Research Goal E: Improve our ability to reduce health disparities and eliminate health inequities among older adults.

During the 21st century, the United States will experience a dramatic increase in the proportion and diversity of racial and ethnic minorities in its older population. Life expectancy at older ages has increased significantly over the past 25 years but unacceptable disparities continue to exist in terms of disease burden and lifespan among racial and ethnic groups in the United States. Socioeconomic factors such as work, retirement, education, income, and wealth can have a serious impact on health and well-being. Economic circumstances can determine whether an individual can afford health care and proper nutrition from early life into old age. Individual and family financial resources and health insurance can determine whether an older adult enters a nursing home or stays at home to be cared for by family and friends.

Health disparities are associated with a broad, complex, and interrelated array of factors. Diagnosis, progression, response to treatment, caregiving, and overall quality of life may each be affected by race, ethnicity, gender, socioeconomic status (SES), age, education, occupation, and other as-yet-unknown lifetime and lifestyle differences. For example, a multi-ethnic epidemiological study supported by NIA indicated that prevalence rates for Alzheimer’s disease may be higher for African Americans and Hispanics than for other ethnic groups. Another study found striking relationships between SES and both health and longevity. Gender differences in health and longevity also are observed across racial and ethnic groups.

We will continue to support essential research to increase our understanding of and reduce health disparities and inequities among older adults. We will support research to establish the scientific basis for redressing differences and inequities affecting older adult populations. We will work to understand the extent to which genetic, behavioral, social, and other factors that show variation across racial and ethnic groups influence health and longevity. In addition, we will use new knowledge to develop behavioral and public health interventions for reducing disparities and increasing quality of life for all older adults.

Our objectives in this area are to:

E-1 Understand health differences and health inequities among older adults.
E-2 Develop strategies to promote active life expectancy and improve the health status of older adults in minority and other underserved populations.
E-3 Use research insights and advances to inform policy on the health, economic status, and quality of life of all older adults.

E-1 Understand health differences and health inequities among older adults.

There are many complex and interacting factors related to race, ethnicity, gender, environment, SES, geography, place of birth, recency of immigration, and culture that can affect the health and quality of life of older adults. Socioeconomic factors related to work, retirement, education, income, and wealth can have a serious impact on the health and well-being of the elderly. Biological and genetic factors can also affect the course and severity of disease and disability. Furthermore, a person’s culture can have a tremendous influence on health-related factors such as diet and food preferences and attitudes toward exercise. All of these factors and their interactions must be understood in order to design effective interventions to improve health equity among various ethnic/racial and low SES population groups.

To support this objective, NIA will continue research to:

• Understand normal aging processes across various ethnic/racial and low SES populations. We will characterize normal processes of aging in minority and low SES populations to increase our understanding of the course of disease and disability, and to identify the similarities and differences among racial and ethnic groups and among groups living in different geographic locations.
  
  
• Determine the effects of early life factors on adult health. Early life events can play an important role in the aging process. Differences in nutrition, education, disease incidence, environmental exposure and health care in fetal development and early life can affect disease and disability in later life. Research into the influence of early and midlife experience on the health of the aging will advance our ability to predict the health status of older adults in the future.
  
  Gather data that further classify patterns of health differences, inequities, and causes.
  
  
  • Compile data from multiple sources to assemble the necessary volume and types of information needed. Research to understand health disparities requires data that are accessible to researchers on a national level as well as appropriate ways to utilize multiple small data sets collected by many different researchers. NIA will support the use of these data to discover new scientific knowledge and to help in the evaluation and design of policies to deal with an aging society. This approach will allow data from several sources to be linked by a common identifier and analyzed in ways not previously possible.
    
    
  • Use ongoing data collection programs to oversample minority populations. These data will provide important information on living arrangements, income, health care needs, and other topics.
    
    
  • Continue to support surveys focused on specific groups and concentrated on issues of illness and well-being. NIA will continue to support and expand surveys of racial, ethnic, and language minority groups in order to provide the data needed by researchers and public policy makers.
    
    
• Determine the influences of and interactions among race, culture, ethnicity, economic status, education, and work experiences in health. Health and quality of life, particularly in later years, are affected by many interrelated factors. NIA will learn more about risk factors for disease and preventive factors contributing to good health by researching these influences individually and in concert. We will place a special emphasis on longitudinal data, which provide information about individuals across their lifespans, to untangle the multitude of factors that affect health and well-being.

