Plan to Address Health Disparities Initiatives

Contents

Strategy for Addressing Health Disparities

Prevention and Interventions for High Risk Groups
Alcohol Treatment and Health Services Research
Adverse Pregnancy and Infant Health Outcomes Related to Alcohol Use
Incidence, Prevalence, and Patterns of Alcohol Use, Abuse and Effects
Biomedical Risk Factors That Contribute to Disparities in the Effects of Alcohol
Neurobiological and Behavioral Risk for Alcohol Dependence

Areas of Emphasis in Research Capacity

Extramural Alcohol Research Infrastructure Development
Intramural Minority Research Development Activities

Areas of Emphasis in Community Outreach, Information Dissemination, and Public Health Education

Increase At-Risk and Minority Access to Alcohol-Related Health Messages
Health Professions and Science Education Initiatives

NIAAA Strategic Plan Working Group

MISSION/VISION STATEMENT

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides leadership to the alcohol research community by directing, supporting, and conducting biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. The Institute conducts its programs primarily by supporting research grants, contracts, and training awards at colleges, universities, and other public and private research institutions nationwide. Important to the mission of the NIAAA is research designed to identify racial and ethnic disparities in the causes and consequences of alcohol-use disorders and to develop treatment and prevention strategies to ameliorate them. Research on alcohol problems in rural and economically disadvantaged populations is also important.

The special emphasis areas, objectives, and proposed action plans that follow comprise an overall strategy to make progress towards NIAAA's goal of a greater understanding of the biological, behavioral, cultural, environmental, and ethnic factors that contribute to differences in alcohol-related problems. Through this understanding, we will devise more effective prevention and treatment approaches for everyone affected by alcohol-related problems.

STRATEGY FOR ADDRESSING HEALTH DISPARITIES

While NIAAA's plan to address health disparities includes many specific objectives, activities and approaches, there are five components or themes to the Institute's overall strategy.

I. Encourage research on health disparities. This strategy requires actively recruiting established alcohol researchers to address issues related to minority populations in their research. By highlighting disparities issues in our requests for applications and program announcements, we will signal our intention to support additional research on health disparities.

II. Build the capacity in minority serving institutions (MSIs) to conduct alcohol research and to contribute to our understanding of alcohol problems. With the support of the National Center on Minority Health and Health Disparities (NCMHD), the NIAAA has pilot tested several approaches to establishing and improving the capacity to conduct alcohol research in MSIs. Workshops, contracts, and cooperative agreements have been used to develop collaborative relationships between scientists/clinicians in MSIs and established alcohol scientists in research-intensive institutions.

III. Bring resources to the alcohol research community. This strategy is linked with strategic components I and II. Minority educators, health care professionals, clinicians, and investigators are integral to promoting health disparities research. Minority populations and study cohorts in minority intensive settings are also essential resources. The NIAAA will work to assure the availability of these resources to those who conduct research in response to this plan.

IV. Transfer research knowledge to practice and experiential/clinical knowledge to research. The NIAAA recognizes the need to assure that minority serving organizations obtain the results of alcohol research and that the experience and clinical knowledge of minority serving health care professionals and community members are transferred to those conducting health disparities research.

V. Build multi-disciplinary, multi-ethnic collaborating teams to address specific research areas. With encouragement and co-funding from NCMHD, the NIAAA has developed an approach to establish interdisciplinary collaborative teams. The results of piloting this model for international collaborative research on fetal alcohol syndrome is an example of the potential success of this approach. This strategy will be used for a number of research and training initiatives in the plan.

AREAS OF EMPHASIS IN RESEARCH

Prevention and Interventions for High Risk Groups

Research on the general population has identified a number of effective or promising strategies for preventing alcohol abuse and its consequences. These include implementation of public policies (Hingson et al., 2000); multi-component community, school, and family-based programs (Holder et al., 2000; Perry et al. , 1996); brief interventions for high-risk college students (Marlatt et al., 1995); a variety of communication/media strategies; and selected worksite and primary care interventions.

The Institute's top priority in this area is research to address underage drinking. Congress has charged the NIAAA with providing leadership in developing model longitudinal prevention/intervention community-based programs focusing on how individual families and school and community networks can help reduce underage drinking in rural and small urban areas. In developing these model programs, NIAAA is charged with recognizing the importance of other high-risk behaviors such as tobacco use, illegal drug use, risky sexual behavior, and psychological and parental risk factors for these problem behaviors. According to SAMHSA's 2002 National Survey on Drug Use and Health, drinking rates among persons aged 12 to 17 are higher in non-metropolitan than in small and large metropolitan areas and highest in completely rural areas. For instance, the prevalence of lifetime drinking among 12 to 17 year olds in completely rural areas is about 50 percent. Compared to youth living in more urbanized areas, youth 12-17 living in completely rural areas also had the highest rates of past year drinking (42%) and past month binge drinking (14%). Rates of tobacco product use and illicit drug use by 12 to 17 year olds are also higher in more rural areas.

To address the research need for studies on practitioner-based interventions among rural youth, NIAAA collaborated with the Association of Academic Health Centers (AAHC) to convene an invitational advisory meeting on February 11, 2004. The AAHC is a national, non-profit organization dedicated to improving health by advancing the leadership of academic health centers in health professions education, biomedical and health services research, and health care delivery. The AAHC identified 20 community-based academic health centers that serve rural and medically underserved communities to participate in this meeting. Several of these centers are located in the Mississippi Delta region of the U.S. The goal of the meeting was to solicit input regarding the feasibility of launching a research initiative to reduce high risk behavior in rural areas by fostering working partnerships between academic health centers (AHCs) and their communities.

While some prevention approaches have been shown to be effective among populations that include members of minority groups, it is unclear whether interventions specifically targeted toward particular minority groups would be even more beneficial than those designed to prevent alcohol problems in the general population. In addition, it is important to study whether and how key components of prevention strategies (such as community activation techniques) and critical precursors of behavioral change (such as alcohol expectancies or beliefs about the benefits and hazards of drinking) vary across racial/ethnic groups and in rural or low socioeconomic (low SES) settings.

Alcohol-focused prevention research also has developed effective environmental strategies that are now being re-tested in minority urban neighborhoods. For example, community-based interventions have sought to alter zoning laws as a means of reducing alcohol-outlet densities and attendant problems in poor, ethnic minority communities. However, further study of such environmental problems and effective solutions is necessary.

Hingson, R., Heeren, T., and Winter, M. Injury Prevention 6: 109-114, 2000.
Holder, H., Gruenewald, P.J., Ponicki, W.R., Treno, A.J., Grube, J.W., Saltz, R.F., Voas, R.B., Reynolds, R., Davis, J., Sanchez, L. Gaumont, G., and Roeper, P. Journal of the American Medical Association 284:2341-2347, 2000.
Perry, C.L., Williams, C.L., Veblen-Mortenson, S., Toomey, T.L., Komro, K.A., Anstine, P.S., McGovern, P.G., Finnegan, J.R., Forster, J.L., Wagenaar, A.C., and Wolfson, M. American Journal of Public Health 86:956-965, 1996.
Marlatt, G.A., Baer, J.S. and Larimer, M. In: Boyd, G., Howard, J., and Zucker, R.A., eds. Alcohol Problems Among Adolescents: Current Directions in Prevention Research, Hillsdale, New Jersey: Erlbaum Associates, 1995. pp. 147-172.

