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Strategic Plan on Reducing Health Disparities |
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MissionThe mission of the National Institute on Drug Abuse (NIDA) is to lead the nation in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components: The first is the strategic support and conduct of research across a broad range of disciplines, and the second is to ensure the rapid and effective dissemination and use of the results of that research to significantly improve drug abuse and addiction prevention, treatment, and policy. Strategy for Addressing Health DisparitiesUnlike other diseases, drug addiction poses many peculiar challenges to health researchers, providers, and public health officials in the search for effective prevention and treatment strategies and policies. These challenges emanate primarily from the fact that drug abuse and addiction are usually the result of illegal activity and drug users are often viewed as morally corrupt or weak-willed individuals who engage in not only voluntary self and socially destructive behavior but also criminal activity. In short, despite the fact that we know unequivocally that addiction is a disease like any other medical disease, it remains a stigmatized disease. And this stigma spills over to all aspects of drug abuse research, prevention and treatment (e.g., obtaining measures of use, safety and legal concerns, early intervention is compromised by efforts to hide the disease, and denial of dependency). Racial/Ethnic minority populations are perhaps most adversely affected by this stigma and its effects leading to misperceptions about drug abuse and addiction in minority communities and the way in which prevention and treatment are delivered to them. For example, the common perception is that minority groups, particularly Blacks and Hispanics, use drugs more than whites even though epidemiologic data show little difference in overall use by race/ethnicity. In fact, in some instances minority groups are less likely to use licit or illicit drugs. There are, however, great differences in the consequences of drug use for racial/ethnic minorities creating a great need to better understand the unique prevention, treatment, and health services needs of these communities. NIDA has made a concerted effort to better understand and address the drug abuse and addiction research needs of racial/ethnic populations focusing on research areas where there are significant gaps in knowledge and/or clear disparities in prevention and treatment. In 1993, NIDA established a Special Populations Office, which has two overall goals: (1) to encourage increased research on drug abuse in minority populations in NIDA divisions, and (2) to encourage and enable increased minority participation in drug abuse research. Moreover, NIDA formed an institute-wide work group, the Consortium on Minority Concerns, which meets monthly to address research and research development issues of concern to minority populations. Each program division and office is represented on the Consortium. Several institute-wide initiatives and policies were implemented which have led to progress in research that addresses health disparities and the under-representation of minority scholars in drug abuse research. Some of these initiatives include:
As a result of these activities and individual division activities, NIDA experienced approximately a 97% growth in minority researchers since FY 1993. With this growth in minority researchers (although all are not involved in minority focused research) and an intense focus on drug use and addiction in minority communities, we have observed an increase in interest in drug abuse disparities and needs in minority communities. This proposed strategic plan reflects NIDA's insights and knowledge gained from our efforts to address health disparities among racial/ethnic groups. In addition, the plan incorporates the recommendations made by the expert work groups described above and an extensive review of NIDA's research programs and activities conducted by staff. Public comments received were also considered and incorporated into the plan. In addition to its interest in minority health disparities, NIDA has a strong interest in pursuing health disparities in rural communities (among racial/ethnic and other populations). Research suggests that drug use and addiction and its related consequences may be a serious and growing problem in rural areas; however, our knowledge base on drug abuse and addiction is limited. Providing drug abuse prevention and treatment and conducting drug abuse research in rural areas are difficult due to issues such as confidentiality, access to services, and a limited cadre of researchers and health care providers in rural areas. NIDA's Division of Epidemiology, Services and Prevention Research is planning an initiative to address drug abuse needs in rural areas. Over the next 5 years, NIDA will strive to: (1) improve our understanding of the incidence and causes of drug abuse and addiction in all racial/ethnic groups recognizing the diversity by gender, SES, and other factors within racial/ethnic populations, (2) strengthen and expand the community and research infrastructure for conducting research within racial/ethnic populations, (3) improve prevention and treatment for racial/ethnic groups at highest risk for addiction and medical consequences of drug use and addiction, and (4) widely disseminate information on drug use and the disease of addiction in racial/ethnic communities identifying best approaches to prevention and treatment. Moreover, NIDA will strive to better identify and understand the drug abuse needs of rural areas. In 2000, NIDA established a Health Disparities Committee, comprised of staff from all of NIDA's programs including the budget office and intramural program, to develop its Strategic Plan to Address Health Disparities. This committee was made a continuing committee by the Director to oversee the implementation of the strategic plan. As part of its work, the committee establishes institute-wide priorities, stimulates interest, and develops support for the goals and activities of the plan. This committee is chaired by staff of the Special Populations Office and reports to the Director of the InstituteIntroduction to the 2004 Revised PlanIn 2000, NIDA developed its plan to reduce drug abuse and addiction in health disparity populations as a part of the overall NIH's Strategic Plan on Reducing Health Disparities. Although NIDA has a history of encouraging and supporting programs and activities to address drug abuse and addiction concerns in racial/ethnic minority populations, the requirement to develop a broader, long-term strategic plan with research, research capacity, and community outreach components provided an excellent opportunity for all program area staff to critically review drug abuse and research needs within health disparity populations and develop a comprehensive institute-wide plan. A number of developments have occurred that necessitate our reviewing and revising our plan beyond the NIH requirement that each IC review and amend its plan, responding to public comments received, as appropriate. We have made progress in the implementation of our original plan and have learned some lessons that will help us to improve our efforts in addressing health disparities. Moreover, we wanted to review the current status of the drug abuse and addiction research needs of health disparity populations as evidenced by epidemiologic findings and expert opinion in order to reassess our health disparity priorities. Progress in Health Disparities Research: Accomplishments and Lessons LearnedSignificant Accomplishments: We have made significant progress in addressing the drug abuse and addiction research needs of racial/ethnic minority and other underrepresented groups. Selected major accomplishments in research, research capacity development including NIDA infrastructure development, and community outreach and dissemination are summarized below. Research. NIDA has stimulated research in health disparities and increased its support of health disparities specific research in the following ways:
Research Capacity Development. NIDA has supported the development of research capacity and infrastructure development through a variety of programs for students, faculty, and institutions, including the following:
Outreach and Dissemination. NIDA has increased its efforts to include and inform minority and other populations about drug abuse and addiction, including the following:
NIDA infrastructure. NIDA has encouraged internal processes and procedures to maintain focus on health disparities.