Links to NIA research relevant to Objective E-1

E-2 Develop strategies to promote active life expectancy and improve the health status of older adults in minority and other underserved populations.

As life expectancy increases among all population groups, there are more adults living with one or more chronic conditions that may not affect the length of life but may dramatically affect quality of life. Research shows that these differences in active life expectancy are more marked among the medically underserved. Genetic, lifestyle, and socioeconomic factors also play an important role in the time of onset or severity of disease and disability. NIA’s efforts to understand the special needs of minority older adults will facilitate the design of effective interventions to improve health status and quality of life for our entire aging population.

NIA will continue research to:

• Track and analyze disease prevalence and course in diverse older adult populations.
  
  
  • Determine the causes of disparities in the prevalence of diseases and conditions such as heart disease, obesity, hypertension, frailty, diabetes, comorbidities, and certain types of cancer among minority and underserved populations. For example, African Americans suffer from hypertension and prostate cancer at higher rates than their white counterparts. Hispanics suffer more from diabetes but less from heart disease. NIA-supported researchers will explore socioeconomic factors such as education, language, and access to health care as well as how genetic, molecular, and cellular factors contribute to differences across populations.
    
    
  • Determine the reasons for variation in the prevalence of cognitive decline and AD across population groups. We will support research to better understand the differences in the prevalence of AD among African Americans, Asians, and Hispanics compared to non-Hispanic whites. For example, Japanese Americans living in Hawaii have lower prevalence of stroke-related dementia and higher rates of AD than Japanese nationals. We will continue to examine a range of possible causes of these disparities, including the impact of diseases such as hypertension, cardiovascular disease, and diabetes; health behaviors; and disease processes in minority populations. This research will draw on culturally appropriate, equivalent, and standardized measures to better understand these differences and to suggest culturally appropriate interventions.
    
    
• Develop appropriate health strategies for disease, illness, and disability prevention and healthy aging among the underserved. Aging Americans need understandable, culturally appropriate interventions they can use to maintain and improve their well-being. For example, adults with low levels of education and limited fluency in English may need specially adapted assessments of cognitive function for the diagnosis of AD. Diet and exercise recommendations may need to be adjusted to take into account religious, ethnic, and cultural sensitivities. Adults are more likely to use their medication appropriately if the labels and instructions are printed in their native language.
  
  To address these and other concerns, NIA will:
  
  
  • Develop and promote culturally appropriate interventions to improve healthy behaviors along with strategies to increase the likelihood that these interventions will be initiated and maintained.
    
    
  • Design and promote interventions appropriate for older adults in diverse populations to more effectively prevent, diagnose, or reduce the effects of disease.
    
    
  • Design and promote culturally appropriate strategies for self management of chronic diseases.
    
    
  • Investigate the factors affecting medication misuse and culturally appropriate strategies for enhancing proper use and compliance with medication regimens.
    
    
• Develop interventions to improve culturally appropriate health care delivery.
  
  
  • Design interventions to facilitate communication between health care professionals and Asian, Hispanic, and other elderly who have come to the United States with a range of educational and language skills. Interactions with health care professionals can be difficult if there are language and cultural barriers. If the elderly individual is hospitalized or placed in a nursing home, communication becomes a critical issue in ensuring appropriate health care. NIA will increase efforts to develop evidence-based practices that will facilitate communication of symptoms and care instructions between the patient and the health care provider.
    
    
  • Develop interventions to reduce health disparities and inequities associated with poor provider-patient interactions. Recent studies have revealed that how older adults are diagnosed and treated is as much a function of who they are, who is treating them, and where care is provided as it is a function of the symptoms they present. NIA will investigate ways to ensure that each individual is treated with appropriate evidence-based interventions regardless of race, ethnicity, or cultural background.
    
    
• Develop strategies to increase inclusion of minorities and other underserved populations in research.
  