Objective: Enhance prevention of alcohol abuse and alcoholism in minority communities.

Develop research initiatives that address gaps in the current state of basic behavioral and applied knowledge on alcohol-focused prevention strategies that are effective for specified minority populations. Ascertain whether prevention interventions that have been proven effective in the general population are also effective for minority groups and subgroups.

Action Plan

Support projects to evaluate the current knowledge base and support future pre-intervention research to determine those aspects of minority drinking environments, patterns, and problems as well as expectancies, risk perceptions, community norms, values, and unique cultural factors that are likely to influence the outcomes of preventive intervention efforts.

Support studies to explore the ways that various prevention messages, information strategies, and emerging technologies can be tailored to address social and cultural factors that increase risk for specific racial/ethnic minority groups and for those in rural or low SES settings.

Objective: Expand analysis of extant data on effectiveness of alcohol research in minority populations.

Improve our ability to prevent problems due to alcohol abuse and alcoholism in racial/ethnic minority communities. Continue to develop and expand strategic, coordinated, methodological and conceptual approaches for evaluating prevention interventions in minority groups and subgroups.

Action Plan

Review and synthesize existing data on effectiveness of prevention interventions among minority populations. Based on the ongoing literature review, support future secondary analyses of data sets that contain minority-focused outcomes but have not yet been analyzed in terms of minority group.

Objective: Promote research to prevent HIV/AIDS infection among individuals with alcohol problems in minority communities.

Develop culturally relevant interventions for primary and secondary prevention of HIV/AIDS infection among alcohol abusers in ethnic minority communities.

Action Plan

Support studies to test the efficacy and effectiveness of prevention interventions including laws and policies, culturally sensitive family-based interventions, multi-component community interventions, and preventive interventions for specific minority and other high risk groups with increasing risk of HIV/AIDS infection.

Objective: Enhance research focused on prevention of alcohol problems in rural communities.

Develop and evaluate culturally sensitive prevention interventions for specific minority populations and for areas where rural populations are at high risk.

Action Plan

Develop, test and evaluate strategies for improving prevention interventions in rural communities. Encourage and support partnerships between experienced prevention researchers and academic health centers or other community groups to design effective prevention and intervention approaches.

Alcoholism Treatment and Health Services Research

Contemporary alcohol treatment providers recognize increasing diversity in American society and appreciate the potential importance of race and ethnicity in response to treatment. However, the number of models that incorporate diversity in the context of treatment conceptualization (Castro & Garfunkle, 2003) and health services research is limited. A workshop proposed in NIAAA's previous Health Disparities Strategic Plan was convened in September 2002. The "NIAAA Workshop on Treatment Research Priorities and Health Disparities" included fifteen experts from the treatment research field who presented epidemiologic and treatment outcome data on Hispanic, African American, Alaskan Natives, and American Indian populations. The results of this workshop were published in Alcoholism: Clinical and Experimental Research, Volume 27 (8).

Subsequent to discussions at the workshop, one participant conducted a secondary analysis of Project MATCH data to examine whether treatments tailored to the health needs of minority populations would be more effective than generic treatments. Project MATCH, a multi-site NIAAA-sponsored clinical trial, previously found no differences in treatment outcomes among minority participants as compared to non-Hispanic whites. Additional examination of the mediators of treatment outcome showed that there are indeed culturally relevant factors that influence the process or "path" to treatment outcomes as a function of ethnicity (Lowman & Le Fauve, 2003). Studies of the social and cultural factors that may influence motivation for treatment, adherence to treatment, and improved treatment outcomes among minority populations are essential to advance understanding in this area. Further, research is needed to validate knowledge about alcoholism treatment gained in studies with non-minority patients, and to extend knowledge about treatment effects in minority populations.

Access, utilization, cost effectiveness, and cost benefit of alcohol abuse and alcoholism treatments are also significant factors in disproportionate adverse consequences of alcoholism in certain populations. In addition, the absence of insurance coverage for alcoholism treatment may be an important barrier to treatment access, while the lack of culturally appropriate aftercare may similarly impede the effective delivery of treatment to non-majority patients. Although access to treatment for some minority populations has not been assessed widely, some factors have been studied.

Castro, F.G. and Garfinkle, J. Alcoholism: Clinical and Experimental Research 27:1318-1320, 2003.
Le Fauve, C.E., Lowman, C., Litten, R.Z., Mattson, M.E. Alcoholism: Clinical and Experimental Research 27:1318-1320, 2003.
Lowman C. and Le Fauve, C.E. Alcoholism: Clinical and Experimental Research 27:1324-1326, 2003.

Objective: Improve our understanding of the impact of race, ethnicity and other socio-cultural factors on treatment.

Continue and expand a research program that examines the influence of race/ethnicity and associated socio-cultural factors on health disparities. Such research should include investigation of their combined impact on the effectiveness of treatment and health services delivery for alcohol abuse and alcoholism in minority populations. Where appropriate, develop new, culturally sensitive treatments for racial and ethnic minorities and for those who are economically disadvantaged. Develop and improve the existing program of research for special subgroups within racial and ethnically diverse populations such as persons with concurrent psychiatric comorbidity, alcohol-related medical comorbidity and/or HIV/AIDS, individuals in the criminal justice system, adolescents, the elderly, and pregnant alcoholic women who place their children at risk for FAS.

Action Plan

Support research to evaluate the effectiveness of established behavioral/psychosocial and pharmacological treatments for alcohol abuse and alcoholism in minority populations and to develop and test new approaches hypothesized to enhance treatment outcomes in these populations. Fund research to critique reliability and validity of culturally relevant constructs and measures (e.g., demographic, economic, and socio-cultural), and encourage the development of new indices where appropriate. Participate in NIAAA-wide requests for applications wherever possible to achieve these objectives. Conduct a literature review to identify the nature and scope of what is currently known about the influence on alcoholism treatment outcomes of race/ethnicity and associated socio-cultural variables.

Continue research projects to identify social and cultural factors that influence motivation for treatment, adherence to treatment, and treatment outcomes; replicate and test in minority populations the relative effectiveness of established treatments for alcoholism, including Brief Intervention, Cognitive Behavioral Therapy, Motivational Enhancement Therapy, Twelve-Step Facilitation Therapy, or combinations of these with pharmacological treatment (e.g., naltrexone, disulfiram); test and implement "customized" treatment strategies to increase motivation, improve treatment entry, promote treatment adherence, and address relapse; develop and evaluate new medications and behavioral/psychosocial therapies that are tailored to the needs of specific racial/ethnic populations. Conduct grant writing and mentoring workshops to provide technical assistance to potential applicants where appropriate.

Objective: Examine the effect of access to alcoholism treatment on health disparities.

Evaluate the current knowledge base and support future research on how to meet special treatment and service needs for alcohol problems in minority subgroups including persons with concurrent psychiatric comorbidity, alcohol-related medical comorbidity, and/or HIV/AIDS, as well as individuals in the criminal justice system, adolescents, the elderly, and pregnant alcoholic women who place their children at risk for FAS.