Lessons LearnedDuring the process of developing and implementing the Health Disparities Plan, a number of issues repeatedly arose among staff, grantees, other scholars and researchers, and the public. The first among these issues concerned the definition of health disparity, its intent and the groups captured by the term. Some suggested that a health disparity population could be any group in which differences in and/or limitations in our knowledge about the group's drug use and addiction appeared to exist. These groups could be defined, for example, by socio-economic status, race/ethnicity, and residence including rural/urban. But the inclusion boundaries seemed to be elastic and capable of capturing other groups in which differences were found or inadequate information was available (but problems were likely). They could be defined, for example, by gender; sexual orientation, preference, and behavior; or medical condition, e.g., HIV or HCV status. The second concern involved determining the criteria by which research should be considered as health disparity research. Options included counting any research pertinent to the health disparity issue, research related to the health disparity issue that includes the health disparity population as participants, or research that focuses on the health disparity issue and population (e.g., research questions and hypotheses are specific to the health disparity issue, health disparity population is a majority of the participants). The third concern involved the process of implementing studies that would yield valid and useful information on health disparity concerns. The third concern proved to be the more difficult challenge. Numerous questions arose concerning design and methodological issues, such as, the necessity of using a comparison group from the majority population, the availability of appropriate measures, operationalizing culture/culturally appropriately, and obtaining adequate sample sizes (related to the NIH inclusion policies). In 2003, the NIH addressed the first two concerns by further clarifying the Health Disparities definition and providing a method for determining research that is appropriate to the definition. The NIH definition is as follows: Health Disparities Research (HD) includes basic, clinical1 and social sciences studies that focus on identifying, understanding, preventing, diagnosing and treating health conditions such as diseases, disorders, and such other conditions that are unique to, more serious, or more prevalent in subpopulations in socioeconomically disadvantaged (i.e., low education level, live in poverty) and medically underserved2 rural3 and urban communities. Overall, health disparities research includes three components:
Grappling with these issues has taught us that we have to provide stronger guidance and leadership in defining NIDA's health disparity priorities and preparing the field to conduct meaningful health disparity research that will advance the field. We also learned that we need more researchers with expertise, experience, resources, and interest in conducting health disparities research. The Revised PlanNIDA has reviewed its original health disparities plan and found that, overall, it still reflects the needs of the field and conforms with the intent of the national and NIH Health Disparities Initiatives. Moreover, based on the epidemiologic data, racial/ethnic minority populations are consistently and greatly overrepresented in the United States as (1) groups who suffer disproportionately from the consequences of drug use and addiction, or (2) groups for whom we have little good scientific data about their drug use but for whom there are disturbing prevention, therapeutic, and service concerns. For example, since the first plan was written, HIV and other medical consequences of drug use have been steadily increasing among African Americans. Today, African Americans comprise about 11-12% of the U.S. population but over half of the new HIV/AIDS cases. The rate for Hispanics is also disproportionately high. We have very limited epidemiologic data on Asian Americans, but some local data and the reports of clinicians and service providers working in those communities suggest that drug use and addiction is a hidden and growing problem. Moreover, the problem varies by ethnicity/country of origin within the broader racial/ethnic classification of Asian American/Pacific Islander. NIDA, therefore, maintains racial/ethnic minority populations as its priority health disparity population in its Health Disparities Plan. This is consistent with the three major categories in the NIH Health Disparities definition. Following this priority, NIDA has great interest in rural populations followed by the other categories of health disparities as described in the NIH definition. NIDA also maintains its priority rankings of endeavors to be pursued through the plan. Namely, research infrastructure is the first priority. This includes not only the development of scientists in the field but also the development of resources and NIDA's/NIH's infrastructure to provide guidance and support to the field. Research and public information and outreach are the next two major priority areas, respectively. Overall, few substantive revisions were made to the plan. Clarifying language has been inserted where needed and dated information (e.g., reference to the next generation prevention program which is no longer open to new awards) has been deleted. Changes of note include the following:
Response to Public CommentsWe reviewed the public comments to determine how to improve our strategic plan and make it more responsive to the needs of our various constituent groups, e.g., academic institutions, professional associations. A number of concerns expressed in the comments had been addressed in our original plan, such as, the need to focus on diversity within racial/ethnic minority populations (e.g. by ethnic/regional subgroups within populations, gender), attend to language and cultural differences, provide research capacity development support to minority researchers and minority-serving institutions, and communicate with representatives from health disparity populations to ensure their perspectives are heard. A number of comments referred to the need for NIH to provide more guidance in conducting valid and appropriate health disparity research (e.g., NIH must define standards for cultural competence, more must be done to adjust research methodologies to the needs of minority communities). In our revised plan, we state more strongly our need to provide this type of leadership in research capacity development.
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