate current information about scientific research and discoveries and other activities regarding health disparities.
• Develop targeted public health education programs focused on particular disease areas in order to reach those individuals within minority, ethnic, and other populations who experience health disparities within these disease areas.

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