Action Plan

Support research to learn how to improve access to and utilization of alcohol treatment services (including access to health coverage) in targeted economically disadvantaged and racial/ethnic minority subgroups. Determine how to increase the cost effectiveness of services for specific racial/ethnic and low socioeconomic status (SES) groups. Evaluate the current knowledge base and support research on under-studied issues related to disparities in access to and utilization of treatment for alcohol abuse and alcoholism (including disparities in coverage under health insurance policies). Investigate disparities in the cost effectiveness and cost benefit of treatments tailored to specific socioeconomic, racial, and ethnic minority groups. Publish results of literature reviews, workshop proceedings, and research findings in peer reviewed journals and NIAAA publications. Support projects that evaluate interventions and services designed to improve alcohol-related treatment outcomes in minority subgroups. Support research to assess the effectiveness of established treatments through secondary analyses and to develop and evaluate new treatments or combinations of treatments hypothesized to meet the special needs of minority and economically disadvantaged subgroups. Support research to examine and reduce disparities in access to and utilization of treatment.

Adverse Pregnancy and Infant Health Outcomes Related to Alcohol Use

Fetal Alcohol Syndrome (FAS) is the leading cause of preventable birth defects in the United States. It produces lifelong neurological, behavioral, and cognitive deficits that prevent normal learning and socialization. It also causes organ abnormalities, other physical malformations, and growth deficiency. Some minority groups suffer far more from FAS than other groups. For example, data from the Centers for Disease Control and Prevention indicate that FAS incidence appears to be seven times higher among African Americans than whites, whereas some American Indian communities have up to a 10-fold greater incidence of FAS than the general population.

Fetal Alcohol Spectrum Disorders (FASD) is the term used to describe the range of conditions caused by maternal alcohol consumption. For example, the incidence of alcohol-related neuro-developmental disorders in children exposed to alcohol during prenatal development is several times higher than that of those with the physical malformations of FAS. Further research is needed to identify why ethnic minority groups appear more vulnerable to the neuronal and behavioral effects of prenatal ethanol exposure. Research to understand the developmental course of these effects and identify the genetic and environmental variables that produce symptoms is also important.

The problems inherent in making progress toward the understanding of the underlying mechanisms of FASD and their diagnosis, treatment and prevention are many. Among them are the small numbers of similar age cases in any one site, the need for close collaboration between basic and clinical research scientists, and the need to exchange information quickly from research to practice and to transfer experiential knowledge from practice to research. NIAAA proposes to expand efforts to accomplish this and to address FASD-related issues by developing collaborative multi-ethnic, multi-disciplinary teams. This approach was found to be exceptionally successful and scientifically productive in an NIAAA-Office of Research on Minority Health , now NCMHD, supported study of FASD conducted in South Africa which yielded numerous co-authored publications and presentations.

In addition, research presented in a recent working group meeting co-sponsored by the National Institute of Child Health and Human Development (NICHD), NIAAA and the Office of Rare Diseases revealed that there is a high incidence of prenatal alcohol consumption in certain minority communities experiencing a high incidence of SIDS and stillbirths. The working group included representatives of the American Indian and Alaskan Native communities as well as sudden infant death syndrome (SIDS) and alcohol research scientists. The communities assisted in planning a research agenda to address the issues presented.

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report 51:433-435, 2002.
National Institute on Alcohol Abuse and Alcoholism. Alcohol-Related Birth Defects: An Update. Alcohol Research and Health 25:149-210, 2001.
Jacobson, J.L., Jacobson, S.W., Sokol, R.J., Martier, S.S., Ager, J.W., and Kaplan-Estrin, M.G. Alcoholism: Clinical and Experimental Research 17:174-183, 1993.

Objective: Develop interventions to prevent and mitigate FASD in high risk and minority populations.

Develop, test, and evaluate targeted strategies to prevent or decrease maternal drinking. Develop, test, and evaluate interventions to prevent or otherwise mitigate behavioral problems (including alcohol use and abuse) among affected children and youth.

Action Plan

Stimulate research that develops and tests interventions to prevent maternal drinking and FASD among high-risk minority and low SES populations. Encourage investigators to develop and test interventions to prevent behavioral problems (including alcohol use/abuse) among affected children.

Objective: Determine biological, genetic, and environmental factors which may contribute to disparate neuropsychological and cognitive outcomes due to maternal alcohol consumption.

Determine biological, genetic, and environmental risk factors that lead to the disproportionately high incidence of FAS and other adverse pregnancy outcomes due to alcohol consumption in African American, Alaska Native, and American Indian populations. Investigate possible causes for the disproportionate impact of prenatal alcohol consumption on certain groups of individuals within minority communities by conducting research on the genetics and metabolism of the mother-child unit, maternal nutrition, and other environmental factors that may affect vulnerability to fetal injury. Determine core deficits in specific age groups of affected minority children. Identify and evaluate pharmacologic and behavioral therapies designed to mitigate the effects of FASD in minority children and develop interventions that improve cognitive function. Identify and evaluate potential therapies for preventing fetal injury. Determine the extent to which high rates of alcohol consumption during pregnancy contribute to the high incidence of stillbirths, infant mortality, and SIDS among some minority groups. Determine if there is common pathology between FAS, stillbirths, and other adverse pregnancy outcomes.

Action Plan

Develop a multi-site, multidisciplinary initiative to integrate basic biological and clinical research on FASD and to accelerate translation of research findings to practice. Involve multidisciplinary teams of alcohol research scientists collaborating with minority communities, minority scientists, and scientists in minority serving institutions. Increase research funding for studies that involve minority investigators and clinicians in determining risk factors for adverse pregnancy outcomes.

Support studies to identify factors responsible for differential susceptibility to FAS and other adverse pregnancy outcomes due to alcohol consumption. Fund projects to evaluate alcohol-metabolizing enzyme variants among minority populations for their capacity to eliminate alcohol from the body. Identify environmental factors that predict alcohol-related adverse birth outcomes. Collaborate with the NICHD in developing methods for evaluating the role of alcohol in the pathophysiology of SIDS and stillbirths.

Identify specific emotional and cognitive deficits associated with lower levels of prenatal exposure to alcohol. Identify individuals more vulnerable to these effects. Examine specific measures of learning, memory, emotional functioning, and brain structure in children exposed to high prenatal alcohol levels. Obtain electrophysiological data on these children. Assess African-American and South African children to further characterize the distinctive pattern of alcohol-related attention deficits and to examine the relationship between prenatal alcohol exposure and socio-emotional function, psychopathology, and adolescent alcohol and drug use. Re-examine MRIs (Magnetic Resonance Imaging) and use other or newly developed methods to identify additional brain structures affected by prenatal alcohol exposure. Compare these images with neuropsychological test outcomes previously obtained in white, African-American and American Indian subjects.

Incidence, Prevalence, and Patterns of Alcohol Use, Abuse and Effects

Detailed epidemiologic information about patterns of alcohol use and alcohol-related problems among various racial and ethnic minorities is fundamental to effective efforts to address alcohol-related health disparities. Epidemiological research increases understanding of the nature and scope of these disparities and generates hypotheses for subsequent research.

