Letter to the Editor - Health Disparities Research: Role for Undergraduate Students
Letter to the Editor
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To the Editor., In a study of The Philadelphia Negro (published in 1899) and in The Health and Physique of the Negro American (a 1906 volume), W.E.B. DuBois documented the differences in quality of health between African Americans and Caucasians (DuBois 1906 1899) during the 1900's. Today, health disparities continue to be a major public health problem. Health disparities are defined as "differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States" (Bennett 2004a; U.S. Department of Health and Human Services 2004). While the overall incidence, prevalence, mortality, and burden of certain diseases have decreased, possibly owing to healthcare technological advances and improved knowledge of diseases, disparities de facto have persisted. For instance, mortality rates of infants in the United States have decreased in recent years, but the infant mortality rate for African Americans has remained higher than that of their Caucasian counterparts (Bennett 2004a; National Center for Health Statistics 2004; U.S. Department of Health and Human Services 2004 2002 2000; DuBois 1906 1899).
Disparities exist for a number of diseases and conditions, within several health domains, and in several key factors such as race/ethnicity, geographic locality, socioeconomic position, gender, age, disability, and sexual orientation (Bennett 2004a; Edwards et al. 2004; Horowitz et al. 2004; Mustillo et al. 2004; National Center for Health Statistics 2004; National Research Council 2004; Thomas et al. 2004; U.S. Department of Health and Human Services 2004; Kawachi and Berkman 2003; U.S. Department of Health and Human Services 2002 2000; DuBois 1906 1899). Some of the main health domains in which inequality exists include health communication, preventive medicine, and medical/healthcare (e.g.., in access and quality, utilization, disease treatment, and management). As noted in Measuring Racial Discrimination (2004), discrimination occurs in multiple domains including healthcare, labor markets, education, housing/mortgage lending, and criminal justice. In terms of healthcare, discrimination manifests in disparate access of African Americans and Caucasians to institutions or procedures [e.g.., insurance and access to care], functioning within a domain [e.g.., quality of care and price], movement through a domain [e.g.., referrals], and key actors [e.g.., healthcare workers, administrators, and insurance companies] (National Research Council 2004).
Research has routinely documented that health disparities exist among racial and ethnic minorities which include African Americans, Hispanics, Native Americans, Alaska Natives, Asians, and Pacific Islanders. Bennett (2004a) highlights that there are "persistent ethnic disparities in rates of mortality and morbidity among nearly all of the leading causes of death and disability in the United States" (487). "Addressing Health Disparities: The NIH Program of Action" highlight President Clinton's 1998 announcement of an ambitious plan to eliminate health disparities by 2010 (U.S. Department of Health and Human Services 2004). The specific areas of health inequality that President Clinton wanted to eliminate were: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS, and immunizations (Bennett 2004a; U.S. Department of Health and Human Services 2004). The U.S. Department of Health and Human Services' Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities states that "the most striking disparities include shorter life expectancy as well as higher rates of cardiovascular disease, cancer, infant mortality, birth defects, asthma, diabetes, stroke, sexually transmitted diseases, and mental illness" (U.S. Department of Health and Human Services 2002, p. 4). Thus, the leading causes of death in the United States,cardiovascular disease and cancer (National Center for Health Statistics 2004),are marked by incongruities amongst different ethnic groups.