  
  • Investigate novel approaches for increasing representation and retention of minorities in research careers. We will work to identify the best strategies for training and attracting a diverse workforce of new, mid-career, and senior researchers for research on aging. We will continue programs to assemble a cadre of high-quality researchers through flexible training mechanisms that reflect the rapidly changing needs of science and provide cross-disciplinary training. We will work to tap the talents of all groups of society by encouraging degree-granting institutions to establish and improve programs for identifying, recruiting, and training women and men—including minorities and individuals with disabilities—for careers in biomedical science. We will work to stimulate the training of investigators who can translate the findings of basic research into medical benefits for older people and expand the pool of clinical geriatric investigators.
    
    
  • Continue to support training for clinical staff in message development, recruitment strategies, and community and media outreach. Our ability to involve adults representative of the total population in research studies is essential to sound research and to obtaining the results needed for evidence-based intervention development. However, historically, members of minority populations have been underrepresented in clinical trials. Outreach efforts, such as involving faith-based and community organizations in emphasizing the importance of medical research and in recruiting study participants, have had varied success in minority populations. NIA will search for more effective ways to mitigate the difficulties associated with enrollment of minority individuals in research studies and clinical trials. For example, we will address cultural and language barriers and encourage effective communication of the potential benefits of studies and trials for improvement in health.
    
    
• Develop training programs to prepare culturally proficient service providers and researchers. We will facilitate training of researchers in the biomedical, behavioral, and social sciences as well as service providers working with older adults to help them better understand the medical implications of the growing diversity of our population. These training programs will help prepare the next generation of our health workforce by incorporating new materials sensitive to these issues.
  
  
• Conduct research to better understand effective strategies for communicating health messages that are culturally appropriate in various racial/ethnic and low SES populations. Because of language, educational, and cultural differences, underserved groups do not always receive the information they need about healthy lifestyle behaviors. NIA-supported communication research with specific target audiences will assist the development of appropriate health messages and dissemination channels.

Links to NIA research relevant to Objective E-2

E-3 Use research insights and advances to inform policy on the health, economic status, and quality of life of all older adults.

A key resource for understanding health disparities and inequities that exist among older adults is data on trends and patterns that can explain the interaction between financial assets and health outcomes in different racial and ethnic groups and within economically disadvantaged groups. Data that increase our understanding of the role of educational status in improving health behaviors and health status will also inform the development of more effective policies.

Minority and underserved elders depend more heavily on Social Security, receive little support from private pensions, derive less income from accumulated assets, and rely to a larger extent on earnings from employment in old age. Challenges for policy makers include finding ways to encourage individual savings and home ownership and facilitate continued employment.

To support this objective, NIA will continue to:

• Study population changes and underlying causes of health and function of older adults across the lifespan. Many studies have identified significant risk factors for the development of chronic diseases that pre-date onset of symptoms by at least a decade. Population-based studies in which individuals are tracked from birth and across the lifespan help researchers understand the changes in health over time and the large variations in health across racial and ethnic populations. NIA-supported research will continue to develop, maintain, and analyze longitudinal data sets.
  
  
• Track and analyze patterns of aging and the burden of disease within and across diverse populations.
  
  
  • Gather and analyze data on burdens and costs of illness, healthy life expectancy, longevity, and mortality trajectories. Determining the costs of specific illnesses has always been difficult due to the lack of adequate data on incidence and prevalence as well as inconsistencies in calculating direct and indirect medical costs. These difficulties are compounded in minority populations by differences in use of formal medical care and informal family caregiving. Projections of future active life expectancy, longevity, and mortality depend on assumptions about how groups of individuals will change over time, particularly as recent immigrants become culturally assimilated. This research will provide valuable information for projecting the specific needs for health care services within various population groups.
    
    
  • Develop cross-national and sub-national databases on health outcomes, risk factors, and SES structural factors, such as societal inequality. Although many of the disparities in adult health and life expectancy across national, racial, occupational, and social class boundaries are well documented, causal mechanisms are less well understood. NIA-supported research to understand these differences will be critical to the development of behavioral and public health interventions.
    
    
• Provide information useful for policy discussion and decision making. We will continue to collect nationally representative longitudinal data on retirement, health insurance, savings, and family variables and share these data and trends with researchers, policy analysts, and program planners. Research findings of reduced disability among the elderly have become prominent in the public policy debate regarding Medicare and Social Security. NIA will investigate whether disability is being prevented or postponed, identify contributors to disability decline, determine the impact of changes in health care, and examine the economic implications of reduced rates of disability.

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