Alcohol consumption is associated with a broad range of adverse health and social consequences, both acute (e.g., traffic deaths, other injuries) and chronic (e.g., alcohol dependence, liver damage, stroke, cancers of the mouth and esophagus). The scope and variety of these problems are attributable to differences in the amount, duration, and patterns of alcohol consumption; differences in genetic vulnerability to particular alcohol-related consequences; and differences in economic, social, and other environmental factors.

Over the past several decades, epidemiologic research has documented substantial variation in patterns of alcohol consumption and differential consequences of that consumption across various racial and ethnic groups. Recent studies have continued to indicate important differences (e.g., Caetano, 2003; Spicer, 2003). We have also learned that racial, ethnic, and cultural disparities in alcohol-related problems vary with the problem under consideration. For example: the alcohol-related death rate (i.e., for all categories of alcohol-related mortality combined) is higher among African Americans than whites (U.S. Alcohol Epidemiologic Data Reference Manual, 1996); cirrhosis death rates are very high among white Americans of Hispanic origin, lower among non-Hispanic African Americans, and lower still among non-Hispanic whites (Stinson, Grant, & Dufour, 2001); alcohol-related traffic deaths are many times more frequent (per 100,000 population) among American Indians or Alaska Natives than among other minority populations (U.S. Department of Health and Human Services, 2000); the incidence of fetal alcohol syndrome (FAS) appears to be higher in some African American and American Indian communities than in the general population (Stratton, Howe, & Battaglia, 1996); and recent increases in risky drinking behavior (i.e., drinking and driving) have been reported among Hispanics (Voas et al., 1998).

Although substantial progress has been made, much remains to be understood if we are to adequately describe differential drinking patterns, their consequences, and associated risk and protective factors by race and ethnicity. Disparities in the sequelae of alcohol consumption may be related to biological and/or environmental factors as well as their complex interactions. Thus, while genetic differences in alcohol metabolism or central nervous system reactivity to alcohol may be important risk factors, so too may be differences in access to health care. Research on the interaction of race, ethnicity, culture and environment as they affect patterns of alcohol consumption may also provide valuable information about the underlying causes of the differential alcohol-related pathology found in some minority populations and subpopulations.

Continuing to develop scientific knowledge about the incidence, prevalence, etiology, and course of alcohol-related problems among minority populations and subpopulations is clearly of central importance to reduction of alcohol-related disparities. The nation's increasing cultural and ethnic diversity adds to the complexity of this task but affords opportunities for significant new insights. Several applications have been funded to conduct secondary analysis of existing data sets in which the primary focus has been health disparities-related issues. This has provided a low-cost opportunity to expand our knowledge base of health disparities concerns by using existing data bases.

NIAAA (with co-funding from NCMHD) funded two initiatives which promise to expand our knowledge of the epidemiology of ethnic and racial minority use of alcohol. One national study surveys Hispanics, with specific attempts to sample from specific national origins groups, e.g., Mexican, Puerto Rican, Cuban, Central and South American. This will provide the first broad-based information on alcohol use among the increasingly diverse Hispanic population. NIAAA is also sponsoring developmental efforts to conduct epidemiologic surveys of Native Hawaiians, Pacific Islanders and Asian Americans in Hawaii.

Caetano, R. Alcoholism: Clinical and Experimental Research 27:1337-39, 2003.
Spicer, P., Beals, J., Croy, C.D., Mitchell, C.M., Novins, D.K., Moore L., and Manson, S.M. Alcoholism: Clinical and Experimental Research 27:11:1785-97, 2003.
Stinson, F.S., Grant, B.F., and Dufour, M.C. Alcoholism: Clinical and Experimental Research 25:8: 1181-87, 2001.
Stratton, K., Howe, C., and Battaglia, F., eds. Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. Washington, DC: National Academy Press, 1996.
U.S. Department of Health and Human Services. Healthy People 2010: Volume II. Objectives for Improving Health. Washington, DC: U.S. Government Printing Office, November 2000, p 26-13.
National Institute on Alcohol Abuse and Alcoholism. State Trends in Alcohol-Related Mortality, 1979-92. U.S. Alcohol Epidemiologic Data Reference Manual, Volume 5, First Edition. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 96-4174, 1996.
Voas, R.B., Wells, J., Lestina, D., Williams, A., and Greene, M. Accident Analysis & Prevention 30:267-275, 1998.

Objective: Assess changes in the prevalence of alcohol disorders and disability in the U. S.

The aim of this objective is to ascertain patterns of alcohol use and to determine the incidence and prevalence of alcohol dependence and abuse and their associated disabilities in the U.S. general population and its racial/ethnic subgroups.

Action Plan

Conduct a nationally representative longitudinal survey of 48,000 individuals, with African-American and Hispanics over sampled, to derive more precise estimates of major alcohol-related variables. This National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) will also include Alaska Natives and Native Hawaiians. (Data were collected in FY 2001-2002 and were collected again in FY 2004.)

Objective: Improve our knowledge of differential patterns of alcohol consumption, use and abuse among racial/ethnic minority and disadvantaged populations and subgroups.

Where appropriate, maintain and expand scientific research about patterns of alcohol consumption and alcohol-related problems within specific minority populations (e.g., African-American, Hispanics, Asian/Pacific Islanders, low SES and rural populations) and subgroups of these populations (e.g., Hispanics of Mexican origin, Asians of Korean origin).

Action Plan

Continue to support existing grants and increase the number of grants for alcohol-related epidemiologic research focused on specific minority populations and subgroups of these populations. Continue to encourage secondary analysis of existing data sets that focus on health disparities.

Biomedical Risk Factors That Contribute to Disparities in the Toxic Effects of Alcohol on Organ Systems

Genetics: Recent data suggest that ethnic groups exhibit genetic diversity in their biologic sensitivity to alcohol. These potential differences in alcohol sensitivity may result, in part, from genetic differences in alcohol metabolizing enzymes.

Different minority populations also may have genetic traits that either increase or decrease their susceptibility to alcohol mediated tissue damage. Variations have been observed between activity levels of the alcohol metabolizing enzymes prevalent among Asian Americans, African Americans, Mexican Americans, and Caucasians.

Evidence suggests that genetic factors may predispose members of particular minority groups to a number of medical complications related to alcoholism including damage to the liver, heart, pancreas, brain, and central nervous system. Studies are needed to determine whether other factors interact with genetic variations in metabolizing enzymes to produce ethnic differences in rates of organ damage. Likewise, additional research is needed to integrate specific genetic, physiologic, and pathologic processes contributing to the high risk for alcoholism among certain populations and subgroups. Measurements of the physiological and pathological outcomes of gene expression will yield more refined markers (e.g., specific physiological traits) that indicate genetic ethnic differences in sensitivity to alcohol.

Cirrhosis: Approximately 50 percent of all deaths due to liver cirrhosis, the 10th leading cause of death in the United States, are alcohol related. Although the death rate due to alcohol-related cirrhosis has been dropping in recent years among African American men, it was still greater than that among Caucasian males as recently as 1997 (Stinson et al., 2001).

Cardiomyopathy: Chronic alcohol abuse can result in alcoholic cardiomyopathy, and there too, disparities appear to exist. One study ascribed the differences in survival rates of African American (71%) and Caucasian (92%) cardiomyopathy patients to socioeconomic factors, but another shows that a serum protein variant (transthyretin Ile 122), which is more prevalent in African Americans, is associated with cardiac disease (Afolabi et al, 2000). The role heavy alcohol consumption plays in cardiomyopathy among African Americans is not known. Similarly, the role alcohol plays in inducing hypertension in hypertension-prone African Americans merits further investigation.