Research has shown that the physical environment as well as the social environment can have a noxious effect on one's health (Kawachi and Berkman 2003; U.S. Department of Health and Human Services 2002 2000). Rural residents, for instance, have worse health outcomes than urban residents (U.S. Department of Health and Human Services 2002 2000). Studies have also shown the beneficial effects of social support on health outcomes (Bennett 2004a; Baker et al. 2003; Adams et al. 1999). In addition, vast amounts of research have documented the inverse relationship between socioeconomic position and health (Bennett 2004a; U.S. Department of Health and Human Services 2002 2000; DuBois 1906 1899). Integral parts of the concept of socioeconomic position are income, education, and occupation,aspects of life where minorities and other marginalized populations are disadvantaged. The web of causation contributing to health disparities is quite complex and perplexing, including factors such as biological (U.S. Department of Health and Human Services 2002), levels of stress/racism/discrimination (Bennett 2004a; Mustillo et al. 2004; U.S. Department of Health and Human Services 2002; Krieger 2000; Clark et al. 1999), coping styles (Bennett 2004b; Edwards et al. 2004; U.S. Department of Health and Human Services 2002), ethnic/familial/behavioral/cultural background (Thomas et al. 2004; U.S. Department of Health and Human Services 2002), and institutional/political (Bennett 2004a; Thomas et al. 2004; U.S. Department of Health and Human Services 2002). Institutional and political factors include public health and social policy.
Recently, the government has allocated substantial resources for initiatives to meet their goal of eliminating health disparities by 2010. These initiatives include formation of U.S. Department of Health and Human Services Priorities; U.S. Department of Health and Human Services' Healthy People 2010; U.S. Department of Health and Human Services' strategic research plans (including the National Center on Minority Health and Health Disparities); U.S. Department of Health and Human Services' Initiative to Eliminate Racial and Ethnic Disparities in Health; Institute of Medicine reports; One America in the 21st Century: The President's Initiative on Race; and state legislatures. Another example of the increasing interest in decreasing health disparity is Healthy People 2010, a national health promotion and disease prevention program, which listed the elimination of health disparities among segments of the population as one of its key objectives (U.S. Department of Health and Human Services, 2000). In addition, the Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities provides millions of dollars to participating National Institutes of Health (NIH) institutes and centers in an effort to ultimately eliminate disparities in health (U.S. Department of Health and Human Services 2002).
The Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities supports research to understand the epidemiology of diseases, to distinguish their causes, and to develop "innovative diagnostics, treatments, and preventive strategies to reduce, and ultimately eliminate, health disparities" (U.S. Department of Health and Human Services 2004, p. 7). It outlines a plan to attack health disparities through 1) research, 2) research infrastructure, and 3) public information and community outreach. The plan also hopes to increase participation by minorities in clinical research. Through research it is expected that an understanding of the "development and progression of diseases and disabilities" that contribute to health disparities will be advanced (U.S. Department of Health and Human Services 2002, p. 5). Development of a research infrastructure is expected "to increase minority health and health disparity research training, career development, and institutional capacity" (U.S. Department of Health and Human Services 2002, p. 5). As a result, the number of minority clinical, basic, and applied medical scientists and researchers, as well as increasing minority institutional research will also increase. Public information and community outreach are expected "to ensure the public, healthcare professionals, and research communities are informed and educated concerning the latest advances in minority health and health disparities research" (U.S. Department of Health and Human Services 2002, p. 5).
As previously observed, the determinants and causal pathways of health disparities is multifarious, including biological, social, behavioral, psychological, cultural, environmental, and political etiological factors (Bennett 2004a 2004b; Edwards et al. 2004; Mustillo et al. 2004; Thomas et al. 2004; U.S. Department of Health and Human Services 2002; Krieger 2000; Clark et al. 1999). There is not a single factor. Therefore, researchers concentrate on all of these etiological factors and often employ a multidisciplinary approach. Researchers and policymakers attempt to ameliorate health disparities through observational, explanatory, and interventional research (Thomas et al. 2004). Specifically, they attempt to elucidate, understand, and document the etiological factors, the interaction of the etiological factors, the extent of the disparity, and the domains of life affected by the disparity. In addition, researchers and policymakers conduct and test interventions based on sound theoretical models, including implementing policies, and make policy recommendations. Thus, they uncover new knowledge about the prevention, detection, diagnosis, and treatment of disease and disability as well as implement health promoting policies (Thomas et al. 2004; U.S. Department of Health and Human Services 2002).