Pancreatitis: This difficult-to-treat, potentially fatal inflammation of the pancreas is more prevalent among African Americans, both men and women, than Caucasians. This disparity may be related to dietary factors, type and quantity of alcohol consumed, or other factors that need to be determined.

Interactions with immune system and immune-mediated organ damage: Alcohol causes an increased absorption of endotoxin from microorganisms and this has been shown to be injurious to the liver and other organs. This cellular injury may be mediated by production of inflammatory cytokines and chemokines, and may be unopposed since the immune response is modulated by alcohol.

HIV/AIDS: Given an incidence of AIDS that is 21-fold higher among African American women and 7-fold higher among Hispanic women compared with Caucasians, there is a significant disparity in exposure rates among minority children. Alcohol use has well-documented adverse effects on reproductive and immune function in women, and perinatal alcohol exposure adversely affects the developing immune system. Emerging evidence suggests that maternal alcohol use may exacerbate negative birth outcomes associated with perinatal HIV transmission. Studies are urgently needed to evaluate the prevalence and patterns of alcohol use among pregnant women infected with HIV-1; the impact of alcohol use on HIV transmission, immune status, and disease progression in mothers and their children; and the impact of alcohol use on the efficacy and metabolic complications of highly active antiretroviral therapy usage.

Afolabi, I., Hamidi Asl, K, Nakamura, M, Jacobs, P, Hendrie, H, and Benson, M.D. Amyloid 7:121-125, 2000.
CDCP, HIV/AIDS Surveillance Report 11: 1-44, 1999
Russo, D., Purohit,V., Foudin, L., and Salin, M. Alcohol 32 37-43, 2004.
Stinson, F.S., Grant, B.F. and Dufour, M.C., Alcoholism: Clinical and Experimental Research 25:1181-87, 2001.

Objective: Determine risk factors for organ damage and alcohol dependence in certain minority communities and disadvantaged populations using genetic parameters.

Determine specific genetic factors that may increase risk for alcohol induced organ damage in certain racial or ethnic groups. Determine how known differences in alcohol-metabolizing enzymes interact with other variables to influence alcohol consumption patterns in minority communities and disadvantaged populations. Study genetic or genetic-environmental interactions (e.g., dietary factors) that may increase our understanding of the increased vulnerability of some minority groups to alcoholic liver disease (ALD) and other disorders. Study the mechanism of onset and disease progression in groups with different survival rates for cardiomyopathy, pancreatitis, and other organ system diseases due to alcohol consumption.

Develop interventions that address those mechanisms.

Action Plan

Encourage submission of applications for biomedical research that identifies alcohol's effects on mechanisms and processes that cause health disparities in racial and ethnic minority and other populations. Support the involvement of minority students and scientists through supplements and fellowships. Stimulate research to identify mechanisms that explain the onset and progression in cardiomyopathy, pancreatitis, and other organ system damage due to alcohol consumption in groups with disparities in survival rates.

Objective: Determine the impact of alcohol on the susceptibility to HIV/AIDS, and perinatal HIV infection.

Determine specific pathogenic factors that may increase risk for HIV and organ damage in certain alcohol dependent minority groups. Determine alcohol's effects on HIV infection in alcohol abusers and pregnant women who abuse alcohol. Determine genetic or genetic-environmental interactions that may explain increased vulnerability of some minorities to HIV and alcoholic liver disease (ALD), hepatitis and other disorders. Identify mechanisms that explain onset and progression of HIV in liver, gut, and other organ systems and that produce damage due to alcohol consumption in groups with disparities in survival rates. Develop interventions that address those mechanisms.

Action Plan

Increase NIAAA support for biomedical research that identifies alcohol's effects on mechanisms and processes that cause health disparities in racial, ethnic, and other minority populations. Encourage research on the effects of alcohol consumption on HIV/AIDS disease progression, with focus on HIV/AIDS-induced organ damage and HIV/AIDS-defining opportunistic infections in populations at increased risk.

Neurobiological and Behavioral Risk for Alcohol Dependence

Alcoholism disproportionately affects social, environmental, and neurological outcomes in some minority groups with devastating consequences. Ethnic groups exhibit genetic diversity in their biologic sensitivity to alcohol. These potential differences in alcohol sensitivity may result, in part, from genetic differences in metabolic factors but may also be due to differences in the central nervous system's reactivity to alcohol. Measurements of the physiological and behavioral outcome of gene expression will yield more refined markers (e.g., specific physiological traits) that indicate genetic ethnic differences in susceptibility to alcoholism.

Minority individuals may possess genetic traits that either increase or decrease their vulnerability to alcohol dependence. Variations have been observed between the structures and activity levels of the alcohol metabolizing enzymes prevalent among Asian Americans, African Americans, and Caucasians. The flushing reaction, found most frequently among people of Asian ancestry, is one example of a protective trait. Flushing has been linked to variants of genes for enzymes involved in alcohol metabolism. It involves a reddening of the face and neck due to increased blood flow to those areas and can be accompanied by headaches, nausea, and other symptoms. Although flushing appears to deter alcohol use, people with the trait may continue to consume alcohol. Additional research is needed to clarify whether specific genetic, physiologic, and behavioral factors may explain the high risk for alcoholism among certain minority groups and subgroups. Alcoholism and its consequences are pervasive in some American Indian populations. For the development of treatment and prevention strategies, it is vital to establish the role and identity of causative factors in these groups.

Objective: Assess neurobiological and behavioral risk for alcohol dependence.

Through this objective we hope to determine how known differences in alcohol-metabolizing enzymes interact with other variables to influence alcohol consumption patterns in minority populations. We also plan to study specific genetic factors that may increase risk for alcohol dependence in minority groups; examine behavioral, neurological, and electrophysiological expression of those factors; and develop interventions that address those mechanisms.

Action Plan

Support research that identifies mechanisms and processes associated with disparities in racial and ethnic minority populations' vulnerability to alcohol abuse. Continue research that reveals heritable phenotypes that contribute to alcoholism susceptibility and severity in African Americans. Study phenotypes of high risk of alcohol abuse and dependence to quantify their association and linkage to candidate genes and quantitative trait loci (QTLs). Assess the heritability of quantitative phenotypes of neural disinhibition and the correlation with clinical diagnoses of predisposing and/or co-morbid Axis I and II disorders.

Define novel phenotypes of the acute response to alcohol and the alcohol elimination rate. Continue support for genome-wide survey analysis, candidate gene association studies, and studies on genetic polymorphisms in a cohort of African American subjects. Encourage new research examining genetic polymorphisms associated with vulnerability to alcohol abuse in Mexican Americans. Continue minority students' and scientists' involvement in these research efforts by encouraging minority supplements and fellowships.

Objective: Promote research that identifies factors that lead to increased prevalence of alcoholism among American Indian and Mexican American populations.

Identify vulnerability and protective alleles that underlie alcoholism's measured heritability. Identification of these alleles will lead to a better understanding of the mechanisms of vulnerability, individualization of treatment, and definition of gene-environment interactions. Assess the level of alcohol consumption among Mexican American young adults (21-25 yrs.) and identify potential risk and protective factors associated with alcohol involvement in this population. Continue to include members of racial and ethnic minority groups being studied in the research as scientific researchers, research support staff, subject interviewers, pedigree researchers, and other similar positions.

Action Plan

Continue the following studies: 1) a linkage study in an American Indian tribe that has a low rate of alcoholism; 2) an EEG linkage study in a tribe with a relatively high rate of alcoholism; 3) the Ten Tribe study, a genetic epidemiological study comparing tribes with low and high rates of alcoholism to identify gene-environment interactions; and 4) a project that uses whole genome linkage analysis and direct scanning of candidate genes to examine functionally significant sequence variations in genes expressed in brain and their role in alcoholism and other behaviors.

Sustain research to elucidate the effect of alcohol on gene/environment interactions among American Indian populations. Support studies that use genotyping assays to identify variants in the genes that we have previously linked to specific behavioral disorders including alcoholism in other populations. Screen for variants in alcohol-metabolizing genes associated with individual responses to alcohol, such as the flushing response in Asian populations. Assess the level of alcohol consumption in Mexican Americans, and look for potential risk and protective factors associated with alcohol involvement in this population. Evaluate neurological functioning in low risk and high risk Mexican American subjects following consumption of alcohol. Examine research to learn whether brain responses to alcohol associated with risk for alcoholism in non-Hispanic populations are also characteristic of high-risk individuals of Mexican descent.

AREAS OF EMPHASIS IN RESEARCH CAPACITY

NIAAA has identified two areas where new and enhanced activities could strengthen its alcohol research infrastructure and better equip the Institute to address health disparities. The areas are increased support for collaborative capacity development in Minority-Serving Institutions (MSIs) and expansion of efforts to attract and retain minority investigators to alcohol research.

Minority clinicians and scientists have much to add to our understanding of alcohol-related health disparities. Established alcohol researchers have demonstrated a willingness to collaborate with minority clinicians/investigators and to include minority populations and communities in their research. Efforts to enhance research at MSIs and an emphasis on health disparities research have evolved into a model for promoting health disparities research participation at several minority-serving institutions. Principal investigators are showing increasing numbers of minority research staff at all levels how to conduct rigorous alcohol research. Research in racial/ethnic minority, rural and low SES populations is emphasized.

The action items in this plan will expand and strengthen the existing NIAAA initiatives:

Cooperative Agreements - In 1997, NIAAA initiated three Collaborative Minority Institution Alcohol Research Development (CMIARD) programs using developmental cooperative agreements. In FY 2003, one these CMIARD programs successfully competed for a second five years of funding at a more advanced level. In 2002 and 2003, NIAAA added four new cooperative agreements. These are exploratory/developmental grants for planning alcohol research at minority-serving institutions. Each cooperative effort relies on strong collaborations with established alcohol research scientists to build on existing expertise at the MSIs. Program advisory committees and substantial involvement of institute scientific staff are also important features of this program.

Developmental Research Project Grants - NIAAA issued a program announcement titled Developmental Grants for Minority Collaborative Projects (R21) to support pilot projects developed collaboratively between scientists in minority institutions and established alcohol researchers. These awards enhance and extend the alcohol research activities of minority scientists. The goal is to provide a transition from mentored collaborative research development to more independent investigator-initiated research projects.

Distance Learning and Mentoring for Potential Grant Applications - In 1999, with co-funding from ORMH-NIH (currently NCMHD), NIAAA issued a contract to support distance learning entitled the Alcohol Research Mentoring System. The program matched new investigators from racial or ethnic minority groups (or non-minority investigators located at Historically Black Colleges and Universities) with senior NIAAA-funded researchers who mentored the new investigators through the development and submission or revision and resubmission of applications in prevention research. The ultimate goal was to increase the number of racial/ethnic minority investigators and expand research with underserved populations. More than 20 mentoring partnerships were fostered. Eleven grant applications were submitted and four competed successfully and were awarded.

Special Efforts in Alaska and Hawaii - With co-funding from ORMH-NIH (currently NCMHD), NIAAA increased its support for studies on health disparities among Alaska Natives with a special research project grant to the University of Alaska on pathways to Alaska Native sobriety. NIAAA also supported the State of Hawaii in conducting a symposium on alcohol research as well as co-sponsoring a workshop and symposium with the HMO Research Network. We now support a developmental cooperative project at the University of Hawaii, a minority serving institution. The aim of this project is to develop a collaborative alcohol epidemiology research program at the University.

Training of Health Care Professionals - Efforts are under way to facilitate moving research results into clinical practice through the development of curricula for pediatricians and prenatal care professionals. A program has been developed to help clinicians identify children affected by prenatal exposure to alcohol. It also promotes screening women of childbearing age for at-risk drinking. A companion booklet in English and Spanish also has been developed to help women cooperate with their health care providers to reduce at-risk drinking.

Technical Assistance Workshops - NIAAA has conducted several workshops to attract faculty in minority-serving institutions to alcohol research. One offered guidance in project development and grantsmanship. Other technical assistance initiatives include programs in distance and face-to-face mentoring in prevention research, discussions of strategies and requirements for doing clinical alcohol studies, and sessions to stimulate collaborative projects.

Minority Supplements - NIAAA continues its participation in the Research Supplements to Promote Diversity in Health and Related Research Program. Through this program, minority scientists at all experience levels work with funded NIAAA grantees on their research projects. The principal investigator serves as a mentor for the minority scientist who sometimes brings expertise and another dimension (such as cultural competence) to the project. Investigators mentored under these supplements often continue research and go on to submit their own grant applications. In fact, past participants in this program now have their own grants and are, in turn, mentoring other young investigators.

Mentor Awards - NIAAA encourages and supports established alcohol scientists on research project grants, centers and contracts to initiate collaborations with minority-serving institutions.

Career Development Awards - NIAAA has funded entry-level mentored awards (K01s) to two minority investigators, one Native Alaskan and one Hispanic American who are both focusing their career development plans on research with Native American, Hispanic American, and rural populations.

Extramural Alcohol Research Infrastructure Development

Objective: Increase alcohol research capacity at Minority Serving Institutions (MSIs).

Develop alcohol research infrastructure at MSIs to plan and implement research endeavors. Increase research capacity development in MSIs through support of mutually beneficial collaborative research with leaders in alcohol research. Involve minority populations and communities in alcohol research and wellness strategies.

Action Plan

Provide support for promising areas of alcohol research development in MSIs. Incorporate lessons learned from NIAAA's current collaborative research development programs. Provide technical assistance and promote strategies to improve institutional expertise and systems to handle the administrative and fiscal responsibilities associated with business management for federal grant programs

Objective: Increase minority investigators' participation in alcohol research.

Attract and develop minority investigators conducting alcohol research. Promote career development for minority investigators by seeking minority candidates at all levels to conduct alcohol research and by encouraging funded alcohol researchers to recruit and include minority students, scientists and clinicians as investigators on their studies. Retain existing minority investigators in alcohol research. Increase the number of minority alcohol research scientists, particularly at minority serving institutions and increase the amount and complexity of research conducted by minority investigators. Bring scientists and clinicians with experience working with minority populations into the alcohol research field.