A useful strategy to make substantial inroads in health disparities is community-based participatory research (Bennett G.G., Personal communication 2005; Jenkins B., Personal communication 2005; Quarells, R.C., Personal communication 2005; Horowitz et al. 2004). Dr. Bill Jenkins, former epidemiologist at the Centers for Disease Control and Prevention and current research associate professor of the Public Health Sciences Institute at Morehouse College and associate director of the Research Center on Health Disparities at Morehouse College, believes "community-based participatory research holds the greatest promise in eliminating health disparities among those emerging methods, which have shown themselves to be effective"(Jenkins B., Personal communication 2005). He argues that "traditional methods, including increasing quality of healthcare, have had almost no impact on reducing health disparities. Interventions, which do not focus specifically on the need of communities, particularly minority communities, have not only had no impact on health disparities, but may actually increase health disparities. These interventions, which target communities most prepared to take advantage of new developments and interventions (high social capital communities), increase the efficiency of interventions but create a wider gap from low social capital communities,such as low income and minority communities. Community-based participatory research improves the effectiveness of interventions, which reduce health disparities and improves the acceptance of those interested in other communities and thereby has substantial impact on research translation or acceptance" (Jenkins B., Personal communication 2005). Dr. Gary Bennett, assistant professor at Harvard School of Public Health and the Center for Community-Based Research at Dana-Farber Cancer Institute, notes, "I do think that community-based participatory research is a strategy that might be able to assist in identifying factors and strategies that can be useful in mitigating health disparities. Too often, research has not been conducted with an eye towards the range of potential social contextual factors that might influence health. Instead, we have adopted approaches that stress identification of single agents of causation. Because community-based participatory research optimally is conducted in collaboration with the community, it offers a good opportunity to identify myriad factors from multiple levels that may interact to affect community health. This would be less possible using traditional methods, in which potential determinants are identified singularly, absent the input from affected individuals, and without the benefit of understanding the context of their expression" (Bennett G.G., Personal communication 2005). The aforementioned comprehensive and often multidisciplinary efforts seem to have had some impact on health disparities, albeit there is much room for improvement.
Beside the numerous benefits and importance of undergraduate students conducting research, including preparing students for graduate and medical school, undergraduate students can help in this national effort to resolve inequalities of health. Undergraduate student researchers should participate in research on health disparities,particularly, students who represent groups afflicted by these inequalities; for instance, racial/ethnic minority, low-income, and female students. Students from groups affected by health inequalities may provide insight assisting the research team such as with culturally relevant and gender sensitive health language and materials. Such student participation may provide unique insight and knowledge not readily available to the research team and the principal investigator. Thomas et al. (2004) noted "efforts to eliminate health disparities must be informed by the influence of culture on the attitudes, beliefs, and practices of not only minority populations but also public health policymakers and the health professionals responsible for the delivery of medical services and public health interventions designed to close the health gap" (p. 2050).
Due to the multifaceted nature of health disparities, student researchers from a number of majors and with varied interests can participate in such research. Since health disparities exist in several health domains, for many diseases and conditions, and by several key factors, a student is bound to identify and area of interest. The Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities aims to recruit people into research early in their careers (U.S. Department of Health and Human Services 2002); undergraduate study provides an excellent opportunity for this endeavor. In addition, undergraduate students who are exposed to research that can provide personal satisfaction and rewards are more likely to stay in the field. A research experience enables undergraduate students to develop and refine their research interests for future study. Thus, as new investigators, they can develop a program of research centered on health disparities.
As Thomas and colleagues (2004) state, "eliminating racial and ethnic health disparities by 2010 will require a sustained sense of urgency over the next 6 years" (p. 2050). Indeed, in order to substantially impact all areas of health disparities related to race/ethnicity, socioeconomic position, geographic locality, gender, age, and healthcare access and quality, the research community,including undergraduate student researchers,must continue its efforts and recognize the exigent nature of this national agenda. I urge undergraduate student researchers first, to understand health disparities and second, to conduct research attempting to decrease health disparities. The undergraduate student definitely has a place in this research agenda of mitigating and ultimately eliminating health disparities.Dustin T. Duncan
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