Action Plan

Contact organizations such as the Hispanic Association of Colleges and Universities, the Minority Health Professions Foundation, the Interamerican College of Physicians & Surgeons, the National Hispanic Medical Association (NHMA), the National HBCU Substance Abuse Conference, and the Association of American Indian Physicians to promote alcohol research opportunities for minority investigators. Support minority supplements for minority clinicians, faculty and students. Alert training grant directors to opportunities for minority students and trainees. Continue Mentoring programs and awards. Encourage training grant program directors to seek out minority investigators. Encourage the Research Society on Alcoholism Education Committee to promote outreach programs for minority students and investigators. Encourage minority investigators to apply for Career Development Grants (K-award series).

Intramural Minority Research Development Activities

The NIAAA intramural program is in a unique position to offer a range of opportunities to recruit minority scientists and to include minority communities in alcohol research. NIAAA intramural scientists are experts in a broad range of scientific areas. Also, conditions that include a location in a metropolitan area that is racially, ethnically, and economically very diverse, the proximity of other NIH intramural programs, the number of minority-serving and other institutions of higher learning, the number of health care providers, and the range of local government structures strengthen potential offerings for minority scientists, clinicians, and students.

Objective: Identify and encourage minority high school and undergraduate students to consider careers in alcohol research.

Give minority high school and/or college and graduate level students and their teachers an opportunity to participate in the NIAAA Intramural Program's cutting-edge basic science research with the hope that this experience will lead students to choose careers in alcohol-related biomedical research.

Action Plan

Host high school, college, or graduate students and teachers from minority institutions for 2 months every summer in the NIAAA intramural laboratory. Assign each individual to a specific laboratory to learn the basics of biological research under the mentorship of the laboratory director or another senior scientist. Encourage the more successful students to return the following summer and let them become more actively involved in specific research projects. At the end of the research period, give minority students and teachers an opportunity to present their work at a laboratory meeting. Give students/teachers feedback from NIAAA intramural scientists on research projects and presentations. Develop and maintain a database to follow the career development of these students.

Objective: Develop a model program for research on screening and interventions for alcohol-related health problems.

NIAAA and NCMHD supported the development of an Alcohol Research Center Program at Howard University. This successful program has been competitively renewed and includes an outreach component to educate the community and to empower health care providers to screen patients for alcohol related problems and refer them as appropriate for treatment and follow-up within their health care system, Howard University or the NIAAA intramural program. Unity Health Care, Inc. administers and manages a system of health care clinics in high risk areas of Washington, D.C.

NIAAA will initiate a partnership between the NIAAA intramural program and the facilities of Unity Health Care Inc. in Washington D.C. NIAAA will provide opportunities to address health disparities across a broad spectrum of alcohol related disorders (alcohol abuse, alcoholism, alcoholic liver disease, pancreatitis, cardiomyopathy, etc.) in a community-based primary care setting.

Action Plan

Collaborate with Howard University and Unity Health Care to provide alcohol related client services and education for patients, families, health care professionals, and community organizations.

1. Client Services:

a. Alcohol Health Education: provide educational flyers, pamphlets, and other community literature regarding alcohol use and alcohol dependency.
b. Alcohol Screening: perform voluntary brief interviews to assess alcohol abuse/alcoholism . Use a variety of brief screening instruments and, where indicated, conduct 5-10 minute one-on-one sessions designed to reduce harmful drinking.
c. Medical Screening: consult with individual health care providers on liver disease and other alcohol related medical complications in their patients.
Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET): CBT and MET will be used to treat alcohol problems in Unity patients.

2. Screen Clients for Potential Participation in Alcohol Health Disparities Research at Howard University and the NIAAA Intramural Clinical Program in Bethesda

3. Recruitment to Research Careers: provide information and a platform for patient providers to become more active in research.

4. Community Outreach: disseminate findings about alcohol problems at local health fairs, church gatherings, and other community based programs and activities.

AREAS OF EMPHASIS IN COMMUNITY OUTREACH INFORMATION DISSEMINATION AND PUBLIC HEALTH EDUCATION

Increase At-Risk and Minority Access to Alcohol-Related Health Messages

Data suggest that some minority groups suffer more adverse effects from alcohol abuse and alcohol dependence than do other populations. Important to the mission of NIAAA is research designed to identify racial and ethnic disparities in the causes and consequences of alcohol-related problems, develop methods to ameliorate them, and disseminate research-based, culturally relevant information to these special populations through appropriate venues. Groups of particular concern include Hispanics, African Americans, American Indians/Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islanders, rural and low SES. In addition, there is significant variability within populations.

Objective: Increase awareness of alcohol abuse, alcohol dependence, and alcohol-related problems experienced by minority, rural and economically disadvantaged populations.

Develop culturally relevant health messages on a variety of alcohol-related issues. During FY 2004 Spanish-speaking focus groups pre-tested three new publications on the following topics: medications interactions with alcohol, alcohol and women, and genetics and alcoholism. The booklets were printed and widely disseminated; the number of publications disseminated and the dissemination venues are being monitored and tracked. In addition, we are conducting focus groups to pretest radio public service announcements that target African American and Hispanic parents. For FY 2004 National Alcohol Screening Day (NASD), a number of culturally-relevant multimedia products were developed for African American and Hispanic audiences. These included a variety of posters, radio promotions, and newspaper advertisements. These products were used to recruit people for NASD sites where they could participate in free, anonymous screening for alcohol problems.

Action Plan

Translate/adapt NIAAA consumer health pamphlets and booklets for minority populations. Pretest materials in focus groups consisting of the members of the targeted communities. Develop a Request for Proposal (RFP) for a 5-Year Health Communications Program for Minority Populations. Get input from experts to improve the cultural relevance of health messages.

Objective Two: Develop and build partnerships with government and private organizations to transmit research-based information to minority, rural and economically disadvantaged populations.

Form partnerships with government agencies and private organizations and associations whose goals are to promote healthy and safe behaviors and to develop comprehensive research plans to address alcohol-related problems for specific audiences. The work of these partnerships will consist of providing information and educational materials and collaborating to increase the availability of research-based information to their constituencies. Speeches and presentations are included.

Action Plan

Identify and establish collaborative partnerships with NIH, other governmental and national organizations such as the National Highway Traffic Safety Administration, the Community Anti-Drug Coalition of America, the National Council on Alcoholism and Drug Dependence, Mothers Against Drunk Driving, the National Organization on Fetal Alcohol Syndrome, Latino associations and rural health organizations to implement various alcohol education and outreach programs.

Health Professions and Science Education Initiatives

Alcohol related disorders occur in approximately 26 percent of general medical patients, a prevalence rate that is similar to that for hypertension. Given this rate of occurrence, the Institute of Medicine recommends that questions about alcohol use be included among the routine behavioral/lifestyle questions asked of all those seeking medical care. Because medical and other health professional schools provide only minimal training to recognize and treat alcohol problems, NIAAA has developed a program to develop better methods for teaching health care professionals to screen for and treat alcoholism. Special treatment issues for minority groups, such as higher incidence rates for alcoholic liver disease and FAS, treatment barriers, and cultural factors, must be incorporated in our health professions training for those who care for racial and ethnic minority, rural and economically disadvantaged individuals. Many patients are willing to accept suggestions from health care professionals. The skills to intervene effectively, refer and follow-up with these individuals must be included in training and continuing education programs. Further, there is a need to reach children-- future teen and adult patients--with information concerning alcohol and its effects on health. School-based science education is a potentially valuable vehicle for this. It is proposed that alcohol related science education curricula and curriculum supplements be developed and field-tested in multi-ethnic or predominately minority serving schools.

Objective: Continue Development of Health Professions Education Program.

Improve physician/health care provider and clergy intervention skills. Make research-based education regarding alcohol use disorders, interventions and treatment a priority in the training of health professionals serving minority populations. Increase the number of faculty role models on the handling of alcohol use disorders and intervention; improve the patient-physician interaction around the topic of alcohol use, abuse and alcoholism. Increase knowledge of clergy and pastoral ministers on the science of alcohol abuse and addiction and the evidence base for interventions.

Action Plan

Improve physicians' and other health care providers' skills in detecting alcohol through the targeted use of R25 Alcohol Education Project grants to train both primary care and emergency department health professionals. Materials and training programs from existing grants will be directed toward health professionals serving minority populations or to minority institutions. Those which prove most effective will be disseminated to the health education community. Support meetings of health professionals and policy makers to discuss the dissemination of evidence-based practice guidelines for alcohol services and policies for rural communities. Develop a science-based curriculum to educate clergy and pastoral ministers about addressing alcohol problems.

Objective: Science education outreach to minority and underserved communities.

NIAAA currently supports science education outreach programs targeted to communities in rural North Carolina. Scientists at the University of North Carolina have developed materials to augment science curricula in schools and have well equipped science laboratory buses and trained staff to deliver instruction to teachers and students in underserved areas. We propose to expand this effort to communities in neighboring Mississippi Delta states. The goal is to enhance existing science education in the Mississippi Delta by providing outreach through mobile laboratories and other means for delivering highly integrated, field-tested, and inquiry-based curricula on the science of alcohol. The plan is to collaborate with communities in the Mississippi Delta to evaluate the effectiveness of these programs on changing risk-taking behavior, increasing academic knowledge, and overall use, adaptability, and enthusiasm as garnered from students, teachers and other appropriate education officials.

We also plan to work with Howard University's Alcohol Research Center to provide outreach to minority youth in the District of Columbia Public School System. As part of Howard's center grant, they have built in local outreach efforts beginning in 2004 with a pilot alcohol education program for pre-college students. They will provide students in DC public schools with hands-on research and /or clinical experience that will serve to motivate them toward careers in the biomedical sciences. The program will also give minority high school students evidence-based information on alcohol use and abuse in an effort to reduce the high risk of developing alcohol-related problems.

According to SAMHSA's 2002 National Survey on Drug Use and Health, drinking rates among persons aged 12 to 17 are higher in non-metropolitan than in small and large metropolitan areas and highest in completely rural areas. For instance, the prevalence of lifetime drinking among 12 to 17 year olds in completely rural areas is about 50 percent. Compared to youth living in more urbanized areas, youth 12-17 living in completely rural areas also had the highest rates of past year drinking (42%) and past month binge drinking (14%). Rates of tobacco product use and illicit drug use by 12 to 17 year olds are also higher in more rural areas.

J. Edward Hill, M.D., former chair of the American Medical Association Board of Trustees (2002-03), worked for health education reform and initiated child health programs throughout the Mississippi Delta. In an amednews.com editorial to all physicians, he highlighted alcohol as one of the major preventable behaviors in these communities that put children at risk. (amednews.com is an internet newspaper for American physicians.) Dr. Hill promotes the idea to fellow physicians that school programs can reduce and prevent their occurrence. "…We must use our professional authority to help establish and fund the best, science-based comprehensive health curricula in our schools."

Action Plan

Adapt and field test NIAAA funded curriculum supplements and materials in multi-ethnic, minority-serving, and underserved K-12 educational settings. Supplement existing science education grants to provide outreach to schools in the Mississippi Delta region. Three curricula of particular relevance are Better Safe than Sorry, a curriculum addressing the prevention of Fetal Alcohol Syndrome, Understanding Alcohol, a curriculum highlighting the pharmacokinetics and pharmacodynamics of drinking alcohol, and My Brain, My Body, an interactive multi- media program focusing on the effects of alcohol on human physiology. A mobile science laboratory known as the Destiny bus will be used to deliver hands-on inquiry-based instruction to students and teachers in Mississippi Delta communities. Provide DC public school students with opportunities to be mentored by alcohol researchers and listen to NIAAA intramural and extramural researchers about their experiences and relevant research portfolios. Give students opportunities to tour and interact with scientists in laboratory settings, and potentially, to receive appropriate academic experience in preparation for undergraduate science programs.

NIAAA HEALTH DISPARITIES INITIATIVE WORKING GROUP

Chairperson
Faye Calhoun, D.P.A., M.S.
Deputy Director
National Institute on Alcohol Abuse and Alcoholism, NIH

Members
Judith Arroyo, Ph. D.
Program Officer
Division of Epidemiology and Prevention Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Mark Egli, Ph. D.
Program Officer
Division of Neuroscience and Behavior
National Institute on Alcohol Abuse and Alcoholism, NIH

Vivian Faden, Ph. D.
Associate Director
Division of Epidemiology and Prevention Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Robert Freeman, Ph. D.
Program Officer
Division of Epidemiology and Prevention Research, NIAAA
National Institute on Alcohol Abuse and Alcoholism, NIH

Andrea Hobbs
Program Analyst
Division Intramural Clinical and Basic Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Robert Huebner, Ph. D.
Deputy Director
Division of Treatment and Recovery Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Jason Lazarow
Program Officer
Office of Research Translation and Communications
National Institute on Alcohol Abuse and Alcoholism, NIH

Diane Miller
Chief, Communications and Public Liaison Branch
Office of Research Translation and Communications
National Institute on Alcohol Abuse and Alcoholism, NIH

Peggy Murray. M.S.W.
Chief, Health Sciences Education Branch
Office of Research Translation and Communications
National Institute on Alcohol Abuse and Alcoholism, NIH

Antonio Noronha, Ph. D.
Director
Division of Neuroscience and Behavior
National Institute on Alcohol Abuse and Alcoholism, NIH

Zhaoxia Ren, Ph. D.
Program Officer
Division of Neuroscience and Behavior
National Institute on Alcohol Abuse and Alcoholism, NIH

Deidra Roach, M. D.
Program Officer
Division of Treatment and Recovery Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Denise Russo, Ph. D.
Program Officer
Division of Metabolism and Health Effects
National Institute on Alcohol Abuse and Alcoholism, NIH

Brenda Sandler
Chief, Administrative Services Branch
Division Intramural Clinical and Basic Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Marcia Scott, Ph. D.
Program Officer
Division of Epidemiology and Prevention Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Harold Yahr, Ph. D.
Program Officer
Division of Treatment and Recovery Research
National Institute on Alcohol Abuse and Alcoholism, NIH

Samir Zakhari, Ph. D.
Director
Division of Metabolism and Health Effects
National Institute on Alcohol Abuse and Alcoholism, NIH

Updated: May 2005